26-70009-000_RFP__11.02.2026_.pdf

Department of State Hospitals RFP Number: 26-70009-000

REQUEST FOR PROPOSAL (RFP) - SECONDARY

Notice to Prospective Proposers

Health Care Provider Network, Third Party Administration, and Prior Authorization/Utilization Management services.

November 2, 2026

The DSH is seeking proposals from qualified entities to provide a Health Care Provider Network (HCPN) of community-based specialty medical services providers, with Third Party Administration (TPA) and Utilization Management (UM) System, including Prior Authorization (PA) services.

Potential proposers are encouraged to download the solicitation package as well as any future addendums from Cal eProcure at: https://caleprocure.ca.gov/. When submitting your proposal, you must comply with the instructions found herein. The deadline for submitting proposals is December 7, 2026, 4:00 PM Pacific Daylight Time (PDT). you must register online at https://caleprocure.ca.gov/pages/bidder-vendor.aspx

In submitting a proposal, Proposers agree that they have read, understood, and will comply with the instructions found herein. Failure to comply with any of the requirements may result in rejection of a Proposer’s proposal. By submitting a response, Proposers agree to the terms and conditions stated in this solicitation and any resulting agreement.

All agreements entered into with the State of California will include by reference the state’s General Terms and Conditions and Contractor Certification Clauses that may be viewed and downloaded at: Standard Contract Language

The successful Proposer will be awarded a contract term of up to three (3) years that is anticipated to begin on March 01, 2027, and end on February 28, 2030. DSH has the option of extending this Agreement for up to two (2) optional one (1) year terms. The entire duration of the Agreement shall not exceed five total years. Contract extensions are subject to satisfactory performance, funding availability, and at DSH discretion.

The DSH encourages potential proposers to read this entire document thoroughly and carefully.

https://caleprocure.ca.gov/ https://caleprocure.ca.gov/pages/bidder-vendor.aspx https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.dgs.ca.gov%2FOLS%2FResources%2FPage-Content%2FOffice-of-Legal-Services-Resources-List-Folder%2FStandard-Contract-Language%3Fsearch%3Dgeneral%2520terms%2520and%2520conditions&data=05%7C02%7CKathryn.Hill%40dsh.ca.gov%7Cac958ecada1d43a8b52108dd6bdcf806%7C807536a6a6b14893a01370509c59ebbb%7C0%7C0%7C638785319036345269%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=a7q65yCZv6lL6c28hr64nqvrPdupm6iQcGue2hnaPpg%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.dgs.ca.gov%2FOLS%2FResources%2FPage-Content%2FOffice-of-Legal-Services-Resources-List-Folder%2FStandard-Contract-Language%3Fsearch%3Dgeneral%2520terms%2520and%2520conditions&data=05%7C02%7CKathryn.Hill%40dsh.ca.gov%7Cac958ecada1d43a8b52108dd6bdcf806%7C807536a6a6b14893a01370509c59ebbb%7C0%7C0%7C638785319036345269%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=a7q65yCZv6lL6c28hr64nqvrPdupm6iQcGue2hnaPpg%3D&reserved=0

Statewide Integrated Health Care Provider Network

TABLE OF CONTENTS

I. GENERAL INFORMATION

A. Background B. Purpose C. Description of Services D. Agreement Term and Security Provisions:

II. MINIMUM QUALIFICATIONS (MQ)

A. Proof of Legal Right To Do Business:

B. References:

C. Agreement to Sign:

D. Background and Structure E. Experience:

III. PROPOSAL REQUIREMENTS AND INFORMATION

A. Key Action Dates:

B. Proposer’s Questions:

C. Addenda:

D. Submission of Proposals:

IV. PROPOSAL EVALUATION AND AWARD

A. Review of Proposal Requirements:

B. False Statements Disclaimer:

C. Intention to Award:

D. Breaking Tie Proposals:

E. Award and Protest:

F. Disposition of Proposals:

G. Tax Delinquency Disclaimer:

V. PREFERENCE AND INCENTIVE PROGRAMS

A. Small Business Preference:

B. Disabled Veteran Business Enterprise Program and Incentive:

C. Calculation of Multiple Preferences:

D. Other Preference Programs:

E. Additional Small Business and Disabled Veteran Enterprise Information:

VI. REQUIRED ATTACHMENTS

A. Listing of Attachments:

ATTACHMENT 1 Proposal Submission Checklist ATTACHMENT 2 Proposer’s Certification ATTACHMENT 3 Minimum Qualifications Response ATTACHMENT 4 Cover Letter ATTACHMENT 5 Proposer’s Letters of Reference

ATTACHMENT 6 Proposer’s Rate Sheet ATTACHMENT 6A Proposer’s Rate Sheet ATTACHMENT 6B Performance Guarantees ATTACHMENT 6C Sample of Scoring Cost Sheet ATTACHMENT 7 Insurance Certifications ATTACHMENT 8 Darfur Contracting Act Certification

ATTACHMENT 9 – PROPOSER DECLARATION FORM (GSPD-05-105)

ATTACHMENT 10 – CONTRACTOR CERTIFICATION CLAUSES (ccc 04/2017)

ATTACHMENT 11 – PAYEE DATA RECORD (STD. 204)

ATTACHMENT 12 – PAYEE DATA RECORD SUPPLEMENT (STD. 205)

ATTACHMENT 13 – CALIFORNIA CIVIL RIGHTS LAW CERTIFICATION

ATTACHMENT 14 – DVBE DECLARATION FORM (STD. 843)

ATTACHMENT 15 – IRAN CONTRACTING ACT CERTIFICATION)

ATTACHMENT 16 Organizational Chart ATTACHMENT 17 Technical Proposal Cover Sheet ATTACHMENT 18 DSH Internal HCPN Forms:

ATTACHMENT 19 DEFINITIONS:

ATTACHMENT 20 Sample Scoring Sheet ATTACHMENT 21 Sample Agreement (Std. 213 and Exhibits)

EXHIBIT A SCOPE OF WORK

EXHIBIT B BUDGET DETAIL AND PAYMENT PROVISIONS

EXHIBIT D SPECIAL TERMS AND CONDITIONS

EXHIBIT E CONFIDENTIALITY AND INFORMATION SECURITY PROVISIONS

EXHIBIT G INSURANCE REQUIREMENTS

EXHIBIT H PERFORMANCE GUARANTEES

EXHIBIT I SAMPLE SERVICE LEVEL AGREEMENT

I. GENERAL INFORMATION

A. Background

DSH manages the nation’s largest inpatient forensic mental health hospital system. Its mission is to provide evaluation and treatment in a safe and responsible manner, seeking innovation and excellence in state hospital operations across a continuum of care and settings. DSH oversees five, 24 hours state hospitals located at Atascadero, Coalinga, Metropolitan – Norwalk (Los Angeles County), Napa, and Patton. In Fiscal Year 2025–26, DSH served approximately 8,739 patients statewide.

DSH is required to maintain legally prescribed staffing ratios to meet licensing and certification requirements for the healthcare services and treatment of forensic patients throughout the State. To fulfill this mission, DSH employs nearly 13,000 personnel, including clinical staff, and provides medical treatment through both on-site hospital resources and outside medical providers under various healthcare contracts.

Given the complexity and acuity of the forensic patient population, DSH relies extensively on specialty medical care delivered by community-based providers when services exceed the scope of internal medical staff or on-site hospital capabilities. Each hospital was responsible for identifying providers, negotiating and executing contracts, overseeing service delivery, processing medical claims and maintaining effective provider partnership.

In 2023 DSH contracted with a HCPN to develop and implement a robust network of community-based healthcare providers, to provide TPA services to process claims and implement an efficient business model for adjudicating claims and to develop an enterprise-level solution for a PA/UM Program that includes prior authorization for medical requests, concurrent review on hospitalized patients, and retrospective reviews to monitor off-site care and costs. The network consists of on-site and off-site specialty care, and a full scope of ancillary services.

To strengthen statewide consistency, improve access to medically necessary services, and enhance fiscal oversight, DSH seeks to continue contracting for the HCPN, TPA, and PA/UM using industry best practices and standards in the industry applicable to the DSH environment.

DSH seeks to implement a coordinated HCPN similar to industry best practices used in other State of California healthcare systems. The HCPN will include hospitals, medical specialty providers, ancillary service providers, and other medical professionals necessary to meet patient needs. HCPN Providers will be required to meet credentialing, licensing, certification, and background check standards established by DSH, and the Contractor will be responsible for maintaining network adequacy, geographic access, appointment availability, and specialty coverage.

DSH processes approximately 113,000 medical claims annually for medical contracts, totaling roughly $67 million in annual expenditure. Historically, DSH has experienced billing challenges related to duplications, overages, and inaccuracies, resulting in inefficient claim processing and inconsistent fiscal controls. To address these challenges, DSH intends to require the Contractor to utilize an agreed upon TPA as the sole claims processing administrator. All providers shall submit claims through the TPA’s system, and the Contractor shall comply with standardized adjudication rules, authorization validation requirements, reporting standards, and audit access protocols.

To ensure alignment between authorized services and claims paid, DSH will require implementation of an electronic prior authorization (ePA) system capable of validating authorizations at the time of claims submission. The ePA system shall support automated routing, clinical review, documentation upload, decision tracking, audit trails, and integration with DSH’s Electronic Health Record (EHR) system. DSH may elect to expand or modify ePA functionality after the first contract year based on operational needs, regulatory requirements, or fiscal conditions.

DSH continues to play a critical role in providing specialized forensic mental health treatment and ensuring continuity of care for a complex patient population across California. Given the significant volume of patients served, the extensive reliance on contracted outside medical providers, and the substantial annual claims expenditures, there is an ongoing need to strengthen operational efficiencies, fiscal oversight, and compliance processes. Implementing a more integrated and automated approach to prior authorization management, claims adjudication, invoice processing, provider network oversight, and contract administration will support DSH’s mission by improving accountability, enhancing timely access to medically necessary services, and ensuring responsible stewardship of public resources.

If requested by the State, the Contractor shall negotiate in good faith to provide substantially similar services, goods, and pricing to other State departments delivering healthcare services to DSH patients or related populations. Such services may be provided through amendment or separate agreement. If any provision of the Agreement is determined to be unenforceable, such provision shall be deemed severable and shall not affect the remainder of the Agreement.

DSH Facility Overview

DSH facilities have long-term working relationships with HCPN providers. To align with DSH Strategic Plan, it is crucial to maintain the professional relationships and communication that are so critical to ensuring appropriate and coordinated patient care. DSH has five hospitals located throughout California. Below outlines the five locations where HCPN providers are needed:

Atascadero (DSH-A)

The Department of State Hospitals Atascadero is a secure forensic hospital located on the Central Coast of California, in San Luis Obispo County that opened in 1954. The majority of the all-male patient population is remanded for treatment by county superior courts or by the California Department of Corrections and Rehabilitation (CDCR). The hospital operates approximately 1,184 beds and provides definitive medical care and evaluation to all residents in the hospital. DSH-A is located in a rural setting, which can create challenges in finding providers in the area that are willing to treat their patients.

Coalinga (DSH-C)

The Department of State Hospitals Coalinga is a secure forensic hospital located at the edge of the coastal mountain range on the western side of Fresno County that opened in 2005. Coalinga is halfway between Los Angeles and San Francisco and sixty miles southwest of Fresno. The hospital operates approximately 1,286 beds and provides primary medical needs within their treatment facility.

Metropolitan (DSH-M)

The Department of State Hospitals Metropolitan is an open campus hospital with a secure perimeter located in the city of Norwalk in Los Angeles County that opened in 1916. The hospital operates approximately 826 beds with a robust, spacious, and advanced clinical department.

Napa (DSH-N)

The Department of State Hospitals Napa is an open campus hospital with a secure perimeter located in the city of Napa, in Napa County that opened in 1875. The hospital operates approximately 1,255 beds and provides various medical services.

Patton (DSH-P)

The Department of State Hospitals Patton is a secure forensic hospital located in the city of Patton, CA, in San Bernardino County and that opened in 1893. DSH-Patton provides treatment to forensically and civilly committed patients within a secure treatment area. The hospital is currently operating with a capacity of approximately 1,527 beds.

B. Purpose

The objective is to contract with a qualified entity to continue the HCPN, TPA, and PA/UM for the following period: Three (3) initial years with Two (2) optional - One (1) year extensions.

The purpose of this Request for Proposals (RFPs) is to contract with a qualified entity to provide an enterprise-level solution for addressing the health care needs of its patient population that encompasses a Statewide HCPN, TPA, to include an enterprise-level solution for a PA/UM Program that includes prior authorization for medical requests, concurrent review on hospitalized patients, and retrospective reviews to monitor off-site care and costs.

This system will ensure a continuum of medical care is available to patients when needed. It is critical for DSH to provide a sustainable network of providers and hospitals for use by the State Hospitals that are reasonable and cost effective to the State of California.

This system will assist the DSH with implementing industry best practices and provide for improved patient outcomes. The improvements will not only be seen at the patient level as part of improved health outcomes but will also be evident in improved efficiencies of staff and operational accountability.

C. Description of Services

Health Care Provider Network (HCPN)

The Contractor shall develop, administer, and maintain a statewide HCPN capable of delivering medically necessary services to patients served by the DSH. The HCPN shall ensure timely access to medical, behavioral health, specialty, hospital, and ancillary services across all DSH hospitals and designated off-site locations.

The awarded Contractor shall furnish all personnel, systems, materials, and operational infrastructure necessary to deliver the services described in this Scope.

Third-Party Administrator (TPA)

The Contractor, acting as the TPA, shall serve as the administrative entity responsible for statewide oversight of the Health Care Provider Network (HCPN), claims administration, utilization management integration, operational coordination, and contractor administration for the DSH. The Contractor shall provide all systems, personnel, infrastructure, and operational support necessary to ensure accurate, timely, and compliant processing of healthcare claims and related administrative functions under the management and approval of DSH.

The Contractor shall provide administrative support for medical claims intake, claims review, adjudication support, payment coordination, claims dispute resolution and appeals process. The Contractor shall maintain effective customer service operations for providers, DSH staff, and authorized stakeholders, including live support and electronic assistance.

The Contractor shall develop and maintain integrated operational systems and workflows supporting provider network administration, prior authorization processing, claims adjudication, reporting, fiscal oversight, and compliance activities. The Contractor shall prepare and submit operational, financial, network, and performance reports in accordance with DSH requirements and shall maintain performance guarantees, escalation procedures, corrective action processes, and performance monitoring standards. Integrated operational systems shall comply with DSH IT, security, and operational standards.

The Contractor shall support audits, investigations, monitoring reviews, and compliance activities conducted by DSH or authorized oversight agencies. The Contractor shall maintain business continuity, cybersecurity safeguards, disaster recovery measures, and protection of confidential and protected health information in compliance with the Health Insurance Portability and Accountability Act (HIPAA), California privacy laws, and all applicable federal and state requirements.

The Contractor shall provide initial training on the TPA system for DSH users and develop a schedule for ongoing training, including written user guides, training materials, and updated documentation following system enhancements.

The Contractor shall comply with State of California Franchise Tax Board levy withholding orders for all HCPN medical providers and shall coordinate with providers on submission and tracking of levy orders.

Prior Authorization (PA) / Utilization Management (UM)

The Contractor shall provide comprehensive PA/UM services to support the DSH statewide healthcare operations. PA/UM services shall ensure that all medical services provided to DSH patients are medically necessary, clinically appropriate, cost-effective, timely, and compliant with State and federal requirements.

UM operations must be fully integrated with the Contractor’s HCPN and TPA systems, including prior authorization, claims adjudication, provider relations, reporting, and compliance monitoring.

Utilizing criteria such as InterQual, Milliman Care Guidelines (MCG) or similar guidelines. This system shall support DSH clinicians, who retain the ability to exercise their professional clinical judgement and act as the final decision-makers. This program must be easily accessible and utilizable and customizable by DSH hospitals, community medical providers, and claims administration, while also meeting the Technical Requirements specified in this RFP.

D. Agreement Term and Security Provisions:

1. If an agreement results from this RFP, the term is anticipated to begin March 1, 2027, and continue for up to three (3) years. Additionally, DSH shall retain the option to extend the agreement for up to two (2) one-year terms, at DSH’s sole discretion, via amendment. Any agreement resulting from this RFP shall have no force or effect until it is signed by both parties and approved by the Department of General Services (DGS) if such approval is required.

Performance shall start no sooner than on the date set by the awarding agency and after all approvals have been obtained and the agreement is fully executed by DGS.

2. All performance under the agreement shall be completed on or before the termination date of the agreement.

3. Should the Contractor fail to commence work at the agreed upon time, the DSH reserves the right to terminate the agreement upon thirty (30) days’ written notice to the Contractor.

4. Contractor shall agree to all security provisions where the performance of work takes place on any state hospital grounds.

5. While the intent of this RFP is to contract for the full spectrum of services described above, DSH reserves the right to delay or exclude the implementation of the PA/UM program altogether.

6. DSH reserves the right to modify or cancel, in whole or in part, this RFP at any time prior to contract award. Any RFP modification(s) and/or cancellation will be made via an addendum to the RFP. Via amendment to any Agreement awarded as a result of this RFP, DSH reserves the right to add services and related costs as described herein and deemed necessary to meet the needs of the project.

7. Failure to provide services on three (3) or more occasions may result in termination of the

Agreement or the institution not having to contact Contractor prior to contacting other contractors for the duration of the Agreement term. The DSH has the sole discretion in this decision.

8. Should DSH need services that the Contractor is unable to provide but, obligated to provide under the Agreement, DSH may retain the services of an outside provider and Contractor agrees to pay the difference between the cost to provide the services under the agreement and the cost to pay an outside provider to provide the services. DSH may within its reasonable discretion select the outside provider.

9. The Parties agree and acknowledge that if any provision of the Agreement as a result of this RFP is determined by a final judgment of a court of competent jurisdiction to be illegal or unenforceable, such determination shall not affect the balance of the Agreement, which shall remain in full force and effect, and such invalid provision shall be deemed severable.

II. MINIMUM QUALIFICATIONS (MQ)

A. Proof of Legal Right To Do Business:

Proposers must submit proof of their legal right to do business in the State of California. The following are required:

1. Proposers must submit a copy of their license to do business in the State of California, where applicable; or Proposers which are corporations, regardless of where they are incorporated, shall submit a print-out from the California Secretary of State website (http://kepler.sos.ca.gov) which shows that their corporation is registered and is currently in good standing.

2. Proposers must certify, in a statement in the cover letter, that they are and will continue to meet all terms and conditions for operating a business in the city/county in which the business is headquartered.

3. Proposers shall provide an organizational chart with names & professions, for all shareholders, directors, and officers if the entity is a corporation; and for all partners and others who have an ownership interest if the bidder is not a corporation.

4. Per the Medical Practices Act (Business and Professions Code § 2000 et seq.), your organization must fall into one of the following categories to submit a bid:

Category Who Qualifies Required Submission Medical Corporation

A corporation organized under California medical corporation law

Copies of valid physician licenses (issued by the Medical Board or Osteopathic Medical Board) for each staff physician relevant to the corporation’s status

Physician-Owned Entity

Entity solely owned by physicians, or an individual physician, licensed and in good standing with the Medical Board of California (or Osteopathic Medical Board).

Individual physician: copy of valid license for each individuals’ license.

Entity solely owned by physicians:

copies of licenses for all owners.

Business & Professional Code § 2401 Entity

An entity meeting the specific definition in that section.

Indicate which type of entity applies, plus proof of meeting the requirements of that subsection.

Public Hospital A hospital owned and operated by a state or local public entity

Proof of public entity status (state or local)

Other Compliant Entity

Any other structure that complies with the Medical Practice Act

Signed declaration describing how the entity complies with the Medical Practice Act

The Proposer must Proposers must certify, in a statement in the cover letter, that firm falls into one or more of the categories detailed in the table above. Failure to do so may disqualify the firm.

http://kepler.sos.ca.gov/

B. References:

Proposer must submit applicable references:

Element Requirement Quantity Three (3) letters of reference from Proposer’s client Service Type Customers for whom the Proposer has provided services of the same nature and type as those outlined in this solicitation

Timeframe Services provided in the past three (3) years, from the date of this solicitation.

Governmental Reference At least one reference, must be from a governmental agency.

DSH Contract Manager If the Proposer has provided services to the DSH during this timeframe, one of the references MUST be from a DSH contract manager.

Detail Letter must contain sufficient information (i.e.

specific times and locations where the Proposer was observed while providing services) in order to verify the Proposer’s experience.

Author For letter not composed by the DSH contract manager, each letter must be composed by someone who had direct experience with the provision of the services outlined in the reference letter.

Must Address (a) The Proposer’s demonstrated ability to perform the contracted services in accordance with the scope of work, service requirements, performance standards, and other contractual obligations.

Must Address (b) The client’s overall assessment of the Proposer’s performance, including the quality and reliability of the services provided.

Proof of Authorship (c) Provide name, address, title, company name, company website, phone number of point of contact, and email of the qualifying employer/company.

Proof of Authorship (d) Be submitted on the employer/company’s official letterhead.

Proof of Authorship (e) Contain an original signature by the completing party.

DSH reserves the right to utilize these letters in determining whether a Proposer is a responsible supplier, in addition to verifying the Proposer’s experience. DSH also reserves the right to contact provided references at any time until the Notice of Intent to Award date listed on the Key Action Dates table.

C. Agreement to Sign:

The Proposer shall certify that, providing a statement in the bidders cover letter, if awarded an agreement, shall sign and return two (2) originals of the Standard Agreement signature pages (Std.

213), to be received by the DSH no later than seven (7) calendar days from the date the DSH e-mails the agreement to the email address provided by Proposer on the Minimum Qualifications Response Form (Attachment 3). This requirement shall be ten (10) calendar days if the DSH elects to mail the agreement. The DSH reserves the right, at its sole discretion, to require documentation to be submitted in addition to the Std. 213. If the DSH exercises that right, the contractor must submit all required documentation within the timeframes noted here.

The Proposer shall further certify that they understand the insurance requirements in Attachment 10, Sample Agreement, Exhibit F, Insurance Requirements, and if awarded an agreement, shall provide the DSH with all required insurance documents as may be applicable, in a timely manner.

The DSH reserves the right, at its sole discretion, to cancel a proposed award to a Proposer who does not submit the required documentation described herein. Should the DSH cancel a proposed award for this reason, the DSH reserves the right, at its sole discretion, to award the contract to the next lowest, responsive and responsible Proposer.

D. Background and Structure

1. Proposer must submit an overview of the firm’s history and ownership.

2. Proposer must submit a current organizational chart for your company. The chart should highlight the leadership team, key personnel assigned to this project, and the reporting structures between management, technical leads, and daily operational staff.

E. Experience:

1. Proposers must provide detailed information about the firm’s background, structure, experience and technical expertise as part of the Technical Proposal. Requirements and details are specified in Attachment 17, Technical Proposal Coversheet.

2. Proposers must submit individual resumes for all Key Personnel: refers to specific individuals named in the contract whose qualifications, expertise, or involvement were material to the contract award and are proposed to work on this project, showing their qualifications for the work they shall perform. Resumes provided will be included as an attachment in the executed contract.

3. Proposers must submit evidence of at least three (3) years of experience and expertise in the following areas. The Proposer experience submission must be contained within a maximum limit of twelve (12) pages. Material exceeding this page limit may be excluded from evaluation.

A. HCPN

i. Provider Network Experience

The Proposer shall demonstrate a minimum of three (3) years of experience developing, managing, credentialing, and maintaining a statewide or multi-regional Health Care

Provider Network that includes medical, behavioral health, specialty, hospital, and ancillary providers.

ii. Credentialing Compliance The Proposer shall demonstrate experience performing credentialing and recredentialing in accordance with National Committee for Quality Assurance (NCQA), Joint Commission, and applicable State of California licensure requirements, including maintaining complete credentialing files and performing background checks.

iii. Network Adequacy Management The Proposer shall demonstrate experience meeting geographic access standards, including urban, rural, and remote provider coverage, and shall show the ability to identify, report, and resolve network gaps through corrective action plans.

iv. Provider Contracting Authority The Proposer shall demonstrate the legal authority and operational capability to negotiate provider contracts, including rate setting under Welfare & Institutions Code (WIC) § 4101.5, and to manage Letter of Agreements (LOAs).

v. Provider Directory Capability The Proposer shall demonstrate the ability to maintain a provider directory with 98% accuracy rate. Accuracy shall be measured across all data searchable data fields, including, but not limited to service delivery indicators (i.e. type of specialty, location/geography, mileage radius, and contracted rated etc.

B. TPA

i. Claims Administration Experience

The Proposer shall demonstrate a minimum of three (3) years of experience providing Third-Party Administrator (TPA) services for medical claims, including claims intake, adjudication, payment file preparation, appeals, Medicare claim processing requirement and runout processing.

ii. Centers for Medicare and Medicaid Services (CMS) Claim Processing The Prosper shall demonstrate understanding, application and process claims according to CMS guidelines.

iii. Financial Information System for California (FI$Cal)/State Controller’s Office (SCO) Integration Capability The Proposer shall demonstrate experience integrating claims systems with FI$Cal, SCO payment processes, and State accounting workflows, including daily batch uploads and audit file generation.

iv. Automated Claims System The Proposer shall demonstrate ownership or operation of a fully automated claims processing system capable of:

• Electronic and paper claim intake

• Pre and post-payment auditing

• Duplicate claim detection. This includes the ability to identify if more than one distinct provider submits a claim for the same type of service and date of service.

• Standardized medical coding systems integration:

1) International Classification of Diseases, 10th Revision (ICD-10)

2) Current Procedural Terminology (CPT)

3) Healthcare Common Procedure Coding System (HCPCS)

4) National Correct Coding Initiative (NCCI)

5) Medically Unlikely Edits (MUE)

• CMS compliance

• Daily claims file transmission

• Provider and DSH web portal access

v. Claims Timeliness & Accuracy Performance

The Proposer shall demonstrate the ability to meet or exceed:

• 98% clean claims processed within 20 calendar days from submission date

• 98% non-clean claims adjudicated within 20 calendar days from submission date

• 98% adjudication accuracy

• 98% of disputes or denied claims are sent notification/letters within 25 calendar days from submission date

• 99% payment electronic file accuracy

vi. Appeals & Overpayment Recovery Experience

The Proposer shall demonstrate experience managing informal and formal appeals, issuing dispute letters, performing overpayment recovery, and complying with Internal Revenue Services (IRS) 1099 reporting requirements.

vii. Security & Privacy Compliance The Proposer shall demonstrate compliance with HIPAA, Confidentiality of Medical Information Act (CMIA), State cybersecurity standards, and secure handling of Personal Health Information (PHI)/Personal Identifiable Information (PII), including breach notification within 24 hours.

C. PA/UM

i. Utilization Management Experience The Proposer shall demonstrate a minimum of three (3) years of experience providing PA/UM services including prior authorization, medical necessity review, inpatient concurrent review, inpatient retrospective review, and care coordination.

ii. Clinical Review Capability The Proposer shall demonstrate the ability to perform medical necessity determinations using evidence-based clinical guidelines, CMS standards, and State regulatory requirements.

iii. Authorization Timeliness Performance The Proposer shall demonstrate the ability to meet or exceed:

• Urgent authorization decisions within 2 business days

• Routine authorization decisions within 5 business days

• 95% completion of medical necessity reviews within required timeframe

iv. Integration with Claims & Provider Network

The Proposer shall demonstrate experience integrating PA/UM systems with claims processing and provider network operations, including prior authorization validation at the time of claims adjudication.

v. UM Reporting Capability The Proposer shall demonstrate the ability to produce PA/UM reports including and real-time reporting dashboard:

• Tracks active, pending, approved and denied prior authorization

• Authorization volumes

• Authorization turn-around times

• Approval or denial rates by DSH hospital location, type of specialty and service type

• Denial reasons

• Inpatient Concurrent review summaries and outcomes

• Retrospective review outcomes

• Care coordination metrics

• Reports based on DSH needs

vi. Compliance & Accreditation

The Proposer shall demonstrate compliance with:

• National Committee for Quality Assurance (NCQA) PA/UM standards

• The Joint Commission requirements

• HIPAA and CMIA privacy requirements

• State and federal medical necessity regulations

III. PROPOSAL REQUIREMENTS AND INFORMATION

A. Key Action Dates:

Date Time*

RFP available to prospective Proposers 11/02/2026 --- Deadline for Submission of Proposer’s Written Questions 11/09/2026 12:00 PM

Responses to Proposer’s Written Questions 11/16/2026 4:00 PM Final Date for Proposal Submission 12/07/2026 4:00 PM Anticipated Evaluations of Submitted Proposals 12/08/2026 - 12/11/2026 --- Anticipated Possible Interviews 1/4/2027 - 1/22/2027 TBD Anticipated Notice of Intent to Award Posted 1/28/2027 5:00 PM Anticipated Start Date March 1, 2027 ---

* All times listed in the Key Action Dates table are Pacific Standard Time

B. Proposer’s Questions:

This section establishes the process by which prospective bidder may seek clarification regarding this RFP.

This process is designed to ensure fairness, transparency, and equal access to information for all bidders.

1. All questions regarding this RFP must be submitted in writing via email to SacContract@dsh.ca.gov with “RFP 26-70009-000, Written Question(s)” in the Subject Line.

2. No other DSH employee, contractor, or representative is authorized to answer questions regarding this

RFP.

3. DSH will consolidate all timely-submitted questions and issue responses to all prospective bidder via addendum to Cal e-Procure (www.caleprocure.ca.gov).

4. Questions must be submitted no later than November 9, 2026 at 12:00PM. Question received after this deadline will not be considered, except at the sole discretion of DSH where the State determines an answer is necessary to the integrity of the solicitation.

5. Questions must:

i. Reference the specific RFP section, page number, and paragraph to which the question pertains.

ii. Be submitted in a single consolidated document per bidder. Multiple emails/submission from the same email address or party may not be considered.

6. Bidder shall not contact any DSH employee or evaluation panel member directly, by phone, email, or in person regarding this RFP outside of this formal question process. Any such contact may result in disqualification of the bidder’s proposal.

7. DSH will consolidate all timely-submitted questions and issue responses to all prospective bidder via addendum to Cal e-Procure (www.caleprocure.ca.gov).

8. Questions and responses will be de-identified; DSH will not attribute a question to the submitting bidder.

9. Reponses will be published in the order and manner the questions were received.

10. DSH reserves the right to:

i. Decline to answer a question that seeks a competitive advantage, requests DSH to interprets a bidder’s own proposal strategy, or is otherwise outside the scope of clarifying the RFP.

ii. Combine, rephrase, or summarize substantially similar questions.

iii. Issue an addendum in lieu of, or in addition to, a Q&A response where the RFP itself requires clarification or modification.

mailto:SacContract@dsh.ca.gov http://www.caleprocure.ca.gov/

11. Only written responses issued through this process constitute an authorized statement of DSH’s position. Any verbal, informal, or unofficial communication is not binding on DSH and may not be relied upon by any bidder in preparing its proposal.

12. Bidders who fail to report a known or suspected problem with the RFP or fail to seek clarification and/or correction of the RFP, submit a proposal at their own risk.

C. Addenda:

Any change, clarification, correction, or modification to this RFP will be issued only by written Addendum, number sequentially and posted to Cal e-Procure (www.caleprocure.ca.gov.) Each Addendum becomes part of, and takes precedence over, the original RFP to the extent of any conflict. It is the sole responsibility of each bidder to monitor the Cal e-Procure (www.caleprocure.ca.gov), for Addenda. DSH is not obligated to separately notify bidders of postings.

D. Submission of Proposals:

1. Electronic Submission:

a) Electronic submittals shall be uploaded to the DSH Share Point site:

i. At least 24 - 48 hours prior to submittal, to request access, please send an email inquiry to bidsubmittal@dsh.ca.gov (and CC Nathan.Alteza@dsh.ca.gov and Paul.Carrillo@dsh.ca.gov) so that the assigned administrator can provide access to upload documents.

ii. Please include the email address of the individual who will be submitting the documents. This email address will be the only address that will be able to access the DSH Share Point.

iii. Once the administrator receives the inquiry, the administrator will grant access, and a link will be provided for document submittal.

iv. All electronic submittals shall be in one continuous PDF with all documents in sequential order according to the Submission Checklist.

b) Please include the email address of the individual who will be submitting the documents.

This email address will be the only address that will be able to access the DSH Share Point.

c) Once the administrator receives the inquiry, the administrator will grant access, and a link will be provided for document submittal.

d) All electronic submittals shall be in one continuous PDF with all documents in sequential order according to the Submission Checklist.

e) Late bid submissions will not be considered.

mailto:bidsubmittal@dsh.ca.gov mailto:Nathan.Alteza@dsh.ca.gov mailto:Paul.Carrillo@dsh.ca.gov

2. Signature Requirements:

a) All documents requiring a signature must bear an original signature of a person authorized to bind the proposing firm.

b) An individual who is authorized to bind the Proposer contractually shall sign the Proposer Certification Sheet. The signature shall indicate the title or position that the individual holds in the firm. An unsigned proposal may be rejected.

3. General Contents:

a) All proposals shall include all of the documents identified in Section VI, Required

Attachments, Attachment 1, Proposal Submission Checklist (Page 28).

b) Proposals should provide straightforward and concise descriptions of the Proposer's ability to satisfy the requirements of this RFP. The proposal must be complete and accurate.

Omissions, inaccuracies or misstatements will be sufficient cause for rejection of a proposal.

c) Proposals must be submitted for the performance of all the services described herein. Any deviation from the work specifications will not be considered and shall cause a proposal to be rejected.

d) A proposal shall be rejected if it is conditional or incomplete, or if it contains any alterations of form or other irregularities of any kind. The state may reject any or all proposals and may waive an immaterial deviation in a proposal. The state’s waiver of an immaterial defect shall in no way modify the RFP document or excuse the Proposer from full compliance with all requirements if awarded the agreement.

e) Before submitting a response to this solicitation, Proposers should review, correct all errors, and confirm compliance with the RFP requirements.

4. General Considerations:

a) No oral understanding or agreement shall be binding on either party.

b) Costs for developing proposals in anticipation of award of the agreement are entirely the responsibilities of the Proposer and shall not be charged to the State of California.

5. Withdrawing and Resubmitting:

c) Proposers may modify a proposal, after its submission, by withdrawing their original proposal package and resubmitting a new proposal package prior to the proposal submission deadline. Proposers modifications offered in any other manner, verbal or written, will not be considered.

d) Proposers may withdraw their proposal by submitting a written withdrawal request to the DSH – Contracts Office at the address below, signed by the Proposer or an authorized agent. A Proposer may thereafter submit a new proposal package prior to the proposal submission deadline. Proposals may not be withdrawn without cause, subsequent to the proposal submission deadline. The DSH Contracts Office is located at:

Procurement and Contract Services Section

1215 O Street, MS-1 Sacramento, CA 95814

6. Modification and Rejections:

a) The DSH may modify the RFP, prior to the solicitation due date and time, by the issuance of an addendum to all parties through Cal eProcure.

b) The DSH reserves the right to reject all proposals. The DSH is not required to award an agreement.

c) The DSH does not accept alternate contract language from a prospective contractor, unless offered through the Question and Answer period. A proposal with alternate contract language will be considered a counter proposal and will be rejected. The State’s General Terms and Conditions (GTC) are not negotiable. Proposers are hereby advised that proposals of alternate contract language or attempts to negotiate the state’s Terms and Conditions after the selection of a proposed awardee shall be considered a counter proposal for the purposes of this solicitation. In such a situation, the DSH shall notify the proposed awardee that they must accept the state’s language and terms as offered or be disqualified from being awarded a contract. Should a contractor fail to accept the language and terms offered, the DSH shall disqualify that vendor and award the contract to the next lowest Proposer and issue a revised Letter of Intent if applicable.

7. Cost Proposal Requirements

Refer to Exhibit A - Scope of Work (See Attachment 14) for details on tasks, deliverables, and milestones.

Use Attachment 5, Proposer’s Rate Sheet, to draft and submit your Cost Proposal.

IV. PROPOSAL EVALUATION AND AWARD

A. Review of Proposal Requirements:

1. Phase 1 – Administrative Evaluation

The DSH will conduct an administrative evaluation in accordance with the RFP requirements to determine a Proposer’s responsiveness and responsibility. Each proposal will be checked for completeness and/or absence of all required information and to ensure that the Proposer meets the Minimum Qualifications in conformance with the submission requirements. During evaluation period, if an item is unclear, or needs for clarification, Proposers may be requested to provide additional documentation for clarification. Proposals that contain false or misleading statements, or which provide references which do not support an attribute or condition claimed by the Proposer, may be rejected.

a) Definitions of Responsive and Responsible Proposers

A responsive Proposer is one who submits a proposal that meets all of the submission requirements and minimum qualification requirements stated in the RFP.

A responsible supplier is one that is trustworthy and possesses the necessary quality, fitness and capacity to satisfactorily perform the proposed work. Proposers who are determined to be not responsible or who submit non-responsive proposals shall have the proposals rejected.

b) Determining Responsive Proposers

i. Each proposal will first be reviewed to determine whether the Proposer is responsive.

This includes but is not limited to, ensuring that the proposal was received by the date and time specified; contains all the required documents; meets the minimum qualifications; meets the format requirements specified; and that there is no material deviation from the terms and conditions of the proposed contract.

ii. A non-responsive proposal is one that does not meet the requirements stated in the RFP, fails to provide all required documents/ attachments, or proposals that deviate substantially from requirements. A proposal that changes the terms and conditions of the RFP or the contract provisions will be considered a counterproposal and will be rejected as non-responsive.

c) Determining Responsible Proposers

i. Responsive proposals shall be considered evidence of the Proposer’s responsibility.

The DSH reserves the right to reevaluate a Proposer’s responsibility prior to award and is in no way limited to submitted proposal packages in making a determination as to a Proposer’s responsibility. In determining whether a Proposer is responsible, the DSH may require Proposers to submit evidence of their qualifications at such times, and under such conditions, as it may require.

2. Phase 2 – Technical Proposal Evaluation

The DSH will conduct an evaluation of each proposal not rejected in Phase 1 by an Evaluation Committee consisting of DSH employees.

a) Rating Criterion Guidelines

i. After studying the RFP, each panel member will review each proposal and assign points for each criterion discussed below. The reviewers will then meet either in person or by teleconference to discuss in detail the strengths, weaknesses, and ratings of each proposal. After this discussion, reviewers will reach a single consensus score for each of the proposals submitted.

ii. The criteria in the Sample Score Sheet of this RFP will be used by reviewers evaluating proposals submitted in response to this RFP. In addition to what is stated below, in scoring the proposal, each criterion will be rated on the basis of completeness, responsiveness, clarity of response, and weighed in the context of its contribution to the end product.

3. Phase 3 – Interviews

Proposers with the three highest scored proposals will be invited to interviews, to be scheduled January 4-22, 2027.

B. False Statements Disclaimer:

1. Proposals that contain false or misleading statements, or which provide references which do not support an attribute or condition claimed by the Proposer, may be rejected.

C. Intention to Award:

1. The DSH intends, if an award is made, to award to a single service provider based upon the highest-scored responsible Proposer in accordance with Section V, Preference and Incentive Programs. Proposers should submit proposals accordingly.

D. Breaking Tie Proposals:

1. In accordance with Government Code section 14838, subdivision (f), in the event of a precise tie between a Small Business or Microbusiness, and a Disabled Veteran-owned Small Business or Microbusiness, the Disabled Veteran-owned Small Business or Microbusiness shall be considered the lower Proposer for ranking purposes.

2. In accordance with the California Code of Regulations, title 2, section 1896.6, if, after the application of the Small Business preference, the proposal of the Small Business is equal to the lowest priced proposal from a responsible non-Small Business, the Small Business shall be considered the lower Proposer for ranking purposes.

E. Award and Protest:

1. Notice of the proposed award shall be posted in a public place in the office of the awarding agency at least five (5) working days prior to awarding the agreement.

2. If any Proposer, prior to the award of agreement, files a written protest with the DGS) and the

DSH, including the grounds that the (protesting) Proposer is highest-scored responsible Proposer, the agreement shall not be awarded until either the protest has been withdrawn or the DGS has decided the matter.

3. Within five (5) days after filing the initial protest, the protesting Proposer shall file with the DGS and the DSH a detailed written statement specifying the grounds for the protest. It is suggested that any protest be submitted by certified or registered mail.

4. Submissions shall be made to:

Department of General Services Office of Legal Services

Attention: Protest Coordinator 707 Third Street, 7th Floor, Suite 7-330

West Sacramento, CA 95605

AND

ATTN: Procurement and Contract Services Section 1215 O Street, MS-1

Sacramento, CA 95814

5. Protests may be sent by regular mail, facsimile, courier or personal delivery though it is suggested that submissions are made by certified or registered mail. Protestants should include their fax numbers, where applicable.

F. Disposition of Proposals:

1. Upon proposal opening, all documents submitted in response to this RFP will become the property of the State of California and will be regarded as public records under the California Public Records Act (Government Code section 6250, et seq.) and subject to review by the public.