CalMaCCS_Request_For_Information.docx

CalMaCCs

25MC-RFI01

Gavin Newsom, Governor State of California Health and Human Services Agency

DEPARTMENT OF MANAGED HEALTH CARE

980 9th Street, Suite 500 Sacramento, CA 95814 Phone: 916-324-8176 | Fax: 916-255-5241 www.HealthHelp.ca.gov

DEPARTMENT OF MANAGED HEALTH CARE (DMHC)

REQUEST FOR INFORMATION (RFI)

25MC-RFI01

California Managed Care Complaint System (CalMaCCS) Date: October 28, 2025 RESPONSE DUE DATE: November 17, 2025 @ 5:00 p.m. Pacific Time (PT) The DMHC invites interested parties to provide information pertaining to in-production solutions developed by the respondent and deployed within the Salesforce (SFDC) or Microsoft Dynamics 365 (D365) / Power Pages modern cloud platforms. The DMHC will utilize responses to select solutions for demonstration.

For more information about the DMHC, please refer to the Internet Web site at https://dmhc.ca.gov.

Please read this document carefully and thoroughly. All interested parties (Participants) shall submit and present a comprehensive response to the RFI requirements identified herein to provide information to assist the DMHC to determine which in-production solutions will be selected for demonstration based on best-fit to meet project objectives, platform capabilities and functional requirements as detailed within this RFI document.

Your response to this RFI must be received by 5:00 p.m. (PT) on Monday, November 17, 2025 Responses received after the submission deadline will not be accepted. The DMHC shall not be responsible for any delays, missed deliveries or transmission errors.

Responses to this RFI must be submitted to the contact outlined in Section 7, RFI Response Requirements.

SECTION 1: REQUEST FOR INFORMATION CONTENT REQUIREMENTS

Introduction

The DMHC’s Help Center and Office of Technology and Innovation (OTI) have requested this RFI to select solutions for demonstration that showcase desired case management capabilities relevant to the DMHC’s consolidated complaint system modernization project known as CalMaCCS - California Managed Care Complaint System, as described in this RFI and its attachments.

The CalMaCCS project will consolidate the DMHC’s disparate Consumer Complaint and Provider Complaint Systems into a single low-code platform for enterprise case management, with the goals of increasing service quality to the public, increasing program operational efficiency, and significantly reducing the time required for OTI to make changes in the system that meet changing program requirements (e.g. low-code capability).

The demonstrated solutions must meet the requirements of this RFI and be delivered within either the Salesforce (SFDC) or Microsoft Dynamics 365 (D365) modern case management cloud platforms and deployed within a Software as a Service (SaaS) model.

1. PURPOSE

The purpose of this RFI is to solicit information and leverage demonstrations of existing in-production case management solutions, deployed within a low-code/configurable SaaS model in either the Salesforce or Microsoft Dynamics 365 platforms.

a) Select the preferred case management platform to be procured for the CalMaCCS project, as part of the DMHC’s ongoing Alternatives Analysis effort.

b) Validate hourly rate and project cost assumptions for project consultants, by project role (Rough Order of Magnitude estimate of hourly consulting rates, by resource classification).

2. RFI DISCLAIMER

A. This RFI is issued for informational and planning purposes only and does not constitute a solicitation. A response to this RFI is not an offer and cannot be accepted by the DMHC to form a binding contract.

B. Respondents are solely responsible for all expenses associated with responding to this RFI. The DMHC is not liable for any costs incurred by Respondent in the preparation, demonstration, and/or evaluation of responses submitted.

C. If applicable, samples of items required must be submitted to the location and by the date and time specified. Unless otherwise specified, samples shall be submitted at no expense to the DMHC.

D. Participants are advised that the responses to this RFI are the property of the State and may be subject to disclosure under the California Public Records Act (Government Code Section 6250 et seq.).

E. Please do not include any proprietary information in response to this RFI.

F. Responding to this RFI creates no obligation on the part of any Respondent to the DMHC. Conversely, issuing this RFI and considering the responses creates no obligation on the part of the DMHC to any Respondent.

G. The DMHC asks willing Respondents to share non-binding budgetary pricing information for each referenced system where requested. Pricing is only for planning and market research purposes. Any pricing provided in response to this RFI will not be considered a proposal/bid on the part of the Respondent.

3. CONTACT INFORMATION

Respondents must submit their response via email to the DMHC contact listed below:

Respondents are directed to submit questions or clarification inquiries in writing in accordance with the instructions detailed in RFI Section 5, Question Submission and Deadline. No other representative of the DMHC is authorized to communicate with Respondents with respect to this RFI.

4. RFI KEY ACTION DATES AND TIMES

5. QUESTION SUBMISSION AND DEADLINE

RFI Response Question(s) Submission: Questions may be submitted via email, and should include the following:

· Email Subject Line: RFI 25MC-RFI01 CalMaCCS – California Managed Care Complaint System Project

· Respondent’s company name, contact person, telephone number, and email address.

· A description of the subject or issue in question, or discrepancy found in the RFI.

· RFI section, page number, and/or other information useful in identifying the specific problem or issue in question.

· The Respondent’s question(s).

RFI Response Submission Deadline:

· All questions and any clarifications must be requested in writing via email and directed to Brian.Levin@DMHC.Ca.Gov as identified in Section 3 and 7 of this RFI, no later than Monday, November 10, 2025, at 5 PM Pacific Time (PT).

· The DMHC will respond to questions via a Q&A document which will be published and made available for viewing in the California State Contracts Register (CSCR) Portal on Thursday, November 13, 2025 at 12 PM Pacific Time (PT).

· To locate and review the Q&A Document on the CSCR:

· Navigate to: https://caleprocure.ca.gov/pages/Events-BS3/event-search.aspx

· Enter “CalMaCCS – California Managed Care Complaint System” in the search box titled “Event Name” and submit.

6. CANCELLATION OF RFI OR POSTPONEMENT OF RFI CLOSING

The DMHC reserves the right to cancel this RFI at any time. The DMHC may change the date and time for submitting responses prior to the date and time established for submittal.

7. RFI RESPONSE REQUIREMENTS AND INSTRUCTIONS

The organization must submit one copy of its RFI response to the DMHC in an electronic format to the email address below.

Department Contact:

Brian Levin Department of Managed Health Care Procurement Unit Brian.Levin@dmhc.ca.gov A. Responses shall address the questions pertaining to the Statement of Need, information requests and future need as described throughout the RFI and in the order presented identifying RFI questions and sections by number (if applicable). Responses need to be specific, detailed, and straight forward using clear, concise, easily understood language and speaks to the Respondent’s approach, commitment and ability to perform the services described in the RFI.

Respondents answering the RFI questions shall examine the entire RFI document including the instructions, background information, specifications, applicable standards, appendix documents, and regulations. Responses should be as concise as possible and focus on similar experience your company has previously provided. Respondents may include active, informative, and up-to-date web links in their RFI response, but web content should not substitute full and complete responses to the questionnaire.

C. Responses to this RFI are due by the date and time stated in Section 4, RFI Key Action Dates and Times. Responses should be submitted via e-mail, in the required format, and to the State’s contact identified in Section 5, Question Submission and Deadline.

D. Each Respondent’s RFI response email shall contain one (1) electronic copy of DMHC CalMaCCS RFI Response Template with the following tabs completed:

· Tab 1-Instructions

· Tab 2-Service & Management Questions

· Tab 3-Core Case Management Capabilities

· Tab 4-Specialized Case Management Capabilities

· Tab 5-Standard Case Workflow

· Tab 6-Specialized Case Workflow

· Tab 7-Rough Order of Magnitude (ROM) Estimates Respondents shall reference Tab 1 for completion instructions.

E. The DMHC may contact Respondents to clarify RFI responses, as needed.

8. PARTICIPATION

A. To the extent it is applicable, this RFI is open to any vendor partner who believes they have an in-production solution, deployed within the Salesforce or Microsoft Dynamics 365 / Power Pages cloud platforms, and deployed in a Software as a Service model, where their responses would add to the DMHC’s understanding of required case management platform capability.

B. The DMHC is interested in learning the reason(s) a vendor chooses not to respond to this RFI. If applicable, please submit an email to: Brian.Levin@dmhc.ca.gov by the response due date and include in the subject line of the email: Declining to Respond to 25MC-RFI01 CalMaCCS California Managed Care Complaint System in addition to the following in the email body:

i. RESPONDENT’s NAME has declined to respond 25MC-RFI01 for the following reason(s):

· Reason A

· Reason B, etc.

ii. Name of person sending declination:

· Title:

· Legal Business Name:

· Address:

· Phone:

9. LIMITED USE OF RESPONSES

A. Responses to this RFI will not be used in the evaluation of future bids or proposals. This RFI will not be used to pre-qualify a Respondent’s system for a future procurement, disqualify any company from responding to a future procurement and selection for a demonstration has no bearing on or connection to any future procurement.

B. Responses are strictly voluntary and failure to provide a response will not affect a company’s standing with the DMHC or its ability to bid or propose on future procurements. By submitting a response to this RFI a Respondent is implicitly agreeing with these conditions.

10. DEMONSTRATIONS

A. At the discretion of the DMHC, Respondents to this RFI may be selected to conduct software demonstrations of their proposed in-production case management solution. Demonstrations will be scheduled according to the timeline in Section 4 (RFI Key Action Dates) and meeting invitations, demonstration scenarios, and/or questions will be provided to demonstration participants in advance. The State will not be reimbursing for any travel as part of this RFI, including travel for demonstrations.

B. Any demonstrations and/or interviews conducted as part of this process are undertaken by a Respondent solely to assist the DMHC in gaining a better understanding of the case management platform capabilities of the solution being demonstrated. Selection of a specific Respondent for inclusion in a demonstration and interview does not guarantee that it or its product/solution will be specified in a future solicitation. Any limitations or conditions related to performing demonstrations should be noted in the response.

11. NEWS RELEASE AND SOCIAL MEDIA

Organizations must obtain prior written approval from the DMHC before issuing any news release, statement to the news media or social media post(s) pertaining to this RFI.

SECTION 2: SCOPE OF NEED

Background

The DMHC’s mission is to ensure health plan members have access to equitable, high-quality, timely, and affordable health care within a stable health care delivery system.

The DMHC Help Center is the first point of contact for consumers and providers with complaints and concerns related to health care and health care service plans licensed by the DMHC in accordance with the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act). The DMHC regulates approximately 97 percent of state regulated commercial and public health plan enrollment, which includes approximately 30 million Californians.

The DMHC’s Help Center (HC) educates consumers and providers about their health care rights, resolves member and provider complaints against health plans, helps health plan members (consumers) understand their coverage and assists members in getting timely access to appropriate health care services. To perform these services, the HC resolves cases in three distinct case domains:

· Consumer Complaints: These include complaints from health plan members (consumers) against health plans concerning access to care, benefits/coverage, claims/financial, enrollment, coordination of benefits, health plan customer service, and provider customer service. Consumer case submissions are conveyed via web form-to-email, mail or fax. Cases are created manually in the existing legacy system by case analysts and include any submitted attachments.

· Independent Medical Reviews: These include cases where a health plan denies, modifies, or delays a member’s request for services as not medically necessary or as experimental or investigational.

· Provider Complaints: These include one or more claims payment disputes from providers against health plans.

Consumers or providers may submit their complaint electronically or on paper through various methods (online complaint portal, email, mail, and fax). The complaints are then manually entered into the applicable complaint system, triaged to the appropriate program areas, and analyzed by case analysts. The analysis often requires communication with members, providers, or health plans for additional information.

In addition, the HC receives correspondence which may include complaint/ Independent Medical Review (IMR) form submissions from members and providers, medical records, medical claims, billing statements. In addition, the HC receives status calls (for members and providers to check on the status of their case), and email inquiries related to open complaints.

The DMHC currently operates two disparate case management systems that are in need of consolidation and modernization: the Provider Complaint System which manages provider complaints, and the Spotlight system that manages consumer complaints and IMRs.

Both applications are built on archaic, legacy technology frameworks and infrastructure that require significant and continuous effort to enhance and maintain. Further, the DMHC’s case management systems were not architected to handle projected future caseloads, and cannot be easily modified to support new case types, information and communication and documents. In summary, these systems also do not allow for timely implementation of system efficiencies to address the increasing workloads.

1. STATEMENT OF NEED

The DMHC seeks to implement a modern Case Management solution within a low code / configurable platform that supports operational efficiencies and business process re-engineering for program staff who will use the system on a daily basis, and the information technology staff that maintain, operate, and enhance the solution.

The DMHC is interested in solutions that demonstrate an ability to meet the following areas of need:

A. Help Center Program Needs

· A consolidated case management solution that can intuitively and consistently manage both Provider and Consumer complaint functions, with minimal user engagement. Each complaint domain has its own distinct set of case types, case type workflows, case type business rules, and case domain users.

· The ability to create a Bulk-Claim Parent Case (and link associated documents), then divide the documents amongst multiple Child Sub-cases that can each be assigned to a unique case manager / case analyst.

· Reducing complaint processing time, leading to faster resolution of user complaints related to health care services, financial responsibilities, and health care education by:

· Reducing average case processing time

· Automating case creation through implementation of an external user portal

· Enabling external users to interact with their case via a portal to check case status and communicate with case analysts

· Providing modern, low-code configurable automation that will quickly streamline the overall case management function and support process re-engineering at the speed of business need.

· Provide consumers, providers, and health plans with real-time case tracking for status, communications, and notifications to improve operational efficiencies by reducing contacts from members and providers requesting case status information.

· Provide guided data entry and data validation to improve quality for Help Center real-time data trend analysis and response activities. .

· Provide workflow automation and workload management that enables case analysts to process more complaints and reduce the need for manual processes.

· Provide more efficient complaint resolution, enhanced communication and transparent resolution process by enabling rapid low-code configuration of functional capability.

· Comprehensive analytics to identify trends and recurring issues, detailed reports for internal DMHC reviews, audits, and compliance documentation.

· Allow major role players in various complaint processes to interact with DMHC through the platform, including but not limited to:

· Anonymous Users

· Consumers

· DMHC Staff

· IMR / 3rd Party Medical Review Organizations

· Health Plans (and their delegate Provider Groups)

· Providers (and their delegate Billing Managers)

B. Office of Technology and Innovation Needs

· Enable IT staff to manage and modify a solution without the need for manual coding by leveraging low-code configuration capabilities to increase developer throughput by up to 500% and enable IT to operate closer to the speed of business need, rather than with a need for business speed.

· Implement a platform that ensures information security risks are managed / mitigated through platform governance and security controls.

· Minimize the time required to manage underlying infrastructure, ensure it is up to date for all web and database services as well as the low-code platform itself.

· Minimize disruptions to applications developed on the low-code platform when updates to the infrastructure take place.

· Streamline backup and recovery operations of the application and data captured by the application.

· Achieve operational efficiencies provided by a low-code platform that pertain to moving applications between environments (e.g. from development to QA to production), and how problematic changes are rolled back.

· Leverage a modern case management platform solution, powered by industry-leading low-code technology, to significantly reduce the time it takes to implement new features and functionality, as compared to more traditional software development efforts that may have preceded low-code adoption.

· Leverage a modern case management platform, deployed within a SaaS model, to enable dynamic scaling of solution architectures to meet increasing case volumes, users and the resulting infrastructure needs.

· Understand best practices to manage and control variable cost components of the solution’s overall cost / cost model / ongoing support costs.

· Enable a solution architecture that allows simplified integration of solution data with DMHC’s existing Data Warehouse / Data Lake / Data Mart environments (Azure) by using bulk-data APIs to transport data.

C. Current State/Environment The DMHC currently operates two separate complaint case management systems to manage and process health plan member complaints and health care provider complaints, both filed against managed health care plans.

The Provider Complaint System (PCS) was implemented in 2015 as a custom software application developed by the DMHC within the Microsoft .NET framework. This custom framework has led to increased challenges when trying to implement any major upgrades or modernization of the PCS. The current PCS cannot easily scale to process all provider complaints, and the underlying technology is outdated and is in need of modernization to both the infrastructure and software’s capacity to streamline and automate workflows. Implementing functionality within the PCS custom .NET application architecture requires custom .NET coding and large complex projects which makes it difficult for the DMHC’s OTI staff to keep current with changing health industry requirements. This results in the OTI staff having to operate with “need for speed” to meet Department mandates, which is not a sustainable long-term solution.

The DMHC’s current consumer complaint System (Spotlight) was implemented in approximately 2001. At that time, Spotlight was implemented within a leading industry solution (Clarify). In 2017, DMHC chose to implement a proprietary sustaining technology (Dovetail Software) that provides a more modern web-interface to legacy Clarify, while retaining the 24-year-old legacy Clarify’s underlying infrastructure. The DMHC began the implementation of the current proprietary technology in May of 2017, and it was rolled out to users in October 2018. Implementing functionality within the current Spotlight framework requires time-consuming custom .NET coding, within the constraints of the framework, which makes it difficult for the DMHC’s OTI staff to provide custom functionality and expediently keep up with the changing health industry requirements.

Consumers or Providers may also submit their complaint electronically or on paper through various other methods (online complaint portal, email, mail and fax). The complaints are then manually entered into the complaint systems, triaged to the appropriate program areas and analyzed by case analysts. The analysis may require communication with members, providers, or health plans for additional information.

In addition, the Help Center receives correspondence (which may include complaint/IMR form submissions from members and or providers), status calls (for members and or providers to check on the status of their case), and Helpline inquiries (emails to submit additional information and attachments to existing cases) related to all these case types.

D. Future State A future state system would result in the implementation of a new Case Management solution designed to provide timely member and provider assistance, address increased complaint volumes and expedited complaints, improve processing times and comply with data reporting and auditing requirements. Automating the complaint management process reduces the administrative burden, allowing staff to focus on critical tasks. This optimization of resources can lead to cost savings and more efficient use of personnel.

Additionally, the solution would provide robust analytics capabilities allowing the DMHC to track and analyze complaint data. The CRM modernization efforts will benefit the licensed health plans, health care providers, and third-party review organizations as users of the system and improve member access to quality health care services. Implementing a CRM system for complaint management is a strategic investment that aligns with the DMHC commitment to high quality healthcare, operational excellence and regulatory compliance.

The solution would be deployed within a low code / configurable platform to achieve operational efficiencies for existing program staff to address the increasing workload and ultimately lessen the need for significant staffing increases for manual processes in the future, including business process efficiencies that would include but not be limited to:

· Reducing complaint processing time.

· Providing health care members, providers, and health plans with real-time case tracking.

· Improving Help Center data entry and quality.

· Remediating information security risks inherent to operating the existing legacy systems on an archaic infrastructure.

· Remediating the operational risks of trying to maintain archaic architecture, and ensure scalability and availability.

· Providing more robust workflow automation.

· Reducing time to implement a more modern case management framework by using industry-leading low-code technologies.

· Enabling rapid low-code workflow automation to achieve up to 500% increase in developer efficiency.

· Reducing the amount of time and resources that OTI requires to maintain and operate the existing systems.

· Fostering more efficient business processes.

· Centralizing two existing system platforms into a single consolidated platform.

· Leveraging data and analytics to support operational management.

· Enabling dynamic solution scalability to handle increasing volumes of complaints as the DMHC grows.

2. SYSTEM DEMONSTRATION REQUIREMENTS

The solutions to be demonstrated shall provide case management capabilities and case workflow automation that is similar to what is described in the attachments outlined below.

A. Platform Capabilities Core Case Management Capabilities are what the DMHC considers to be standard case management capabilities typically available within the standard configuration of most case management platforms and solutions. The DMHC would like as many of these capabilities demonstrated as is feasible, within the platform and solution chosen for demonstration. Core Case Management capabilities can be found in the following attachment:

· DMHC CalMaCCS RFI Response Template.xlsx, Tab 3 (Core Capabilities) Core Case Management Capabilities typically include, but are not limited to:

1) Case / Ticketing engine

2) Contact / Account Management

3) Omni‑channel intake and routing

4) Workflow and Business Rules Orchestration

5) Knowledge management / KB

6) Self‑service portal & case submission

7) SLAs and Escalations

8) Notifications

9) Communications

10) Document & records management

11) Audit Logs

12) Task Management

13) Parent Case, Child Sub-Case, Grandchild Sub-Subcase Hierarchy

14) Routing

15) Operational Reporting

16) Operational Analytic Dashboards

17) Integrations / APIs

18) Security, identity & access management

19) Compliance & data governance

20) Audit logging and monitoring

21) Extensibility & customization

22) AI / Automation features (optional/advanced)

23) Mobile access (optional/advanced) Specialized Case Management Capabilities are what the DMHC considers to be DMHC-specific case management capabilities that may not be typically available within the standard configuration of most case management platforms and solutions. The DMHC would like as many (all, if feasible) of these capabilities demonstrated within the platform and solution chosen for demonstration. Specialized Case Management Capabilities can be found in the following attachment:

· DMHC CalMaCCS RFI Response Template.xlsx, Tab 4 (Specialized Capabilities)

· DMHC CalMaCCS Demo Use Cases.xlsx, Tab 3 (Specialized Capabilities) B. Workflow Automation As part of this RFI, the DMHC has provided attachments that articulate example workflows that closely match our case management requirements. The DMHC would like to see demonstrations of solutions with similar workflows.

Standard Case Management Workflow describes the case workflow of a typical case in the DMHC’s complaint case management systems. The supporting documents for Specialized Case Management Workflow can be found in the following attachments:

· DMHC CalMaCCS Demo Use Cases.xls, Tab 1 (Standard Case Workflow)

· DMHC Demo Use Case Workflow.pdf, Page 1 (Help Center Standard Case Workflow) Specialized Case Management Workflow consist describes the case workflow of a specialized case from the DMHC’s Provider Complaint system. Specialized Case Management Workflow can be found in the following attachments:

· DMHC CalMaCCS Demo Use Cases.xls, Tab 2 (Specialized Case Workflow)

· DMHC Demo Use Case Workflow.pdf, Page 2 (Help Center Bulk Submission Case Workflow) C. Mid-Level Requirements Mapping DMHC has provided a mapping of Demo Use Cases to the Mid-Level Requirements, and the Mid-Level Requirements document, as a reference for respondents. This information can be found in the following attachments:

· DMHC CalMaCCS Demo Use Cases.xlsx, Tab 4 (Mid Level Reqs Mapping)

· DMHC CalMaCCS Mid-Level Requirements.xlsx

Appendix A: Attachments The following documents are included in this Request for Information (RFI) packet to support your evaluation and preparation for the upcoming case management solution demonstrations. The Department of Managed Health Care (DMHC) understands that it may not be feasible for Respondents to demonstrate all specified use cases and workflows within a single, unified workflow. These materials are intended to provide insight into both standard and specialized case management processes, enabling Respondents to effectively showcase the capabilities outlined and required for demonstration.

DMHC CalMaCCS Demo Use Cases.xlsx This document describes an ideal case management workflow for demonstration purposes.

· Tab 1: Standard Case Workflow (text description)

· Tab 2: Specialized Case Workflow (text description)

· Tab 3: Specialized Capabilities

· Tab 4: Mid-Level Requirements Traceability from Demo Use Cases DMHC Demo Use Case Workflow.pdf This document provides visual representations of the ideal case management workflow.

· Page 1: Standard Case Management Workflow

· Page 2: Specialized Case Management Workflow DMHC CalMaCCS Mid-Level Requirements.xls This document Contains mid-level requirements for the CalMaCCS project, as defined by the California Department of Technology (CDT) Project Approval Lifecycle (PAL), Stage II – Alternatives Analysis.

· Instructions

· Functional Mandatory

· Functional Desired

· Non-Functional Mandatory

· Non-Functional Desired

· Project-Transition Mandatory

· Project-Transition Desired DMHC CalMaCCS RFI Response Template.xlsx This document is the standardized template for submitting responses to this RFI.

· Instructions

· Service and Management Questions

· Core Capabilities

· Specialized Capabilities

· Standard Case Workflow (text description)

· Specialized Case Workflow (text description)

· Rough Order of Magnitude (ROM) Estimates image1.png