Final_RFP_746_2700000006_2_SO_FORM.PDF

Document ID: RFP 746 2700000006 Page: 1

Commonwealth of Kentucky

SOLICITATION MODIFICATION

Modification: Yes Version #: 2

TITLE: External Independent Third-Party Review (C6102)

Date Issued:

09/14/2026 Record Date:

09/08/2026

Solicitation Closes Date:

09/30/2026 Time:

14:00

Solicitation No:

RFP 746 2700000006

Reason for Modification

Addendum 1 September 14, 2026

This addendum is to provide responses to Vendor questions and to update Section 2.01.01 Staffing, Section

4.00 Schedule of RFP Activities and Section 10.30 contract terms.

Vendor questions and responses start on page 34.

Online Bidding Prohibited: No

For Information Call:

David Locker 502-564-7736

Bid Receiving Location:

Bid Receiving

See Terms & Conditions for Bid Submission Instructions

Other KY

Vendor Customer Number:

Vendor Name:

Phone Number:

Fax Number:

Email Address:

Ordering

Address:

City, State, Zip:

Contact Name:

Contact Email:

Contact Phone Number:

Payment

Address:

City, State, Zip:

Contact Name:

Contact Email:

Contact Phone Number:

Ownership Type

__ Sole Proprietorship __ Partnership __ Corporation __ Other_________________________

SIGNATURE OF AUTHORIZED AGENT IS REQUIRED UNLESS RESPONSE

IS SUBMITTED ELECTRONICALLY. FAILURE TO SIGN SHALL RENDER

THE BID INVALID.

Document ID: RFP 746 2700000006 Page: 2

Signature X_________________________________________ FEIN#____________________ Date____________

All offers subject to all terms and conditions contained in this solicitation.

Document ID: RFP 746 2700000006 Page: 3

Line Items

Commodity Group: Default

Line CL Description Quantity UOM Unit Cost Line Total or Contract Amnt

1 FY27 External Independent Third-Party Reviewer

Comm Code Comm Description Manufacturer Model # Manuf Part #

952 HUMAN SERVICES

Extended Description Upon request from a Medicaid provider, the Contractor will assist the Department of Medicaid Services (DMS) by providing External Independent Third- Party Reviews (EITPR).

Line CL Description Quantity UOM Unit Cost Line Total or Contract Amnt

2 FY28 External Independent Third-Party Reviewer

Comm Code Comm Description Manufacturer Model # Manuf Part #

952 HUMAN SERVICES

Extended Description Upon request from a Medicaid provider, the Contractor will assist the Department of Medicaid Services (DMS) by providing External Independent Third- Party Reviews (EITPR).

Shipping Information

Billing Information CHFS DMS Division of Fiscal Management dms.invoice@ky.gov 275 E Main Street 6W-C

Frankfort KY 40621

Document ID: RFP 746 2700000006 Page: 4

Submission Checklist

The following items will be required to be submitted with bid:

Item Technical Proposal Cost Proposal Oral Presentations, if necessary.

ADDENDUM HISTORY

Addendum 1 September 14, 2026

This addendum is to provide responses to Vendor questions and to update Section 2.01.01 Staffing, Section 4.00 Schedule of RFP Activities and Section 10.30 contract term.

Vendor questions and responses start on page 34.

Document Phase Document Description Page 5

2700000006 Final External Independent Third-Party Review (C6102) Total Pages: 49

Revised February 2026

PROPOSAL SUBMISSION CHECKLIST

The Vendor MUST include the following with the proposal submission.

If the items highlighted below are not submitted with the proposal submission, the Commonwealth MUST deem the proposal non-responsive and SHALL NOT consider for award.

All other items MUST be submitted prior to award.

_____ SIGNED AND COMPLETED SOLICITATION –Section(s) 8.00 and 8.10 of this RFP (not required if submitting electronically)

_____ *PROPOSED SOLUTION (TECHNICAL) UNDER SEALED COVER AND BY CLOSING DATE --

Section(s) 8.00 and 8.10 of this RFP

_____ *PROPOSED SOLUTION (COST) UNDER SEALED COVER AND BY CLOSING DATE --

Section(s) 8.00 and 8.10 of this RFP

_____ TRANSMITTAL LETTER – Section 8.20 of this RFP

_____ PROOF OF REGISTRATION WITH SECRETARY OF STATE BY A FOREIGN ENTITY

(Section 8.00 of the Personal Service Contract Terms and Conditions of this RFP)

_____ REQUIRED AFFIDAVIT(S) – Section 8.20 of this RFP

*The Commonwealth defines SEALED as “a closure that must be broken to be opened and that thus reveals tampering” (Merriam-Webster Dictionary, https://www.merriam-webster.com/dictionary/seal

Document Phase Document Description Page 6 https://www.merriam-webster.com/dictionary/seal

REQUEST FOR PROPOSAL

FOR

PERSONAL SERVICE CONTRACT

Cabinet for Health and Family Services (CHFS) Department for Medicaid Services External Independent Third-Party Review

RFP 746 2700000006

This document constitutes a Request for Proposals for a Personal Service Contract from qualified individuals and organizations to furnish those services as described herein for the Commonwealth of Kentucky, Cabinet for Health and Family Services, on behalf of the Department for Medicaid Services.

Offerors are advised that any personal service contract resulting from this RFP must comply with all applicable provisions of KRS 45A and KRS 12.210 prior to becoming effective.

A contract, based on this RFP, may or may not be awarded. Any contract award from this RFP is invalid until properly approved and executed by the Finance and Administration Cabinet and filed with the Legislative Research Commission, Government Contract Review Committee.

1.00 Purpose and Background

The Cabinet for Health and Family Services, Department for Medicaid Services (“DMS”), is responsible for administering the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with a requirement that may be imposed or opportunity presented by federal law to qualify for federal Medicaid funds. KRS 205.646 (Kentucky Senate Bill 20 (RS 2016)) required DMS to promulgate administrative regulations to implement the External Independent Third-Party Review (“EITPR”) process required by that statute 907 KAR 17:035 was developed from this mandate and establishes provisions regarding a Medicaid provider's right to an EITPR of a managed care organization (“MCO”) adverse final decision of a provider's appeal of a denial of a claim for reimbursement of a service. Upon request from a Medicaid provider, the external independent third-party reviewer will assist DMS by providing an EITPR of the adverse final decision made by an MCO based on medical necessity or service coverage requirements.

2.00 Scope of Work

1. At a minimum, perform accurate and timely external independent third-party reviews in compliance with 907

KAR 17:035.

2. Conduct an EITPR and issue a final decision, including a review summary, to DMS, the MCO, and the Medicaid provider within thirty (30) calendar days of the receipt of the record on appeal materials submitted by the MCO through DMS.

3. Make medical necessity determinations by a clinician or clinicians who have clinical expertise regarding the subject matter of the case, and are currently licensed, preferably in the Commonwealth of Kentucky, regarding the subject matter.

4. Make administrative determinations such as determining whether the Medicaid program covers the service or whether the provider followed the MCO’s requirements for the covered service. These determinations are expected to be made by an appropriate professional or specialist with expertise in the subject matter.

5. Develop a formal process for identifying appropriately qualified clinicians to review and respond to specific medical issues and make medical necessity determinations.

6. Develop timelines for the review of medical necessity determinations.

7. Ensure reviewers of each EITPR have no conflict of interest regarding the review.

8. Be responsible for producing all regularly scheduled monthly, quarterly and annual reports and reports upon request.

9. Transmit and receive all data via encryption or secure file transport protocol (FTP) site.

2.01 Deliverables

External Independent Third-Party Review

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1. Issue a final decision to DMS, the MCO, and the Medicaid provider for each conducted EITPR within thirty (30) calendar days of the receipt of the record on appeal materials submitted by the MCO.

2. Produce a review summary for each EITPR final decision that includes, at a minimum, the following information:

a. Analysis of the information reviewed

b. Rationale for EITPR determination

c. Final determination of EITPR

d. Identification of the discipline of the individual(s) reviewing the case

The review summary is expected to be sent to DMS, the MCO, and the provider at the same time as the final decision is issued.

3. Submit a written Standard Operating Procedure detailing a formal process developed to identify appropriately qualified clinicians to review and respond to specific medical issues and make medical necessity determinations.

Submit, implement, and maintain a comprehensive Standard Operating Procedure that establishes a formal, mandatory process for the identification, credentialing, and assignment of appropriately qualified clinicians to review and respond to specific medical issues and to make medical necessity determinations. The Standard Operating Procedure is expected to:

a. Define minimum qualification and licensure standards aligned with Kentucky state requirements.

b. Include procedures for ongoing verification of credentials and competency; and

c. Be subject to review and approval by the Department for Medicaid Services prior to commencement of any review activities.

Failure to maintain or follow the approved Standard Operating Procedure can constitute a material breach of the contract.

4. Turn around Times: Depending on the type of external review (medical necessity, administrative, or Pharmacy) the turnaround times for an expected rendered decision may differ in the following ways:

a. Administrative - 30 calendar days

b. Pharmacy - 3 calendar days

c. Expedited/Urgent - 24 hours

5. Coordinate a kick-off meeting with DMS within fifteen (15) business days of contract initiation to discuss the project strategy, work plan, timeline and identify stakeholders.

a. Confirm points of contact

b. Establish a recurring meeting schedule (if needed)

c. Confirm system access and testing completion

d. Confirm the date the first cases will be transmitted

e. Review any outstanding deliverables before go-live

f. Any questions the vendor may have

6. Conduct Administrative Meetings between the Vendor and DMS as requested by DMS.

7. Maintain a signed statement for each EITPR that states the reviewer has no conflict of interest regarding the review.

8. Maintain confidentiality of information or results contained in reports or other deliverables. Disclosure of such information to any individual or entity is expected to prior approval by DMS.

2.01.01 Staffing

General Staffing

1. The Contractor is expected to retain adequate staffing and implement all aspects of the work required herein within the stated timeframes. Staffing levels are to be sufficient to support and complete all the responsibilities under the scope of work. The Contractor is expected to determine staffing requirements by both individual position and complexity, according to Full-Time Equivalent (FTE) hours. Specified positions are detailed in the Specific

Document Phase Document Description Page 8

Staffing Requirements of this Section. Commonwealth hours of operation are 8:00 a.m. to 4:30 p.m. EST, Monday through Friday. Holidays are defined as those recognized by the Commonwealth.

2. DMS reserves the right to approve or deny approval of all initial or replacement key personnel prior to their assignment to the Contractor's project. The Contractor must notify DMS within ten (10) business days in the event of any changes to key staff. The Contractor is expected to replace departing key staff within sixty (60) days with a person of equivalent experience, knowledge, and talent. DMS to have the right to require the Contractor to remove any personnel found by Medicaid to be unwilling or unable to perform under the terms of the contract.

3. The Contractor is to ensure that all entities or individuals, whether defined as "Key Personnel" or not, performing services under this contract are not "Ineligible Persons" to participate in the Federal health care programs, or in Federal procurement or non-procurement programs, or have been convicted of a criminal offense that falls within the ambit of 42 U.S.C 1320a-7(a), but have not yet been excluded, debarred, suspended, or otherwise declared ineligible.

Exclusion lists include the Department of Health and Human Services/ Office of Inspector General List of Excluded Individuals/Entities and the General Services Administration’s List of Parties Excluded from Federal Programs.

4. All temporary, permanent, subcontracted, part-time, and full-time Contractor staff working on this contract are to complete an annual statement that includes an acknowledgement of confidentiality requirements and a declaration as to whether the individual has been convicted of a felony crime or has been determined an "Ineligible Person" to participate in Federal healthcare programs or in Federal procurement or non-procurement programs.

5. The Contractor is to keep the individual statements on file and submit a comprehensive list of all current staff in an annual statement to the Contract Monitor, indicating if the staff is free of convictions or ineligibility as referenced above.

6. If the Contractor has actual notice that any temporary, permanent, subcontracted, part-time, or full-time Contractor staff has become an "Ineligible Person" as defined above, the Contractor is to remove said personnel immediately from any work related to this contract and notify DMS on the same date the Contractor receives the notice of a conviction or ineligibility. For felony convictions, DMS will determine whether the Contractor is to permanently remove the individual from the contract project.

7. The Contractor is expected to provide staff who have a thorough understanding of medical necessity determinations, including a clinician or clinicians who have clinical expertise regarding the subject matter of the case, and are currently licensed, preferably in the Commonwealth of Kentucky, regarding the subject matter.

8. The Contractor is expected to have sufficient information system staff to manage contract requirements, including data collection, analysis, and storage.

Specific Staffing

While specific certifications are not explicitly named in the state’s description of the process, the reviewer is expected to have the necessary experience and knowledge to assess the merits of the claims dispute, which often involves the correct application of medical coding and billing regulations. The independent review is designed to provide an objective, binding decision based on the documentation and arguments presented by both parties.

The process relies on the chosen reviewer’s ability to accurately interpret complex billing, coding, and contract information.

Project staffing is to include the following required key personnel positions assigned to this project:

1. Contract Manager

The Contract Manager is expected to be the primary point person and day-to-day liaison between DMS and the Contractor. The Contract Manager is expected to be dedicated to the Kentucky Medicaid program, responsible for the successful implementation and ongoing operations. The Contract Manager is expected to have leadership and problem-solving abilities demonstrating organization, facilitation, communication, and presentation skills.

Requirements

a. Bachelor’s or Master's degree in health administration or in any other health-related fields.

b. Three (3) years’ experience in health care research, health policy analysis, or similar research experience.

2. Process Supervisor

Document Phase Document Description Page 9

The Process Supervisor is expected to oversee operational workflows associated with External Independent Third-Party Reviews (EITPR) performed under this Contract and ensure compliance with all applicable federal and state Medicaid requirements, Department policies, and contractual performance standards.

Requirements

a. A Bachelor’s degree from an accredited college or university in one of the following or closely related fields: Preferred: Master’s degree in healthcare administration, public health, business administration, or related field.

b. Minimum five (5) years of professional experience in healthcare operations, managed care, utilization review, quality improvement, or regulatory compliance.

c. Minimum two (2) years of supervisory or team leadership experience overseeing staff performing case review, appeals, grievances, or utilization management activities.

3. Operations Supervisor

The Operations Supervisor is expected to oversee and manage day-to-day operational activities performed under this Contract, including intake, processing, tracking, quality oversight, and timely completion of External Independent Third-Party Reviews (EITPR). The Operations Supervisor is expected to ensure all operational functions are conducted in compliance with applicable federal and state Medicaid regulations, contractual obligations, and Department performance standards.

Requirements:

a. Bachelor’s degree from an accredited college or university. Preferred: Master’s degree in Healthcare Administration (MHA), Public Health (MPH), Business Administration (MBA), or related discipline.

b. A minimum of five (5) years of experience in healthcare operations, managed care administration, utilization review, quality improvement, or healthcare regulatory compliance.

c. A minimum of three (3) years of supervisory or operational leadership experience overseeing staff responsible for case processing, appeals, grievances, utilization management, or independent review activities.

4. Clinical Reviewer

The Clinical Reviewer is expected to conduct independent clinical reviews and render medical necessity determinations for cases assigned under this Contract, including External Independent Third-Party Reviews (EITPR), and related clinical reconsiderations. All reviews are expected to be performed in accordance with applicable federal and state Medicaid requirements, recognized clinical standards of care, and Department contractual requirements.

Requirements:

a. Hold a current, active, and unrestricted professional license in the United States in one of the following disciplines: Physician, registered nurse, or other licensed healthcare professional.

b. Maintain licensure in good standing with no active sanctions or disciplinary restrictions.

c. Minimum five (5) years of post-licensure clinical experience in direct patient care or clinical practice.

5. Certified Coder

The Certified Coder is expected to provide coding analysis and review services to support clinical and administrative case reviews performed under this Contract. Responsibilities are expected to include evaluation of medical coding accuracy, billing compliance, and alignment with applicable coding standards to support External Independent Third-Party Reviews (EITPR) and related review activities.

Requirements:

High school diploma or equivalent required. Associate or Bachelor’s degree in Health Information Management, Health Information Technology, Healthcare Administration, or related field preferred.

Minimum three (3) years of professional medical coding experience.

All external reviews conducted under this Agreement are to be performed by individuals who:

1. Hold an active and valid professional certification, licensure, or accreditation recognized by the Department for Medicaid Services relevant to the subject matter under review; and

Document Phase Document Description Page 10

2. Demonstrate documented experience or training specific to Kentucky Medicaid programs, regulations, and policies.

3. The Contractor is expected to submit the credentials of any proposed external reviewer to the Department for Medicaid Services for approval prior to initiating any review. The Department for Medicaid Services reserves the right to reject any proposed reviewer who does not meet the qualifications.

The Contractor is expected to ensure that all external reviewers maintain good standing with any applicable Kentucky licensing or certifying boards during the term of this Agreement. If a reviewer loses certification or otherwise becomes ineligible during the term of this Agreement, that individual cannot continue to review claim or service denials.

Additional specialty personnel are defined based on the needs of the Medicaid program. Access to a Physician, Dentist, Optometrist, Physical Therapist, and other appropriate medical professionals to review and approve the Contractor's decision.

The Contractor is expected to immediately notify the Department for Medicaid Services and propose a qualified replacement subject to approval.

The Contractor is expected to report the above-listed key personnel, including the names, job descriptions, and CVs, by July 15, each contract year.

Subcontractors are not allowed.

2.02 Reporting Requirements

Transmittal and receipt of all data is expected to be via an encrypted or secure file transfer protocol (FTP) site.

1. Be responsible for producing all regularly scheduled monthly, quarterly and annual reports.

2. Complete and submit to DMS a monthly detail and summary report within 30 days past the end of each month.

Reports are to be provided in Excel format, and the reports are expected to include the following:

a. Member Name

b. Date of Service (DOS)

c. External Independent Third-Party Review (EITPR) Vendor Number

d. Managed Care Organization (MCO)

e. Date Submitted by the Department

f. Date the EITPR Vendor Initiated Work on the Case

g. Date Completed

h. Date Letter Submitted to Provider

i. Letter Submitted by (Clinical Reviewer)

j. Turnaround Time (Date Work Initiated to Date of Rendered Decision)

k. Rendered Decision; upheld, partial, or overturned

3. Complete and submit to DMS a quarterly detail and summary report within 30 days past the end of each quarter, and an annual report by June 30 of each contract year. Reports are to be provided in Excel format, and the reports are expected to include the following:

a. Total number of completed EITPR by MCO

b. Total number of completed EITPR by MCO by medical necessity versus administrative (SB 20)

c. The total number of final decisions overturned, upheld, and partially overturned per MCO.

d. Total number of EITPR reviews completed in the following time periods:

1) 30 days or less.

2) Between 31 days and 60 days.

3) Between 61 days and 90 days.

4) More than 90 days.

Document Phase Document Description Page 11

e. The average and the median time to complete EITPR.

f. Total number of EITPR cases is currently pending.

g. Total number of EITPR cases denied due to incomplete appeal record.

h. The average and the median time to deny an EITPR due to an incomplete appeal record.

i. Report details and other reports as requested.

4. If requested by DMS following submission of the final report, participate in discussions of review findings and recommendations to DMS for improving the EITPR process.

5. Ensure the release of the report complies with the privacy of patient information as per 42 CFR 438.

6. Develop report formats that meet all State and Federal reporting requirements. The vendor is expected to compose the reports in a manner consistent with DMS specifications and with the vendor’s stated criteria. All report formats are expected to have prior approval by DMS.

7. Ensure a complete understanding of the specifications and requirements for all reporting and other activities under the contract.

8. Ensure the accuracy of all reports, including correct tables, charts, data, grammar, punctuation and spelling prior to providing the report in final form to DMS. The Vendor is expected to provide DMS with written reports that are clear, concise and useful for the intended audience.

9. Respond to all DMS requests for information concerning reports within 10 calendar days following the request, unless otherwise agreed upon by both parties.

10. Report the information in a manner that is consistent with the needs of DMS, and that utilizes generally accepted auditing principles and standards. Submission of all draft Contractor reports are expected to undergo internal review before submission to DMS with the understanding that all reports are potentially made public other than those with PHI documentation. The Vendor is expected to consistently identify those areas of the EITPR process that demonstrate opportunities for improvement.

11. If the Vendor fails to submit a report within the required timeframe, a corrective action plan will be initiated, and a penalty can be imposed of $100.00 per day until the report is received.

2.03 CHFS Responsibilities

Upon notification from an MCO of a Medicaid provider’s request for an EITPR of an adverse final decision based on medical necessity, or request for an administrative review, DMS is expected to assign the Vendor the case to review. DMS is expected to provide the Vendor with all the documentation received from the MCO related to the final decision of the Medicaid provider’s appeal. Upon receipt of the MCO documentation, the Vendor has thirty

(30) calendar days to conduct an EITPR and render a final decision.

EITPR cases deemed incomplete under 907 KAR 17:035(2)(7) due to inaccurate documentation and/or incomplete appeal records are expected to be automatically denied by the Vendor and reported monthly as stated above.

Any cases identified in which the Vendor deemed a case incomplete erroneously and DMS finds that a complete and accurate appeal record was provided initially, the Vendor is expected to be assessed a $5 per day, per case penalty assessment until a complete and accurate final decision is received. The penalty assessment period is expected to begin thirty (30) calendar days from the date the appeal record was initially submitted to DMS.

The Department will complete a review of the cases identified as incomplete and correct the case submission and send notification to the Contractor within thirty (30) calendar days of receipt of the monthly report. The Vendor will have thirty (30) calendar days from that receipt date to render a final decision.

The CHFS/Department for Medicaid Services will:

1. Provide the Vendor with a contact person who will coordinate the activities required under the contract.

2. Provide the Vendor with related program information required by the Vendor for completing their contract responsibilities.

3. Conduct reviews of all materials submitted to DMS by the Vendor.

4. Modify any report format and timetables for submission because of changes in Commonwealth policy or direction.

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5. Provide timely notifications to the Vendor of all changes and/or amendments to the MCOs’ contract(s) and/or any waiver terms and conditions; and

6. Review and approve/disapprove the Vendor’s invoices and supporting documents.

2.04 Monitoring Requirements – Federal and State

1. Faithful performance of the Agreement and the expectation to have internal monitoring procedures and processes in place to ensure quality and compliance.

2. Cooperate with DMS and/or its agents in any monitoring, tracking and/or auditing activity, provide documents, allow random inspections of its facilities, participate in scheduled meetings and monitoring, respond to requests for corrective action plans, and provide management reports as requested by DMS. Participation in these activities is expected to be at no additional cost to DMS.

DMS and or its agents reserve the right to monitor, audit and track the Contract’s performance over the course of the Contract. The information gathered may be used in the administration of the Contract, including payment.

2.05 Pricing and Payment Requirements

External Independent Third-Party Case Reviews are billed in the quarter in which the review is completed. Billable reviews include all rendered decisions, including upheld, reversed, modified, and partially modified decisions.

Invoices for payment are expected to be submitted electronically to CHFSpayablesbranch@ky.gov.

Invoices must be submitted no later than thirty (30) calendar days after the quarter in which the completion of the service(s) occurs.

Payment is conditioned upon receipt of appropriate, accurate, and acceptable invoices submitted in a timely manner.

Invoices are expected to contain:

1. The Legislative Research Commission’s Government Contract Review Committee Invoice is broken down by the time worked, and/or completed work, along with any Supporting Documentation.

Invoices that do not contain the requirements above will be rejected and sent back to the Contractor for re-invoicing.

All services, monitoring such services, and billing and invoicing for such services are expected to in compliance with all applicable state and federal statutes, regulations, policies, and procedures governing the Medicaid Program, including but not limited to the State Plan approved by the federal Centers for Medicare and Medicaid Services. No payment is expected to be made for non-compliant services or invoices.

3.00 Evaluation Criteria

The Cabinet for Health and Family Services (CHFS) shall conduct a comprehensive, fair, and impartial evaluation of all proposals. CHFS may reject any proposal that is incomplete or in which there are significant inconsistencies or inaccuracies. CHFS reserves the right to reject all proposals.

CHFS has established a Proposal Evaluation Committee to review, evaluate and verify information submitted by the offeror.

Each Vendor is responsible for submitting all relevant, factual and correct information with their offer to enable the evaluator(s) to afford each Vendor the maximum score based on the available data submitted by the Vendor.

CHFS shall evaluate the proposals by assigning scores as indicated.

Technical Proposal Evaluation Criteria Maximum Points Possible

Approach to Scope of Work

1. Provide evidence of the ability to conduct successful external independent third-party reviews.

2. Provide evidence of the organization's ability to make administrative determinations by an appropriate professional or specialist with expertise in the external independent third-party reviews.

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3. Provide a sample review timeline of case processing from vendor received date to vendor decision rendered date.

4. Describe your process to securely transmit and receive all data related to the external independent third-party review.

Approach to Deliverables

1. Provide a sample of a successful project work plan showing turnaround times, based on the type of external review (medical necessity, administrative, or pharmacy) in accordance with Section 2.01.

2. Provide a sample of a review summary for an EITPR in accordance with Section 2.01 items 1-8.

Approach to Reporting Requirements

Describe your organization’s process for generating reports and provide examples of previously generated reports for all reports as described in Section 2.02.

Approach to Monitoring Requirements

Describe your organization’s process to ensure that internal monitoring is in place for quality and compliance of the EITPR review process.

Personnel Specifications:

Provide detailed staffing plan to ensure Section 2.01.01 Staffing requirements are met.

Maximum Points Possible 1000 Proposals scoring fewer than 600 points on the Technical Evaluation shall be eliminated from further consideration.

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Cost Proposal Evaluation Criteria Maximum Points Possible The offeror is responsible for providing an all-inclusive rate per rendered decision. There are approximately 7,200 cases per year.

Offerors shall ONLY provide cost information on the Cost Proposal Form.

Offeror is to provide the cost on the attached Cost Proposal Form in accordance with Section 8.30; otherwise, the proposal may be deemed non-responsive.

Maximum Points Possible 400

Oral Demonstration/Presentation Evaluation, if required Criteria Maximum Points Possible Oral Presentations/Demonstrations

The Commonwealth reserves the right to require Oral Presentations/Demonstrations to verify or expand on the Technical or Cost Proposals. Oral Presentations/ Demonstrations may be conducted through videoconferencing or by conference call, if it is in the best interest of the Commonwealth to do so. This is the opportunity for the Offeror to present and demonstrate the solution and to answer questions or to clarify the understanding of the evaluation committee in accordance with the requirements of this RFP.

The Commonwealth reserves the right to reject any or all proposals in whole or in part based on the oral presentations/ demonstrations.

If required, the top 2 highest ranking Offerors may be invited.

Scheduling will be at the discretion of the Commonwealth.

The Commonwealth reserves the right not to require oral presentations/demonstrations.

Maximum Points Possible

Total Proposal Evaluation

Criteria Maximum Points Possible Technical Proposal 1000

Cost Proposal 400

Oral Demonstrations/Presentations, if required 200

MAXIMUM POINTS POSSIBLE 1600

4.00 Schedule of RFP Activities

The following schedule presents the major activities associated with the RFP distribution, written questions and proposal submission. The Commonwealth reserves the right at its sole discretion to change the Schedule of Activities, including the associated dates and times.

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Release of RFP 08/07/2026

Written Questions due by: 2:00pm 08/17/2026

Anticipated Commonwealth Response to Written Questions 09/3/2026 09/14/2026

Proposals Due by: 2:00pm 09/15/2026

09/30/2026

*NOTE: ALL TIME REFERENCES ARE TO THE EASTERN TIME ZONE.

5.00 Offeror’s Conference

Not applicable.

6.00 Point of Contact

The Agency Contact named below shall be the sole point of contact throughout the procurement process. All email communications concerning this procurement shall be addressed to:

David Locker David.Locker@ky.gov

From the issue date of this RFP until a Contractor(s) is selected and the selection is announced; Offerors shall not communicate with any other Commonwealth staff concerning this RFP.

7.00 Questions Regarding this RFP

Questions must be submitted in writing to the Agency Contact. The Commonwealth will respond to salient questions in writing by issuing an Addendum to the Solicitation. The Addendum shall be posted to the Commonwealth’s eProcurement page.

8.00 Proposal Submission

Electronic Proposals

Proposals shall be received by electronic submission in the eProcurement system, Kentucky Vendor Self Service System.

An electronic proposal shall be authorized by the proper agent of the firm by submitting it electronically through the eProcurement system.

Proposal information MUST be completed online. Response must contain all required information for the Solicitation.

All bidders MUST be registered in the Commonwealth eProcurement System via the Vendor Self Service System at https://vss ky.gov.

Allow 24 – 48 hours to complete Vendor Registration. Vendors must be logged in to their Vendor Self Service (VSS) account in order to submit a response. Registrations completed on the day of bid closing must be completed by the Vendor in the VSS portal. The Customer Resource Center is not able to complete registrations and activate accounts on the same day. Closing dates will not be extended for Vendors not registered by the date/time of the bid closing.

All bidders are cautioned to begin their electronic submission in sufficient time to complete before the closing date and time. Delays due to technical difficulties or document upload impediments shall not be justification for acceptance of a late bid or proposal. Vendor attention to this advisory is encouraged. Instructions “How to Submit an Online Response for a Business Opportunity” are posted to Kentucky’s Vendor Self Service, https://vss.ky.gov.

If you need assistance, please contact the Customer Resource Center (CRC) by email at Finance.CRCGroup@ky.gov or phone 502-564-9641 or toll-free 877-973-HELP (4357).

Proposals shall be submitted in three (3) parts: The Technical Proposal, the Cost Proposal, and Proprietary Information. Each part shall consist of one document attachment. Do not submit multiple document

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2700000006 Final External Independent Third-Party Review (C6102) Total Pages: 49 https://vss.ky.gov/vssprod-ext/Advantage4 mailto:Finance.CRCGroup@ky.gov attachments as Technical, Cost or Proprietary. All files shall be labeled accordingly. Attachments may not exceed 65,000 KB.

Proposals submitted online must be in an “Accepted” status and shall be assigned a date and time stamp from the eProcurement system at the time of final acceptance and formal submission by the Vendor. The system will not allow submission of an online proposal after the published date and time for closing.

A proposal may be modified or withdrawn by electronic or written notice ONLY if received prior to the bid closing date and time. An electronic offer may be modified by applying the appropriate electronic signature and following the procedure in the state’s eProcurement signature.

Acknowledgment of Addenda

It is the Vendor's responsibility to check the web site for any modifications to this solicitation. Vendors are encouraged to acknowledge each addendum by signing and submitting the latest addendum with their response. However, signing the face of the solicitation as indicated above constitutes the Vendor’s acknowledgement of an agreement to be bound by the terms of all addenda issued.

Failure to specifically acknowledge addenda will not excuse the Vendor from adhering to all changes to the requirements of the solicitation set forth therein nor provide justification for any pricing changes.

8.10 Format of Response

Electronic Proposals

Proposals shall be submitted in three (3) parts: The Technical Proposal, the Cost Proposal, and if applicable, Proprietary Information. Each part shall consist of one document. Do not submit multiple documents as Technical, Cost or Proprietary.

1. Proposals must be submitted electronically in the eProcurement System, Kentucky Vendor Self Service site.

a. The Technical Proposal shall be submitted on one (1) document marked Technical (in Microsoft Word, Microsoft Excel or PDF format ONLY). Do not include embedded documents, hyperlinks or hyperlinks to videos. The document should be named in the following manner: Technical – Name of offeror – RFP number

b. The Cost Proposal shall be submitted on one (1) document marked Cost (in Microsoft Word, Microsoft Excel or PDF format ONLY). Do not include embedded documents, hyperlinks or hyperlinks to videos.

The document should be named in the following manner: Cost – Name of offeror – RFP number

c. Any Proprietary Information shall be submitted on one (1) document marked Proprietary (in Microsoft Word, Microsoft Excel, or PDF format ONLY). Do not include embedded documents, hyperlinks or hyperlinks to videos. The document should be named in the following manner: Proprietary

– Name of offeror– RFP number

All proposals must be received no later than the close time and date listed in Section 4.00.

Pricing shall only be provided in the Cost Proposal. DO NOT SUBMIT ANY PRICING INFORMATION IN

THE TECHNICAL PROPOSAL.

All submitted Technical and Cost Proposals shall remain valid for a minimum of six (6) months after the proposal due date.

8.20 Format of Technical Proposal

The Technical Proposal must be arranged and labeled in the manner set forth below.

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Transmittal Letter – a Transmittal letter shall be submitted on Offeror’s letterhead and signed by an agent authorized to bind the Offeror. The Transmittal letter shall include the following:

a. A statement that deviations are included, if applicable.

b. A statement that proprietary information is included, if applicable.

c. A statement that, if awarded a contract as a result of this Solicitation, the Offeror shall comply in full of all the requirements of the Kentucky Civil Rights Act, and shall submit all data required by KRS

45.560 to 45.640.

d. A sworn statement that, pursuant to KRS 11A.040, that Offeror has not knowingly violated any provisions of the Executive Branch Code of Ethics.

e. A statement certifying that the price in this proposal was arrived at independently without collusion, consultation, communication, or agreement as to any matter relating to such prices with any other Offeror or with any competitor.

f. A statement affirming that the Offeror is properly authorized under the laws of the Commonwealth of Kentucky to conduct business in this state and will remain in good standing with the Office of the Kentucky Secretary of State for the duration of any awarded contract resulting from this Solicitation.

g. The name, address, telephone number, fax number and email address and website address, if available, of the contract person to serve as a point of contact for day-to-day operations.

h. Subcontractor information to include the name of the company, address, telephone number and contact name, if applicable.

i. Foreign entity’s organization number issued by the Secretary of State in a certificate of authority or a statement of foreign qualification, if applicable.

Completed and Signed Solicitation and Addenda – An authorized representative MUST complete and sign the Solicitation form and include the following:

a. “Vendor” box and “Payment” box should be completed.

b. Vendor shall indicate ownership type.

c. Vendor shall provide “FEIN” if applicable.

d. Vendor shall provide date the form is completed and signed.

e. Signed face of the most recent Addenda, if applicable.

Signed and Notarized Required Affidavit for Bidders or Offerors - available at the following link:

https://finance.ky.gov/office-of-the-secretary/Pages/finance-forms.aspx.

Signed and Notarized Required Affidavit for Bidders, Offerors and Contractors Claiming Resident Bidder Status – if applicable. Available at the following link:

https://finance.ky.gov/office-of-the-secretary/Pages/finance-forms.aspx.

*Offerors not claiming Resident Bidder Status need not submit this affidavit.

Signed and Notarized Required Affidavit for Bidders, Offerors and Contractors Claiming Qualified Bidder Status – if applicable. Available at the following link:

https://finance.ky.gov/office-of-the-secretary/Pages/finance-forms.aspx.

*Offerors not claiming Qualified Bidder Status need not submit this affidavit.

Response to the Technical Portion of the RFP – Please provide a detailed response to the technical requirements outlined in the Evaluation Criteria. No cost information shall be provided in the technical portion.

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8.30 Format of Cost Proposal

The Cost Proposal must be submitted under separate cover from the Technical Proposal and must be arranged and labeled in the manner specified. The proposal with the lowest price receives the maximum score. The remaining proposals with the next lowest price receives points by dividing the lowest price by the next lowest price and multiplying that percentage by the available points.

8.40 Certification Regarding Debarment and Suspension

In accordance with Federal Acquisition Regulation 52.209-5, 2 CFR 180.300, 2 CFR 200.318, 2 CFR 200.303, and FAP 111-59-00 the Offeror shall certify, by signing the Solicitation, that to the best of its knowledge and belief, the Offeror and/or its Principal(s) is (are) not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any state or federal agency. If debarred during the life of the contract, the Offeror shall notify the Commonwealth buyer of record within seventy-two (72) hours of the federal debarment.

For the purposes of this certification, “Principals”, means officers, directors, owners, partners, and persons having primary management or supervisory responsibilities within a business entity (e.g., general manager, plant manager, head of subsidiary, division, or business segment, and similar positions.

9.00 Rules of Procurement

To facilitate this procurement, various rules have been established. These are described in the following paragraphs.

Offerors should review and comply with the General Conditions and Instructions for Solicitation/Contract listed under “Response to Solicitation” located on the eProcurement web page at https://finance.ky.gov/eProcurement/Pages/doing-business-with-the-commonwealth.aspx

The procurement process will provide for the evaluation of proposals and selection of the winning proposal in accordance with state law and regulations. KRS Chapter 45A of the Kentucky Model Procurement Code provides the regulatory framework for the procurement of services by state agencies.

9.10 Technical Proposal Evaluation

CHFS will evaluate the proposal based on the technical portion of the Evaluation Criteria. Each Offeror is responsible for submitting all relevant, factual and correct information with their offer to enable the evaluator(s) to afford each Vendor the maximum score based on the available data submitted by the Offeror. Past Offeror Performance may be considered in the award of this Contract. Offerors with a record of poor performance in the last twelve (12) months may be found non-responsible and ineligible for award.

9.20 Cost Proposal Evaluation

CHFS will evaluate the proposal based on the cost portion of the Evaluation Criteria.

Offeror shall only provide cost on the attached Cost Proposal Form; otherwise, the proposal may be deemed non-responsive.

9.30 Right to Reject/Waiver of Minor Irregularities

The Commonwealth reserves the right at its discretion to reject any and all offers. The Commonwealth also reserves the right at its discretion to waive informalities and minor irregularities in offers received.

9.40 Clarification of Proposals

The Commonwealth reserves the right at its discretion to request additional information as may reasonably be required for selection and to reject any proposals for failure to provide additional information on a timely basis.

The Commonwealth reserves the right to conduct discussions with any Offeror who has submitted a proposal to determine the Offeror’s qualifications for further consideration. Such discussions shall not disclose any information derived from proposals submitted by other Offerors.

9.50 Best and Final Offers

The Commonwealth reserves the right at its discretion to request a Best and Final Offer (BAFO) for technical and/or cost proposals. Offerors are cautioned to propose their best possible offers at the outset of the process, as there is no guarantee that any Offeror will be allowed an opportunity to submit a Best and Final technical and/or cost offer.

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9.60 Vendor Response and Public Inspection

This RFP specifies the format, required information and general content of proposals to be submitted in response to the RFP. CHFS shall not disclose any portions of the proposals prior to contract award to anyone outside CHFS, representatives of the agency for whose benefit the contract is proposed, representatives of the federal government, if required, and the members of the evaluation committee. After a contract is awarded in whole or in part, the Commonwealth shall have the right to duplicate, use, or disclose all proposal data submitted by Offerors in response to this RFP as a matter of public record.

Any and all documents submitted by an Offeror in response to the RFP shall be available for public inspection after contract award pursuant to the Kentucky Open Records Act, KRS 61.870 to 61.884 (“the Act”). When responding to a request to inspect records submitted in response to this RFP, the Commonwealth will not redact or withhold any information or documents unless the records sought are exempt from disclosure pursuant to KRS 61.878 or other applicable law. Similarly, no such documents shall be exempt from public disclosure, regardless of the Offeror’s designation of the information contained therein as “proprietary,” “confidential,” or otherwise, except in cases where the requested documents (or information contained therein) would be excluded from application of the Act under KRS 61.878(1)(c).

The Commonwealth of Kentucky shall have the right to use all system ideas, or adaptations of those ideas, contained in any proposal received in response to this RFP. Selection or rejections of the proposal will not affect this right.

9.70 Reciprocal Preference for Kentucky Resident Bidders and Preferences for a Qualified Bidder

The scoring of bids/proposals is subject to the reciprocal preference for Kentucky resident bidders and preferences for a Qualified Bidder or the Department of Corrections, Division of Prison Industries (See KRS 45A.490(1), (2), 45A.492, 45A.494 and 200 KAR 5:410).

Vendors not claiming resident bidder or qualified bidder status need not submit the corresponding affidavit.

Determining the residency of a bidder for purposes of applying a reciprocal preference

Any individual, partnership, association, corporation, or other business entity claiming resident bidder status shall submit the attached Required Affidavit for Bidders, Offerors and Contractors Claiming Resident Bidder Status as part of its response. CHFS reserves the right to request documentation supporting a bidder’s claim of resident bidder status.

Failure to provide such documentation upon request shall result in disqualification of the bidder or contract termination.

As part of its response, a nonresident bidder shall submit its certificate of authority to transact business in the Commonwealth of Kentucky, Secretary of State. The location of the principal office identified therein shall be deemed the state of residency for that bidder.