Independent Review RFI - 01.12.2024.docx

Request for Information

Dates are subject to change. All times contained in the Bid Solicitation refer to Eastern Time.

Request for Information Issued By:

State of New Jersey Department of the Treasury Division of Purchase and Property Trenton, New Jersey 086250230 On Behalf of:

State of New Jersey Department of the Treasury Division of Pension and Benefits

Date: 1/12/2024

TABLE OF CONTENTS

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PURPOSE AND INTENT

This Request for Information (RFI) is issued by the Procurement Bureau, Division of Purchase and Property (Division), Department of the Treasury, State of New Jersey (State) on behalf of the Department of the Treasury’s Division of Pensions and Benefits (DPB). The purpose of this RFI is to gather information regarding the current practices of the independent medical review industry and solutions in the market that could provide independent medical review of claims denials when requested by providers who have exhausted first- and second-level internal appeals.

This RFI is not soliciting proposals and no contract will be awarded based on responses received. Background information regarding the specific State application is provided simply for context of the RFI. As noted below, the State may or may not issue a formal Request for Proposals (RFP) in the future.

DPB administers two self-insured insurance programs, the State Health Benefits Program and School Employees Health Benefits Program (SHBP/SEHBP). DPB contracts with health insurance carriers that manage provider networks and prior approval services, and receive and process providers’ submitted medical claims. The State contracts with a Claims Reviewer entity that reviews submitted medical claims for appropriateness of service and billing. In the case of a finding that results in a claim denial, providers may submit request for first-level and second-level appeals. These appeals processes are administered by the Claims Reviewer. The State is considering instituting a process that would allow providers to seek further review by an external medical claims reviewer after exhausting the second-level internal appeal.

The intent of this RFI is to gain insight into the marketplace of independent review and utilization review organizations, as well as systems and technologies that support independent review. This RFI seeks input regarding implementation strategies, timelines, and pricing models for planning and budgetary purposes. For purposes of this RFI, the term “Respondent” refers to the entity responding to this RFI.

Information submitted by any Respondent is done so voluntarily and with the understanding that a formal Bid Solicitation {Request for Proposal (RFP)} may or may not be issued as a result of, and subsequent to, this RFI.

The State reserves the right to contact Respondents for additional information at its sole discretion.

REQUEST FOR INFORMATION (RFI) SUBMISSION

Responses to the State’s RFI should be submitted electronically through NJSTART no later than February 6, 2024 at 2:00PM.

There is a 40 page limit on all responses. The Agency will also accept hyperlinks to marketing and other standard literature.

CONTENTS OF RFI SUBMISSIONS

Responses to this RFI can be released by the State to the public pursuant to N.J.A.C. 17:12-1.2(b) and (c), or under the New Jersey Open Public Records Act (OPRA), N.J.S.A. 47:1A-1.1 et seq., or the common law right to know.

All information submitted to the State in response to this RFI is considered public information notwithstanding any disclaimers to the contrary submitted by a Respondent. Proprietary and confidential information may be exempt from public disclosure by OPRA and/or the common law.

As part of its response, a Respondent may designate any data or materials it asserts are exempt from public disclosure under OPRA and/or the common law, explaining the basis for such assertion. The location in the response of any such designation should be clearly stated in a cover letter. The State reserves the right to make the determination as to what is proprietary or confidential, and will advise the Respondent accordingly. Any proprietary and/or confidential information in a response will be redacted by the State. The State will not honor any attempt by a Respondent to designate its entire response as proprietary, confidential and/or to claim copyright protection for its entire response. Copyright law does not prohibit access to a record which is otherwise available under OPRA. In the event of any challenge to the Respondent’s assertion of confidentiality with which the State does not concur, the Respondent shall be solely responsible for defending its designation, but in doing so, all costs and expenses associated therewith shall be the responsibility of the Respondent. The State assumes no such responsibility or liability.

DOCUMENTS REQUESTED

Respondents are encouraged to submit any other relevant or pertinent information related to the scope of this RFI including:

A. Data sheets about Respondent’s solution (specifically in State government implementations);

B. Blank reporting templates;

C. Copies of standard service level agreements (SLA), licensing agreements, or standard terms and conditions documents; and D. Copies of relevant marketing literature.

AREAS OF INQUIRY

The State is interested in general information about Respondent’s solution and approach. This RFI is NOT requesting specific proposals to provide independent review services. The objective of this RFI is to gather information about the industry and the market so that the State can make informed decisions about potential next steps.

Detailed questions are set forth below to help frame the general scope of the State’s inquiry. A point-by-point response is NOT required.

RESPONDENT BCKGROUND AND INFORMATION

A. Respondent name.

B. Respondent address.

C. Respondent point of contact for RFI response including name, title, phone number, and email address.

D. Respondent area(s) of expertise, including products and services offered.

E. Identify federal, state, or local government contracts held by the Respondent, including size and scope of each contract.

F. Other general information about the Respondent.

RESPONDENT’S SOLUTION – OVERVIEW

The State is interested in learning about independent review services and about related supportive systems that could meet the State’s needs:

A. What systems and procedures does the industry employ for receiving records and submitting decisions?

B. What level of data and narrative typically accompany the decision on each review?

C. What is the standard turn-around time from receipt of a request for review to issuing a determination with an explanation?

D. What is the review process? In other words, what steps does a reviewer take before making a determination?

E. What evidence-based criteria guidelines are used in making a determination? To what extent are industry organizations able to switch from one to another set of criteria based on customer specifications? Are there situations in which the Respondent chooses to include other professional resources aside from customer-specified criteria and, if so, what are some typical contexts?

F. Given that reviewers are themselves clinicians, how do review organizations in the industry demonstrate independence from both carriers and providers?

G. What technologies and software solutions are used in the industry?

H. What data security features are standard in the industry? What exposures or breaches have been identified in the industry within the past five years?

RESPONDENT’S SOLUTION – IMPLEMENTATION

A. In general, what does the industry see as a “standard” or “recommended” implementation timeline?

B. What does an average implementation look like from customer’s perspective?

C. How does the industry approach data transfer, specifically, transfer of requests for review from the customer, and transfer of a determination with accompanying documentation to the customer?

SERVICE LEVEL AGREEMENTS AND CUSTOMER SERVICE

A. Does the industry have standard service level agreements (SLAs) and, if so, what functions do they address? Are SLAs generally negotiable?

B. Has the industry standardized on system availability metrics, system response times, support ticket resolution times, recovery point objectives (RPO) or recovery time objectives (RTO)?

C. What are the standard reporting capabilities, and over what periods is work reported?

D. What are typical actions or policies that the industry might recommend, depending on findings observed in period reporting?

E. What type of customer support services are available?

F. What type of training is typically recommended for customers? Are there typically end users aside from customers and providers submitting appeals?

G. Does the industry offer standardized post-sales or customer success services? If so, what e content, format, and deliverables are included in these services?

PRICING

Please do not submit any pricing, pricing schedules, or pricing requests.

A. Without providing specific pricing, please explain your standard pricing model including differentiation between any specific aspects of support costs, where applicable.

B. Please explain any key pricing variables for solutions in this industry.

C. What models exist for a situation in which the number of reviews per month or per quarter is unknown?

D. In the event the State issues a Bid Solicitation {RFP}, how would Respondent recommend the State solicit pricing information to ensure fairness for all bidders?

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