Medical Care Utilization Review Services-02.doc

State of Missouri Office of Administration, Division of Purchasing

Request for Proposal (RFP) for

Medical Care Utilization Review Services

PROPOSAL DUE NO LATER THAN: October 5, 2026 AT 2:00 PM CENTRAL TIME

Proposal response must be submitted electronically through MissouriBUYS, powered by MOVERS, at https://missouribuys.mo.gov.

E-mailed, mailed, courier, or hand-delivered proposal responses will not be accepted.

RFP CONTACT INFORMATION:

BUYER: Ariel Bradford

PHONE NO.: (573) 751-2497

EMAIL: Ariel.Bradford@oa.mo.gov

See “RFP Questions” in Section 1 for appropriate communications during the procurement process.

DELIVER SUPPLIES/SERVICES FREE ON BOARD (FOB) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Commerce and Insurance

301 West High Street

Jefferson City, MO 65101

ATTENTION:

1. After reviewing the Request for Proposal (RFP), the vendor must complete and return Exhibit A, Proposal Signature Page and all other necessary exhibits.

2. Due to lead times for obtaining the information needed to complete the various Business Compliance Exhibits herein as explained in the RFP’s Vendor Response Exhibits, vendors are encouraged to IMMEDIATELY begin securing these verifications.

3. The vendor must be registered in MissouriBUYS, powered by MOVERS in a “Prospective” or “Spend Authorized” registration status to submit a proposal. The vendor must achieve “Approved” registration status in MissouriBUYS (WebProcure/Proactis) and “Spend Authorized” registration status in MissouriBUYS, powered by MOVERS to be considered for a contract award. Reference Section 5.

AMENDMENT #02 to STATE 0000000557SL

TITLE:

Medical Care Utilization Services

CONTRACT PERIOD:

Effective Date of Contract through One Year

PLEASE BE ADVISED OF THE FOLLOWING CHANGES AND CLARIFICATIONS:

1. Closing Date has been REVISED.

As stated: Return proposal no later than September 30, 2026 at 2:00 PM.

Changed To: Return proposal no later than October 5, 2026 at 2:00 PM.

2. Paragraph 1.2.7 b has been REVISED.

3. Paragraph 1.2.8 a, b, and c has been ADDED.

4. Paragraph 2.1.5 a has been REVISED.

5. Paragraph 2.2.1 c 1. has been ADDED.

6. Paragraph 2.3.1 c has been REVISED.

7. Paragraph 2.4.4 has been REVISED.

8. Paragraph 2.4.5 b has been REVISED.

9. Paragraph 2.9.7 has been DELETED.

Vendors may review the revision(s) to the MissouriBUYS, powered by MOVERS electronic solicitation and the amendment document(s) at https://MissouriBUYS.mo.gov. You may be required to acknowledge the electronic amendment.

ATTENTION: IF YOU HAVE ALREADY SUBMITTED A RESPONSE TO THE SOLICITATION, ACCEPTANCE OF THE AMENDMENT AND RESUBMISSION YOUR SOLICITATION RESPONSE IS NECESSARY TO ENSURE THE STATE OF MISSOURI SUCCESSFULLY RECEIVES YOUR SOLICITATION RESPONSE.

Follow the instructions in the Reference Guide for How to Submit Response Online (https://missouribuys.mo.gov/media/pdf/movers-bid-response-instructions ) and outlined below if previously responded to the solicitation prior to the amendment issuance.

1) Log into MissouriBUYS, powered by MOVERS (https://missouribuys.mo.gov/).

2) Under Tasks click View Negotiations below Solicitations.

3) The Active Solicitations page will appear. Utilize the search filters and click on the Solicitation Number to open.

4) The Overview page will display. Click Create Response.

5) A Warning pop-up box will open. The supplier must click Yes to continue to view and acknowledge amendments.

6) The supplier should highlight the Amendment(s) and view the changes made via the amendment(s). Once the review is complete, select the Acknowledgement checkbox for each amendment and click Submit at the top right-hand corner of the page. NOTE: A Warning pop-up box will open if all amendments have not been acknowledged. Click Yes to continue.

7) A Confirmation pop-up box will open confirming amendments have been acknowledged. It will also warn that resubmission of the previously submitted response is necessary prior to response to the amendment. Click OK.

8) Supplier will need to click Create Response again and respond to the amended solicitation. NOTE: The Create Response step includes attaching the supplier’s response again.

REVISED PER AMENDMENT 02

Proposal response must be submitted electronically through MissouriBUYS, powered by MOVERS, at https://missouribuys.mo.gov.

E-mailed, mailed, courier, or hand-delivered proposal responses will not be accepted.

RFP CONTACT INFORMATION:

BUYER: Ariel Bradford

PHONE NO.: (573) 751-2497

EMAIL: Ariel.Bradford@oa.mo.gov

See “RFP Questions” in Section 1 for appropriate communications during the procurement process.

DELIVER SUPPLIES/SERVICES FREE ON BOARD (FOB) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Commerce and Insurance

301 West High Street

1. After reviewing the Request for Proposal (RFP), the vendor must complete and return Exhibit A, Proposal Signature Page and all other necessary exhibits.

2. Due to lead times for obtaining the information needed to complete the various Business Compliance Exhibits herein as explained in the RFP’s Vendor Response Exhibits, vendors are encouraged to IMMEDIATELY begin securing these verifications.

3. The vendor must be registered in MissouriBUYS, powered by MOVERS in a “Prospective” or “Spend Authorized” registration status to submit a proposal. The vendor must achieve “Approved” registration status in MissouriBUYS (WebProcure/Proactis) and “Spend Authorized” registration status in MissouriBUYS, powered by MOVERS to be considered for a contract award. Reference Section 5.

AMENDMENT #01 to STATE 0000000557SL

TITLE:

Medical Care Utilization Services

CONTRACT PERIOD:

Effective Date of Contract through One Year

PLEASE BE ADVISED OF THE FOLLOWING CHANGES AND CLARIFICATIONS:

1. Closing Date has been REVISED:

As Stated: Return proposal no later than 9/16/2026 at 2:00 P.M.

Change To: Return proposal no later than 9/30/2026 at 2:00 P.M Vendors may review the revision(s) to the MissouriBUYS, powered by MOVERS electronic solicitation and the amendment document(s) at https://MissouriBUYS.mo.gov. You may be required to acknowledge the electronic amendment.

ATTENTION: IF YOU HAVE ALREADY SUBMITTED A RESPONSE TO THE SOLICITATION, ACCEPTANCE OF THE AMENDMENT AND RESUBMISSION YOUR SOLICITATION RESPONSE IS NECESSARY TO ENSURE THE STATE OF MISSOURI SUCCESSFULLY RECEIVES YOUR SOLICITATION RESPONSE.

Follow the instructions in the Reference Guide for How to Submit Response Online (https://missouribuys.mo.gov/media/pdf/movers-bid-response-instructions ) and outlined below if previously responded to the solicitation prior to the amendment issuance.

1) Log into MissouriBUYS, powered by MOVERS (https://missouribuys.mo.gov/).

2) Under Tasks click View Negotiations below Solicitations.

3) The Active Solicitations page will appear. Utilize the search filters and click on the Solicitation Number to open.

4) The Overview page will display. Click Create Response.

5) A Warning pop-up box will open. The supplier must click Yes to continue to view and acknowledge amendments.

6) The supplier should highlight the Amendment(s) and view the changes made via the amendment(s). Once the review is complete, select the Acknowledgement checkbox for each amendment and click Submit at the top right-hand corner of the page. NOTE: A Warning pop-up box will open if all amendments have not been acknowledged. Click Yes to continue.

7) A Confirmation pop-up box will open confirming amendments have been acknowledged. It will also warn that resubmission of the previously submitted response is necessary prior to response to the amendment. Click OK.

8) Supplier will need to click Create Response again and respond to the amended solicitation. NOTE: The Create Response step includes attaching the supplier’s response again.

REVISED PER AMENDMENT 02

Proposal response must be submitted electronically through MissouriBUYS, powered by MOVERS, at https://missouribuys.mo.gov.

E-mailed, mailed, courier, or hand-delivered proposal responses will not be accepted.

RFP CONTACT INFORMATION:

BUYER: Ariel Bradford

PHONE NO.: (573) 751-2497

EMAIL: Ariel.Bradfprd@oa.mo.gov

See “RFP Questions” in Section 1 for appropriate communications during the procurement process.

DELIVER SUPPLIES/SERVICES FREE ON BOARD (FOB) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Commerce and Insurance

301 West High Street

1. After reviewing the Request for Proposal (RFP), the vendor must complete and return Exhibit A, Proposal Signature Page and all other necessary exhibits.

2. Due to lead times for obtaining the information needed to complete the various Business Compliance Exhibits herein as explained in the RFP’s Vendor Response Exhibits, vendors are encouraged to IMMEDIATELY begin securing these verifications.

3. The vendor must be registered in MissouriBUYS, powered by MOVERS in a “Prospective” or “Spend Authorized” registration status to submit a proposal. The vendor must achieve “Approved” registration status in MissouriBUYS (WebProcure/Proactis) and “Spend Authorized” registration status in MissouriBUYS, powered by MOVERS to be considered for a contract award. Reference Section 5.

RFP Organization:

RFP Vendor Response Exhibits

(Return these exhibits with the proposal)

BUSINESS COMPLIANCE EXHIBITS

Separate Documents: The vendor is advised that the separate documents to this document referenced above provide additional requirements, information, and/or instruction. The separate documents must be downloaded from the Division of Purchasing’s MissouriBUYS, powered by MOVERS, website at: https://missouribuys.mo.gov/. The separate documents are downloadable from the same web page where the solicitation document is downloadable. It shall be the sole responsibility of the vendor to obtain each of the separate documents. The vendor shall not be relieved of any responsibility for performance under the subsequent contract due to the failure of the vendor to obtain a copy of the separate documents.

1. INTRODUCTION AND BACKGROUND INFORMATION SECTION

1.1 Introduction:

1.1.1 This document constitutes a request for competitive, sealed proposals for the provision of Medical Care Utilization Review Services as set forth herein for Department of Commerce and Insurance (hereinafter referred to as “state agency”).

1.1.2 Minimum Experience Qualifications: There are minimum experience qualifications in the RFP (See Section 2.2, Minimum Experience Requirements in Section 2: Scope of Work).

1.1.3 Titles: Titles of paragraphs used herein are for the purpose of facilitating reference only and shall not be construed to infer a contractual construction of language.

1.2 Background and Historical Usage Information:

1.2.1 Missouri law (sections 376.1350 – 376.1399, RSMo) outlines health care utilization review procedures for health plans subject to regulation by the state. Specifically, section 376.1387, RSMo and 20 Code of State Regulation (CSR) 100-5.020 outlines a process by which consumers who receive an adverse determination under their fully insured health plan can seek an external review of the health carrier’s determination from an independent review organization (IRO). The IRO provides the Department of Commerce and Insurance (DCI) with an independent resource to evaluate medically necessary and covered services. DCI’s Division of Consumer Affairs oversees and monitors this process. Additional information about the external review process in Missouri can be found at the following website: https://insurance.mo.gov/consumers/health/externalreviewprocess.php.

1.2.2 DCI is aware of no more than one lawsuit arising from external review activities. For historical purposes only, the case was Hundley v. Wenzel, 59 S.W.3d 1 (Mo. App. 2001).

1.2.3 The quantities below represent the total number of cases referred by DCI for external review during the calendar years 2010 to 2025. Examples of cases referred include reviews of medical necessity consisting of residential inpatient treatment (i.e. alcohol and substance dependency, mental health issues, and eating disorders); Lifevest Wearable Defibrillator – experimental or investigational; radiation therapy for cancer (i.e. proton beam radiation, IMRT, and SIRT); IVIG infusion therapy; genetic cancer testing (i.e. Decision Dx, Tempus xT, Guardant360 CDx, and myPath melanoma test); Intracept spinal nerve ablation; percutaneous peripheral spinal nerve stimulation implant (PNS); ReActiv8 restorative neurostimulation device; endoscopy with dilation of the maxillary sinus; and hypoglossal nerve stimulator.

a. 2010 – 13 cases referred

b. 2011 – 17 cases referred

c. 2012 – 28 cases referred

d. 2013 – 17 cases referred

e. 2014 – 17 cases referred

f. 2015 – 37 cases referred

g. 2016 – 58 cases referred

h. 2017 – 46 cases referred

i. 2018 – 91 cases referred

j. 2019 – 130 cases referred

k. 2020 – 117 cases referred

l. 2021 – 92 cases referred

m. 2022 –47 cases referred

n. 2023 –56 cases referred

o. 2024 –56 cases referred

p. 2025 –71 cases referred

1.2.4 For purposes of this contract, grievance is defined in section 376.1350, RSMo, found on the following website: https://revisor.mo.gov/main/OneSection.aspx?section=376.1350.

1.2.5 For purposes of this contract, an expedited review is available when the medical condition or status is as described in section 376.1389, RSMo, found on the following website: https://revisor.mo.gov/main/OneSection.aspx?section=376.1389.

1.2.6 In calendar year 2021, DCI referred three cases requesting expedited external review. In 2022, there was 1 such case. In 2023, 3 cases; in 2024, 13 cases; and in 2025, 10 cases involved expedited external review requests.

1.2.7 The state agency shall make no guarantee as to an minimum or maximum amount of services or level of work that may be required. However, the state agency notes the following about the time spent per case over the last two years:

a. 2024, the average time per case was 2.8 hours for physicians and 3.2 hours for nurse reviews

REVISED PER AMENDMENT 02

b. 2025, the average time per case was 2.8 hours for physicians and 3.2 hours for nurse reviews with the total number of hours for physician/medical professional reviewing being 201 hours and the total number of hours for nurse reviewers being 225.

ADDED PER AMENDMENT 02

1.2.8 The annual number of cases assigned to each contractor for 2023 through 2025.

a. 2023 – Vendor 1 = 19, Vendor 2 = 18, Vendor 3 = 19

b. 2024 – Vendor 1 = 19, Vendor 2 = 21, Vendor 3 = 19

c. 2025 – Vendor 1 = 24, Vendor 2 = 23, Vendor 3 = 24

1.3 Current and/or Previous Contract Information:

1.3.1 Current contracts exist for the services being obtained via this RFP. A copy of the contracts can be viewed and printed from the Division of Purchasing Awarded Bid & Contract Document Search System located on the Internet at: https://purch.oa.mo.gov/bidding-contracts/awarded-bid-contract-document-search. In addition, all proposal and evaluation documentation leading to the award of the contracts may also be viewed and printed from the Division of Purchasing’s Awarded Bid & Contract Document Search System. Please reference the current contract number RFPS30034902201029 and contract number(s) CS220129001, CS220129002, and CS220129003 when searching for these documents.

1.3.2 State Expenditures: The Missouri Accountability Portal (MAP) located on the Internet at: http://mapyourtaxes.mo.gov/MAP/Expenditures/ provides financial data related to the purchase of the services under the contract. Be sure to read the information provided in the site information and disclaimer links:

https://mapyourtaxes.mo.gov/MAP/Help/MapExpendituresHelp.htm and https://mapyourtaxes.mo.gov/MAP/Help/MapExpendituresHelp.htm#disclaimer. Then search by the contract numbers shown above when searching for the financial information.

1.4 RFP Questions:

1.4.1 Buyer is Single Point of Contact for Solicitation: Vendors and their agents (including subcontractors, employees, consultants, or anyone else acting on their behalf) must direct all of their questions or comments regarding the RFP, the evaluation, etc., to the buyer indicated on the first page of this RFP. It is preferred that questions be emailed to the buyer.

a. Except as noted herein, vendors and their agents are instructed not to contact any other state employee regarding any of these matters during the solicitation and evaluation process. Inappropriate contacts are grounds for suspension and/or exclusion from specific procurements. Vendors can be sanctioned for unauthorized contact with any evaluator under 1 Code of State Regulation (CSR) 40-1.060(8)(G) and (H) available at http://www.sos.mo.gov/adrules/csr/csr.asp.

b. Service Disabled Veteran Enterprise certification or subcontract questions should be directed to the Office of Equal Opportunity (OEO) at http://oeo.mo.gov.

1.4.2 Vendor is Responsible for Asking Questions About the RFP: It is the vendor’s responsibility to ask questions, request changes or clarifications, or otherwise advise the Division of Purchasing if the vendor believes that any language, specifications, or requirements are: (1) ambiguous, (2) contradictory or arbitrary, (3) violate any state or federal law or regulation, (4) restrict or limit the requirements to a single source, or (5) restrict or limit the vendor’s ability to submit a proposal.

1.4.3 Vendor Question Deadline: Every attempt shall be made to ensure that the vendor receives an adequate and prompt response. However, in order to maintain a fair and equitable procurement process, all vendors will be advised, via the issuance of an amendment to the RFP, of any relevant or pertinent information related to the procurement. All questions and issues should be submitted no later than ten (10) calendar days prior to the proposal closing date and time of the proposals. If not received prior to ten (10) calendar days before the proposal closing date and time, the Division of Purchasing may not be able to fully research and consider the respective questions or issues.

1.4.4 State’s Response to Vendor Questions: Upon the Division of Purchasing’s consideration of questions and issues, if the Division of Purchasing determines that changes are necessary, the resulting changes will be included in a subsequently issued RFP amendment(s); absence of such response indicates that the questions and issues were considered but deemed unnecessary for an RFP amendment. All vendors will be advised of any change to the RFP’s language, specifications, or requirements by a formal amendment to the RFP. There will be no posted written records of the questions/communications (i.e., formal question/answer document).

1.4.5 RFP is State’s Only Official Position: The only official position of the State of Missouri shall be that which is contained in the RFP and any amendments thereto.

1.5 Amendments:

1.5.1 If the Division of Purchasing determines that changes to the RFP are necessary, the resulting changes will be included in a subsequently issued RFP amendment(s) prior to the proposal closing date and time.

1.6 Glossary of Terms and Acronyms:

1.6.1 Whenever the following terms and acronyms appear in the RFP document or any amendment thereto, the definitions or meanings described below shall apply.

1.6.2 General Glossary, Acronyms, and Abbreviations:

a. Agency and/or State Agency means the statutory unit of state government in the State of Missouri for which the equipment, supplies, and/or services are being purchased by the Division of Purchasing (Purchasing). The agency is also responsible for payment, unless otherwise specified herein.

b. Amendment means a written, official modification to a solicitation or contract.

c. Attachment applies to all documents which are included with an RFP to incorporate any informational data or requirements related to the performance requirements and/or specifications.

d. Buyer means the procurement staff member of Purchasing.

e. Code of State Regulation (CSR) contains the current administrative rules of executive agencies of Missouri government. The regulations are arranged by agency rather than by subject.

f. Contract means a legal and binding agreement between two or more competent parties, for consideration for the procurement of equipment, supplies, and/or services.

g. Contractor means a supplier, offeror, person, or organization who is a successful vendor as a result of an RFP and who enters into a contract.

h. Exhibit applies to forms which are included with an RFP for the vendor to complete and submit with their proposal prior to the specified closing date and time.

i. May means that a certain feature, component, or action is permissible, but not required.

j. Must means that a certain feature, component, or action is a mandatory condition.

k. Party refers to either the State of Missouri or the contractor as an entity that may enter into a contract pursuant to the terms herein.

l. Pricing Page(s) applies to the form(s) on which the vendor must state the price(s) applicable for the equipment, supplies, and/or services required in the RFP. The pricing pages must be completed and submitted by the vendor with the proposal prior to the specified proposal closing date and time.

m. Proposal Closing Date and Time and similar expressions mean the exact deadline required by the RFP for the receipt of sealed proposals.

n. Purchase Order means the authorized document issued by the state agency to the contractor indicating descriptions, quantities, and agreed prices for products and/or services.

o. Reasonable, Necessary or Proper as used herein shall be interpreted solely by the State of Missouri.

p. Request for Proposal (RFP) means the solicitation document issued by Purchasing to potential vendors for the purchase of equipment, supplies, and/or services as described in the document. The definition includes the following sections: Introduction and Background Information; Scope of Work; Terms and Conditions (“terms and conditions” and “Terms and Conditions” are used interchangeably throughout the RFP); General Contractual Requirements; and Vendor Submission, Evaluation, and Award Information; and the RFP Vendor Response Exhibits, Attachments, and Amendments of the RFP.

q. RSMo (Revised Statutes of Missouri) refers to the body of laws enacted by the Legislature which govern the operations of all agencies of the State of Missouri. Chapter 34 of the statutes is the primary chapter governing the operations of Purchasing.

r. Shall has the same meaning as the word must.

s. Should means that a certain feature, component and/or action is desirable but not mandatory.

t. State collectively referring to the state government and/or the agencies thereof.

u. Supplier has the same meaning as the word, vendor.

v. Vendor means the supplier, offeror, person, or organization that responds to an RFP by submitting a proposal with prices to provide the equipment, supplies, and/or services as required in the RFP document.

1.7 Accuracy of Background Information:

1.7.1 Although an attempt has been made to provide accurate and up-to-date information, the State of Missouri does not warrant or represent that the background information provided herein reflects all relationships or existing conditions related to this RFP.

****END OF INTRODUCTION AND BACKGROUND INFORMATION SECTION****

2. SCOPE OF WORK SECTION

2.1 General Requirements:

2.1.1 The contractor shall provide medical care utilization review services for the Department of Commerce and Insurance (hereinafter referred to as the state agency) in accordance with the provisions and requirements stated herein and to the sole satisfaction of the state agency.

2.1.2 The contractor’s services shall primarily pertain to the state agency’s external review process; however, the services may also include providing medical expertise on health-related issues. For example, the state agency’s regulatory activities include reviewing insurance policies and products, monitoring the insurance marketplace in the state, and assisting consumers by responding to complaints and inquiries. The contractor shall understand and agree that there may be instances where the state agency seeks general medical expertise in carrying out these regulatory activities.

2.1.3 The contractor shall understand and agree that the requests for external review shall be assigned to all contractors by the state agency on a rotational basis pursuant to section 376.1387, RSMo, and the state agency will choose the rotational order in which the contractors are assigned external reviews and will maintain a record of the order.

2.1.4 The contractor shall be accredited or certified by a nationally recognized private accrediting organization for Health Utilization Management and/or an Independent Review Organization (hereinafter referred to as IRO), or have an accreditation or certification for services substantially similar to the medical care utilization review services to be provided under the contract.

a. The contractor should submit proof of IRO certification at the time of proposal submission.

2.1.5 The contractor shall have experience with medical care utilization review services and shall be certified by the state agency as a utilization review agent, pursuant to sections 374.500 through 374.515, RSMo.

REVISED PER AMENDMENT 02

a. The contractor shall submit their Certificate of Registration as a utilization review agent at the time of proposal submission.

b. The contractor shall understand and agree that it is highly desirable that the contractor has medical care referral and external review experience with other state insurance departments within the United States or the District of Columbia.

2.1.6 The contractor shall comply with all applicable State of Missouri laws and regulations, specifically sections 376.1350 through 376.1399, RSMo and 20 C.S.R. 100-5.010 through 20 C.S.R. 100-5.020.

2.1.7 The contractor shall understand and agree that the contractor and the state agency shall not be required to release the name of any medical personnel who conduct an external review throughout the duration of the contract.

2.1.8 The contractor shall understand and agree that the state agency shall electronically transmit medical cases for external review using a secure web-based platform, unless otherwise mutually agreed upon between the contractor and the state agency.

2.1.9 The contractor shall review medical cases to establish whether an admission, availability of care, continued stay, and/or other health care services meet the requirements for medical necessity, appropriateness, health care setting, efficacy, effectiveness, and level of care.

2.1.10 The contractor shall not have any history of disciplinary action taken against them by their licensing entity.

2.1.11 Identification of Debarred Individuals or Excluded Providers – The contractor shall exclude all medical personnel that meet any of the exclusion criteria specified below. The contractor shall understand and agree that the state agency shall conduct a periodic review to determine if appropriate exclusions have occurred.

a. Personnel who have failed to renew their license, certification, or registration, or have had their professional license, certification, or registration revoked;

b. Personnel who have been terminated by a state agency;

c. Personnel who have been convicted of fraud or abuse; and

d. Personnel who have been identified as having Office of Inspector General (OIG) sanctions. The contractor can access OIG sanction information at the following website: https://exclusions.oig.hhs.gov/?AspxAutoDetectCookieSupport=1, and shall maintain documentation of verification of OIG sanctions.

2.1.12 Contractor’s Obligation: Unless otherwise specified herein, the contractor shall furnish all material, labor, facilities, equipment, and supplies necessary to perform the services required herein.

2.2 Minimum Experience Requirements:

2.2.1 The contractor’s service must meet or exceed the following minimum experience requirements at the time of proposal submission and for the duration of the contract:

a. The contractor should have a minimum of one (1) year of experience with Medical Care Utilization Review Services, including services provided to another state entity.

b. The contractor should have a minimum of one (1) year of experience in providing medical expertise on health related issues.

c. The contractor should have a minimum of one (1) year of experience in electronically transmitting external reviews using a secure, web-based platform.

ADDED PER AMENDMENT 02

1) The state agency will utilize the NAIC’s State Based Services System (SBS). This is expected to be used by the contractor and the state agency will provide access and facilitate training through SBS.

d. The contractor should have a minimum of one (1) year of experience with the completion of expedited reviews.

e. The contractor should have a minimum of one (1) year of knowledge and experience with maintaining written policies and procedures that govern conflicts of interest.

f. The contractor should have a minimum of one (1) year of knowledge and experience with maintaining written policies and procedures that govern all aspects of the external review process and the expedited external review process.

g. The contractor should have a minimum of one (1) year of knowledge and experience with maintaining Quality Assurance policies and procedures.

2.3 Personnel Requirements:

2.3.1 The contractor shall include the following personnel to administer and perform the contract requirements:

a. Medical Director - The contractor shall provide a Medical Director who shall oversee all contract services provided herein and shall be available for discussion with the state agency regarding specific medical cases under review. The Medical Director shall hold a non-restricted medical license from a state within the United States or the District of Columbia.

b. Project Personnel - The contractor shall provide, at a minimum, two full time registered nurse (RN) nurse reviewers to provide medical case referrals and reviews. The registered nurse reviewers shall be licensed in a state within the United States or the District of Columbia.

REVSIED PER AMENDMENT 02

c. The contractor shall at all times have available at a minimum of two health care professionals, which shall include a physician or other health care professional with equivalent credentials in each of the 33 areas of specialty detailed in Attachment 1 – Licensed Medical Personnel Areas of Specialty.

· The contractor shall understand and agree that the health care professionals shall include medical personnel from different geographic areas (i.e., rural and urban settings) and from different working environments (i.e., physician offices, hospital inpatient and outpatient facilities, nursing homes, home health care treatment, specialized treatment centers, and managed care settings).

· The health care professionals shall be clinical peers as defined by section 376.1350(5), RSMo; shall be experts in the treatment of the medical condition of the consumer who is the subject of an external review; and shall be knowledgeable with the recommended health care service or treatment through recent and/or current actual clinical experience treating patients with the same or similar medical condition as the consumer.

· The contractor shall demonstrate availability after the contract performance commences by having a minimum of two health care professionals available in each category.

· The contractor shall understand and agree that it is highly desirable that the health care professionals are licensed in the State of Missouri.

2.3.2 The contractor’s medical personnel shall not have any history of disciplinary action taken against them by their licensing entity.

2.3.3 The contractor shall understand and agree that the state agency reserves the right to request any of the contractor’s personnel assigned to provide the services be removed without just cause. The contractor shall understand and agree that the state agency will allow the contractor a reasonable time to find a replacement. The state agency shall approve replacement personnel for the Medical Director described in paragraph 2.3.1.a and Project Personnel described in paragraph 2.3.1.b. The state agency reserves the right to require background checks and non-disclosure agreements (NDA) of selected contractor personnel, at the contractor’s expense.

2.3.4 Contact Person: The contractor shall designate a contact person who shall serve as the contractor’s contact and shall be the liaison between the contractor and the state agency by no later than five (5) business days after authorization to proceed.

2.4 Performance Requirements

2.4.1 The contractor shall understand and agree that the state agency shall electronically transmit medical cases for external review using a secure web-based platform, unless otherwise mutually agreed upon between the contractor and the state agency.

2.4.2 The contractor shall review medical cases to establish whether admission, availability of care, continued stay, and/or other health care services meet the requirements for medical necessity, appropriateness, health care setting, efficacy, effectiveness, and level of care.

2.4.3 The contractor shall provide an external review report to the state agency via a secure web-based platform indicating the contractor’s medical opinion with justification supported by the medical records concerning the medical necessity and quality of medical care within 20 calendar days of the contractor’s receipt of the state agency’s request for external review. The contractor shall understand and agree that the state agency shall have the right to modify, require changes, and/or require additional elaboration to the contractor’s external review report as deemed necessary to accomplish and fulfill the needs of the state agency.

a. The contractor’s external review report shall include the following:

1) A general description of the reason for request made by a consumer for external review;

2) The date the contractor received the assignment from the state agency to conduct the external review;

3) The date(s) the external review was conducted, and the date the external review was completed;

4) The principal reason or reasons for the contractor’s decision in the external review including what, if any, applicable evidence-based standards were a basis for the contractor’s decision, and references utilized in reaching the contractor’s decision; and

5) The rationale for the contractor’s decision.

b. Under exceptional circumstances, the contractor may request in writing to the state agency, an extension in the time to process an external review. The request for extension shall not exceed five (5) calendar days and shall include specific reasons for the request and a specific timeframe in which an external review is expected to be completed. The contractor shall understand and agree that the state agency will have the sole discretion to approve, deny, or modify any such request for extension of time.

REVSIED PER AMENDMENT 02

2.4.4 The contractor shall understand and agree that dependent upon the nature of the request for external review, the state agency may require the contractor to provide an expedited review as defined in 20 CSR 100-5.020 (16). If the state agency requires an expedited review, the contractor shall complete such review within 72 hours after receipt of the state agency’s request. The contractor shall understand and agree that holidays and weekends shall not be excluded from the request for an expedited review. A list of Missouri state holidays can be found on the following website: http://oa.mo.gov/commissioner/state-holidays.

a. The contractor shall understand and agree that the state agency shall be solely responsible for the state agency’s determination related to the appropriateness of a request for an expedited review.

b. The contractor shall understand and agree that the state agency will make every effort to provide full and complete information to the contractor upon submission of a request for an expedited review. The contractor may seek the state agency’s assistance in obtaining additional information, but in no event shall the time between when the state agency receives a request for an expedited review and when the contractor issues the decision be more than 72 hours after the receipt of a request for an expedited review by the state agency.

2.4.5 If requested by the state agency, the contractor shall attend quarterly status progression meetings with the state agency.

a. The scheduling of the status progression meetings shall be mutually agreed upon between the state agency and the contractor.

REVISED PER AMENDMENT 02

b. The location of the status progression meetings shall be at the discretion of the state agency and shall be within the State of Missouri or may be held virtually using Webex or Teams however, the meetings are not mandatory.

2.5 Conflict of Interest Requirements:

2.5.1 The contractor shall not have a conflict of interest or any appearance of a conflict of interest that will influence the contractor’s independence. The contractor shall have and maintain written policies and procedures that govern conflicts of interest, which shall allow the contractor to ascertain whether the contractor’s personnel and all clinical peers have an imminent or possible conflict of interest, as described herein.

a. Immediately following the effective date of the contract and upon request of the state agency, the contractor shall provide such policies and procedures to the state agency.

2.5.2 The contractor shall not own or control, or be owned or controlled by a health insurance issuer, a group health plan, the sponsor of a group health plan, a trade association of plans or issuers, or a trade association of health care providers.

2.5.3 The contractor’s personnel and all clinical peers shall not have a material professional, familial, or financial conflict of interest with any of the following:

a. A health carrier that is the subject of an external review;

b. A covered person whose treatment is the subject of an external review or a covered person’s authorized representative;

c. Any officer, director, or management employee of a health carrier that is the subject of an external review;

d. A health care provider, a health care provider’s medical group, or an independent practice association recommending a health care service or treatment that is the subject of an external review;

e. A facility at which a recommended health care service or treatment would be provided; and

f. A developer or manufacturer of a principal drug, device, procedure, or other therapy being recommended for a consumer whose treatment is the subject of an external review.

2.6 Recordkeeping and Reporting Requirements:

2.6.1 The contractor shall maintain written records in the aggregate by the State of Missouri and by health carriers on all external review requests. Upon request of the state agency, the contractor shall submit an annual report to the state agency in an Excel spreadsheet format via a web-based platform that shall include the following:

a. The total number of external review requests received from the state agency;

b. The total number of external review requests resolved, including the number of review requests resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;

c. The total and average length of time for an external review;

d. A summary of the types of coverage or cases for which an external review was sought;

e. The number of external reviews that were determined as the result of a reconsideration by a health carrier of its adverse determination or final adverse determination after the receipt of additional information from a consumer or a consumer’s authorized representative; and

f. Any other information requested by the state agency.

2.7 Quality Assurance Requirements:

2.7.1 The contractor shall have and maintain written policies and procedures that govern all aspects of the external review process and the expedited external review process that shall include, at a minimum, the following:

a. A quality assurance mechanism that ensures (1) that external reviews are conducted within the specified timeframes and that any required notices are provided in a timely manner; (2) the selection of qualified, knowledgeable, and impartial personnel employed by or under contract with the contractor who will conduct external reviews on behalf of the contractor; (3) the confidentiality of medical and treatment records and clinical review criteria; and (4) all personnel employed by or under contract with the contractor adhere to the requirements of all applicable state laws and regulations; and

b. A toll-free phone service that shall receive information on a 24-hour, seven day per week basis related to external reviews. The contractor’s toll-free phone service shall have the capability of accepting, recording, or providing appropriate instruction to incoming callers at all times.

2.7.2 Immediately following the effective date of the contract and upon request of the state agency, the contractor shall provide such policies and procedures to the state agency.

2.8 Contract Monitoring Requirements:

2.8.1 If there are reported concerns related to the contractor’s performance of services, if the contractor’s performance does not meet the requirements stated herein, and/or if the contractor’s services are not to the satisfaction of the state agency, the state agency shall document the performance issues and shall notify the contractor of such issues. Upon notification from the state agency of issues of concern, the contractor shall submit a written corrective action plan to the state agency within the timeframe specified by the state agency at the time of notification.

a. A corrective action plan shall include the actions the contractor proposes to take to remedy concerns, timeframes for achieving such actions, the personnel responsible for the necessary actions, the improvement that is expected, and a description of how progress shall be measured.

b. Within ten business days after receipt of a corrective action plan, the state agency will notify the contractor in writing if a corrective action plan is approved. If the state agency informs the contractor that a corrective action plan is not approved, the contractor shall submit a revised corrective action plan to the state agency within five business days.

c. Failure of the contractor to submit a corrective action plan deemed satisfactory to the state agency shall be considered a breach of contract and shall be subject to the remedies available to the State of Missouri, including breach of contract.

d. The contractor shall adhere to any state agency approved corrective action plan. Failure of the contractor to take corrective action as indicated in the state agency approved corrective action plan within 90 calendar days shall be considered a breach of contract and shall be subject to the remedies available to the State of Missouri, including contract cancellation.

2.9 Electronic Funds Transfer, Invoicing, and Payment Requirements and Travel Expenses:

2.9.1 Electronic Funds Transfer (EFT): The State of Missouri will submit contract payments to the contractor at the remittance address listed in the contractor’s MissouriBUYS (WebProcure/Proactis) vendor registration. However, the contractor understands and agrees the state reserves the right to make contract payments to the contractor through electronic funds transfer (EFT). Therefore, prior to any payments becoming due under the contract, the contractor must verify and update, if applicable, their vendor registration with their current remittance address and ACH-EFT payment information at https://MissouriBUYS.mo.gov.

2.9.2 Invoicing: The contractor shall submit invoices no later than 60 business days after an external review has been completed.

a. The contractor shall invoice the state agency on the contractor’s original descriptive business invoice form and submit the invoice to the address on the front page of this document / the following address:

Department of Commerce and Insurance

Attention: Director, Consumer Affairs Division

P.O. Box 690

Jefferson City, MO 65102

b. The contractor’s itemized invoice shall include each external review received by the state agency and the total number of hours worked for each medical personnel classification indicated on Exhibit C, Pricing Page.

c. The contractor shall use uniquely identifiable invoice numbers to distinguish an invoice from a previously submitted invoice and shall include on the invoice the remittance address listed in the contractor’s MissouriBUYS (WebProcure/Proactis) vendor registration.

d. Each contractor invoice must be on the contractor’s original descriptive business invoice form and must contain a unique invoice number and the remittance address included in the contractor’s MissouriBUYS (WebProcure/Proactis) vendor registration. The invoice number will be listed on the state’s EFT addendum record to enable the contractor to properly apply state payments to invoices. The contractor must comply with all other invoicing requirements stated in the RFP.

e. The statewide financial management system has been designed to capture certain receipt and payment information. For each purchase order received, an invoice must be submitted that references the purchase order number and should be itemized in accordance with items listed on the purchase order. Failure to comply with this requirement may delay processing of invoices for payment.

f. The contractor shall not invoice federal or state taxes unless otherwise required under law or regulation.

2.9.3 Payment: Upon approval of the contractor’s itemized invoice, the contractor shall be paid in accordance with the applicable per hour, per person price stated on Exhibit C, Pricing Page of the contractor’s awarded proposal.

a. The applicable per hour, per person price shall be prorated in 15-minute increments of hourly time for services actually provided.

b. Payments are due upon receipt of a valid invoice, payable in 30 calendar days. All invoices for equipment, supplies, and/or services purchased by the State of Missouri shall be subject to late payment charges as provided in section 34.055, RSMo.

c. The State of Missouri does not pay state or federal taxes unless otherwise required under law or regulation.

d. The State of Missouri assumes no obligation for equipment, supplies, and/or services shipped or provided in excess of the quantity ordered. Any unauthorized quantity is subject to the state's rejection and shall be returned at the contractor's expense.

e. The contractor may obtain detailed information for payments issued for the past 24 months from the State of Missouri’s central accounting system (SAM II) on the Vendor Services Portal at https://www.vendorservices.mo.gov/vendorservices/Portal/Default.aspx.

2.9.4 Travel Expenses: The contractor must have the prior written approval of the state agency for any travel related expenses.

a. The contractor shall invoice and be reimbursed for actual and reasonable travel expenses either at the Contiguous US Per Diem Rates (CONUS) or the travel reimbursement rates set by the contractor’s internal written policy, whichever is lower.

1) The CONUS can be found by clicking on the link for “Per Diem Rates” at the following Internet address: http://www.gsa.gov.

b. The contractor must have the prior written approval of the state agency for any travel related expenses that may exceed the CONUS rates.

c. Other Miscellaneous Travel Expenses – The contractor shall be reimbursed the actual amount of other travel expenses incurred, provided that the state agency approved the possibility for and estimates of such expenses in advance and that the actual expenses incurred are reasonable for the location in which the travel occurred.

d. Travel Expenses Invoicing and Payment – The contractor must itemize all expenses incurred including miles traveled on the invoice submitted to the state agency for reimbursement and must attach original receipts for travel expenses.

1) The contractor shall be reimbursed for such travel expense, after receipt of all required documentation and approval by the state agency of the invoice and documentation.

2) In no event shall the contractor be reimbursed for any…