RFI 30-2025-026-DHB Due Process Appeals Clearinghouse.pdf

RFI 30-2025-026-DHB: Page 1 of 14 Rev. 2025.03.27 Due Process (Appeals) Clearinghouse

STATE OF NORTH CAROLINA REQUEST FOR INFORMATION NO.

30-2025-026-DHB

Department of Health and Human Services Division of Health Benefits

Issue Date: June 25, 2025 Due Date: July 30, 2025

Refer ALL Inquiries regarding this RFI to:

Michael Brown – Contract Specialist michael.c.brown@dhhs.nc.gov Medicaid.Procurement@dhhs.nc.gov

Commodity Number: 811620 Description: Due Process (Appeals) Clearinghouse

Solution Using Agency: North Carolina Department of Health and

Human Services, Division of Health Benefits

This Request for Information (“RFI”) is available electronically on the North Carolina electronic Vendor Portal (“NC eVP”) at https://evp.nc.gov/.

The purpose of this RFI is to survey the market for information requested herein and not to award a contract. Submission of a response does not create an offer, and no award will result by submitting a response.

The State recognizes that considerable effort may be required in preparing a response to this RFI. However, the Respondent shall bear all costs for preparing and submitting a response. Information obtained through this RFI process may be used to develop a future solicitation.

Responses to this RFI will be received until 2:00 p.m. EST, July 25, 2025.

EXECUTION

RESPONDENT NAME: E-MAIL:

STREET ADDRESS: P.O. BOX: ZIP:

CITY & STATE: TELEPHONE NUMBER: TOLL FREE TEL. NO:

TYPE OR PRINT NAME & TITLE OF PERSON SIGNING: FAX NUMBER:

AUTHORIZED SIGNATURE:

DATE:

mailto:michael.c.brown@dhhs.nc.gov mailto:Medicaid.Procurement@dhhs.nc.gov https://evp.nc.gov/

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Table of Contents

SECTION I. RESPONDENT QUESTIONS, RESPONSE INSTRUCTIONS, AND CONFIDENTIALITY

A. Anticipated Schedule B. Instructions for Developing Responses C. Instructions for Submitting Responses D. Notice Regarding Confidentiality

SECTION II. RIGHTS AND OBLIGATIONS

A. Rights to Submitted Material B. Obligations of the State

SECTION III. DUE PROCESS (APPEALS) CLEARINGHOUSE SOLUTION

A. Background and Program Information B. Purpose of the RFI C. Definitions and Acronyms D. Desired Outcomes E. Standard Requirements

SECTION IV. REQUESTED INFORMATION FROM RESPONDENT

A. Content and Format B. Information about Respondent C. Solution Functionality and Performance D. Financial / Total Cost of Ownership E. Implementation Timeline

ATTACHMENT 1

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SECTION I. RESPONDENT QUESTIONS, RESPONSE INSTRUCTIONS, AND CONFIDENTIALITY

A. Anticipated Schedule

The Department Contract Specialist will make every effort to adhere to the following schedule.

Action Responsibility Date Time (EST)

RFI Issued Department June 25, 2025

Responses Due Respondent(s) July 30, 2025 2:00 pm

Table 1 – Anticipated Schedule

B. Instructions for Developing Responses When developing Responses to this RFI, the Respondent should consider the following:

1. Read and carefully review all Sections of this RFI.

2. Prepare responses in a straightforward and detailed manner. Responses are to be submitted to the

Department according to the instructions found on the cover page of the RFI and this Section II.

3. Complete the Execution section on Page 1 of this RFI and number the pages in the responses.

4. Clearly identify the specific question, section, and subsection number(s) or other identifier that corresponds with each response. This allows the Department to clearly understand the specific questions or items addressed. To the extent possible within each section of the response, the items should be addressed in the order in which they appear in the RFI.

5. Provide detailed information in a format that may include a narrative, exhibits, charts, tables or other artifacts that support the response.

6. Responses to all questions and items within the RFI are encouraged but there is no obligation to do so.

7. The Department reserves the right to contact any Respondent and request additional information.

Include the contact information for the individual(s) best suited to engage with the Department.

C. Instructions for Submitting Responses

1. Respondent must submit their response to this RFI via the Ariba Sourcing Tool by the specified time and date provided in the Anticipated Schedule.

2. When submitting a response, include all pages of the RFI, a completed and signed EXECUTION

Section on page 1, and responses to the requested information contained in Section IV.

3. The following copies are required to be provided to the Department in response to this RFI:

a. One (1) electronic copy of the signed, completed response identified as RFI #30-2025-026-DHB

- Respondent’s Name.

b. One (1) electronic copy of a redacted response in accordance with Chapter 132 of the North Carolina General Statutes, the Public Records Act, identified as RFI #30-2025-026-DHB - Respondent’s Name - Redacted. For the purposes of this RFI, redaction means to edit a document by obscuring or removing information that is considered confidential and/or proprietary by the Respondent and that meets the definition of Confidential Information set forth in G.S. 132-1.2. Any information removed by the Respondent should be replaced with the word, “Redacted.” If Respondent’s response does not contain Confidential Information, the Respondent must submit a signed statement to that effect identified as RFI #30-2025-026-DHB

- Respondent’s Name - Statement of Confidential Information.

4. The electronic copies of the response must not be password protected.

5. The electronic copies of the response must be in PDF format.

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For training on how to use the Ariba Sourcing Tool to view solicitations, submit questions, develop responses, upload documents, and submit offers to the State, Respondents should go to the following site: https://eprocurement.nc.gov/training/vendor-training.

Questions or issues related to using the Ariba Sourcing Tool itself can be directed to the North Carolina eProcurement Help Desk at 888-211-7440, Option 2. Help Desk representatives are available Monday through Friday from 7:30 AM EST to 5:00 PM EST.

D. Notice Regarding Confidentiality

1. Per NCGS 132-1, et seq., information or documents provided to the Department in response to this RFI are Public Record and subject to inspection, copy and release to the public unless properly marked and exempt from disclosure by statute, including, but not limited to, NCGS § 132-1.2.

2. As provided for in the North Carolina Administrative Code (NCAC), including but not limited to 01 NCAC 05B .0103, 09 NCAC 06B .0103 and 09 NCAC 06B .0302, all information and documentation whether electronic, written or verbal relative to the development of a contractual document for a proposed procurement or contract shall be deemed confidential in nature. In accordance with these and other applicable rules and statutes, such material shall remain confidential until the award of a contract or until the need for procurement no longer exists. Any proprietary or confidential information, which conforms to exclusions from public records as provided by NCGS § 132, must be clearly marked as such with each page containing the trade secret or confidential information identified in boldface as “CONFIDENTIAL.” If only a portion of each page marked “CONFIDENTIAL” contains trade secret information, the trade secret information shall be designated with a contrasting color or by a box around such information. In addition to marking confidential information as required by NCAC 05B.0103, confidential pages or portions of the response shall be reflected in the redacted copy identified as RFI 30-2025- 026-DHB - Respondent’s Name – Redacted. By submitting a redacted copy, the Respondent warrants that it has formed a good faith opinion, having received such necessary or proper review by counsel and other knowledgeable advisors that the portions marked confidential and redacted meet the requirements of NCGS §132. The Respondent must identify the legal grounds for asserting that the information is confidential, including the citation to state law.

SECTION II. RIGHTS AND OBLIGATIONS

A. Rights to Submitted Material

All responses, inquiries or correspondence relating to or in reference to this RFI, and all documentation submitted by the various Respondents shall become the property of the Department when received.

Ideas, approaches, and options presented by Respondents may be used in whole or in part by the State in developing a future solicitation should the Department decide to proceed with a solicitation.

Further, combinations of ideas from various Respondents may also become part of a solicitation, based on consideration of various RFI submissions and the needs of the Department, which may differ from any Respondent’s experience in other places.

B. Obligations of the State The Department may choose to issue a solicitation for the procurement of a solution. However, this RFI is not a guarantee that a solicitation will be issued for any or all of the services or systems referenced herein, about which ideas and approaches are being sought. As provided in Section I.E of this RFI, information submitted by Respondents for this RFI will remain confidential until after the award of any solicitation or until the State decides not to issue a solicitation.

https://eprocurement.nc.gov/training/vendor-training

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SECTION III. DUE PROCESS (APPEALS) CLEARINGHOUSE SOLUTION

A. Background and Program Information

The 14th Amendment of the U.S. Constitution and North Carolina Gen. Stat. §108A-70.9 entitle Medicaid beneficiaries to due process and requires the Department to provide beneficiaries with a pathway to dispute and resolve their respective grievances and appeals, including the right to receive a fair hearing when that hearing is formally requested as described in Title 42 of the U.S. Code of Federal Regulations (CFR) and in North Carolina General Statute.

On October 1, 2008, North Carolina Session Law 2008-118 transferred Medicaid due process responsibilities to North Carolina Office of Administrative Hearings (OAH) for all Medicaid beneficiaries appealing the reduction or denial of services. In September 2015, the North Carolina General Assembly (General Assembly) enacted North Carolina Session Law 2015-245, directing the transition of North Carolina’s Medicaid program from a predominantly Fee-for-Service model to a predominantly Managed Care model. North Carolina State law requires the North Carolina Department of Health and Human Services (“Department”), through the Division of Health Benefits (DHB or NC Medicaid), to serve as the State Medicaid Agency (SMA) and operate a Medicaid Managed Care program. Currently, the North Carolina Medicaid program consists of a Medicaid Fee-For-Service model (Medicaid Direct) and a Medicaid Managed Care model.

In the Medicaid Managed Care model, the Department contracts with Pre-paid Health Plans (PHP) and Pre-paid Inpatient Health Plans (PIHP) to provide physical health, behavioral health, and intellectual and developmental disability services to Medicaid beneficiaries. Medicaid beneficiaries are enrolled in either Medicaid Direct or Managed Care based on physical and behavioral health needs. Both models authorize physical and behavioral health services and adjudicate claims submitted by providers for payment for services provided to beneficiaries. Vendors and Managed Care Plans are required by 42 CFR Part 438, Subpart F, and North Carolina Gen. Stat. §108A-70.9 and 108D, to provide written notice of the decisions and due process rights to each member or their authorized representative when services or payment for services rendered are denied, in whole or in part. Members and their authorized representatives may challenge service denials, terminations, suspensions, and denial of payment for services rendered through an appeal process that is separate from the provider appeal process. On July 1, 2021, NC Session Law 2021-62 modified the Medicaid rules to allow Medicaid beneficiaries an option to file oral appeals in addition to written appeals.

The Department is required by new CMS Final Rule 42 CFR Part 438, Subpart F to monitor all of the independent, third-party vendors that make determinations regarding services subject to prior authorization, as well as those that issue adverse benefit determinations. This includes PHPs, PIHPs (Local Managed Entities), and Managed Care Organizations, to ensure compliance with State and Federal requirements related to Medicaid beneficiary grievances and appeals (“Due Process and Beneficiary Appeals”).

In accordance with N.C. Gen. Stat. 108A and 108D, vendors and Managed Care entities are required to provide OAH with an electronic copy of each notice. To support compliance, NC Medicaid utilizes a clearinghouse to receive all adverse determinations from vendors and Managed Care entities through a secure file transfer, making the notices available to OAH upon receiving a state fair hearing request.

A vendor under contract with the Division of Health Benefits currently operates and maintains a single-portal, web-based platform, that includes the following:

• Secure, password-encrypted access;

• Electronic, centralized data collection, reporting, and monitoring;

• Data analytics; and

• Financial analytics.

The Department requires a single web-based platform that provides consistent and reliable reports and analyses, drawn from a robust and integrated database, and allows for the secure electronic upload and storage of all letters of adverse determination produced under all delivery systems. The files include, RFI 30-2025-026-DHB: Page 6 of 14 Rev. 2025.03.27 but are not limited to, beneficiary notifications of adverse benefit determination (NABD) letters, appeal extension letters, expedited appeal request reviews, final agency decisions, reports from mediators, and OAH submitted forms and grievances associated with appeals. These documents create an “appeal file”. The solution clearinghouse must be capable of storing, tracking and organizing the appeal file by individual case, date of NABD, service type, and agency type.

The Vendors and Plans are required to be uploaded daily and upon request, in accordance with contractual agreements. Other agencies, such as OAH, upload documents following the completion of mediations and State Fair Hearings. The clearinghouse must provide all users with confirmation of a successful upload or an error report within twenty-four (24) hours of upload. The report must be made available to the State Medicaid Agency for oversight and ensure compliance with contractual requirements.

Beneficiaries may request an expedited review of appeals at the local level or during the State Fair Hearing process. The expedited appeal process involves Health plans, Vendors, and the Department receiving and reviewing appeal documents containing Protected Health Information (PHI). Decisions must be made within seventy-two (72) hours. Since the need to share documents uploaded to the clearinghouse is time-sensitive, the solution must include a system that will allow uploaded documents to be available for viewing in a secure format within twenty-four (24) hours of upload. Sharing functionality includes viewing and exporting individual documents or the appeal file. Documents should be accessible to be viewed by multiple authorized users at the same time.

The Solution should provide all the services and materials related to Due Process and Beneficiary Appeals, as well as all software and systems to the State, in order to fulfill the State and Federal requirements regarding Due Process and Beneficiary Appeals.

B. Purpose of the RFI

The purpose of the RFI is to:

1. Solicit feedback from potential vendors with experience developing and deploying solutions to operate and maintain the Due Process (Appeals) Clearinghouse Solution that will perform the requirements of the Due Process and Beneficiary Appeals Program.

2. Obtain a rough order magnitude estimate of the total cost of ownership to develop, implement, and maintain the solution defined in the RFI.

3. Obtain information which may be used to develop a Request for Proposal (RFP) to solicit a vendor to provide, operate and maintain a Due Process (Appeals) Clearinghouse Solution to the Department.

C. Definitions and Acronyms

1. Adverse Determination: a determination to deny, terminate, suspend, or reduce a Medicaid service or an authorization for Medicaid service. [42 CFR 438.400(b), N.C. Gen. Stat. 108A- 70.9A(a), 108D-1(1)].

2. CFR: Code of Federal Regulations

3. Claim: A request for payment for services and benefits provided by the medical Provider

4. Clearinghouse: A public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and “value-added” networks and switches are health care clearinghouses if they perform these functions): 1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction; 2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity.

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5. CMS: Centers for Medicare & Medicaid Services. A federal agency within the U.S. Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer Medicaid.

6. Denied Claim: A claim is denied if the program does not cover the services rendered

7. Department: Collectively North Carolina Department of Health and Human Services, Division of

Health Benefits

8. DHB: Division of Health Benefits also referred to as NC Medicaid

9. DOJ: Department of Justice

10. EDI: Electronic Data Interchange. A standardized method for businesses to exchange business documents electronically.

11. EPSDT: Early Periodic Screening, Diagnosis and Treatment. Program combines screening, diagnostic and treatment services to Medicaid-eligible individuals

12. HCPCS: Healthcare Common Procedure Coding System: a standardized coding system used to report medical procedures, supplies, and services to Medicare, Medicaid, and other health insurance programs.

13. Health Plan: An entity that assumes the risk of paying for medical treatments.

14. HIPAA: Health Insurance Portability and Accountability Act of 1996, as amended and its promulgating regulations

15. ICD10: a set of Electronic Data Interchange (EDI) standards, specifically HIPAA X12, mandated by the Health Insurance Portability and Accountability Act (HIPAA) for the electronic exchange of healthcare transactions like claims, eligibility inquiries, and remittance advice.

16. LME: Local Managed Entities: Manage the care of NC Medicaid beneficiaries who receive services for mental health, developmental disabilities or substance use disorders.

17. MCO: Managed Care Organizations: Manage the care of NC Medicaid beneficiaries who receive services for mental health, developmental disabilities or substance use disorders.

18. MIS: The Medicaid Integration Services (MIS) platform is a centralized infrastructure that facilitates seamless data exchange and integration across various Medicaid systems, partners, and stakeholders. It acts as a common foundation for all Medicaid Enterprise System (MES) modules, ensuring interoperability and efficient data transfer.

19. NC DHHS: North Carolina Department of Health and Human Services

20. NC eVP: North Carolina electronic Vendor Portal located at https://evp.nc.gov/

21. NABD: Notices of Adverse Benefit Determination. Informs a beneficiary that a health plan has declined, in whole or part, a requested treatment or service, and outlines their appeal rights and the process.

22. NCAC: North Carolina Administrative Code at http://reports.oah.state.nc.us/ncac.asp

23. NCGS: North Carolina General Statutes at https://www.ncleg.gov/Laws/GeneralStatutesTOC

24. NCID: The North Carolina Identity Management Service (NCID) is the standard identity and access management platform provided by the Department of Information Technology.

25. OAH: Office of Administrative Hearings. An independent forum for prompt and impartial resolution of administrative law contested cases involving citizens and state agencies, investigation of alleged unlawful employment practices in state government, and codifying administrative rules.

26. PHP: Pre-paid Health Plans: Also known as managed care plans, are a type of health insurance where individuals pay a fixed monthly premium to receive healthcare services.

27. PIHP: Pre-paid Inpatient Health Plans: organizations that manage Medicaid services related to mental health, intellectual/developmental disabilities, and substance use disorders within specific geographic areas under contract with the state.

28. Provider: A person who is trained and licensed to give health care. Also, a place that is licensed to give health care.

https://evp.nc.gov/ http://reports.oah.state.nc.us/ncac.asp https://www.ncleg.gov/Laws/GeneralStatutesTOC

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29. RFI: Request for Information

30. UR: Utilization Review: a process designed to ensure that medical care is effective, efficient, and in line with evidence-based standards of care.

31. UR Vendor: A vendor contracted by the Department to conduct medical necessity reviews of prior authorization requests for Medicaid beneficiary services.

32. X12: a set of Electronic Data Interchange (EDI) standards, specifically HIPAA X12, mandated by the Health Insurance Portability and Accountability Act (HIPAA) for the electronic exchange of healthcare transactions like claims, eligibility inquiries, and remittance advice.

D. Desired Outcomes The solution should have the capability to provide the following functionality:

1. Through the Due Process (Appeals) Clearinghouse Solution:

a. Multiple agencies upload and access records and documents necessary for resolution of

Medicaid beneficiary requests for appeal of adverse determinations in compliance with all Title 42 U.S. CFR and North Carolina General Statutory requirements. These agencies consist of the following:

i. State Office of Attorney General;

ii. Office of Administrative Hearings;

iii. Division of Health Benefits Chief Medical Officer;

iv. State policy experts;

v. Managed Care Plans; and

vi. UR Vendors.

b. Provide the State Medicaid agency performance and fiscal reports on activities related to the Due Process and Beneficiary Appeals Program.

2. The Due Process (Appeals) Clearinghouse Solution should support:

a. Managed Care Plans, UR Vendors, mediations, and OAH documentation uploads.

b. Seamless sharing of information among multiple agencies responsible for timely resolution of appeal requests at informal mediations and formal fair hearings.

c. Informed defense information of Medicaid's adverse determination decisions.

d. Quality assurance of the elements of formal beneficiary communications including tracking and reporting of:

i. Adherence by UR Vendors, Managed Care Organizations and Local Managed Entities to required timelines for issuance of notices of adverse determination;

ii. Compliance with the State and Federal requirements for addressing and letter dating regarding adverse determination letters;

iii. Required rationale for adverse determinations and policy citations within adverse determination documents; and

iv. Maintenance of Services and Continuation of Benefits during pendency of appeals, including cost analysis.

e. Data analytics related to timeliness of appeal resolution by UR Vendor, appeal volume by service type, successful ingestion of notices (Sample Attachment 1) and EPSDT reviews conducted for beneficiaries under twenty-one (21) years old; and

f. Financial analytics related to efficiency of the Due Process and Beneficiary Appeals Program, costs of Maintenance of Service and cost effectiveness of prior authorization within service types.

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3. Monitoring and data analytics on processes of resolution of informal (MCO/capitated plans: first level reconsideration requests) and formal requests for appeal of adverse determinations for all service types subject to prior authorization in order to:

a. Have compliance with State and Federal laws and regulations.

b. Ensure issuance of timely adverse determinations.

c. Verify timely resolution of beneficiary appeal requests.

d. Provide proactive forecasts and risk assessments.

e. Eliminate performance gaps in issuance of adverse determinations to Medicaid beneficiaries.

f. Minimize service side impacts of errors in issuance of adverse determinations.

g. Provide fiscal analysis and reports on outcomes of the State appeal process.

h. Forecast, assess and manage risk.

i. Monitor authorization rates and other metrics to identify potential issues in care access and delivery.

E. Standard Requirements

1. Implementation of the law requires a system with the following capabilities:

a. Secure electronic upload and storage of all letters of adverse determination produced by Utilization Review Vendors and Managed Care entities;

b. Secure electronic upload, storage and tracking of documents generated in the course of resolution of final beneficiary appeal requests, by beneficiary name, identifier, individual case number and by service type. Documents include (but may not be limited to), the initial adverse determination, its associated appeal request, reports of mediators, OAH submitted forms and final agency decisions.

c. Ingest thousands of pages daily and organize notices based on key words and phrases;

d. Identify key words and phrases from narrative style and form field style templates and organize documents in a manner that can be easily located by key search words.

e. The system dashboard and search capabilities should be user-friendly.

f. Secure (role-based security access) sharing of case-related documents among multiple agencies, including:

i. North Carolina Department of Justice;

ii. OAH or other entities with which the State contracts for resolution of appeal requests;

iii. DHB Chief Medical Officer;

iv. DHB or its contracted agents, Subject Matter Experts (Clinical Policy); and

v. Utilization Review (UR) Vendors.

g. Capacity to perform data analytics related to:

i. Timely resolution of appeal requests;

ii. Quantity of appeal requests filed, by service type, UR Vendor, date and beneficiary;

iii. Monitoring of UR Vendor and Managed Care Plan’s performance in deciding and defending adverse determinations;

iv. Compliance with Clearinghouse ingestion requirements through interactive real-time dashboards;

v. Comparative analysis and trending service types by Managed Care Plan, Medicaid

Direct and demographics such as age and geographic location;

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vi. Assurance of assignment of benefit continuation during the pendency of an appeal; and

vii. Adherence of required content of formal communications to State and Federal statutory requirements.

h. Capacity to perform fiscal analytics related to:

i. Costs and cost-effectiveness of the Division of Health Benefits processes related to delivery of an integrated system of appeal request resolution;

ii. Costs associated with continuation of benefits during pendency of appeals (Maintenance of Services); and

iii. Assessment of costs related to prior approval of specific service types.

i. Capacity to perform monitoring of UR Vendor product outputs related to Due process and audits related to contract metrics for UR Vendors submitting adverse determinations.

j. Provides the option of uploading notices manually or through optical character resolution.

k. Capability to identify errors before the document upload is completed manually to avoid ingestion failure or duplicates.

l. Capability of developing a web-based oral (telecommunication) appeal form that mirrors the State’s Fair Hearing Form (Attachment 1); populated with appeal information shared by beneficiaries and authorized representatives. The solution must have the capability of creating a record of the call to include:

i. Date and time of the call;

ii. Start and stop time;

iii. Member’s name;

iv. Telephone number;

v. Identification number; and

vi. all information included on the attached State Fair Hearing Form.

m. Capability to produce routine and ad-hoc reports for DHHS leadership and stakeholders to provide high level and granular data for Vendors and Managed Care entities.

n. Capacity to provide detailed reports related to Clearinghouse ingestion errors for Managed Care Plans and vendors.

o. Flexibility to update the Clearinghouse system as laws, templates and new programs are established.

2. This comprehensive set of monitoring and analytic functions is needed to ensure and verify:

a. State Medicaid beneficiaries are appropriately served in accordance with all Federal Due

Process guarantees and CFR requirements.

b. The State Medicaid agency and its agents are compliant with State and Federal laws and regulations applicable to Medicaid's Due Process mandate.

c. The State operates its Due Process and Beneficiary Appeals Program in a uniform, efficient, fiscally responsible, and cost-effective manner.

d. The solution provides the Department with notification of OAH filings and sends Vendors email confirmation of uploads.

e. The solution sends notification to parties should outage occur and maintain emergency backup system to avoid business interruption.

f. The solution has the ability to receive transferring documentation.

g. Cloud storage should be sufficient to store documents dating back to 2010 (Estimated capacity 550GB) and the ability to store approximately 50GB per year.

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h. Capability for predictability and trend analytics to determine the frequency of denials based on ingestion and identify potential technical issues based on trend.

i. Ability to maintain firewalls between the Department and OAH access.

j. Ability to function as an audit tool and maintain review history.

k. Interface with vendors and Managed Care Entities for document sharing related to grievances, expedited appeals and state fair hearings.

l. Ability to send outbound communication to vendors and Business Units when documents are uploaded daily.

m. Ability to send weekly communication regarding successful ingestion of notices and provide details on notices that failed to ingest or ingested with errors.

n. Ability to randomly pull Notices of Adverse Benefit Determination (NABD) from various UR vendors and Managed Care Plans to conduct compliance reviews using prepopulated options, store the outcome of the reviews and produce reports to display the findings.

o. Data should be available 99% of the time 8 am to 5 pm, allow for no more than the loss of 2 hours of data and recover from issues within 3 hours.

SECTION IV. REQUESTED INFORMATION FROM RESPONDENT

A. Content and Format The Department requests concise, detailed responses to the inquiries in Sections IV.B. and IV.C below.

The response in its entirety shall be limited to ten (10) pages.

B. Information about Respondent

1. Responses should provide an overview of Respondent company’s history, scope of products and services offered, and locations of operation. Response should describe Respondent(s) experience providing solutions similar in size and scope to the projects desired outcomes.

2. Response should provide the following:

a. Description of the Respondent’s primary customer base or market, including other state

Medicaid programs;

b. Description of relevant additional services offered by Respondent;

c. Listing of states or agencies which utilize Respondent’s solution in a manner that is the same as or similar to those required by this RFI. Response should include the state/agency name, most recent implementation, contract start and end date, description of scope of work, the duration of the any contracts, and the termination dates; and

d. Lessons learned from working with other states or agencies to implement a solution of similar size, scope and with requirements the same or similar to those required by the Department.

C. Solution Functionality and Performance Respondents should provide detailed information regarding their Solution and associated capabilities on how the desired outcomes are achieved to include sufficient information in the following areas:

1. Solution Architecture

a. Describe how the solution captures EDI healthcare data with secure sharing of case-related documents.

b. Describe how the solution would leverage DHB Enterprise Architecture and the Medicaid Integration Services (MIS) platform for data ingestion, analytics, and security services to access the DHHS repository for all beneficiary adverse notices and state fair hearing documentation.

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c. Describe the features and capabilities of the tools used to build, operate, and automate functions of the solution.

2. Data

a. Describe how the solution supports storing and viewing both the raw and curated data.

b. Describe any import/export and/or extraction translation and load tools included in the solution.

3. Analytics and Reporting.

a. Describe the solution’s capability to generate summarized, detail, and custom reports.

4. Operations

a. Describe the level of business resources the Department would need to implement, support, and maintain the solution.

b. Describe the level of IT resources Department would need to implement, operate, and maintain to support the solution.

c. Describe the solution’s capability to align with national standards such as X12 changes and

ICD10 and HCPCS code changes.

5. Security

a. Describe if the solution provides a portal and, if so, how the Department would access the portal while maintaining security measures.

b. Describe how the solution can integrate with NCID, the statewide identity management system.

c. Describe how your proposed solution complies with applicable security standards identified by the State.

• NCDHHS Privacy Manual and Security Manual, both located here:

https://policies.ncdhhs.gov/departmental/policies-manuals/section-viii-privacy-and-security

• NC Statewide Information Security policies, located here:

https://it.nc.gov/resources/cybersecurity-risk-management/esrmo-initiatives/statewide-information-security-policies

• HIPAA Requirements https://www.hhs.gov/hipaa/for-professionals/privacy/index.html https://www.hhs.gov/hipaa/for-professionals/security/index.html https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html

6. User-friendly interface

a. Describe the system’s user-friendliness and ease of use of the system in navigating the interface.

b. Describe the system’s compliance with the Section 508 accessibility requirements (If it is a public facing website).

D. Financial / Total Cost of Ownership

1. Respondents are asked to provide information regarding estimated costs to procure and operate a

Solution as described in this RFI. This information will help the Department understand acquisition and on-going costs and be used to support budget development and funding requests.

2. Respondents are asked to provide cost information in the format of the Respondent’s choosing, and to the extent possible, include the following:

https://policies.ncdhhs.gov/departmental/policies-manuals/section-viii-privacy-and-security https://it.nc.gov/resources/cybersecurity-risk-management/esrmo-initiatives/statewide-information-security-policies https://it.nc.gov/resources/cybersecurity-risk-management/esrmo-initiatives/statewide-information-security-policies https://www.hhs.gov/hipaa/for-professionals/privacy/index.html https://www.hhs.gov/hipaa/for-professionals/security/index.html https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html

RFI 30-2025-026-DHB: Page 13 of 14 Rev. 2025.03.27

a. An estimated cost model or likely range of costs to purchase, implement, and operate the described solution including the cost items in Table 2. Include any basis of estimates and assumptions used to develop the costs; and

Cost Items Guidance

Implementation Services Describe the scope of services provided during the Implementation phase

Implementation Fees Describe other fees required during the implementation phase

Annual Software Licensing Fees Provide any annual software licensing fees

Annual Software Maintenance Fees Provide any annual software maintenance fees

Annual Cloud Hosting Fees Provide any annual cloud hosting fees

Annual Other Fees Describe any other annual fees

Other Unit Costs - Describe Describe any unit costs associated with event driven activities or cost per unit of data storage or similar.

Table 2 – Cost Items

b. If pricing information is limited or unavailable, describe Respondent’s preferred pricing model or structure, including unit costs based on key variables. Include any basis of estimates and assumptions used to develop the costs.

3. Respondents will not be held to pricing estimates provided in response to this RFI should the Department decide to proceed with a competitive solicitation.

E. Implementation Timeline

1. Respondents are asked to provide information regarding estimated Implementation schedules and timelines including the project phases listed in Table 3. This information will help the Department understand the time required to plan, design, develop, and implement the solution.

Phase Guidance Range of Time

Planning Provide scope of activities during the planning phase

Design Provide scope of activities during the design phase

Development Provide scope of activities during the development phase

Implementation Provide scope of activities during the implementation phase

Table 3 – Project Phases

RFI 30-2025-026-DHB: Page 14 of 14 Rev. 2025.03.27

ATTACHMENT 1

STATE FAIR HEARING ORAL REQUEST FORM

Date: PA:

Office of Administrative Hearings (OAH) Attention: Clerk of Court

1711 New Hope Church Road Raleigh, NC 27609

Fax: 984-236-1871

[ ] DHHS [ ] MCO [ ] PHP

Beneficiary would like to appeal 's decision on their request for .

Reason for Appeal?

Beneficiary is requesting an interpreter to assist during the appeal. Beneficiary’s primary language is:

Español Sign Language Other:

Beneficiary is requesting an expedited State Fair Hearing

Beneficiary will (PLEASE CHECK ONE)

Represent themselves

Be represented by someone else

If choosing a representative, complete the section below:

Name of Representative:

Relationship to Beneficiary:

Mailing Address:

Telephone of Representative

The beneficiary/caller hereby affirms that the information they have provided over the telephone is accurate to the best of their ability. The beneficiary/caller understands that the North Carolina Office of Administrative Hearing (OAH) administers the State Fair Hearing but is not the Medicaid State Agency who administers NC Medicaid Program. If the beneficiary/caller has questions about the appeal, they will FIRST contact NC Medicaid at 1 (888) 245-0179

ATTACHMENT 1