RFP 2022-25 Clarifying Questions 3 v2.pdf
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- Attached to
- RFP 2022-25 Prior Authorization Services
- Solicitation number
- S-X26083-00005145
- Issued by
- Multnomah County, Oregon
About this file
This document is a response to clarifying questions for RFP 2022-25 for Prior Authorization Services issued by CareOregon, a Coordinated Care Organization (CCO) in the state of Oregon. The RFP is seeking a contractor to assist and support CareOregon staff in processing prior authorization services for their Medicaid (CCO plans) and Medicare (Dual Special Needs Plan) programs. The response provides clarification on productivity standards, quality standards, licensing requirements, workflow processes, documentation, systems access, consultation with medical directors, and interrater reliability assessment requirements. CareOregon is open to considering the use of LPNs for certain reviews and is willing to explore alternatives to their current interrater reliability assessment process.
The RFP is for jurisdictions within Multnomah County and the city of Portland, Oregon. Pricing terms, set asides, and funding requirements are not explicitly stated in the document. However, it is noted that the vendor nurses will work alongside CareOregon nurses and have their own assigned work.
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Text version
315 SW Fifth Ave, Portland, OR 97204 | 800-224-4840 | TTY 711 | careoregon.org
George Marlton Procurement Director
Procurement Department 503-416-4706 Procurement@careoregon.org
REQUEST FOR PROPOSALS #2022-25
PRIOR AUTHORIZATION SERVICES
RESPONSE TO CLARIFYING QUESTIONS #3
December 22, 2022
Note that these are questions submitted by interested firms to the above referenced solicitation.
The below answers are for clarification purposes only and in no way alter or amend the RFP as published.
1. What are your current productivity standards (#cases/hour) of your fully trained/experienced nurses?
Answer: See Clarifying Questions #2, Questions 3 through 5.
2. What are your current quality standards for internal nurses?
Answer: See Clarifying Questions #2, Question 6.
3. Do nurses need to be licensed in Oregon or any other state?
Answer: Nurses denying services for CareOregon members need to be licensed in Oregon.
4. Are LPNs allowed for any review or are RN's required for all nurse reviews?
Answer: CareOregon is open to considering using LPNs for certain reviews. RN would be required to deny a service without medical director.
5. Is there any need for physician medical director support? Or, will CareOregon medical directors review all cases that vendor nurses are not able to approve?
Answer: CareOregon Medical Directors will review all cases for medical necessity.
Nurses may deny services for administrative reasons which would not include medical director review.
6. Will vendor nurses be working alongside CareOregon nurses? Or will vendor nurses be the only nurses working all the cases?
Answer: Vendor nurses will work alongside CareOregon nurses. Vendor nurses will have their own assigned work.
7. Describe the request for necessary additional info. Is this by phone call(s), Fax(s)… How many attempts? How long is case held for additional info?
Answer: CareOregon makes 3 outreach attempts using 2 different methods (fax, phone call) over 3 days to receive additional information.
8. Will vendor nurses only be asked to create letter denial language on cases that each individual nurse performed the initial review? Or could a nurse create a letter for a case denied by a medical director that was initially reviewed by a different nurse?
http://careoregon.org/ mailto:Procurement@careoregon.org
Answer: Vendor nurses would create letters they performed the initial review. The only exception would be if coverage was needed because the original vendor nurse is not working the day the review comes back from the MD.
9. Describe the workflow for a nurse to perform/document the initial review case documentation, determination, and tasking. What systems contain the policy criteria, the clinical records, job aids, nurse determination? Are all systems linked? Do the systems have separate log ins?
Answer: Training documents, clinical records, job aides, and tasking are housed in CareOregon’s SharePoint system. Clinical review is performed in QNXT. The systems are not linked but do not require separate logins.
Nurses pull work from a queue (SharePoint), and perform a review based on National, Federal, or State regulations and/or organizational criteria. If criteria is met, the RN will approve and/or may send the request back to support staff for completion. When criteria are not met, the RN will assign the authorization request to an Medical Director (MD) queue in QNXT. Once their review is completed, the MD will return the request to the RN who initially reviewed the request. The RN will then process as an approval or denial based on the MD determination.
10. What are the requirements for the self-internal audits? (number of cases to be audited, coaching/feedback…) Answer: Self-internal audits should be representative of the work and preferably statistically valid. At the beginning of a process a higher percentage of audits would need to be performed while nurses are onboarding and reduced as confidence in the process is obtained.
11. What member communication is required other than creating letter denial language?
Answer: Only written member communication is required
12. What is required for nurses to be able to access CareOregon systems to perform reviews?
Answer: RNs will utilize their own equipment to log into CareOregon systems via a
VPN. RNs would need a private, dedicated work location and stable internet to be able to access systems. To acquire access, CO would need full names, dates of birth, and organizational email addresses to initiate.
13. Are the CareOregon PA systems and tools web based? Is any citrix/virtual desktop VPN environment required?
Answer: Prior auth systems and tools are accessed via internal SharePoint libraries and/or websites/web content. RNs would be required to install a Citrix receiver prior to being able to access the network.
14. Describe the consultation process with CareOregon's medical directors.
Answer: CareOregon medical directors are available to consult with the nurses as needed. The medical director may also reach out to the nurse for clarification.
Communication could be via Teams chat, email, or phone call.
15. Describe interrater reliability assessment requirements? Can the vendor follow NCQA requirements for UM IRR?
Answer: CareOregon has a IRR process but is open to exploring alternatives.
16. Would CareOregon be submitting the Prior Authorization request through the Vendor’s secure web-portal?
Answer: No.
17. Is the vendor expected to work out of CareOregon’s Prior Authorization systems?
Answer: Yes.
End of Clarifying Questions #3
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