RFP 2024-04 AI Co-Pilot Services - Final.pdf

2026-04 - AI Co-Pilot Services (Rev 2/2023)

REQUEST FOR PROPOSALS #2026-04

AI Co-Pilot Services

Publish Date: 4/30/26

CareOregon, Inc. (“CareOregon”) is inviting submission of proposals for the AI CO-Pilot project.

Closing Date/Time: May 28, 2026 - 2:00 PM, Pacific Time

Project Summary: CareOregon seeks to deploy an AI-enabled workflow-integrated co-pilot to support the end-to-end Prior Authorization process and support various components of its Utilization Management functions, including Prior Authorization and Appeals processes, to work in alignment with the QNXT UM platform and other enterprise infrastructure.

Contact Information: The sole point of contact for procurement process or technical questions is: Ann

Gregory, Procurement and Contract Analyst II; gregorya@careoregon.org;

503-416-1421

RFP Location: RFP Documents can be downloaded from OregonBuys at the following address:

https://oregonbuys.gov/bso/. Prospective Proposers will need to sign in to download the information and that information will be accumulated for a Plan Holder's List. Prospective Proposers are responsible for obtaining any Addenda or clarifying questions from OregonBuys.

Submission: All proposals must be emailed to vendorservices@careoregon.org. Do not attempt to submit proposals through or to the OregonBuys website. All proposals must be submitted to the email listed.

CareOregon encourages proposals from minority, women, service-disabled veteran, and emerging small businesses.

**NO PROPOSALS WILL BE RECEIVED OR CONSIDERED AFTER THE ABOVE RFP

CLOSING DATE/TIME**

SCHEDULE

Request for Proposals Issued…….................................................. April 30, 2026

Deadline to Submit Clarifying Questions....................................... May 21, 2026, 5:00 PM, Pacific Time

Request for Proposals Closing Date and Time (“Closing”)........... May 28, 2026, 2:00 PM, Pacific Time

Anticipated Contract Start Date……..............................................August 1, 2026 mailto:gregorya@careoregon.org https://oregonbuys.gov/bso/ mailto:vendorservices@careoregon.org

2026-04 - AI Co-Pilot Services Page 1

SECTION 2

INSTRUCTIONS TO PROPOSERS

2.1 Modification or Withdrawal of Proposal: Any Proposal may be modified or withdrawn at any time prior to the Closing deadline, provided that a written request is received by Procurement, prior to the Closing.

The withdrawal of a Proposal will not prejudice the right of a Proposer to submit a new Proposal.

2.2 Requests for Clarification and Requests for Change: Proposers may submit questions regarding the specifications of the RFP until the deadline in the Schedule. Requests for changes must include the reason for the change and any proposed changes to the requirements. The purpose of this requirement is to permit CareOregon to correct, prior to the opening of Proposals, RFP terms or technical requirements that may be unlawful, improvident or which unjustifiably restrict competition. CareOregon will consider all requested changes and, if appropriate, amend the RFP. No oral or written instructions or information concerning this RFP from CareOregon employees or agents to prospective Proposers shall bind CareOregon unless included in an Addendum to the RFP.

2.3 Addenda: If any part of this RFP is changed, an addendum will be published on OregonBuys. It shall be Proposers responsibility to regularly check OregonBuys for any notices, published addenda, or response to clarifying questions.

2.4 Submission of Proposals: Proposals must be submitted in accordance with Section 5. All Proposals must include a signature that affirms the Proposer’s intent to be bound by the Proposal (this may be on cover letter, or on the Proposal). The Certification page must be signed as well. If a Proposal is submitted by a firm or partnership, the name and address of the firm or partnership shall be shown, together with the names and addresses of the members. If the Proposal is submitted by a corporation, it shall be signed in the name of such corporation by an official who is authorized to bind the contractor. No late Proposals will be accepted.

2.5 Acceptance of Contractual Requirements: Failure of the selected Proposer to execute a contract and deliver required insurance certificates within ten (10) calendar days after notification of an award may result in cancellation of the award. This time period may be extended at the option of CareOregon.

2.6 Investigation of References: CareOregon reserves the right to investigate all references in addition to those supplied references and investigate past performance of any Proposer with respect to its successful performance of similar services, its compliance with specifications and contractual obligations, its completion or delivery of a project on schedule, its lawful payment of subcontractors and workers, and any other factor relevant to this RFP. CareOregon may postpone the award or the execution of the contract after the announcement of the apparent successful Proposer in order to complete its investigation.

2.7 RFP Proposal Preparation Costs and Other Costs: Proposer costs of developing the Proposal, cost of attendance at an interview (if requested by CareOregon), or any other costs are entirely the responsibility of the Proposer, and will not be reimbursed in any manner by CareOregon.

2.8 Clarification and Clarity: CareOregon reserves the right to seek clarification of each Proposal, or to make an award without further discussion of Proposals received. Therefore, it is important that each Proposal be submitted initially in the most complete, clear, and favorable manner possible.

2.9 Right to Reject Proposals: CareOregon reserves the right to reject any or all Proposals or to withdraw any item from the award, if such rejection or withdrawal would be in CareOregon’s interest, as determined by CareOregon. Proposals may be rejected in whole or in part if they attempt to limit or modify any of the terms, conditions, or specifications of the RFP or the Sample Contract.

2026-04 - AI Co-Pilot Services Page 2

2.10 Proposal Terms: All Proposals, including any price quotations, will be valid and firm through a period of one hundred and eighty (180) calendar days following the Closing date. CareOregon may require an extension of this firm offer period. Proposers will be required to agree to the longer time frame in order to be further considered in the procurement process.

2.11 Oral Presentations: At CareOregon’s sole option, Proposers may be required to give an oral presentation of their Proposals to CareOregon, a process which would provide an opportunity for the Proposer to clarify or elaborate on the Proposal but will in no material way change Proposer’s original Proposal. Any costs of participating in such presentations will be borne solely by Proposer and will not be reimbursed by CareOregon.

Note: Oral presentations are at the discretion of the evaluating committee and may not be conducted; therefore, written Proposals should be complete.

2.12 Review for Responsiveness: Upon receipt of all Proposals, the Procurement Department will determine the responsiveness of all Proposals before submitting them to the evaluation committee. If a Proposal is incomplete or non-responsive in significant part or in whole, it will be rejected and will not be submitted to the evaluation committee. CareOregon reserves the right to determine if an inadvertent error is solely clerical or is a minor informality which may be waived, and then to determine if an error is grounds for disqualifying a Proposal. The Proposer’s contact person identified on the Proposal will be notified, identifying the reason(s) the Proposal is non-responsive.

2.13 Communication Blackout Period: Except as called for in this RFP, Proposers may not communicate with members of the Evaluation Committee or other CareOregon employees or representatives about the RFP during the procurement process until the apparent successful Proposer is selected. Communication in violation of this restriction may result in rejection of a Proposer.

2.14 Prohibition on Commissions and Subcontractors: CareOregon will contract directly with persons/entities capable of performing the requirements of this RFP. Contractors must be represented directly.

Participation by brokers or commissioned agents will not be allowed during the Proposal process. Contractor shall not use subcontractors to perform the Work unless specifically proposed or authorized to do so by CareOregon.

Contractor represents that any employees assigned to perform the Work, and any authorized subcontractors performing the Work, are fully qualified to perform the tasks assigned to them, and shall perform the Work in a competent and professional manner. Contractor shall not be permitted to add on any fee or charge for subcontractor Work. Contractor shall provide, if requested, any documents relating to subcontractor’s qualifications to perform required Work.

2.15 Collusion: By responding, the Proposer states that the Proposal is not made in connection with any competing Proposer submitting a separate response to the RFP, and is in all aspects fair and without collusion or fraud. Proposer also certifies that no officer, agent, or employee of CareOregon has a pecuniary interest in this Proposal.

2.16 Evaluation Committee: Proposals will be evaluated by a committee consisting of representatives from CareOregon and potentially external representatives. CareOregon reserves the right to modify the make-up in its sole discretion.

2.17 Nondiscrimination: The successful Proposer agrees that, in performing the Work called for by this RFP and in securing and supplying materials, contractor will not discriminate against or treat differently, any person on the basis of race, color, religious creed, political ideas, sex, age, marital status, sexual orientation, gender identity, veteran status, physical or mental disability, national origin or ancestry, or any other class protected by applicable law.

2.18 Best and Final Offer: CareOregon may request best and final offers from those Proposers determined by CareOregon to be reasonably viable for contract award. However, CareOregon reserves the right to award a contract on the basis of initial Proposal received. Therefore, each Proposal should contain the Proposer’s best terms from a price and technical standpoint. Following evaluation of the best and final offers, CareOregon may

2026-04 - AI Co-Pilot Services Page 3 select for final contract negotiations/execution the offers that are most advantageous to CareOregon, considering cost and the evaluation criteria in this RFP.

2.19 PROPOSAL CONFIDENTIALITY: Submitted proposals will be treated as confidential and will only be shared internally with applicable staff for this project. Proposers that responded to the RFP will be notified of the award at the completion of the process. Proposer scores and evaluation notes shall remain private and confidential information for CareOregon purposes only.

2.20 RFP LIST OF EXHIBITS: Reserved.

2026-04 - AI Co-Pilot Services Page 4

SECTION 3

SCOPE OF WORK

3.1 BACKGROUND

Founded in 1993, CareOregon is a 501(c)(3) public benefit nonprofit company that draws nearly all its revenue from public programs such as Medicaid (the Oregon Health Plan – “OHP”), Medicare and the State Children’s Health Insurance Program (“SCHIP”). Coordinated care organizations (“CCOs”) are an Oregon innovation that integrates physical, behavioral and oral health care, and treats the whole person.

Through partnerships with our CCOs, we provide integrated managed care services. We partner with Health Share of Oregon to serve the tri-county Portland metro area. We own Jackson Care Connect and Columbia Pacific CCO. In addition to Medicare plans and CareOregon Dental lines of business, Housecall Providers delivers primary, palliative and hospice care to home-bound patients.

Our mission is to inspire and partner to create quality and equity in individual and community health.

Our vision is healthy communities for all individuals, regardless of income or social circumstances.

We focus on the total health of our members, not just traditional health care. In teaming up with members, their families and their communities, we help Oregonians live better lives, prevent illness and respond effectively to health issues.

We care about people We serve Oregonians eligible for the OHP and Medicare Advantage members who have us as their health care option. But that’s not all. We are a managed health care company with an overarching goal: to make world-class, high-quality health care available to all Oregon residents, regardless of income.

We support our neighbors We know that some Oregonians are in need but don’t qualify for OHP benefits. We work to strengthen the health care safety net that these Oregonians rely upon, from local health departments and community clinics to rural and migrant health centers. We partner with policy makers and legislators to improve services and provide access to quality care throughout the state, from urban centers to rural neighborhoods.

We work with first-class providers CareOregon has built a health care delivery system that assures access to physicians and health care professionals who understand special needs and provide quality care regardless of a patient’s financial resources.

We work with policy makers to ensure access We provide OHP enrollees access to health care services in exchange for a per member, per month capitation rate. The Oregon Legislature sets this payment rate. The payments are subject to available state funding. CareOregon takes full financial risk for the health care services our members use. CareOregon, formed by safety net health care providers in the state, is a Safety Net Health Plan. Safety Net Health Plans are nonprofits that derive their revenue from public programs.

To put it simply, CareOregon ensures that members have timely access to high quality health care from a broad network of providers, and CareOregon works hard every day to keep people healthy and active in their homes and communities.

2026-04 - AI Co-Pilot Services Page 5

Equity, Diversity, and Inclusion:

CareOregon recognizes that to achieve the vision of “Healthy communities for all individuals, regardless of income or social circumstances,” it must intentionally cultivate authentic member engagement, community partnerships, and recruit, retain and develop a staff as diverse as the communities it serves.

CareOregon has embarked on a continuous effort to understand the effects of historical, institutional and structural oppression on the various communities represented within its membership and personnel.

CareOregon strives to internally, and in partnership with other like-minded organizations across sectors, to redress policies, systems and health related environmental issues that affect health care disparities and inequities.

Equity, diversity, and inclusion is a cornerstone of CareOregon’s mission, vision and strategic objectives.

CareOregon’s priority is strengthening our communities by making health care work for everyone by ensuring access to a broader and more diverse network of physical, behavioral, and oral health services that address the individual needs and cultural values of our members and reduces barriers to getting needed care.

It is the intent of CareOregon, through issuance of this RFP, to collaborate with like-minded firms that share the same values and that will take actual steps to embody those values in the services provided to CareOregon and its providers, members and clients.

Project Background:

CareOregon is a nonprofit, Medicaid-focused coordinated care organization responsible for ensuring timely, clinically appropriate, and regulatory-compliant Prior Authorization (PA) determinations across medical, behavioral and social health services.

CareOregon processes a substantial volume of PA requests annually through multiple intake channels, including fax, scanned documents, PDFs, and electronic submissions. Many submissions contain unstructured clinical documentation requiring manual intake, data extraction, policy review, case routing, and determination documentation.

The Utilization Management (UM) function includes 150 staff, including non-clinical staff (Authorization Assistants (AAs), Grievance Coordinators (GCs), Appeal Coordinators (ACs) and clinical staff comprised of Registered Nurses (RNs), Behavioral Health Specialists (BHSs) and Medical Directors MDs), all of whom may serve as the primary users of any proposed solution. Operational leadership, Compliance, and IT teams will provide governance and oversight.

CareOregon currently operates QNXT for its UM platform, supported by document intake tools, policy repositories, enterprise document management systems, and data warehouse reporting infrastructure within a HIPAA (Health Insurance Portability and Accountability Act) regulated environment. Any proposed solution would be expected to align with CareOregon’s enterprise architecture, data security standards, and Medicaid regulatory requirements. The infrastructure for all reviews in the current environment are:

• PA management software (QNXT)

• Shared library with completed records/documents (SharePoint)

• Repository of standard verbiage (Excel document within SharePoint)

• Review support tool to assess medical necessity against standard InterQual

• Provider Portal to check member eligibility, submission of PA requests.

The organization is exploring a mature solution, which may include healthcare-grade AI (Artificial Intelligence)-enabled, to further modernize and optimize PA workflows while maintaining clinical integrity, audit defensibility, and human oversight. The solution should:

• Reduce processing / turnaround times

2026-04 - AI Co-Pilot Services Page 6

• Reduce overall cost

• Increase accuracy of assessments

• Increasing overall function capacity

• Reduce repetitive human work and optimizing work

Final medical necessity determinations will remain under licensed human authority. This is not a fully automated auto-determination project.

3.2 SCOPE OF WORK

3.2.1 Scope:

CareOregon seeks to deploy an AI-enabled workflow-integrated co-pilot to support the end-to-end Prior Authorization processes and support various components of the UM function, including Prior Authorizations and Appeals processes. Proposers’ solution is expected to be implemented by the end of 2026.

The proposed solution would ideally integrate into CareOregon’s existing UM environment (including but not limited to QNXT, Excel, SharePoint, etc.) and support the following core capabilities:

• Automated Document Ingestion and Data Extraction

• Policy and Clinical Guidance Surfacing

• Auto-Approval and Streamlined Review Support

• Intelligent Routing and Triage

• Determination Support and Letter Automation

• Reviewer Analytics and Operational Transparency

• AI Governance, Security, and Compliance

• Implementation Approach

The solution would be expected to function as a decision-support system embedded within daily workflow operations. Human reviewers must retain ultimate authority over determinations – this is not a fully automated auto-determination project. Ideally, the solution will have the ability to understand and process natural language documents with unstructured data, including data in image format, and create standardized outputs and assessments, ability to make workflow routing decisions based on best-guess logic, allow users to interact with the tool using natural language.

3.2.2 Work Schedule:

The table outlines target timelines for this project, as more fully detailed below. It is important for Proposers to highlight their ability to meet these timelines or to propose alternatives based on their recommendations.

Phase Estimated Duration Key Deliverables RFP awarded Mid July 2026 Contract & Governance 0–1 month Executed agreement Discovery & Design 1–2 months Requirements & KPIs Data Integration 2–3.5 months Validated data feeds Model Training 3–4.5 months Configured AI model

2026-04 - AI Co-Pilot Services Page 7

Validation & UAT 4.5–5.5 months Clinical approval Pilot Go-Live 5.5–6 months Limited production Full Rollout 6–9 months Scaled deployment

Phase 0: Contracting & Governance Setup (Weeks 0–4) Purpose: Establish legal, compliance, and governance foundations before any data movement.

Key Activities

• Finalize contract, BAAs, and data use agreements

• Define AI use case boundaries (recommendation vs. automation)

• Establish AI governance structure:

o Clinical oversight committee o Compliance & legal review o Model risk management owner

• Confirm regulatory alignment:

o CMS Medicare rules o OHP/Medicaid CCO requirements o UM timeliness and notice rules

Milestones

• Contract executed

• Governance charter approved

• Implementation plan signed off

Phase 1: Discovery & Requirements Definition (Weeks 4–8) Purpose: Translate UM workflows into AI-supported processes.

Key Activities

• Current-state UM workflow mapping:

o Prior auth intake o Medical necessity review o Peer-to-peer escalation o Appeals/grievances

• Define AI functions:

o Clinical criteria matching o Documentation summarization o Risk flagging (denial overturn likelihood) o Recommendation confidence scoring

• Identify decision points where AI assists vs. informs

• Define success metrics (KPIs)

Milestones

• Functional requirements document

• Clinical decision boundaries approved

• KPI baseline established

Phase 2: Data Integration & Security Readiness (Weeks 8–14) Purpose: Prepare clean, compliant data pipelines.

Key Activities

• Data source integration:

o UM case history o Claims & encounter data o Clinical notes o InterQual/MCG outputs (where licensed)

• Interface development (API / batch feeds)

2026-04 - AI Co-Pilot Services Page 8

• Data normalization and labeling

• Security controls:

o Role-based access o Audit logging o PHI encryption (at rest and in transit)

Milestones

• Data feeds validated

• Security & privacy sign-off

• Test dataset approved

Phase 3: Model Configuration & Training (Weeks 12–18) (May overlap with Phase 2) Purpose: Tune AI to your population, policies, and clinical standards.

Key Activities

• Train models on historical UM decisions

• Configure:

o Medical policy rules o State-specific coverage nuances o Dual-eligible considerations

• Bias and fairness testing:

o Medicaid vs. Medicare o Behavioral health vs. medical

• Human-in-the-loop workflows defined Milestones

• Model training completed

• Explainability thresholds met

• Bias assessment documented

Phase 4: Validation, Compliance & UAT (Weeks 18–22) Purpose: Prove safety, accuracy, and regulatory defensibility.

Key Activities

• Parallel run:

o AI recommendations vs. human decisions

• Clinical validation by RN/MD reviewers

• CMS/OHP audit scenario testing

• UM timeliness and notice compliance checks

• User Acceptance Testing (UAT)

Milestones

• Clinical validation sign-off

• Compliance attestation completed

• Go-live authorization

Phase 5: Pilot Go-Live (Weeks 22–26) Purpose: Controlled deployment with real cases.

Key Activities

• Limited population or service lines

• Shadow or assistive mode only

• Daily performance monitoring

• Rapid feedback loops with UM staff

Milestones

• Pilot go-live

• First 30-day performance report

2026-04 - AI Co-Pilot Services Page 9

• Decision to scale

Phase 6: Full Deployment & Optimization (Months 6–9) Purpose: Scale safely and improve performance.

Key Activities

• Expand to full UM volume

• Staff training and SOP updates

• Ongoing model monitoring:

o Accuracy drift o Denial overturn rates o Disparity monitoring

• Continuous improvement releases Milestones

• Full production deployment

• SLA performance achieved

• Optimization roadmap approved

3.2.3 Term of Contract: The term of the contract shall be from the effective date for an initial term of three (3) years, with the option for two (2) additional one (1) year renewals thereafter subject to the mutual agreement of the parties.

3.2.4 Sample Contract: Submission of a Proposal in response to this RFP indicates Proposer’s willingness to enter into a contract containing substantially the same terms (including insurance requirements) of the sample contract identified below. No action or response to the sample contract is required under this RFP. Any objections to the sample contract terms should be raised in accordance with Paragraphs 2.2 of this RFP pertaining to requests for clarification of the RFP/specifications. This RFP and all supplemental information in response to this RFP will be a binding part of the final contract.

The applicable Sample Professional Services Contract for this RFP can be found at https://careoregon.org/contact-us/vendor-resources.

Professional Services Contract (unless checked, item does not apply) The following paragraphs of the Professional Services Contract will be applicable:

Travel and Other Expense is Authorized Protection of Patient Privacy and Security (PHI) Criminal Background Check Requirements Key Persons On-Call Contract Basis CareOregon Data Security Requirements Hosted Software Offshore Services Prohibited

The following insurance requirements will be applicable:

Commercial General Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence, with an annual aggregate limit of $2,000,000 for Bodily Injury and Property Damage.

Professional Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence, with an annual aggregate limit of $2,000,000 for damages caused by error, omission, or negligent acts.

https://careoregon.org/contact-us/vendor-resources

2026-04 - AI Co-Pilot Services Page 10

Automobile Liability: combined single limit, or the equivalent, of not less than $1,000,000 per occurrence for Bodily Injury and Property Damage.

Cyber Liability: combined single limit, or the equivalent, of not less than $3,000,000 per occurrence for network security (including data breach), privacy, interruption of business, media liability, and errors and omissions.

Project Specific Contract Terms: It is understood that most software purchases will be completed using a Proposer specific contract template rather than CareOregon’s standard template Professional Services Agreement. For this project, CareOregon is open to using the selected Proposer contract, however, CareOregon’s template Contracting Addendum for Software shall be required to be executed and will specifically supersede several typical clauses contained in the Proposer’s software agreements. In particular, the Addendum terms prohibit the use of Offshore Services to access or house CareOregon data. In addition, to comply with HIPAA rules and CareOregon’s internal Data Security Policies, the selected Proposer will be required to execute a Business Associate Agreement, and the Terms and Conditions for Cloud Services and the CareOregon Data Security Agreement – Tier 1 will apply. All referenced documents may be found on our website at https://careoregon.org/vendor-resources. Most of the clauses in these documents are required and will not be negotiated so it is important for interested Proposers to carefully read the referenced documents and understand that they will be executed along with the resulting Proposer contract.

https://careoregon.org/vendor-resources

2026-04 - AI Co-Pilot Services Page 11

SECTION 4

EVALUATION PROCEDURE

4.1 An evaluation committee will review all Proposals that are initially deemed responsive and they shall rank the Proposals in accordance with the below criteria. The evaluation committee will select one or more Proposers from the written responses for follow up Proposal interviews/presentations.

Interviews/presentations will consist of the highest scoring Proposers. The invited Proposers will be notified of the time, place, and format of the interview/presentation. Based on the interview/presentation, the evaluation committee may revise their scoring.

Written Proposals must be complete and no additions, deletions, or substitutions will be permitted during the interview/presentation (if any). The evaluation committee will recommend award of a contract to the final CareOregon decision maker based on the highest scoring Proposal. The CareOregon decision maker reserves the right to accept the recommendation, award to a different Proposer, or reject all Proposals and cancel the RFP.

Proposers are not permitted to directly communicate with any member of the evaluation committee during the evaluation process. All communication must be facilitated through the assigned Procurement Analyst.

4.2 Evaluation Criteria

Category Points available:

Proposer’s General Background and Qualifications 0-30 Scope of Work 0-35 Equity, Diversity, and Inclusion Efforts 0 Interviews/Presentations 0-10 Fees 0-25

Available points 0-100

4.3 Once a selection has been made, CareOregon will enter into contract negotiations. During negotiation, CareOregon may require any additional information it deems necessary to clarify the approach and understanding of the requested services. Any changes agreed upon during contract negotiations will become part of the final contract. The negotiations will identify a level of Work and associated fee that best represents the efforts required. If CareOregon is unable to come to terms with the highest scoring Proposer, discussions shall be terminated and negotiations will begin with the next highest scoring Proposer. If the resulting contract contemplates multiple phases and CareOregon deems it is in its interest to not authorize any particular phase, it reserves the right to return to this solicitation and commence negotiations with the next highest ranked Proposer to complete the remaining phases.

2026-04 - AI Co-Pilot Services Page 12

SECTION 5

PROPOSAL CONTENTS

5.1 Vendors must adhere to submission instructions and be advised as follows:

1. Complete Proposals must be emailed to vendorservices@careoregon.org. The subject line of the email must identify the RFP title. Proposers are encouraged to contact Procurement to confirm receipt of the Proposal.

2. CareOregon reserves the right to solicit additional information or Proposal clarification from the vendors, or any one vendor, should CareOregon deem such information necessary.

3. Proposal may not exceed a total of 30 pages (single-sided), inclusive of all exhibits, attachments or other information.

4. Proposers are required to structure Proposals following the below question outline. It is important for answers to be clear and concise.

5.2 Proposer’s General Background and Qualifications (30 Max points):

1. Description of the firm.

2. Credentials/experience of key individuals that would be assigned to this project.

3. Description of providing similar services to non-profit entities of similar size within the past five (5) years.

4. Describe your typical customer profile, such as size and service provided. What are your customer retention rates?

5. Description of the firm’s ability to meet the requirements in Section 3.

6. Description of what distinguishes the firm from other firms performing a similar service.

7. Describe if any of the proposed services will be performed by offshore (not US state or US territory) employees or subcontractors?

8. Describe if your firm is currently or potentially engaged in litigation.

9. Provide information demonstrating that your firm is financially stable.

10. Identify any issues or concerns in social media about your firm?

5.3 Scope of Work (35 Max points):

Automated Document Ingestion and Data Extraction:

1. Describe how your solution ingests PA submissions from multiple sources, e.g., OCR (Optical Character Recognition) methodology, data extraction approach, confidence scoring, and human validation workflows.

2. Provide quantitative benchmarks from production deployments including extraction accuracy, error rates, processing times, and manual correction rates.

3. Explain how incoming documentation is matched to existing PA cases and how mismatches are handled.

Policy and Clinical Guidance Surfacing:

4. Describe how your system identifies and surfaces relevant medical policies, criteria, and benefit rules.

Explain version control management, updating or writing to current processes or changes in handling, and structured criteria outputs.

5. Describe your experience and success in integrating with nationally recognized decision support tools.

Auto-Approval and Streamlined Review Support:

mailto:vendorservices@careoregon.org

2026-04 - AI Co-Pilot Services Page 13

6. Describe rule-based and AI-supported identification of eligible cases, human oversight controls, and measurable outcomes including time savings and appeal impacts.

Intelligent Routing and Triage:

7. Describe triage logic, routing transparency, and workload balancing capabilities for AAs, RNs, and MD escalation.

Determination Support and Letter Automation:

8. Describe AI-assisted determination support, e.g., rationale drafting, letter generation capabilities, compliance safeguards, multilingual support, and measurable reductions in drafting time or documentation errors.

Reviewer Analytics and Operational Transparency:

9. Describe any dashboards, operational reporting capabilities, and enterprise BI (Business Intelligence) integration to track performance improvement.

AI Governance, Security, and Compliance:

10. Describe your model governance, security, and compliance with standard healthcare requirements, e.g., bias monitoring, clinical risk controls, CMS (Centers for Medicare & Medicaid Services) audit defensibility, HIPAA compliance, audit logging, subprocessor/contractor disclosure (if any), and data retention policies.

Demonstrated Outcomes:

11. Provide at least two production healthcare payer deployments including deployment date, scope, baseline and post-implementation metrics, methodology, duration measured, and client reference contact if possible.

Implementation Approach:

12. Describe implementation timeline and approach, e.g., discovery, integration design, testing, pilot deployment, phased rollout, required CareOregon resources, risks, and change management strategy.

13. How would you approach the outlined implementation phases noted in the Scope of Work section above? Will you be able to work within this schedule or, if not, how would you propose to accomplish the required work deliverables?

5.4 Equity, Diversity and Inclusion Efforts (No points awarded):

1. Describe your firm’s equity, diversity and inclusion values, policies, efforts, and successes. Include specific details of efforts and how they have shaped the composition and spirit of your firm.

2. Supplier diversity is the intentional inclusion of historically underutilized businesses in a firm’s supply base to achieve innovation, cost reduction, and building economic growth in our communities. If you plan to use subcontractors or other third-party services for the services proposed to CareOregon, describe your supplier diversity program.

3. Outline the specific elements of your proposed services that will support and advance CareOregon’s equity, diversity, and inclusion mission.

2026-04 - AI Co-Pilot Services Page 14

5.5 Interviews/Presentations (10 Max points): Partial list of potential questions/issues that should be addressed by any Proposers invited to do a presentation:

1. Walk us through a real prior authorization case from intake to determination where your AI was involved. Where did humans intervene, and why?

2. How does your system prevent “automation bias” among nurses and medical directors?

3. What guardrails exist to prevent recommendations from drifting outside InterQual, CMS, or OHP policy boundaries?

4. How do you handle disagreement between AI recommendations and clinician judgment—and how is that logged for audit purposes?

5. If CareOregon were audited tomorrow, what artifacts would your system produce to demonstrate compliant decision support—not automated determinations?

6. How does your platform support appeal and grievance workflows differently than initial PAs?

7. Describe how you track and explain changes in AI recommendations over time during policy updates.

8. What has been your most challenging integration with a UM platform like QNXT, and how did you solve it?

9. How do you manage mismatched, incomplete, or contradictory documentation across fax, PDF, and portal submissions?

10. What level of CareOregon IT effort do you realistically expect during data integration and ongoing support?

11. How do you test for bias across Medicaid vs. Medicare, behavioral vs. medical, and English vs.

non-English submissions? Can you share an example where bias testing led you to retrain or constrain a model?

13. How do frontline staff see indicators or warnings related to equity or risk?

14. What operational KPIs improved first at your other payer clients—and which took longer than expected?

15. What resistance have you encountered from UM staff, and how did you overcome it?

16. How do you train reviewers to trust—but not blindly follow—the AI?

17. How do you manage model drift, and how often do you expect retraining to occur in a Medicaid environment?

19. If regulations or CareOregon policy materially change, what is your turnaround time to update the system?

20. If this pilot fails to meet expectations after 90 days, what do you believe are the three most likely causes—and which of those would be your responsibility vs. ours?

5.6 Fees (25 Max points): Fees quoted should be on a fixed fee basis. Fees should be sufficiently descriptive to facilitate acceptance of a Proposal. Fees and fee schedules should outline all estimated expenses, implementation fees, subscription fees, hourly rates for all assigned individuals, and other reimbursable expenses. If services are extended past the initial contract term, provide a maximum escalator to the fee for additional terms.

5.7 References (No points awarded). Provide at least three (3) references from clients your firm has served similar to CareOregon in the past three (3) years, including one client that has newly engaged the firm in the past thirty-six (36) months and one (1) long-term client. Provide the name, address, email, and phone number of the references. Please note the required three references may not be from CareOregon staff, but additional references may be supplied. Points awarded for this criteria are based on both the providing of references as well as information gleaned from the provided contacts. Evaluation Committee members may contact references at their sole discretion.

5.8 Completed Proposal Certification - You must complete the form below and attach it to your Proposal.

2026-04 - AI Co-Pilot Services Page 15

PROPOSAL CERTIFICATION

RFP #2026-04

Submitted by:

(Must be entity’s full legal name, and State of Formation)

Each Proposer must read, complete and submit a copy of this Proposal Certification with their Proposal. Failure to do so may result in rejection of the Proposal. By signature on this Proposal Certification, the undersigned certifies that they are authorized to act on behalf of the Proposer and that under penalty of perjury, the undersigned will comply with the following:

SECTION I. NONDISCRIMINATION: That the Proposer has not and will not discriminate in its employment practices with regard to race, color, creed, age, religious affiliation, sex, marital status, disability, sexual orientation, gender identity, national origin, veteran status, or any other protected class. Nor has Proposer or will Proposer discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business that is certified under ORS 200.055.

SECTION II. CONFLICT OF INTEREST: The undersigned hereby certifies that no officer, agent or employee of CareOregon is personally interested, directly or indirectly, in any resulting contract from this RFP, or the compensation to be paid under such contract, and that no representation, statements (oral or in writing), of the CareOregon, its officers, agents, or employees had induced Proposer to submit this Proposal. In addition, the undersigned hereby certifies that this proposal is made without connection with any person, firm, or corporation submitting a proposal for the same material, and is in all respects fair and without collusion or fraud.

SECTION III. COMPLIANCE WITH SOLICITATION: The undersigned further agrees and certifies that they:

1. Have read, understand and agree to be bound by and comply with all requirements, instructions, specifications, terms and conditions of the RFP (including any attachments);

2. Are an authorized representative of the Proposer, that the information provided is true and accurate, and that providing incorrect or incomplete information may be cause for rejection of the Proposal or contract termination;

and

3. Will furnish the designated item(s) and/or service(s) in accordance with the RFP and Proposal.

Name:_______________________________________ Date:______________________________________

Signature:____________________________________ Title:______________________________________

Email:_______________________________________ Phone:_____________________________________

Oregon Business Registry Number:________________ OR CCB # (if applicable):________________________

Proposer Primary Point of Contact (Coordination during process and for award information):

Name:_______________________________________

Email:_______________________________________ Phone:_____________________________________

Business Designation (check one):

Corporation Partnership Sole Proprietorship Non-Profit Limited Liability Company

Minority (MBE), Women (WBE), Service-Disabled Veteran (SDV), and Emerging Small Business (ESB):

Certified by the State of Oregon (provide certification number as applicable):

MBE WBE SDV ESB

Self-identified (check as applicable):

MBE WBE SDV ESB