RFP 2025-02 Laboratory Claims Management Clarifying Questions 1 - final.pdf
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- Solicitation number
- S-X26083-00013738
- Issued by
- Multnomah County, Oregon
About this file
This document is a response to clarifying questions for Request for Proposals #2025-02 for Laboratory Claims Management Services issued by CareOregon, covering Health Share of Oregon and CareOregon Advantage. The RFP seeks a contractor to provide comprehensive laboratory claims management services for approximately 209,866 covered lives, involving 990,000 lab claims with a $382M billed amount and $38.5M paid amount. The contract will have an initial one-year term with options for four additional one-year renewals, with a new proposal submission deadline of June 9, 2025, at 2:00 PM Pacific Time. CareOregon is currently performing these services in-house and is seeking a vendor to optimize test utilization, reduce healthcare costs, and manage laboratory service payments.
The clarifying questions reveal that CareOregon has an open network with all labs, primarily paying fee-for-service, and is open to post-payment cost containment solutions with the potential to transition to pre-payment. The organization is willing to enter into provider-specific contracts with payment rates less than Medicare or Medicaid rates. Existing laboratory service contracts must be administered as part of the new contract. Vendors are expected to provide deidentified claims data and can communicate with CareOregon's network providers, with written correspondence subject to CareOregon's review. The procurement encourages proposals from minority, women, service-disabled veteran, and emerging small businesses, indicating a commitment to diverse vendor participation.
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315 SW Fifth Ave, Portland, OR 97204 | 800-224-4840 | TTY 711 | careoregon.org
REQUEST FOR PROPOSALS #2025-02
Laboratory Claims Management Services
RESPONSE TO CLARIFYING QUESTIONS
May 15, 2025
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. We do not process claims or edit claims. We provide a laboratory benefit management program (LBMP). The LBMP includes making recommendations for claims processing and claims editing. It also assists in obtaining the correct claims processor and/or claims editor and maximizing the value of the claims processor/claims editor selected. The selected claims processor/claims editor is incorporated into our LBMP. Since it appears to us that this requires the participant to be a claims processor/claims editor, does the fact that we are not a claims processor/claims editor exclude us from participation in this RFP process?
Answer: No, claims processing/editing is not a requirement for participation.
2. What is your definition of genetic testing and what specifically is excluded? Is it an option to include if difficult to exclude since our program is based on genetic testing being included?
Answer: Section 3.2.1 Scope states, “Genetic testing is out of scope for this request.”
3. Our pricing structure is based on the longer of 3 years or the length of the exclusive/preferred laboratory contracts negotiated. Is that type of term an option? That term allows us to spread our costs over a longer term.
Answer: If a firm is awarded a contract as a result of this RFP, the initial term will be for one year with the option for four (4) additional one (1) year renewals thereafter.
Reference page 1 of the RFP, Section, Project Summary.
4. Exhibit A section 8 – allows for termination without cause. Is this firm? See our comment in number 3. We have guarantees if we do not perform.
Answer: Termination without cause is a standard requirement for CareOregon contracts.
5. Exhibit A Section 16 – we would request that this is mutual.
Answer: Section 16 allows the addendum to be executed in several counterparts.
6. We ask for deidentified data and do not process or edit claims therefore we do not have SOC II. We have successfully completed full security reviews with all clients and would anticipate the same with CareOregon. Also, we receive deidentified data. Is that an option?
Answer: Per Section 3.2.7 Performance Requirements, ISO 27001, or HITRUST may be considered in place of SOC2 Type II audit at the discretion of CareOregon. If the scope of work can be completed with deidentified data, then that is an option.
7. What do you consider an open specialty lab?
Answer: A lab that focuses on specific areas of medical testing and diagnostics, such as http://careoregon.org/
George Marlton Procurement Director
Procurement Department 503-488-7646 vendorservices@careoregon.org genetic testing, pathology, or advanced imaging, and is accessible for use without strict scheduling constraints.
8. Can you expand on the question, Determine and provide a roster of which physicians can request testing. Do you mean list of tests allowed to be done in office or a list of physicians that can order tests.
Answer: A method to verify that the provider that ordered the lab service is credentialed to do so.
9. What do you consider an open preferred lab?
Answer: a lab that any provider can refer to that is contracted with CareOregon.
10. Do the Medicaid numbers include SCHIP?
Answer: Yes.
11. Can you share relevant Oregon Revised Statues, and Oregon Administrative Rules that need to be followed?
Answer: We need to follow all legislation under Health Systems Division: Medical Assistance Programs - Chapter 410.
https://secure.sos.state.or.us/oard/displayChapterRules.action?selectedChapter=87
As a CCO, we are also bound by the contract templates here:
Oregon Health Authority : CCO Contract Forms : Oregon Health Plan : State of Oregon
12. Confirm your current Medicare advantage members are included.
Answer: yes, ~17,000.
13. Can you provide the details of your current network?
a. Open, preferred, exclusive
b. FFS, capitated, combined
Answer: we currently have an open network with all labs. Most lab services are paid fee for service.
14. We request a one week extension due to the Memorial Day holiday.
Answer: CareOregon agrees to provide a one week extension of the closing date and time due to the Memorial Day holiday. The new RFP Closing Date/Time is June 9, 2025, at 2:00 PM Pacific Time.
15. Will there be an info session to discuss this RFP at some point?
Answer: No. There is no information session scheduled for this RFP.
16. Is there an existing vendor for these services, or is CareOregon performing these services in-house at this time?
Answer: CareOregon is performing these services in-house at this time.
http://careoregon.org/ mailto:vendorservices@careoregon.org https://secure.sos.state.or.us/oard/displayChapterRules.action?selectedChapter=87 https://www.oregon.gov/oha/hsd/ohp/pages/cco-contract-forms.aspx
Procurement Director
Procurement Department
17. The RFP notes that CareOregon has 575,000 Medicaid members and 17,205 Medicare members. What portion of your covered lives account for the 990,000 lab claims mentioned? Stated another way, is CareOregon assuming risk for lab spending on all 592,205 members? If no, what proportion is CareOregon assuming risk on?
Answer: CareOregon is assuming risk for lab services on 209,866 covered lives.
18. Does the cover letter and signed proposal certification count toward the 20-page response limit?
Answer: Yes, Section 5.1.3 states, “Proposal may not exceed a total of 20 pages (single-sided), inclusive of all exhibits, attachments or other information.”
19. If a bidder demonstrates unique and differentiated value through a solution that includes routine and genetic labs, would CareOregon be open to such a solution?
Answer: Section 3.2.1 Scope states, “Genetic testing is out of scope for this request.”
20. Claims Submission Workflow: Will CareOregon provide a standardized file format or template for submitting and returning claim reviews?
Answer: Section 3.2.3.10 Deliverables states, “Claims audit. Proposer to provide de-identified claims data in a file layout acceptable to CareOregon or a mutually acceptable independent third-party retained by CareOregon to perform a claims audit.”
21. Provider Communication: To what extent can vendors communicate directly with CareOregon’s network providers—are there any restrictions?
Answer: CareOregon does not restrict vendors from communicating with the providers on CareOregon’s behalf. The contents of written correspondence need to be reviewed by CareOregon prior to sending.
22. Appeals and Denials: Will CareOregon handle provider appeals internally, or does the selected vendor act on their behalf in full?
Answer: CareOregon does allow for some vendors to handle first and second level appeals. Please include information within the proposal.
23. Reporting Specifics: What format is preferred for monthly reports? Are there required KPIs or dashboards expected?
Answer: Main metadata for formatting is line of business distinction, savings, expense.
The remaining formatting can be discussed as we transition into production. CareOregon does not have a standard preferred format. Graphs, Charts, or data in a dashboard could all be considered sufficient if it is clear and consistent.
24. Audit and Testing Requirements: Is CareOregon open to using the vendor’s audit methodology, or will a predefined process be provided?
Answer: CareOregon is open to using vendor’s audit methodology as long as it is in alignment with state and federal guidelines. CareOregon also requests collaboration with CareOregon’s internal clinical team.
mailto:vendorservices@careoregon.org
Procurement Director
Procurement Department
25. Data Integration and Access: Will CareOregon offer system access (e.g., SFTP or secure portals), or is the vendor responsible for building the interface?
Answer: Depending on the type of information needed by the vendor, CareOregon may grant read-only access to the claims system in addition to SFTP.
26. Implementation Expectations: Are there any in-person requirements for go-live support or training, or will virtual-only implementations be considered acceptable?
Answer: There are no in-person requirements for implementation
27. The RFP contained the number of labs claims that were handled by CareOregon, but it did not state the billed or allowed amounts for these claims. Can the billed and paid amounts be disclosed?
Answer: For 990,000 claims CareOregon had $382M billed amount and $38.5M for paid amount
28. Is it expected that claims will be sent directly to the Laboratory Claims Management Services organization or will claims flow first to Care Oregon and then to the Laboratory Claims Management Services organization? If claims will be sent directly to the Laboratory Claims Management Services organization, will beneficiary information be provided to allow for eligibility checking?
Answer: Claims will first flow through CareOregon’s claim editing system. Then the claims will go through the Vendor. We are open to solutions that either flow through the Vendor prior to payment, or solutions that review claims post-payment.
29. Is CareOregon required by law to pay 100% of the Medicare and/or Medicaid reimbursement for labs claims, or can labs choose to enter into contracts for less than 100% of the fee schedule amount as a part of cost containment programs?
Answer: CareOregon is allowed to enter into provider specific contracts that include carve outs with payment at a rate that is less than the Medicare or state Medicaid rates for services.
30. Are there existing laboratory services contracts that CareOregon has already entered into that must be administered as a part of the Laboratory Claims Management Services contract?
Answer: Yes
31. Are there local coverage determination or other beneficiary-specific coverage rules CareOregon would like to be included in the cost containment rules?
Answer: See Question 11
32. Would Care Oregon prefer a pre-payment or post-payment cost containment solution?
Answer: Post-payment with the option to move into pre-payment once established.
End of Clarifying Questions mailto:vendorservices@careoregon.org
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