RFP 2025-02 Laboratory Claims Management - Final.pdf

RFP 2025-02 Laboratory Claims Management

REQUEST FOR PROPOSALS #2025-02

Laboratory Claims Management Services Publish Date: May 1, 2025

CareOregon, Inc. (“CareOregon”) on behalf of Health Share of Oregon and Health Plan of CareOregon, Inc. (CareOregon Advantage) is inviting submission of proposals for the Laboratory Claims Management Services project.

Closing Date/Time: June 2, 2025, at 2:00 PM, Pacific Time

Project Summary: CareOregon, along with its subsidiaries and affiliated entities, Health Share of Oregon and Health Plan of CareOregon (CareOregon Advantage), is seeking one or more Contractors to provide a payment integrity program that offers cost containment services to include laboratory benefit management. Work is to begin approximately second half of 2025, and continue for one year with the option for four (4) additional one (1) year renewals thereafter.

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

Reinholtz, Procurement & Contract Analyst II, reinholtzl@careoregon.org.

503-416-1797

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…….................................................. May 1, 2025

Deadline to Submit Clarifying Questions....................................... May 12, 2025, 5:00 PM, Pacific Time

Request for Proposals Closing Date and Time (“Closing”)........... June 2, 2025, 2:00 PM, Pacific Time

Anticipated Contract Start Date……...........................................Second half of 2025 mailto:reinholtzl@careoregon.org https://oregonbuys.gov/bso/ mailto:vendorservices@careoregon.org

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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.

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.

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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 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.

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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.

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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:

The Centers for Medicare and Medicaid Services (“CMS”) and the Oregon Health Authority (“OHA”) require managed Medicare and Medicaid plans to have payment integrity programs. Outsourcing pertinent services allows CareOregon (a Medicare and Medicaid payor and client) to meet these regulatory requirements and minimize claim overpayments.

3.2 SCOPE OF WORK

3.2.1 Scope:

CareOregon, Inc. along with its subsidiaries and affiliated entities, Health Share of Oregon and Health Plan of CareOregon, Inc. (CareOregon Advantage), is seeking one or more Contractors to provide a payment integrity program that offers cost containment services to include laboratory benefit management. CareOregon’s goal is to optimize test utilization and reduce healthcare costs by controlling the funding and payment for laboratory services, while also helping reduce confusion and preventing testing barriers for targeted services. The solution should reduce costs to CareOregon by managing the use of and payment for laboratory testing. Based on proposals received, CareOregon may award a single contract or multiple contracts with a selection of some of the proposer’s services.

Proposers must collaborate with providers effectively. This includes not adding administrative burden, delaying patient care, deterring growth and innovation within the diagnostics industry, or limiting physician or patient choice for their health care management.

Firms shall have expertise in clinical, pathology, and toxicology. Genetic testing is out of scope for this request.

The following regulatory frameworks must be followed: HIPAA, 42 CFR Part 2, CMS, Oregon Revised Statues, and Oregon Administrative Rules.

CareOregon may add Medicare members to the Services proposed under this RFP within approximately two (2) years. Proposer shall comply with the Medicare Compliance Addendum, hereby incorporated by reference and found at https://www.careoregon.org/about-us/vendor-resources.

https://www.careoregon.org/about-us/vendor-resources

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3.2.2 Services.

1. Provide optimization of billing for laboratory services.

a. Identify information derived from historical claims.

b. Identify certain criteria where claims could be pended or put on hold for processing.

c. Send claims files to CareOregon for review.

d. Provide trend reductions.

e. Reduce downstream costs.

f. Improve overall measures of quality.

g. Identify new opportunities for savings.

h. Provide reimbursement management.

i. Evaluate tests for patients.

j. Provide a clinical team to review appeals and support peer review requests.

k. Provide support for denials.

2. Evaluate current state of laboratory testing.

3. Manage the use of testing by determining when a prior authorization is required from a physician before a test can be ordered.

4. Review clinical evidence and medical necessity to determine outcomes for prior authorizations.

5. Help develop policies that include determining coverage, reimbursement, and claims payments, i.e., control testing by controlling the funding and payment for lab services.

6. Guide physicians toward clinically actionable tests for members.

7. Improve result interpretations and treatment decisions.

8. Improve lab efficiency by reviewing lab protocols to ensure robust policies are followed.

9. Assist in CPT code identification and usage, facilitating full reimbursement for lab services.

10. If CareOregon identifies any claims (such as Covid blood draw and rapid testing) for the Proposer to review, Proposer shall coordinate efforts to identify this criteria. CareOregon turnaround time of 5 business days for review must be met.

11. Prevent unnecessary testing and recommend labs that perform reliable testing.

12. Provide a team of clinical and legal support services that help determine policies based on different sources such as CPT codes, evidence-based literature, laboratory, and medical policies, thus promoting higher quality results.

13. Educate providers if there is an error or otherwise incorrect claim filing, reducing such instances to reduce financial impact to CareOregon.

14. Use all appropriate safeguards to prevent unauthorized use or disclosure of CareOregon Data, including member Protected Health Information (“PHI”).

15. Offshore Services. All Services shall be provided within the United States or a Territory of the United States (America Samoa, Guam, Northern Marianas, Puerto Rico, and Virgin Islands). This requirement applies to Proposer’s employees, subcontractors, and location where CareOregon Data will be accessed or stored.

3.2.3 Deliverables.

1. Determine and provide a roster of open specialty laboratories that will be paid for testing.

2. Determine and provide a roster of which physicians can request testing.

3. Select and manage list of open preferred laboratories for payors and physicians.

4. Provide monthly detailed reports, and ad-hoc reports when requested, for additional accuracy verifications.

5. Build files detailing Proposer’s audit scope of work and share such files with CareOregon.

6. If pre-payment, Proposer shall meet CareOregon’s process requirement of a five business day turnaround.

7. If post-payment, Proposer is to provide a monthly file via Secure File Transfer Protocol

(“SFTP”). CareOregon will review these claims files and then have the claims files sent to Proposer to be processed.

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8. Proposer shall provide an extensive list of reporting requirements such as pre-payment analysis for statistical needs. i.e., show us where CareOregon falls under these statistics as a percentage of the industry standard. Report shall be presented in a client-friendly format.

9. Proposer to provide monthly reporting to include specialized reporting to understand which providers are outliers, etc.

10. 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.

11. Acceptance testing. Proposer to work with CareOregon to create an acceptance testing plan. Both parties shall agree to the plan in writing and the plan must be completed prior to CareOregon acceptance of the solution.

12. CareOregon to provide historical claim files for pre-payment review via SFTP.

3.2.4 Claims Volume:

1. CareOregon’s 575,000 Medicaid members generated 8,247,136 total claims processed in 2024.

2. 17,205 Medicare members generated an additional 852,759 total claims processed in 2024.

3. Specific to lab claims, in 2024 CareOregon had over 990,000 claims processed.

4. CareOregon anticipates the claim volumes listed above to remain steady through the duration of the contract.

3.2.5 Work Schedule:

Milestones/Timeline.

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

Target date for contract award July 2025 Begin training internal/external customers August 2025 Implementation of solution is completed. Go-Live September 2025

CareOregon staff training and support to be provided by Proposer at no charge for no less than three (3) months after go-live date.

3.2.6 Term of Contract: The term of the contract shall be from the effective date for an initial term of one (1) year, with the option for four (4) additional one (1) year renewals thereafter subject to the mutual agreement of the parties. After the initial term and the first annual renewal, Proposer may request an annual increase in any applicable fees, and such fees shall not increase by more than two percent (2%) over the fees for the prior year.

3.2.7 Performance Requirements:

1. SOC2 Type II certification conducted annually.

2. Proposer to provide SOC2 Type II report and any associated bridge letters and updates to

CareOregon upon request for performance review purposes.

3. ISO 27001, or HITRUST may be considered in place of SOC2 Type II audit at the discretion of

CareOregon.

4. CareOregon to audit Proposer’s compliance program and systems.

5. One (1) day notification of discovery of an incident or presumed breach.

6. Project status reporting to include weekly written status reports submitted to the CareOregon

Contract Administrator. These status reports should include overall summarization of the project progress, deliverables achieved, deliverables remaining, progress and expected delivery on each, and issues and concerns affecting specific services or deliverables, and the project schedule or any other aspect of the project.

3.2.8 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

RFP 2025-02 Laboratory Claims Management Page 7 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

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 $2,000,000 per occurrence, with an annual aggregate limit of $4,000,000 for damages caused by error, omission, or negligent acts.

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 $7,000,000 per occurrence for network security (including data breach), privacy, interruption of business, media liability, and errors and omissions.

Umbrella coverage in the sum of $7,000,000 and will apply over all required liability policies, without exception.

3.2.9 For Software Purchases

It is understood that most software purchases will be completed using the Proposer specific contract template. For this project, CareOregon is open to using the selected Proposer contracts;

however, the attached Contract Addendum (attached as Exhibit A) shall be required to be executed and will specifically supersede several typical clauses contained in the Proposer’s software agreements. Most of the clauses are required and will not be negotiated so it is important for interested Proposers to carefully read the Contract Addendum and understand that it will be executed along with the resulting Proposer contract.

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

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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 may recommend an award based solely on the written responses or may request interviews/presentations with Proposers. Interviews/presentations, if deemed beneficial by the evaluation committee, 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 0-10 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.

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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 20 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. Describe your firm.

2. List the credentials/experience of key individuals that would be assigned to this project.

3. Describe 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. Describe your firm’s ability to meet the requirements in Section 3.

6. Describe what distinguishes your 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 (do not provide confidential information).

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

5.3 Scope of Work (35 Max points):

General Questions

1. How are claims submitted to Proposer for review if claim system access is not provided?

2. Will Proposer be communicating directly with the service providers as a representative of

CareOregon? How are the review findings submitted to the provider?

3. Provide a flow chart of the process from claim identification to initial review findings.

4. Describe the invoice reconciliation process.

5. Does Proposer require medical records as part of the review process?

6. Does Proposer have a clinical team to review appeals and support peer review requests from providers?

7. Will Proposer supply clinical and legislative support for proposed procedure denials upon request?

8. Is your solution software only or a combination of a software and people solution?

9. Are there additional costs for support services? If so, provide those costs.

10. How is the support team structured and what are their qualifications?

11. Can you provide examples of how your support team has helped other clients?

12. Will you handle all appeals?

13. What is your appeals rate and overturn rate on those appeals?

14. Does the review process include the identification of correct coding guidelines? If yes, do you partner with clients to build out edits within the client’s platform to prevent inappropriate payments?

15. What are your top five claim savings determinations based on your current client partnerships?

16. Provide a detailed description of Proposer’s HIPAA Privacy and Security Compliance programs as these would apply to CareOregon Data. Include information related to any policies and practices developed to address the storage, handling, sharing, and creation of any confidential information.

mailto:vendorservices@careoregon.org

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17. Fully describe Proposer’s cost-containment programs as well as any specialized or enhanced elements Proposer offers.

18. Describe Proposer’s standard reporting package along with any unique reporting capabilities that distinguish Proposer from other firms.

19. What safeguards exist for preventing breaches in patient confidentiality with regard to pharmacy/medical claims information?

20. Indicate how many claims management engagements have been implemented in the last two (2) years by your firm, and what percentage of business revenue is derived from claims management engagements.

21. Describe at least two project successes and two failures of a claims management engagement.

Include how each experience improved Proposer’s services.

Service Level Agreement

1. If applicable, provide your standard Service Level Agreement.

2. Confirm that customer support will be available minimally M-F, 8:00 am-5:00 pm, Pacific Time.

3. Describe operational and service level agreements and uptime guarantees.

4. Describe how your support process works, including expected response times and availability.

5. What skills are required for CareOregon staff to interact with the proposed solution?

6. Describe how you maintain system currency, including any update cycles or defined maintenance windows.

7. How will you communicate and engage CareOregon staff during the operation of the solution? How do you communicate with your customers when a problem or incident is underway?

8. Describe the managed services (if any) provided within the proposal. What is the total scope of services expected, and how does that break down into responsibilities between CareOregon and the service provider?

9. Describe how the vendor-customer relationship will be managed. What points of contact will you provide, and what are their roles?

Implementation

1. If applicable, provide an implementation plan and estimated timeline from a hypothetical contract execution date.

2. Are implementation services provided by your company or subcontracted to a third-party vendor? If another company:

a. Will CareOregon have to contract directly with the implementation firm or will they be a subcontractor?

b. Provide background information about the implementation firm including contact information, firm background, assigned staff credentials, and any other helpful information for us to evaluate.

3. If implemented by your company, provide a description of the skills and experience (CV) of the individuals who would be assigned to the project.

4. Does any part of the implementation need to be in-person?

5. Provide a matrix of responsibilities (RACI) including milestones, prerequisite milestones, and milestone durations.

6. Describe training to be provided by your firm. Be specific if the offered and included training is for general users, power users, or administrator of the solution?

7. Do you offer training guides? FAQs? Recordings of training sessions?

8. What is your project approach/strategy?

9. Does your project approach/strategy include a vendor-supplied project manager?

10. Do you provide a project approach playbook for all phases of the project (design planning, workflow configuration, testing, implementation, go-live, post go-live)?

11. What is the number of hours per week we should anticipate dedicating to the project?

12. What is the number of hours per week we should anticipate your team will be working or meeting with us directly?

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13. Describe how your firm will provide bulk upload services for existing contracts?

14. How do you ensure a positive onboarding experience including deployment services and technology configuration?

15. The final solution may be composed of multiple integrated modules, features, and services. Describe the order in which you recommend implementing these modules and why. Describe any required prerequisites for these modules.

16. Please provide a template(s) that you use relating to an implementation.

Technical Questions

1. If applicable, does your solution have a test environment that will be used for development and testing before being migrated to production?

2. Will you provide a best practice for how your clients administer the solution regarding:

a. Solution configuration practices.

b. User and license management.

3. Please provide details on clients’ data security.

a. Is client data encrypted at rest?

b. CareOregon Data at all times must be located in the continental United States. Confirm that all applications and data base servers are located in the continental United States.

4. Describe your data security procedures and audit.

5. Provide a copy of your most recent data security audit.

6. Describe your standard updates/patches frequency, version upgrades, and the process to notify customers of upcoming new releases.

7. What customizations would you need to make to your standard product offerings to fit this solution to CareOregon’s needs?

8. What are the technical requirements for CareOregon staff to operate and manage the solution

(hardware, software, connectivity)?

9. Describe how the solution integrates with other platforms and systems. Are these built-in or custom integrations?

10. Is the technology proposed built, owned, and managed by the original software vendor? Describe the role any third-party technologies or services play in the proposed solution.

11. Are there additional third-party products/services that CareOregon will need to license/procure separately from this solution?

12. What capabilities does your system have for both extracting and ingesting information?

13. What does the process look like if or when we identify a need to ‘add’ a new inbound connector?

14. Please provide the discreet data elements which we would ideally track related to provider contracts/business contracts.

Information Security

1. Describe how this solution will help us keep compliant with health care regulations, such as HIPAA.

2. Describe your Information Security program, including organizational structure, leadership, and framework.

3. How does your product provide high availability and resiliency to address service outages, compromises, data corruption, or other impairments?

4. Describe disaster recovery and business continuity plans, specifically addressing the most recent date and the number of times vendor has practiced and tested its procedures in the past 5 years, and the results of those exercises.

5. Describe all places where CareOregon data may be stored by your staff, such as on workstations or paper, and physical locations such as in offices and/or data centers. Describe your physical security model. Do you allow customer data to be downloaded or moved outside of your applications and data centers?

6. How will you ensure that CareOregon data is not stored or processed outside of the United States?

7. How does the proposed solution protect CareOregon data from unauthorized access, both at rest and in transit?

RFP 2025-02 Laboratory Claims Management Page 12

8. Describe how you keep CareOregon data separate from other customer data.

9. How do you screen your employees and contractors to ensure the safety of customer data?

10. Is the data stored in this solution accessible by the service provider’s support staff? Please describe.

11. How does the proposed solution implement single sign-on with third-party identity systems, such as

Active Directory, Azure Active Directory, and/or other OAuth identity services?

12. Describe how the system records and reports on user access and activity. Do you periodically review your own staff access logs?

13. Are your system security measures validated regularly by a third party? Please describe and include any industry certifications you have achieved.

14. What provisions do you have to allow us to retrieve data if/when our agreement ends? How do you ensure data is destroyed and/or permanently removed from your systems?

5.4 Equity, Diversity and Inclusion Efforts (10 Max points):

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.

5.5 Fees (25 Max points):

1. Provide a fee sheet to include all the services your firm will provide to CareOregon. Include a breakout of your pricing per each proposed Service. The fees will be fixed for the first two years of the contract.

Thereafter the fee may not increase by more than two percent (2%) per year.

2. Include any applicable administrative fees. Note: This fee is expected to be zero ($0.00) dollars.

3. CareOregon shall establish which vendor will have first pass and which will be in a second pass position. If your firm will only accept first pass position, indicate that in your answer to this question.

4. If applicable, provide a fee for software implementation. List an hourly fee and then estimate the total hours for implementation completion. List the estimated total fee for implementation.

5. If applicable, provide a fee for software maintenance and support services. List an hourly fee for support services. Also provide information about available service packages if applicable, priced annually. Include your firm’s Service Level Agreement.

6. There are NO additional fees (beyond those outlined in the Fees Section) required to administer the services outlined in this RFP. Any mandatory fees must be clearly outlined in the Fees Section of Proposer’s Proposal.

5.6 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 (1) 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.

Evaluation Committee members may contact references at their sole discretion.

5.7 Completed Proposal Certification (see the below form)

RFP 2025-02 Laboratory Claims Management Page 13

PROPOSAL CERTIFICATION

RFP #2025-02 Laboratory Claims Management

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

RFP 2025-02 Laboratory Claims Management Page 14

EXHIBIT A

SOFTWARE CONTRACT ADDENDUM

This is a Sample Form - Do Not Complete or Sign This Software Contract Addendum (“Addendum”) is entered into by [Name of Contractor] (“Contractor”) and CareOregon, Inc. on behalf of Health Share of Oregon and Health Plan of CareOregon, Inc. (CareOregon Advantage) (collectively, “CareOregon”).

This Addendum shall be attached to, and incorporated into, the [Description of contract being attached] (“Vendor Agreement”). As used below, "Contract" means this Addendum and the Vendor Agreement and “Services” refers to the goods and/or services described in the Vendor Agreement. To the extent there is any conflict between the Addendum and the Vendor Agreement, the terms of this Addendum shall control.

1. Term. The Contract shall become effective upon signature of both parties. Unless earlier terminated or extended, this Contract shall expire on . This Contract or any Order Form may be extended only if ninety (90) days prior to the then expiration date, the Contractor provides a written quote to CareOregon for a one-year (unless the parties negotiate otherwise) renewal term, and CareOregon accepts a renewal term by the issuance of a CareOregon purchase order or agrees to a new Order Form. Except for the renewal term and associated fee, no other terms and conditions of the original Contract may be changed through this process.

2. Contractor and CareOregon Contract Administrators.

Contractor Administrator:

Phone:

Email:

Address:

CareOregon Administrator:

Phone:

Email:

Address:

3. Invoices and Payments. Invoices shall be submitted to: covendorinvoices@careoregon.org.

Payment for completion of CareOregon contracts are made within 30 days following the date the entire order is delivered or the date the accurate invoice is received whichever is later. Contractor may not assess an overdue account charge in excess of eight percent (8%) per annum on outstanding balances. If Contractor fails to present invoices in proper form within sixty (60) calendar days after the end of the month in which the Services were performed, Contractor waives any rights to present such invoice thereafter and to receive payment therefor.

4. Fee Escalation Cap. In the event any Order Form, Statement of Work, or any other contract authorizing Services is entered into between the parties, any applicable fee shall not increase by more than two percent (2%) over the prior year fees.

5. Travel and Other Expense. If travel expense reimbursement is authorized in this Contract, such expense shall only be reimbursed at the rates in the CareOregon Contractor Travel Reimbursement Allowance, hereby incorporated by reference and found at: https://www.careoregon.org/about-us/vendor-resources. Travel expense reimbursement is not in excess of the not to exceed compensation amount.

6. Insurance. Contractor shall secure at its own expense and keep in effect during the term of the performance…