RFP 2025-04 Home Health and Skilled Nursing Facility Audit and Review Services.pdf

RFP 2025-04 Home Health and Skilled Nursing Facility Audit and Review Services

REQUEST FOR PROPOSALS #2025-04

Home Health and Skilled Nursing Facility Audit and Review Services

Publish Date: October 28, 2025

CareOregon, Inc. (“CareOregon”) on behalf of Health Plan of CareOregon (CareOregon Advantage), and Health Share of Oregon, is inviting submission of proposals for the Home Health and Skilled Nursing Facility Audit and Review Services project.

Closing Date/Time: December 8, 2025 - 2:00 PM, Pacific Time

Project Summary: The Centers for Medicare and Medicaid Services (“CMS”) and the Oregon Health Authority (“OHA”) require managed Medicare and Medicaid plans to implement payment integrity programs. Outsourcing Skilled Nursing Facility and Home Health claims audits on a prepayment basis allows CareOregon to meet these regulatory requirements and minimize claim overpayments. Work is to begin approximately January, 2026, and continue for one (1) year with the option for two (2) 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…….................................................. October 28, 2025

Deadline to Submit Clarifying Questions.......................................November 11, 2025, 5:00 PM, Pacific Time

Request for Proposals Closing Date and Time (“Closing”)........... December 8, 2025, 2:00 PM, Pacific Time

Anticipated Contract Start Date……..............................................February, 2026 mailto:reinholtzl@careoregon.org https://oregonbuys.gov/bso/ mailto:vendorservices@careoregon.org

NAME OF RFP 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.

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

RFP 2025-04 Home Health and Skilled Page 2 Nursing Facility Audit & Review Services 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

RFP 2025-04 Home Health and Skilled 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:

Exhibit A – Software Contract Addendum.

Exhibit B – Business Associate Agreement.

Exhibit C – Terms and Conditions for Cloud Services.

Exhibit D – CareOregon Data Security Requirements for Tier 1 Contractors.

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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 implement payment integrity programs. Outsourcing Skilled Nursing Facility (“SNF”) and Home Health audits for high dollar claims prior to claim completion, allows CareOregon to meet these regulatory requirements and minimize claim overpayments.

Currently, CareOregon has 575,000 Medicaid members with 8,247,136 claims processed in 2024, and 17,205 Medicare members with an additional 852,759 claims processed in 2024. In terms of volume, for home health, CareOregon had 346,542 paid claims processed and for skilled nursing facility, 17,336 paid claims processed.

The following regulatory frameworks must be followed: The Health Insurance Portability and Accountability Act (“HIPAA”), 42 Code of Federal Regulations (“CFR”) Part 2, CMS, Oregon Revised Statues (“ORS”) and Oregon Administrative Rules (“OAR”). CareOregon to provide access to provider contracts if required. These services are paid by CareOregon to the providers under a variety of payment methodologies, including fee-for-service, per diem, and case rates. CareOregon uses MicroDyn to assist with pricing of some facility claims.

Proposer shall be granted read-only access to the current claims system, QNXT, if required.

CareOregon may award the services to one or more qualified firms. Proposer shall submit their Proposal(s) for one or both of the home health and/or skilled nursing facility audit services.

3.2 SCOPE OF WORK

3.2.1 Scope:

CareOregon, along with its subsidiaries Health Share of Oregon, and CareOregon Advantage, is seeking a payment integrity program that offers forensic review cost containment services to include review of referred skilled nursing facility and home health claims for potential billing errors and inconsistencies.

Once potential billing issues are identified through home health and Skilled Nursing Facility audit

RFP 2025-04 Home Health and Skilled Page 6 review, and if claim savings warrant it, Proposer shall prepare a forensic review report (reports can be submitted as frequently as daily) listing each identified issue and specifying the adjusted billed charge amount for all uncontested charges. Under the direction of the CareOregon Contract Administrator, Proposer to assist CareOregon with resolution and/or appeal support for the billing issues identified for up to one year following delivery of such report to CareOregon.

Proposer shall provide all personnel, materials, equipment, peer review, and peer review panel costs necessary for Proposer’s performance of the services.

Proposer must keep current with OHA guidelines and CMS guidelines.

Proposer shall use only Certified Coding Specialists (“CCS”) or Certified Professional Coders (“CPC”) and Proposer personnel must be currently certified by the American Health Information Management Association (“AHIMA”) or the American Academy of Professional Coders (“AAPC”). Proposers are required to have a medical director on staff.

3.2.2 Services:

A. Home Health Audit and Review.

• Vendor to define criteria and scope for pre-payment and post-payment review.

• Audit services apply to both HCFA1500 (professional charges) and UB04 (facility charges).

• Vendor sets scope for coordinating home health claim reviews with CareOregon.

• Post-pay review may include claims up to 12 months post-processing.

• SNF and home health claims compliance audits, including delivery of audit reports, and any assumptions related to the anticipated schedule.

Audit to Include

• Billing for services/items not rendered.

• Medically unnecessary services.

• Duplicate billing.

• Incentives to actual/potential referral sources.

• Services billed for non-homebound patients.

• Recommendations for payments and denials. Review of visit notes and other clinical documentation. Over-/under-utilization.

• Insufficient documentation to support reimbursement.

• Improper patient solicitation.

• Poor subcontractor management causing billing errors.

• Orders, Plan of CareOregon, and primary prescriptions alignment.

Automation & Analytics Requirements

• Vendor automation must not disrupt CareOregon claims examiners’ workflows.

• Analytics must support claims examiners' daily operations.

• Overpayment analytics must include edit recommendations to avoid repeated errors.

Home Health Audit Responsibilities

• Vendor verifies medical records support claim validity.

• Review revenue codes, Current Procedural Terminology (“CPT”), Healthcare Common

Procedure Coding System (“HCPCS”), International Classification of Diseases (“ICD”).

• Request and evaluate provider medical records.

RFP 2025-04 Home Health and Skilled Page 7

• Ensure federal, state, and payer guidelines are met.

• Return audit recommendations to CareOregon in a timely manner, within five days for pre-payment claims and thirty days for post-payment claims.

Focus Areas in Claims Review

• Physical, occupational, and speech therapy.

• Face-to-face documentation.

• Telehealth services.

• Physician’s orders and plan of care.

• General compliance documentation.

• Visit note documentation.

• Finding logic to group the PDPMs for complexity of the member.

• Designating/describing complexity that the facilities are receiving.

Communication & Adjustments

• Timely updates and prompt responses to CareOregon inquiries.

• Adjustments for overpayments must be communicated within the timelines outlined in the deliverables, i.e. five (5) calendar days for pre-payment review and thirty (30) calendar days for post-payment review.

Cost Containment Focus

• Proposer to provide long-term solutions for cost containment.

• Note: CareOregon does not require pricing assistance.

B. Skilled Nursing and Hospice Facility Audit Review.

• Define criteria and actions for both pre-payment and post-payment claim reviews.

ο Skilled Nursing Facility claims.

ο Hospice claims.

ο Both HCFA1500 (professional) and UB04 (facility) forms.

• Post-payment reviews to look back up to 12 months from processing date.

• Targeted SNF reviews to validate:

ο Coding accuracy.

ο Compliance with CMS, State, and health plan policies.

ο Service utilization standards.

Medical Record Review

• Assess whether records support acuity of care billed.

• Review shall cover:

ο Revenue codes.

ο CPT codes.

ο HCPCS codes.

ο ICD codes.

• Ensure alignment with federal, state, and payer compliance guidelines.

Health Insurance Prospective Payment System (“HIPPS”) Code Validation

• Focus on documentation supporting:

ο Physical therapy (“PT”).

ο Occupational therapy (“OT”).

ο Speech-language pathology.

RFP 2025-04 Home Health and Skilled Page 8 ο Nursing services with functional scores.

ο Non-therapy ancillary services.

Documentation Focus Areas

• Diagnosis coding accuracy.

• Minimum Data Set (“MDS”) documentation.

• Compliance standards.

• Individual therapy minutes tracked and verified.

Automation & Analytics Requirements

• Vendor automation must not interfere with CareOregon examiners’ workflows.

• Vendor analytics must support CareOregon examiners’ work and improve daily progress tracking.

Pricing

• CareOregon does not require pricing assistance from the Vendor.

3.2.3 Deliverables:

Review Reports

• Pre-payment review report: provide within 5 calendar days of receiving medical records.

• Post-payment review report: provide within 30 calendar days of receiving medical records.

• Ad hoc reports requested by CareOregon must be submitted in the format prescribed by

CareOregon within reasonable timeframes as specified by CareOregon.

• Claim files shall be shared only via secure file transfer protocol (“SFTP”).

• Claims without received medical records may be denied per CareOregon policies.

3.2.4 Work Schedule:

The table below 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 December 2025 Train internal/external customers One month before go-live Implement solutions and go-live by April 2026 Training and support Available three months post go-live date at no charge to CareOregon.

3.2.5 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 two (2) 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.

3.2.6 Performance Requirements: Project status reporting to include weekly written status reports submitted to the CareOregon Contract Administrator. Status reports to 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.

3.2.7 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 2025-04 Home Health and Skilled Page 9 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 $1,000,000.00 per occurrence, with an annual aggregate limit of $2,000,000.00 for Bodily Injury and Property Damage.

Professional Liability: combined single limit, or the equivalent, of not less than $1,000,000.00 per occurrence, with an annual aggregate limit of $2,000,000.00 for damages caused by error, omission, or negligent acts.

Automobile Liability: combined single limit, or the equivalent, of not less than $1,000,000.00 per occurrence for Bodily Injury and Property Damage.

Cyber Liability: combined single limit, or the equivalent, of not less than $7,000,000.00 per occurrence for network security (including data breach), privacy, interruption of business, media liability, and errors and omissions.

Umbrella coverage in the sum of $7,000,000.00 and will apply over all required liability policies, without exception.

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 contract, however, the attached Contract Addendum (attached as Exhibit A) shall be required to be executed that 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 Proposal interviews/presentations. 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 30 pages (single-sided), inclusive of all exhibits, attachments, or other information.

4. Proposers are required to structure Proposals following the below question outline. Make your answers as clear and concise as possible.

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):

1. Is your focus on both Home Health Audit or Skilled Nursing or both?

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

3. If software related, what kind of support is included with the software?

4. Are there any additional costs for support services?

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

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

7. What is your typical process for handling provider appeals?

8. Do you have clinical staff for peer review?

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

10. Describe Proposer’s distinctive cost containment services.

Home Health and Skilled Nursing Facility

1. For Home Health, define your scope for coordinating home health claim reviews.

2. For Skilled Nursing, define your criteria and actions for both pre-payment and post-payment claim reviews.

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

4. How are the audit findings submitted to CareOregon?

5. Describe the invoice reconciliation process.

mailto:vendorservices@careoregon.org

RFP 2025-04 Home Health and Skilled Page 12

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 time 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 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?

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

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

Implementation

1. 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 you. 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?

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?

RFP 2025-04 Home Health and Skilled Page 13

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 have related to an implementation.

Technical Questions

1. 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 and provide a copy of your most recent data security audit.

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

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

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

(hardware, software, connectivity)?

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

9. 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.

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

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

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

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

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

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

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

17. 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?

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

19. 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

RFP 2025-04 Home Health and Skilled Page 14 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 may be contingency fees based on a percentage of the savings achieved by Proposer’s firm. The fees will be fixed for the first two years of the contract. Thereafter the fees 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 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 these criteria are based on both the provision of references as well as information gleaned from the provided contacts. Evaluation Committee members may contact references at their sole discretion.

5.7 Completed Proposal Certification (see the below form). You must complete the form below and attach it to your Proposal.

RFP 2025-04 Home Health and Skilled Page 15

PROPOSAL CERTIFICATION

RFP #2025-04 Home Health and Skilled Nursing Facility Audit and Review Services

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 2025-04 Home Health and Skilled Page 16

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’s 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 under this Contract the insurance required and minimum coverage mailto:covendorinvoices@careoregon.org https://www.careoregon.org/about-us/vendor-resources

RFP 2025-04 Home Health and Skilled Page 17 indicated below. A checked box indicates the coverage is required. If the box is not checked, it is not required. The insurance requirements outlined below do not in any way limit the amount of scope of liability of Contractor under this Contract. Contractor shall provide proof of said insurance and name CareOregon, Health Share of Oregon, and Health Plan of CareOregon, Inc. (CareOregon Advantage) as additional insureds on commercial general liability and business automobile liability policies. Contractor shall provide proof of insurance and shall provide CareOregon at least 30 days prior notice of any policy material change, lapse, or termination. Proof of insurance and any notification shall be emailed to: CareOregon Procurement Department at procurement@careoregon.org.

Required insurance:

• Workers’ Compensation: Contractor shall comply with the statutory workers’ compensation requirements in ORS 656.017, unless exempt under ORS

656.027 or 656.126.

•…