RFP 2025-04 Home Health Skilled Nursing Facility Services Clarifying Questions 1.pdf
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- Solicitation number
- S-X26083-00015254
- Issued by
- Oregon
About this file
This document is a clarifications response to RFP 2025-04 issued by CareOregon, Inc. on behalf of CareOregon Advantage and Health Share of Oregon for Home Health and Skilled Nursing Facility Audit and Review Services. The RFP seeks a contractor to conduct prepayment and post-payment audits and clinical medical record reviews of home health, skilled nursing facility, and hospice claims to identify billing inaccuracies and ensure medical necessity. The scope encompasses claim selection performed collaboratively between the supplier and CareOregon, with CareOregon preferring a mix weighted toward prepayment reviews. The selected vendor must employ only Certified Coding Specialists or Certified Professional Coders and maintain a medical director on staff. CareOregon processes approximately 346,542 home health claims and 17,336 skilled nursing facility claims annually, with no specified volume limits for audit selections. The contract is scheduled to commence in January 2026 with an initial one-year term and two optional one-year renewals. Proposals are due by December 8, 2025, at 2:00 PM Pacific Time, with evaluation based on background and qualifications (30 points), scope of work (35 points), equity and diversity efforts (10 points), and fees (25 points).
CareOregon does not currently outsource these audit services to any external supplier, making this a new service initiative. The contract will feature fixed pricing for the initial two years with potential annual fee increases of up to 2 percent in subsequent years; no specific budget amount is disclosed. Proposers will receive read-only access to CareOregon's QNXT claims system and provider contracts as needed and will have access to claims data including HCPCS codes, modifiers, and place of service indicators, though Electronic Visit Verification data will be provided through direct data transfer between CareOregon and the supplier rather than direct system access. CareOregon does not reimburse providers for medical record requests, and claims without submitted medical records may be denied per CareOregon policy. The RFP actively encourages submissions from minority-owned, women-owned, service-disabled veteran-owned, and emerging small businesses. Provider disputes and appeals are limited to two levels, and the repricing process must be supported by federal, local, or legislative requirements and existing written policies.
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315 SW Fifth Ave, Portland, OR 97204 | 800-224-4840 | TTY 711 | careoregon.org
REQUEST FOR QUOTES #2025-04
Home Health and Skilled Nursing Facility Audit and Review Services
RESPONSE TO CLARIFYING QUESTIONS #1
November 12, 2025
Note that these are questions submitted by interested firms to the above referenced solicitation.
The below answers are for clarification purposes only and in no way alter or amend the RFQ as published.
1. Does this RFP process include post-pay collections of providers?
Answer: Section 5.3 Scope of Work states, “For Home Health, define your scope for coordinating home health claim reviews….For Skilled Nursing, define your criteria and actions for both pre-payment and post-payment claim reviews.
2. For prepay audit review, will CareOregon provide claims on a daily basis?
Answer: We can batch claims to the supplier as necessary to fulfill the scope of work.
3. For prepay vs. post-pay audit volume, how will that be determined? By CareOregon or the supplier?
Answer: By CareOregon as outlined by the scope of work.
4. Please confirm that Hospice claims are in scope for the SNF audits.
Answer: RFP Section 3.2.2 B Skilled Nursing and Hospice Facility Audit Review states, “Define criteria and actions for both pre-payment and post-payment claim reviews.
• Skilled Nursing Facility claims.
• Hospice claims.”
5. Can CareOregon clarify whether the scope of this proposal is limited to high-dollar claims, or is the intent is to include all claims? If restricted to high-dollar claims, what is the defined threshold above which claims will be considered under this RFP?
Answer: RFP Section 3.1 Background, Project Background states, “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.”
6. Can CareOregon confirm whether the services outlined in this RFP are currently being performed? If so, please indicate which of these services are managed internally by CareOregon and which are currently outsourced to external suppliers?
http://careoregon.org/
George Marlton Procurement Director
Procurement Department 503-488-7646 vendorservices@careoregon.org
Answer: Not currently being performed by CareOregon or any existing supplier activities.
7. What is the anticipated mix of pre-payment versus post-payment reviews (e.g., percentage of volume & savings)?
Answer: This will be determined by the supplier proposal, but CareOregon prefers pre-pay
8. What are the primary challenges or areas of improvement within the CareOregon’s current Payment Integrity program? Are there specific issues they aim to address through suppliers selected via this RFP?
Answer: CareOregon currently has a robust PI program. We are looking to target specific savings surrounding home health and skilled nursing payments.
9. Can CareOregon clarify whether claim selections for audit are expected to be performed by the supplier or managed internally?
Answer: These would be performed by the supplier in collaboration with CareOregon.
10. Will the supplier be responsible for performing recovery or collections activities for identified overpayments, or would CareOregon be recouping? If so, what is the expected mix between recoupments and check collections?
Answer: Section 5.3 Scope of Work states, “For Home Health, define your scope for coordinating home health claim reviews….For Skilled Nursing, define your criteria and actions for both pre-payment and post-payment claim reviews.”
11. Regarding the Skilled Nursing Program, what is CareOregon's volume forecast by payment methodology, Tiered SNF Per Diem and/or PDPM?
Answer: Currently not forecasted.
12. Regarding the Home Health Program, what is CareOregon's volume forecast by payment methodology, Per Visit and/or PDGM?
Answer: Currently not forecasted.
13. Can CareOregon please clarify whether documentation of a face-to-face encounter is a required component of a valid Home Health claim? Would a lack of such documentation constitute a sufficient reason to deny a claim?
Answer: RFP section 3.2.2 Services, A. Home Health Audit and Review states, “Vendor sets scope for coordinating home health claim reviews with CareOregon.”
mailto:vendorservices@careoregon.org
Procurement Director
Procurement Department
14. How many levels of provider disputes/appeals will be allowed?
Answer: 2 levels will be allowed.
15. Will CareOregon grant supplier subject matter experts read-only access to its claims system and provider contracts to support the development and validation of audit selection algorithms?
Answer: RFP Section 3.1 Project Background states, “Proposer shall be granted read-only access to the current claims system, QNXT, if required.”
16. Does CareOregon's provider contract allow providers to request reimbursement for medical records? If reimbursement for medical records is allowable per provider agreement, is it CareOregon's expectation that those fees will be borne by the supplier or passed through to CareOregon?
Answer: No, CareOregon doesn’t reimburse for medical record requests.
17. What is CareOregon’s procedure if requested medical records are not submitted within the required timeframe?
Answer: RFP Section 3.2.3 Deliverables states, “Claims without received medical records may be denied per CareOregon policies.”
18. Does CareOregon have a limit for pre-payment audit selections? Is this by day, week, or month? Are there volume limits by provider?
Answer: No limits. We can batch claims to the supplier as necessary to fulfill the scope of work. There are no volume limits by provider.
19. Can CareOregon share information about any provider exclusions that apply to services in scope?
Answer: The supplier will receive access to provider contracts.
20. Section 2.4 Submission of Proposals. This section indicates that 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). Please confirm that the cover letter referenced in RFP Section 2.4 is excluded from the 30-page limit.
Answer: Please refer to Section 5.1.3 Proposal Contents, stating, “Proposal may not exceed a total of 30 pages (single-sided), inclusive of all exhibits, attachments, or other information.”
Procurement Director
Procurement Department
21. Section 2.4 Submission of Proposals. Please confirm that the Proposal Certification form be exempt from the 30-page limit due to the amount of detail that the CareOregon would like to include within the required page limit.
Answer: Please refer to Section 5.1.3 Proposal Contents, stating, “Proposal may not exceed a total of 30 pages (single-sided), inclusive of all exhibits, attachments, or other information.”
22. Section 2.19 Proposal Confidentiality. Please confirm that CareOregon will accept a redacted version of a proposal for CareOregon to use in response to any FOIA/Open Records requests it may receive in the future since a Proposer’s proposal will contain trade secrets.
Answer: As a private non-profit, CareOregon is not subject to public records laws or Freedom of Information Act requests. CareOregon considers contracts, proposals, evaluation materials, and internal decision making to be confidential proprietary information and does not share such information with outside entities.
23. There are four exhibits: Exhibit A Software Contract Addendum, Exhibit B Business Associate Agreement, Exhibit C Terms and Conditions for Cloud Services, and Exhibit D CareOregon Data Security Requirements for Tier 1 Contractors. Could you please confirm whether these documents are provided solely as samples for the contractor's review and understanding, and that neither signatures nor redlining are required at this stage?
Answer: Please refer to Section 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 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.”
24. Please provide total annual home health outpatient spend and claim count. Please include Calendar Year 2024 and available Calendar Year 2025 data.
Answer: Please refer to Section 3.1 Background, Project Background, which states, “In terms of volume, for home health, CareOregon had 346,542 paid claims processed and for skilled nursing facility, 17,336 paid claims processed.”
25. Please provide total annual home health professional spend and claim count. Please include Calendar Year 2024 and available Calendar Year 2025 data.
Procurement Director
Procurement Department
26. Please provide total annual skilled nursing inpatient spend and claim count. Please include Calendar Year 2024 and available Calendar Year 2025 data.
27. Can CareOregon confirm that Proposer has primary claims selection responsibility. If no, does Proposer have any claims selection responsibility?
28. If CareOregon is initiating and selecting claim required for audit, will this process be applied for all claim types (e.g., home health, skilled nursing, and hospice)? If not, please specify which claim types are subjected to CareOregon claim selection criteria.
29. Will the Proposer be able to make claim selections against home health, skilled nursing, and hospice?
30. Please provide CareOregon annual audit claim volume expectations by claim type (home health, skilled nursing, hospice).
Answer: Please refer to RFP Section 3.1 Background, Project Background, which states, “In terms of volume, for home health, CareOregon had 346,542 paid claims processed and for skilled nursing facility, 17,336 paid claims processed.”
31. Will the Proposer be required to initiate separate repricing files with MicroDyn?
Answer: No.
32. Please confirm the CareOregon repricing process requirements.
Answer: All claims repricing must be supported by federal, local, legislation for already written policies.
Procurement Director
Procurement Department
33. Are audit review requirements based on single claim review and/or case level claim reviews (case level: multiple claims per patient episode)? Please define if applicability to both pre and post-pay reviews.
Answer: We are open to single claim review and case level claim review for both pre and post-pay reviews.
34. Does your prior authorization guarantee payment?
35. Please confirm your data feed will include a field to indicate if prior authorization was given.
Answer: Confirmed this will include a field.
36. Please confirm the scope is all clinical medical record reviews. If no, is the additional scope data mining or other? If other, please provide description.
Answer: The scope is clinical medical record reviews and single case agreement negotiations.
37. Does the scope include medical necessity and/or billing claim accuracy?
Answer: Yes for both.
38. Please confirm reimbursement methodology for home health for both Medicare and Medicaid populations.
Answer: These services are paid by CareOregon to the providers under a variety of payment methodologies, including fee-for-service, per diem, and case rates.
39. Please confirm reimbursement methodology for skilled nursing for both Medicare and Medicaid populations.
Answer: These services are paid by CareOregon to the providers under a variety of payment methodologies, including fee-for-service, per diem, and case rates.
40. Please confirm if requested Health Insurance Prospective Payment System (HIPPS) Code validation is a requirement for only skilled nursing reviews? If not, please specify which claim types will necessitate this review.
Answer: Supplier should illustrate the use of HIPPS or any other validation requirements in its proposal.
Procurement Director
Procurement Department
41. Please provide additional details for the requirements CareOregon is seeking from a Proposer to identify incentives for actual/potential referral sources, as well as improper patient solicitation for home health audit reviews.
Answer: CareOregon does not understand the question.
42. Please provide clarification on Proposer expectations for identifying and evaluating subcontractor management practices contributing to billing inaccuracies.
43. For all Home Health Care Services (HHCS) that require Electronic Visit Verification (EVV) Compliance; will Proposer have access to Healthcare Common Procedure Coding System (HCPCS) codes, Modifiers, and Place of Service (POS) or Type of Bill (TOB) Indicators? If no, how will the data be provided to the Proposer?
Answer: Yes, proposer will have access to all necessary claims data.
44. Since the State of Oregon uses the Provider Choice Model for Electronic Visit Verification (EVV) and each Home Health Care Agency and Providers have the responsibility of selecting their own Electronic Visit Verification (EVV) Supplier, will Proposer have access to all required information through CareOregon's aggregator system, Express Payment, and Reporting System (eXPRS)? If no, how will the data be provided to the Proposer?
Answer: No, supplier will not have direct access. CareOregon will provide the data transfer direct between the two entities.
45. Would CareOregon consider using an active Master Services Agreement (for substantially similar services) with a Proposer, along with any negotiated adjustments to accommodate the Scope of Work of this RFP, as the basis for the awarded contract?
Answer: Not typically; however, CareOregon could review an applicable Master Services Agreement to make a determination.
46. Will CareOregon please confirm, for the avoidance of doubt, that Exhibit A will not apply if software is not being licensed or otherwise provided to CareOregon by a Proposer as part of its solution?
Answer: Exhibit A would be applicable if any software/licenses/subscription is being purchased by CareOregon.
47. Would CareOregon consider relying upon an active Business Associate Agreement included in an active Master Services Agreement with a Proposer, in lieu of negotiating a new BAA for purposes of the contract awarded pursuant to this RFP?
Procurement Director
Procurement Department
48. Answer: CareOregon would make this decision post-award.
49. Would an extension to 12/15 for the RFP due date be considered given the holiday within the proposal period?
50. Could you please confirm the run-out period for the existing supplier to ensure a smooth transition and avoid any overlap in audit activities?
Answer: CareOregon does not have an existing supplier; this is a new services activity.
51. Will CareOregon be able to provide a file of tagged claims identified by the existing supplier?
Answer: CareOregon does not have an existing supplier; this is a new services activity.
52. Regarding offshore services, can you please clarify the process to obtain authorization for any portion of the work to be performed offshore? The RFP states: “Unless specifically authorized in this Contract, all Services shall be provided within the United States or a Territory of the United States (American Samoa, Guam, Northern Marianas, Puerto Rico, and Virgin Islands).” We would appreciate confirmation of the approval pathway and any conditions that may apply.
Answer: In the event services would be performed offshore, our internal department would need to obtain an internal policy exception.
53. Are there any limitations or thresholds on the number of medical records that may be requested as part of this engagement?
54. Would the supplier be granted remote access to CareOregon’s claims processing and prior authorization systems?
Answer: RFP Section 3.1 Background, Project Background, states, “Proposer shall be granted read-only access to the current claims system, QNXT, if required.”
55. What is the name of the claims processing system currently in use at CareOregon?
Answer: QNXT.
End of Clarifying Questions
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