RFP 2026-03 Second Pass Claims Editing System.pdf

RFP 2026-03 Second Pass Claims Editing System

REQUEST FOR PROPOSALS #2026-03

Second Pass Claims Editing System Publish Date: March 12, 2026

CareOregon, Inc. (“CareOregon”) is inviting submission of proposals for the Second Pass Claims Editing System project

Closing Date/Time: April 9, 2026 - 2:00 PM, Pacific Time

Project Summary: CareOregon seeks a software solution that will provide payment accuracy and integrity solutions and services to ensure claims are coded and processed correctly. Services are to begin in June 2026 and continue through May 31, 2027, with the option for two (2) additional one (1) year renewal terms thereafter.

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

Reinholtz, Senior Procurement & Contract Analyst; 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…….................................................. March 12, 2026

Deadline to Submit Clarifying Questions....................................... March 26, 2026, 5:00 PM, Pacific Time

Request for Proposals Closing Date and Time (“Closing”)........... April 9, 2026, 2:00 PM, Pacific Time

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

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2.1 Modification or Withdrawal of Proposal: Any Proposal may be modified or withdrawn at any time prior to the Closing deadline, provided that a written request is received by Procurement, prior to the Closing.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

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. CareOregon is soliciting proposals from qualified firms to provide a second pass claims editing system for payment integrity. Be advised that our first pass vendor has rights to claims within the first 1-60 days.

CareOregon seeks a software solution that will provide payment accuracy and integrity solutions and services to ensure claims are coded and processed correctly. Proposer’s solution should increase claim payment accuracy and compliance and identify potential overpayments. Proposers shall define within their proposal what their criteria is for second pass claims editing system services described in this Request for Proposals. The Proposer shall set the scope for the process of analyzing these claims and must demonstrate in their Proposal how their services will help CareOregon reduce claim overpayments.

• Claims Statistics:

573,000 Medicaid members with 8,209,405 claims processed in 2025.

14,300 Medicare members with an additional 789,000 claims processed in 2025.

Total amount for professional claims was $961,290,171.55 in 2025.

Total amount for outpatient facility claims was $265,164,960.64 in 2025.

Total inpatient facility claims were $295,070,459.47 in 2025.

2,654,822 claims received for CES processing in 2024.

3,166,867 claims received for CES processing in 2025.

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3.2 SCOPE OF WORK

Services:

• Second Pass Claims Editing Solution Functionalities:

The Proposer selected for this engagement must provide a second pass claims editing solution that works with QNXT and contains the following functionalities:

Edit and identify prepay issues not identified by current editing system. Edit capabilities should include but not be limited to duplicates, modifiers, bundling/unbundling, National Correct Codding Initiative (“NCCI”)/ Medically Unlikely Edit (“MUE”) alignment, Diagnosis-Related Group (“DRG”)/ Medicare Severity Diagnosis Related Groups (“MS- DRG”), Outpatient/Ambulatory Payment Classifications (“APC”) related, site-of-service, units, age/sex, and additional specialty edits.

Solution edits shall include but not be limited to the following claim types: facility, professional, ancillary/lab, behavioral health (“BH”), pharmacy (“Rx”), and durable medical equipment (“DME”).

Edit outcomes to include deny, pend, and informational activities.

Apply multiple procedure payment reduction.

Provider records access and edits: Edit core system provider data to ensure accurate primary and secondary provider specialty(ies), provider type, and other data identifying scope of practice.

CareOregon shall have access to all pricing.

Authorization and automation: must have read authorizations, manual processes that could be automated, and evaluate prepay options (e.g., error script.).

Duplicate services: in-house (CareOregon system) duplicate edit capabilities, clarification on duplication detection for provider claims.

Customizability: Proposer to configure and customize edits and logic. Configuration may be sourced and must have a clear and timely path to submit edits.

Provider billing detection: solution shall detect excess utilization at the provider level.

Clinical validation approach: quality assurance and audit processes (sampling, validation, false positive monitoring), clinical/coding credentials involved in development, appeals and reconsideration support (evidence packets, turnaround, overturn tracking).

Table maintenance: Solution shall provide custom edits, manage table maintenance, maintain criteria, code changes, provider ID updates, and assume responsibility for ongoing maintenance.

Implementation and integration with QNXT. Flow: QNXT → 1st Pass provider → New service. (QNXT is a comprehensive healthcare administration platform designed to streamline claims processing, member management, and provider network operations for health plans and payers).

Coordination of Benefits (“COB”) and primary/secondary identification.

Fraud, waste, and abuse functionalities.

Facilitate prior authorization integration for Utilization Management (“UM”) / Prior

Authorization (“PA”) exchanges.

Consistency with data migration for member, provider, claims history, and PA data migrations.

Deliverables:

• A complete second pass claims editing solution integrated with QNXT.

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• Various comprehensive reports as listed below in the Section, Requirements, and on a cadence acceptable to the CareOregon Contract Administrator.

• System audit logs available to the CareOregon Contract Administrator as requested.

• Provide a business continuity and disaster recovery plan with written performance results annually.

• Proposer’s Project Manager to provide status reports and documentation upon request by

CareOregon.

Requirements:

• Edit Sources: Centers for Medicare and Medicaid (“CMS”)/Medicare guidance, State of Oregon Medicaid policy, Oregon Health Authority (“OHA”), Oregon Administrative Rules (“OAR”), fee schedules, other payer actions, e.g., managing care quality, administrative processes, and financial sustainability.

• Operations: Solution to clarify turnaround time (real-time vs. overnight vs. 24+ hours). No claim adjudication - editing only; manual intervention handled by CareOregon. QNXT will perform denials. Solution to employ Oregon specific edits.

• Reporting Requirements: Provider-reported hours, cross-payer reporting, savings and outcomes, provide sample reporting dashboard, Protected Health Information (“PHI”) breakdown.

• Claim Pattern Review: Solution to evaluate provider billing patterns, time-based codes, SIU-related analytics, support targeted scenario analysis.

• Electronic data interchange (“EDI”) compliance: Support required X12 transactions: 270, 271, 276, 277, 278,820, 835, 837.

• Configurations of benefit setups.

• Must provide CareOregon the ability to review audit logs showing changes to system configuration over time.

• Data Security to include demonstrable Health Insurance Portability and Accountability Act

(“HIPAA”) compliance, SOC2/HITRUST or equivalent, multi-factor authentication, incident notification, data retention and return/transition support, written disaster recovery strategy.

• Provide a Project Manager for implementation:

Lead requirements gathering sessions. Meetings to be scheduled by the

CareOregon Project Manager.

Validate functional and technical specifications.

Facilitate communication with the CareOregon Project Manager.

Risk identification and mitigation planning.

Manage issue tracking and resolution in partnership with CareOregon Project

Manager.

Ensure regulatory and compliance alignment (e.g., HIPAA).

Oversee Proposer configuration activities at implementation Manage testing cycles - System Integration Testing (“SIT”), User Acceptance

Testing (“UAT”).

Coordinate training planning and materials for CareOregon staff members.

Ensure deployment readiness and go-live planning.

Support post go-live stabilization.

Provide status reporting and documentation on a monthly cadence.

Monitor and track compliance with Deliverables and Service Level Agreements

(“SLA”).

• Provide a business continuity and disaster recovery plan upon request.

Plan to broadly adhere to national or international business continuity standards such as NFPA 1600 or ISO 22301.

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Plan must be reviewed and updated as required by operational needs and once per year, at a minimum.

Revisions shall address changes to technology, functions, procedures, or personnel that could impact the integrity and viability of the plan.

Copies of the plan(s) must be shared annually with CareOregon.

• Provide a support contact person to be available 24/7, as well as two points of escalation.

• Test business continuity and disaster recovery plan annually and provide written results of performance test along with corrective action plan to CareOregon within one month of test completion.

• In the event of service disruption, work 24/7 to restore services and provide written updates on status every eight hours.

• Disaster Recovery (RPO/RTO): Recovery Point Objective is 24 hours. Recovery Time Objective is 8 hours.

• Proposer to notify CareOregon of any scheduled maintenance that could affect provision of the Services at least 24 hours prior to the maintenance.

Performance Guarantees and SLA Requirements:

CareOregon Contract Administrator and Proposer to meet no less than monthly to evaluate the progress of implementation, any issues impeding progress, the ongoing Services after go-live, any corrective actions needed, and next steps. Performance issues to be remediated by Proposer within thirty (30) days or the next monthly meeting.

Performance guarantees, uptime/downtime:

• Uptime guarantee that service will be available 99.9% of the time.

• Downtime guarantee that services will be down no more than 1% of the time.

Remediate underperformance within 30 days or no later than the next monthly meeting for:

• API latency - System responds to 95% of API requests within 5 seconds.

• Incident response and resolution requirements.

Severity 1 – within two (2) hours.

Severity 2 – within eight (8) hours.

Claim timeliness requirements.

• Medicare:

95% within 60 days.

• Medicaid:

90% within 30 days.

95% within 45 days.

99% within 60 days.

Proposer’s claims system solution must be fully integrated within QNXT.

Edit quality service level agreement:

• Audited PPV / precision.

• Incorrect edit rate.

• Overturn / appeal rate by edit family.

Proposer guarantees a turnaround time of three (3) business days for updates and responses to all inquiries from CareOregon.

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Milestones & Work Schedule:

• June 2026 through October 2026 - Proposer implementation of the solution.

• November 2026 – Solution Go-Live.

• November 2026 through January 2027 - Proposer to provide comprehensive training to

CareOregon staff members at no charge for up to three (3) months after go-live date.

It is important for Proposers to highlight their ability to meet these timelines or to propose alternatives based on their recommendations.

Term of Contract: The Initial Term is estimated to be from June 1, 2026, through May 31, 2027, with the option for two (2) additional one (1) year renewal terms thereafter.

Sample Contract: Submission of a Proposal in response to this RFP indicates Proposer’s willingness to enter into a contract containing substantially the same terms (including insurance requirements) of the sample contract identified below. No action or response to the sample contract is required under this RFP.

Any objections to the sample contract terms should be raised in accordance with Paragraphs 2.2 of this RFP pertaining to requests for clarification of the RFP/specifications. This RFP and all supplemental information in response to this RFP will be a binding part of the final contract.

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

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

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

The following insurance requirements will be applicable:

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

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

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.

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

RFP 2026-03 Second Pass Claims Editing System Page 9 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.

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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 40 pages (single-sided), inclusive of all exhibits, attachments or other information.

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

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

1. Description of the firm.

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

3. Description of providing similar services to non-profit entities, preferably Medicaid carriers, 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 your firm is currently or potentially engaged in litigation.

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

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

5.3 Scope of Work (35 Max points):

1. How easy is it for CareOregon to customize one of your standard changes? Is there an additional charge associated with customization?

2. Please clarify what customization is supported.

3. How long will implementation of the solution take?

4. What would be the required hours for maintenance (for a plan our size, what would the typical hours for maintenance look like for this particular set of software)?

5. Provide a detailed implementation document with a timeline showing each step of the implementation process.

6. How long does it typically take to implement services? Provide details on the following:

a. Phases (e.g., discovery, build, UAT, pilot, rollout).

b. Staffing plan and what services are onshore/offshore.

c. Key dependencies (data, file extracts, Subject Matter Expert (“SME”) time, policy decisions).

d. Pilot strategy (which edit families first; how success is measured).

e. Training approach for CareOregon Claims Operations / Provider Relations staff members.

7. Proposer must document successful work with QNXT. Proposer’s claim system solution must be fully integrated within QNXT. Provide a visual aid document that maps how the second pass claims editing solution (“CES”) integrates with QNXT. Describe how you integrate with payer core processing workflows and your approach to integrating with QNXT.

8. Provide illustration of your track record implementing your solution as a second pass editor integrated with QNXT. If there are any platform availability requirements, please describe in detail.

9. How do you identify and suppress “high abrasion / low value” edits?

10. Explain how edits expand or enhance over time.

mailto:vendorservices@careoregon.org

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11. Provide your approach to how edits will be designed and tested (development/testing/UAT/production) as well as your cutover approach.

12. How will you continue expanding the edits library in the future, and what potential additional charges, if any, will come with the future expansion of edits?

13. Describe the typical edit processing workflow.

14. How do you monitor provider impact/billing patterns (complaints, overturns, repeat issues)?

15. Describe your policies and standards around logging/auditability (configuration versioning, who changed what and when, traceability from input → edit → disposition.)

16. Describe your Data Security and Governance policies and processes:

a. Security/compliance qualification (HIPAA/Business Associate Agreement (“BAA”) readiness, SOC2/HITRUST or equivalent, encryption, role-based access control (“RBAC”) / multi-factor authentication (“MFA”), incident notification).

b. Data ownership, retention, return/transition support at termination.

c. List your material subcontractors and where PHI is processed/stored.

d. Is your customer data encrypted and while at rest?

e. Is your customer date encrypted during electronic transmission?

f. Does your firm process or transfer customer data to portable or laptop computing devices or any portable storage medium?

g. Proposer will limit the storage and transmission of CareOregon Data to data centers and network paths physically located in the United States. List all physical locations where your firm stores customer data, including your firm’s data center assets.

h. Does your firm agree to use CareOregon Data solely for the purposes specified in the Contract resulting from this RFP?

i. Does your firm agree that CareOregon Data shall not be shared, distributed, or repurposed across applications, environments, business units, subcontractors or other interested third parties of Proposer without written consent from CareOregon?

17. Describe how your company applies Multiple Procedure Payment Reduction (“MPPR”).

18. Can your company maintain calculators for pricing?

19. Describe how conflicts between guidance sources are resolved.

20. Please share, visually, and describe your firm's roadmap for implementation to production, including with Artificial Intelligence (“AI”).

21. Explain how Proposer collaborates with clients to resolve issues:

a. Supported integration modes:

i. Batch.

ii. Real-time API.

iii. Supported formats: 837/835, flat file.

iv. Supported transport methods: SFTP, etc.

b. Throughput and scalability assumptions.

c. How peak-day claim volumes are handled.

22. Describe your current business continuity and disaster recovery strategy including:

a. Standards you follow.

b. Recovery Time Objective (RTO)/ Recovery Point Objective (RPO).

c. Backup and storage strategies.

d. 12 Month uptime history.

e. Incident management and communication strategy.

23. Service Level Agreement:

a. Provide your standard Service Level Agreement.

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

Time.

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

RFP 2026-03 Second Pass Claims Editing System Page 13

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

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

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

g. 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?

h. 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?

24. Technical Questions:

a. Does your solution have a test environment that will be used for development and testing before being migrated to production?

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

i. Solution configuration practices.

ii. User and license management.

25. 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.

c. Describe your data security procedures and audit.

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

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

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

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

(hardware, software, connectivity)?

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

e. 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.

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

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

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

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

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

a. 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.

b. 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.

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

RFP 2026-03 Second Pass Claims Editing System Page 14

5.5 Fees (25 Max points):

What are Proposer’s fees, which shall be firm for the initial term of Contract. Possible fee basis options:

a. Fixed Fee. Provide a fixed fee to complete the project, or

b. T&M. Provide fees on a time and materials basis with a not-to-exceed price to complete the project, or

c. Contingency. Provide a contingency fee percentage of the total savings resulting from the claims editing services.

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 this criteria are based on both the providing of references as well as information gleaned from the provided contacts. Evaluation Committee members may contact references at their sole discretion.

5.7 Completed Proposal Certification (see the below form)

RFP 2026-03 Second Pass Claims Editing System Page 15

PROPOSAL CERTIFICATION

RFP #2026-03 Second Pass Claims Editing System

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