PHILIP D. MURPHY

Governor State of New Jersey

DEPARTMENT OF THE TREASURY

DIVISION OF PURCHASE AND PROPERTY

PROCUREMENT BUREAU

33 WEST STATE STREET

P. O. BOX 230

TRENTON, NEW JERSEY 08625-0230

ELIZABETH MAHER MUOIO

State Treasurer

TAHESHA L. WAY

Lt. Governor

AMY F. DAVIS, ESQ.

Acting Director https://www.njstart.gov

September 15, 2025

To: All Interested Bidders

Re: Bid Solicitation # 25DPP01097 T2691- NJFamilyCare Utilization Review Audits, DMAHS

Bid Amendment #8

The following constitutes Bid Amendment #8 to the above referenced Bid Solicitation:

· This Bid Amendment includes:

· Extension of the Quote Submission Due Date to September 30, 2025 (2:00 p.m. Eastern Time);

· Answers to questions;

· Revisions to the Bid Solicitation; and

· A Revised State-Supplied Price Sheet titled “T2691 Revised State-Supplied Price Sheet 09.15.2025”, and hereafter referred to in this document as the “Revised State-Supplied Price Sheet”, has been added to the Bid Solicitation via the Attachments tab of this Bid Solicitation in NJSTART. Bidders must submit the Revised State-Supplied Price Sheet as part of the Quote.

· Please note that for all additions, deletions, clarifications and modifications to the Bid Solicitation, please refer to the Revised Bid Solicitation titled “T2691 Revised Bid Solicitation 09.15.2025” and hereafter referred to in this document as “Revised Bid Solicitation”. The following revisions are included in the Revised Bid Solicitation:

· Section 1.1, Purpose and Intent – revised;

· Section 3.12, Quote Content – revised;

· Section 3.13.14, Certification Of Non-involvement In Prohibited Activities In Russia Or Belarus Pursuant To P.l.2022, C.3 – revised;

· Section 3.18, Mobilization Plan – revised;

· Section 3.20, Bidder Qualifications – revised;

· Section 3.27, State-Supplied Price Sheet Instructions – revised;

· Section 4.1, General Requirements for Utilization Review (UR) Contractor – revised;

· Section 4.2, Contractor Qualifications – revised;

· Section 4.3, Staffing Requirements – revised;

· Section 4.4, Utilization Review (UR) Audit – revised with deletions;

· Section 4.5, Quality of Care Audits – revised;

· Section 4.6, Diagnosis Related Groups (DRG) Validation Audits – revised;

· Section 4.7, Ad-Hoc Audits – revised,

· Section 4.10.1, Appeals Process for All Determinations – revised;

· Section 4.10.2, Fair Hearing Process – addition added;

· Section 4.11, Deliverables – revised;

· Section 4.11.2, Reports – revised;

· Section 4.11.3, Meetings – added;

· Section 4.14, State Specific Compliance Requirements – added;

· Section 5.4, Ownership of Material – revised format;

· Section 6.3, Compliance – revised;

· Section 6.5, Security Awareness and Training – revised;

· Section 6.7, Privacy – revised;

· Section 7.4, Insurance – revised; and

· Section 9.3, Contract-Specific Definitions – revised.

It is the sole responsibility of the Bidder to be knowledgeable of all of the additions, deletions, clarifications, and modifications to the Bid Solicitation and/or the New Jersey Standard Terms and Conditions relative to this Bid Solicitation as set forth in all Bid Amendments.

All other instructions, terms, and conditions of the Bid Solicitation shall remain the same.

Bid Solicitation #25DPP01097 T2691 - NJFamilyCare Utilization Review Audits, DMAHS

Answers to Questions

Where applicable, each question references the appropriate Bid Solicitation section.

Note: Some questions have been paraphrased in the interest of readability and clarity

Section Reference Question (Bolded) and Answer

Please be advised that all Quotes shall be submitted electronically through NJSTART.

Bidders may refer to the Vendor Registration and Submit a Quote Quick Reference Guides for instructions on how to enroll in NJSTART and how to submit an electronic Quote through NJSTART. The Quick Reference Guide entitled Submit a Quote is available here: https://www.state.nj.us/treasury/purchase/njstart/pdf/Create-a-Quote.pdf.

Additionally, to ensure that you have properly submitted the required documents you may also review the Quick Reference Guide entitled How to Review a Submitted Quote which is available here: https://www.state.nj.us/treasury/purchase/njstart/pdf/HowtoReviewaSubmittedQuote.pdf. Answers to Frequently asked Questions and all Quick Reference Guides are located on the NJSTART Vendor Support Page. If further assistance is needed, please email NJSTART Vendor Administration Team at: njstart@treas.nj.gov

Yes. Prior to the Quote Opening Deadline, a Bidder should review the documents comprising the submitted Quote to ensure that all of the required documents have been completed and attached. Oftentimes a Quote is deemed non-responsive because a Bidder fails to attach a required form or attaches a blank form. To review a submitted a Quote, a Bidder should log into NJSTART and review each document attached to the Quote submission. Instructions on how to review a submitted Quote can be found in the Quick Reference Guide entitled How to Review a Submitted Quote, which is available on the NJSTART Vendor Support Page under Vendor Reference Guides.

It is recommended that users utilize Microsoft Edge to view PDFs. Certain PDF forms cannot be opened in the Chrome or Firefox built in PDF viewers that are enabled by default. If using Chrome or Firefox it is recommended that the file is downloaded instead by clicking the download button in the upper right-hand corner of the browser after an error message is received. An alternative option is to disable the built in PDF viewers in Chrome or Firefox.

As stated in Revised Bid Solicitation Section 2.2, Exceptions to the State of NJ Standard Terms and Conditions (SSTC): “Questions regarding the State of New Jersey Standard Terms and Conditions and exceptions to mandatory requirements MUST be posed during the Electronic Question and Answer period and shall contain the Bidder’s suggested changes and the reason(s) for the suggested change(s).”

Additionally, as stated in Revised Bid Solicitation Section 3.11, Bidder Additional Terms Submitted with the Quote:

“A Bidder may submit additional terms as part of its Quote. Additional terms are Bidder-proposed terms or conditions that do not conflict with the scope of work required in this Bid Solicitation, the terms and conditions of this Bid Solicitation, or the State of New Jersey Standard Terms and Conditions. Bidder proposed terms or conditions that conflict with those contained in the State of New Jersey Standard Terms and Conditions will render a Quote non-responsive. It is incumbent upon the Bidder to identify and remove its conflicting proposed terms and conditions prior to Quote submission.

Quotes including Bidder proposed additional terms may be accepted, rejected, or negotiated, in whole or in part, at the State’s sole discretion.

If Bidder intends to propose terms and conditions that conflict with the State of New Jersey Standard Terms and Conditions, those Bidder proposed terms and conditions shall only be considered if submitted and agreed to pursuant to the electronic question and answer procedure. Bidders shall not submit exceptions or modifications as part of the Quote or on the “Terms and Conditions” Tab through NJSTART.”

Deliverables are presented to the State Contract Manager (SCM) and the State’s stakeholders via monthly meetings, as requested by the SCM. Any denied deliverables shall be edited and presented at the next monthly meeting.

For additional information please refer to the Revised Bid Solicitation Section 4.11.3, Meetings, as this section has been revised.

Any Bid Amendments posted to extend the Quote Submission Due Date was to accommodate the time required to respond to all questions submitted during the Question & Answer period. Additionally, this postponement provided time for Bidders to prepare their Quotes.

Please reference Revised Bid Solicitation Section 2.3, Bid Amendments, for additional information.

The State expects approximately 2,200, or 50% of denied cases, to be appealed.

Unless specified otherwise, the data provided as part of this Bid Amendment is meant to be informational in nature, and the State makes no representations or guarantee as to such data during any contract term, including any extension(s) thereof.

The State will rely on the Contractor to recommend audit protocols.

Question #2 - How should medical necessity be defined or interpreted (e.g., specific guidelines or evidence-based standards)?

Medical necessity for hospitalization is defined by evidence based clinical guidelines such as those from MCG or InterQual. In accordance with Revised Bid Solicitation Section 4.12, Utilization Management Criteria Framework Software Licensure: “The Contractor shall maintain in full force and effect a licensee agreement with a nationally recognized software vendor who provides Utilization Review (UR) criteria to include evidence based clinical guidelines and standards of care.”

The State determines the start and end dates of each audit cycle.

Question #2 - If the State determines the audit cycle timeframe, could [the State] please clarify the typical duration of each audit cycle, or the time frame set previously by the last Contractor?

The audit cycle timeframe is 12 months.

Question #3 - Additionally, to ensure timely reporting, is there a standard definition or notification process for when an audit is considered “closed” and the six-month reporting window begins?

The audit cycle closes after all second (2nd) level appeals are finalized. The report must be submitted to the SCM within six (6) months of the audit close date, or by a timeframe determined or approved by the SCM if six (6) months is not operationally feasible.

The Contractor is responsible for creating the list of discharges for random samplings, which is submitted to the SCM for approval.

Please refer to Revised Bid Solicitation Section 4.7, Ad-Hoc Reports, as this section has been revised.

Question #2 - Are there pre-approved methodologies or tools for generating statistically valid samples?

No. The Contractor’s statistician would develop methodologies and tools for State approval.

Please see the answer to Question #10.

As listed in Revised Bid Solicitation Section 3.20, Bidder Qualifications, the following certifications required by the Bidder are as follows:

1. Bidders must possess a Quality Improvement Organization (QIO) certification provided by Centers for Medicare and Medicaid Services (CMS).

For certifications, licenses, and/or degrees needed for Bidder’s staffing requirements, please reference Revised Bid Solicitation Section 4.3, Staffing Requirements, as this section has been revised.

Additionally, the Bidder and its named Subcontractors must have a valid Business Registration Certificate. Please reference Revised Bid Solicitation Section 3.13.13, Business Registration, for further details.

Bidders should note the above is not meant to be exhaustive, and for all requirements Bidders should refer to Revised Bid Solicitation Section 3, Quote Submission Requirements.

There is no on-site requirement for audit; however, there may be a judicial specific requirement for in-person appearances for Fair Hearings.

Question #2 - Can the State confirm that all interactions—including education, communication, and audit procedures—may be conducted exclusively via the designated interface systems and remote platforms?

Meetings will primarily be held virtually through a medium approved by the SCM; however, other mediums and other forms of communication may be necessary. The Contractor shall follow the instruction of the SCM should the Contractor be expected to conduct a meeting through other means.

Please refer to Revised Bid Solicitation Section 4.11.3, Meetings.

This is a duplicative question. Please see the answer to Question #13.

Question #2 - Can the State confirm that all interactions—including education, communication, and audit procedures—may be conducted exclusively via the designated interface systems and remote platforms?

This is a duplicative question. Please see the answer to Question #13.

Yes, there are State-specific standards Contractors must adhere to. Please note that regulations and policies are subject to modification. State-specific standards Contractors must adhere to are the following:

1. N.J.A.C. 10:52-1.6 “Covered Services- Inpatient and Outpatient”;

2. N.J.A.C. 10:52-1.8- “Non-covered Services (inpatient and outpatient);

3. N.J.A.C. 10:52-1.9 “Administrative Days (nursing facility level of care)-general, special (Classification A&B) and private psychiatric hospitals;

4. N.J.A.C. 10:52-1.14 “Social Necessity Days”;

5. N.J.A.C. 10:52-1.15 “Utilization Control-Inpatient Services”;

6. N.J.A.C. 10:52-1.16 – “Utilization Control: inpatient psychiatric services for beneficiaries under 21 years of age in private psychiatric hospitals”;

7. Newsletter Volume 28, #7 “Acute Medical Detoxification”; and

8. In the event of any changes to DMAHS policy or code, all other subsequent newsletters, Medicaid alerts or additional codes as instructed by the SCM.

In addition, please refer to Revised Bid Solicitation Section 4.14, State Specific Compliance Requirements.

Please refer to the Bid Solicitation for all requirements.

Question #2 - Could [the State] outline the measures the State has in place to ensure the confidentiality, integrity, and security of Medicaid data throughout the audit process, including during data transmission, access, and storage?

The State adheres to all control policies within the State Information Security Manual to protect all State Data, including medical information. In addition, the State adheres to all Federal requirements, as applicable. The State Information Security Manual can be found by accessing the following link: https://www.cyber.nj.gov/home/showpublisheddocument/36/638568130115330000.

The security measures necessary to protect Medicaid data shall be detailed and provided by the Contractor, not the State, by meeting those requirements set forth in Revised Bid Solicitation Section 6, Data Security Requirements – Contractor Responsibility.

State and Federal Regulations Question #1 - What is the process for disclosing and resolving conflicts of interest?

The Contractor shall have an ongoing duty to disclose any potential or actual conflicts of interest that arise, within 72 hours of identifying said potential or actual conflict of interest. The Contractor shall also prepare and submit, at the time of such disclosure, a proposed plan of action to manage the conflict of interest. The SCM shall have an opportunity to review the Contractor’s proposed plan and determine whether to approve the proposed plan or continue discussions with the Contractor to revise the plan to adequately, within the SCM’s view, place safeguards to minimize or eliminate the conflict of interest. The inclusion of this provision does not waive any rights the State may have under this Contract, at law, or in equity. The SCM will provide written notice to the Contractor on its course of action.

Please refer to the Revised Bid Solicitation Section 4.2.D, Contractor Qualifications, as this section has been revised.

Question #2 - How will the State communicate changes in federal/State regulations that affect this Contract?

Initial communications regarding changes in law that impact this Contract will take place between the SCM and the Contractor. For additional information, please refer to State of New Jersey Standard Terms and Conditions (SSTCs) Section 5.5, Change in Law.

Pursuant to Revised Bid Solicitation Section 4.13, Electronic Data Interchange (EDI) Submitter Agreement: “The Contractor shall obtain and maintain in full force and effect an agreement with the State’s fiscal agent, the contractor for T2409 Medicaid Management Information System MMIS, in order to process claim Adjustments and voids.”

Yes. However, the Contractor is responsible for using their own data analytics resources.

The Contractor is required to build a new secure user interface.

Please reference Revised Bid Solicitation Section 4.11.1, Web User Interface for additional information.

The Division of Medical Assistance and Health Service (DMAHS) requires approval to occur within the mobilization period which begins with the date of notification of Contract award and lasts no longer than 120 calendar days, and prior to the commencement of services. Interested Bidders should consult the Health Insurance Portability and Accountability Act (HIPAA) Companion Guide at www.NJMMIS.com for approval requirements.

The Contractors are to send to the State’s fiscal agent an EDI 837I transaction after all appeals are closed for any claims that were not answered by the hospital.

Question #2 - Are there specific formatting requirements, submission protocols, or coordination steps with the State’s fiscal agent that contractors must follow when submitting these void transactions?

Please refer to the HIPAA Companion Guide, available on the State’s MMIS website (www.NJMMIS.com) for this information.

Testing and certification processes for EDI 8371 submissions are available in the HIPAA Companion Guide, located on the State’s MMIS website (www.NJMMIS.com).

Question #2 - What are the states?

The State is unable to answer this question due to lack of clarity.

Question #3 - What are the State’s encryption and data security protocol standards for this?

The State’s encryption and data security protocol standards are listed in the HIPAA Companion Guide. To obtain this guide, please go to https://www.njmmis.com/. From there, complete the following steps:

1. On the left navigation plane, choose ‘HIPAA Submitter Login’ under the ’Account Links’ heading.

2. Under the Username and Password fields, select ‘click here’ to download the HIPAA Companion Guide.

The required formats for monthly and ad-hoc reports are Excel, CSV, or PDF, as appropriate.

Question #2 - Is there an existing dashboard or reporting system the State prefers to use?

There is no existing dashboard or reporting system that the State prefers. However, the Contractor’s choice of dashboard or reporting system must first be approved by the State before it can be used for the Contract.

The State will provide continuous oversight and feedback to the Contractor on performance. Please refer to State of New Jersey Standard Terms and Conditions (SSTCs) Section 5.15, Maintenance of Records and Audits, for details regarding audits.

The State reserves the right to award any or all price lines per Bid Solicitation Section 1.1, Purpose and Intent. To the extent the State only awards a portion of the price lines, the awarded Contractor will only be compensated for the performance of the awarded price lines.

Per Revised Bid Solicitation Section 3.27, State-Supplied Price Sheet Instructions:

The Bidder shall:

A. Submit a Firm Fixed Task Price for the completion of Price Line 1 – Web Face Interface;

B. Submit a Firm Fixed Price for each Contract Year (1 through 4) of each Price Line 2 through Price Line 7:

1. See below for additional information related to the Unit of Measure for each Price Line:

a. Price Lines 2 to 5: A Unit Price per EACH audit;

b. Price Line 6: A Unit Price per EACH report; and

c. Price Line 7: A Unit Price per EACH task.

For additional information, please refer to Revised Bid Solicitation Section 3.27, State-Supplied Price Sheet Instructions.

Question #2 - What are the invoice submission requirements?

The Contractor must submit completed payment vouchers and invoices and be registered in NJSTART. In accordance with SSTCs Section 6.3, Payment to Vendors: “The Contractor must submit invoices to the Using Agency with supporting documentation evidencing that work or goods for which payment is sought has been satisfactorily completed or delivered. For contracts featuring services, invoices must reference the tasks or subtasks detailed in the Scope of Work and must be in strict accordance with the firm, fixed prices submitted for each task or subtask. When applicable, invoices should reference the appropriate task or subtask or price line number from the contractor’s proposal. All invoices must be approved by the State Contract Manager or Using Agency before payment will be authorized.”

Please refer to SSTC section 6.3, Payment to Vendors, and SSTC Section 6.5, New Jersey Prompt Payment Act. The New Jersey Prompt Payment Act requires state agencies to pay for goods and services within 60 days of the agency’s receipt of a properly executed State Payment Voucher or within 60 days of receipt and acceptance of goods and services, whichever is later.

The specific timing of the first payment will depend on when the initial work is completed and invoiced by the Contractor, and the approval of the invoice(s) in accordance with the above-referenced sections of the SSTC.

Question #2 - Are there specific e-invoicing protocols, formats, or submission systems that the Contractor must follow when submitting invoices for payment?

Please reference Accessing Purchase Orders & Electronic Invoicing and/or Electronic Invoicing Video which can be found on the Division of Purchase and Property (DPP) website under Vendor Support – Vendor Quick Reference Guides at www.nj.gov/treasury/purchase/vendor.shtml for information related to submitting an invoice for payment.

Please also refer to Question #26 (Question #2).

In accordance with Revised Bid Solicitation Section 4.11.2, Reports, “The Contractor shall submit accurate and complete reports in accordance with the time schedules noted below. Timely submission shall be a prerequisite for authorization of payment to the Contractor. Failure to provide accurate and complete reports by reporting deadlines may result in a delay or suspension of payment to the Contractor until the reports are received and approved by the SCM.”

Additionally, late deliverables and/or missed performance benchmarks for requirements under the Contract may result in formal complaints filed by the Using Agency with the Contract Compliance and Audit Unit.

Question #2 - Are there performance-based incentives?

No, there are no performance-based incentives in this Contract.

The State hopes to provide notice of Contract award by the end of calendar year 2025; however, this is only an estimate and subject to change.

Question #2 - What is the anticipated end date or renewal period?

The State is unable to provide an anticipated Contract end date or renewal period. However, per Revised Bid Solicitation Section 5.1, Contract Term and Extension Option, this Contract’s base term is four (4) years with two (2) optional 1-year extensions.

The Contractor shall develop a template to be reviewed and approved by the SCM.

Question #2- What metrics must be included?

The Contractor shall determine what metrics to use when developing the template, based on their expertise. These metrics must be submitted to and be approved by the SCM.

Yes. All services must be performed in the United States. Please refer to Bid Solicitation Section 3.13.6, Service Performance in the United States, and SSTC Section 3.7, Service Performance Within U.S.

Question #2- Do they apply to this contract?

Yes, off-shoring restrictions apply to this Contract. As stated in Bid Solicitation Section 3.13.6, Service Performance in the United States, pursuant to N.J.S.A. 52:34-13.2, all Contracts primarily for services shall be performed within the United States. Please refer to the answer above.

No, there is no flexibility. The Contractor shall be fully functional within 120 calendar days of notice of Contract award. Please refer to Revised Bid Solicitation Section 4.11, Deliverables.

Question #2 - Does the State mean 120 business days before the solution should be operational?

The Contractor shall be fully functional and ready to perform work under the Contract within 120 calendar days of notice of Contract award.

Yes, the Subcontractor must possess federal certification as a Quality Improvement Organization (QIO) or QIO-like entity, in accordance with federal regulations, should the Subcontractor be performing any audits as defined in Bid Solicitation Section 4, Scope of Work. This proof must be provided prior to Contract award. Please refer to Revised Bid Solicitation Section 3.20, Bidder Qualifications, as this section has been revised.

Question #2 - Additionally, must the certification for both parties be issued by the Centers for Medicare and Medicaid Services (CMS) and submitted prior to Contract award?

Yes, in accordance with Revised Bid Solicitation Section 3.20, Bidder Qualifications: “Prior to Contract award, the Bidder shall submit proof of federal certification as a Quality Improvement Organization (QIO) or QIO-like entity in accordance with federal regulations. This proof of certification must come from the Centers for Medicare and Medicaid Services (CMS).”

The State will provide training, reference materials, and education on State specific expectations. The State, with the Contractor, will coordinate training on systems as needed.

Question #2 – Additionally, could [the State] outline how the State intends to collaborate with the selected Contractor throughout the audit process—for example, through regular check-ins, access to technical support, or designated points of contact for issue resolution?

The SCM and designated staff will meet regularly with the Contractor to provide technical support and will serve as the primary point of contact for issue resolutions.

Contractors will need access to the MMIS mainframe, MMIS Shared Data Warehouse (MMIS SDW).

Question #2 - What will be the onboarding process for gaining access to provider data?

Applications for the Contractor’s authorized employees will be submitted to SCM for approval and will be processed by coordination between State’s Office of Internet Technology (OIT) and the Contractor.

Question #3 - What is the time frame for [question 2] above after the award has been granted?

The timeframe for Question #2 above is as follows:

1. The Contractor must establish access to the SDW within 30 calendar days from notification of Contact award; and

2. The Contractor must establish NJMMIS mainframe access within the implementation period, which is 120 calendar days from notification of Contract award.

Please refer to Revised Bid Solicitation Sections 4.1.K, General Requirements for Utilization Review (UR) Contractor, as this section has been revised.

After the initial review of each audit, the hospital will have 20 calendar days to appeal adverse determinations. The Contractor will have 20 calendar days to answer appeals. The hospital has 60 calendar days to request a Fair Hearing.

Additionally, the Contractor shall have 30 calendar days to complete any individual audit. For retrospective reviews, quality of care audits, DRG validation audits, and ad-hoc audits, the Contractor shall complete the medical record review in 30 calendar days following receipt of the records and identify and document findings in an Adverse Determination Letter to the provider and the MCO within five (5) calendar days of after completion of the medical record review. The Contractor shall have 20 calendar days of any adverse determination by physicians with like or similar specialties or subspecialties to complete any internal appeal process for the reconsideration for all determinations. The Contractor shall also instruct hospitals to submit for Fair Hearings to the DMAHS Fair Hearing Unit within 60 calendar days of the date of an adverse determination notice.

Please refer to Revised Bid Solicitation Sections 4.4, Utilization Review (Ur) Audit, 4.5, Quality Of Care Audits, 4.6, Diagnosis Related Groups (DRG) Validation Audit, 4.7, Ad-Hoc Audits, 4.10.1, Appeals Process For All Determinations, And 4.10.2, Fair Hearing Process, as these sections have been revised.

Question #2 - Additionally, are there defined deliverables and standardized reporting formats that the Contractor is required to follow when submitting audit results and associated documentation?

Audit results are to be made available to the hospital and DMAHS on the web user interface in the form of an Adverse Determination Letter which must contain, at a minimum, all items listed in: Revised Bid Solicitation Section 4.4.F.3.c, Utilization Review (UR) Audit; Revised Bid Solicitation Section 4.4.G.5; Revised Bid Solicitation Section 4.5.G, Quality of Care Audits; Revised Bid Solicitation Section 4.6.E, Diagnosis Related Groups (DRG) Validation Audit; and Revised Bid Solicitation Section 4.7.F, Ad-Hoc Audits, in PDF format. All other reports defined in Revised Bid Solicitation Section 4.11.2, Reports, should be available to SCM in electronic format(s), approved by the SCM, such as Excel or PDF format.

The last completed audit cycle contained 44,000 reviewed claims for delegated hospitals. The State cannot confirm the projected volume for non-delegated.

Question #2 - Are the ~35,000 annual claim audits evenly distributed throughout the year, and can you confirm the projected volume and mix of Delegated vs. Non-Delegated hospitals?

Yes, the audits are evenly distributed throughout the year.

Per Question #1 above, the last completed audit cycle contained 44,000 reviewed claims for delegated hospitals. The State cannot confirm the projected volume for non-delegated. However, historically, DMAHS has designated 0 to 3 hospitals as non-delegated per audit cycle.

Unless specified otherwise, the data provided as part of this Bid Amendment is meant to be informational in nature, and the State makes no representations or guarantee as to such data during any contract term, including any extension(s) thereof.

Purpose and Intent

[Bid Solicitation Section 1.1, Purpose and Intent,] states that “the State may award any or all price lines." Please clarify the minimum requirements for each Bidder to submit quotes.

To meet the minimum requirements, Bidders are required to submit all requirements designated as a “shall” or “must” under Revised Bid Solicitation Section 3, Quote Submission Requirements, which are as follows:

1. Ownership Disclosure Form – Revised Bid Solicitation Section 3.13.2, Ownership Disclosure Form;

2. Subcontractor Utilization Form (if Subcontractors are used) - Revised Bid Solicitation Section 3.13.8, Subcontractor Utilization Plan;

3. Technical Quote - Revised Bid Solicitation Section 3.14, Technical Quote;

4. Management Overview - Revised Bid Solicitation Section 3.15, Management Overview;

5. Additional Plans (Recruitment Plan) - Revised Bid Solicitation Section 3.19, Additional Plan(s); and

6. State-Supplied Price Sheet - Revised Bid Solicitation Section 3.27, State-Supplied Price Sheet Instructions.

Please note that some items, as listed in the Bid Solicitation, “should” be submitted with the Bidder’s Quote, but are required prior to Contract award. Please refer to the Bid Solicitation for all requirements.

Bidders must submit Quotes on time addressing all mandatory requirements (designated by “shall” or “must”) including forms. Quotes missing mandatory requirements may be deemed non-responsive. Not submitting requested information (“should”) may impact the technical evaluation score.

Please note that it is the responsibility of the Bidder to meet all requirements specified by the Bid Solicitation, and the Bidder should include the level of detail it determines necessary to assist the Evaluation Committee in its review of the Bidder’s Quote.

Order of Precedence of Contractual Terms

Question #1 - Would the State consider the following changes to [Bid Solicitation] Section 1.4? The Contract awarded, and the entire agreement between the parties, as a result of this Bid Solicitation shall consist of: (1) "any negotiated document," the final Bid Solicitation, (2) State of New Jersey Standard Terms and Conditions, (3)" the final Bid Solicitation," the Quote, and if applicable (4) any Bidder responses to clarifications; (5) a Bidder’s Best and Final Offer, and or (6) other negotiated document; and/or (7) third party document. In the event of a conflict in the terms and conditions among the documents comprising this Contract, the order of precedence, for purposes of interpretation thereof, shall be as listed from highest ranking to lowest ranking as noted above.

The State does not accept the proposed modification to the order of precedence of contractual terms.

Question #2 - As an alternative, would the State clarify that any [responses to the Q&A] would be included in the final Bid Solicitation?

Responses to all questions submitted during the Q&A period are posted in this Bid Amendment. Any changes made to the Bid Solicitation as a result of questions asked is marked with a tracked change in the Revised Bid Solicitation.

Quote Submission In addition to a non-redacted version of the Quote, will the State allow the Bidder to provide a redacted version of the electronic response?

The State requires the submission of a full non-redacted Quote in order to be considered for award. If a Bidder wishes to additionally provide a redacted version together with the completed signed Confidentiality/Commitment to Defend Form, they may do so. However, any Quote having required information which is not visible will be considered non-responsive.

Small Business and/or Disabled Veterans’ Business Subcontracting Set-Aside Contract

Please confirm that there are no specific goals for the percentage of the Contract to be allotted for [New Jersey Small Business Enterprises and/or Disabled Veterans’ Businesses] DVOB subcontractors.

There are no percentage goals for the New Jersey Small Business Enterprises and/or Disabled Veterans’ Businesses subcontracting requirement for this Bid Solicitation. However, per Revised Bid Solicitation Section 3.13.8.1, Small Business and/or Disabled Veterans’ Business Subcontracting Set-Aside Contract, if a Bidder intends to subcontract they must make a good faith effort to solicit and hire eligible New Jersey Small Business Enterprises and/or Disabled Veterans’ Businesses.

Technical Quote Question #1 - Can the State clarify where the Bidder's response to [Bid Solicitation] Sections 3.15, [Management Overview], through 3.26, [Financial Capability of the Bidder, are to] be included?

The Bidder may include Revised Bid Solicitation Sections 3.15 to 3.26, under the Technical Quote, pursuant to Revised Bid Solicitation Section 3.12, Quote Content.

Please note that the Bidder should include the level of detail it determines necessary to assist the Evaluation Committee in its review of the Bidder’s Quote.

Question #2 - Should this content follow “Technical Quote” which is Bid Solicitation Section 3.14, Technical Quote, and before the State-Supplied Price Sheet?

Please see answer to Question 1 above.

Mobilization Plan [Bid Solicitation Section 3.18, Mobilization Plan,] states “a detailed timetable for the mobilization period of 120 days." Please confirm that the 120 days refers to business days.

The mobilization period is 120 calendar days. Please refer to Bid Solicitation 3.18, Mobilization Plan, as this section has been revised.

Experience with Contracts of Similar Scope and Size If a Bidder provides three (3) references with two (2) contact names and telephone numbers each in response to Bid Solicitation Section 3.21, [Organizational Experience,] is it acceptable for the Bidder to list only one (1) contact name and telephone number (such as the contract monitor), for other contracts with similar scope in Bid Solicitation Section 3.25, [Experience with Contracts of Similar Size and Scope]?

As the information requested in Revised Bid Solicitation Section 3.25, Experience with Contracts of Similar Size and Scope, is designated as a ‘should’, the Bidder may provide the contract information of one (1) individual over two (2); however, not submitting requested information (“should”) may impact the Bidder’s scoring upon Technical Evaluation.

Please note the Bidder should include the level of detail it determines necessary to assist the Evaluation Committee in its review of Bidder’s Quote.

Scope of Work Will the State please accept and score a brief Executive Summary included in the Bidder’s proposal that summarizes its approach to the Scope of Work and overall value proposition to the State?

Yes, the State will accept and evaluate a Bidder’s Executive Summary; however, Bidders are cautioned that the Quote must meet the requirements specified by the Bid Solicitation, including but not limited to Section 3.14, Technical Quote, and Section 3.15, Management Overview.

Please note the Bidder should include the level of detail it determines necessary to assist the Evaluation Committee in its review of Bidder’s Quote.

General Requirements for Utilization Review Contractor

Would the [Contractor] be responsible for generating the claims to review?

Yes, the Contractor is responsible for generating claims for review based on the criteria provided by DMAHS. Please refer to Revised Bid Solicitation Section 4.1.C, General Requirements for Utilization Review Contractor.

General Requirements for Utilization Review Contractor "The scope of each audit is based on statistically valid sampling of discharges, with a 95% confidence level (5% error rate) for each provider (approximately 35,000 claim audits per year)." Please provide the approximate volume assigned for each provider category: i. Acute general hospitals ii Special hospitals iii Private Psychiatric hospitals iv. Hospital based rehabilitation hospitals v. Freestanding rehabilitation hospitals."

The State is unable to provide an approximate volume for every category. However, the State can confirm that 95% of all reviews are toward acute care general hospitals.

Unless specified otherwise, the data provided as part of this Bid Amendment is meant to be informational in nature, and the State makes no representations or guarantee as to such data during any contract term, including any extension(s) thereof.

General Requirements for Utilization Review Contractor Staffing Requirements Please clarify the estimated annual audit volume. Page 17 Section 4.1.B states 35,000 claim audits per year. Page 18 Section 4.3.E states: ”At least one (1) Full-Time Medical Review Auditor for every 2,500 reviews annually (approximately 20 full-time auditors)”. Based on that assumption the annual volume would be 50,000 reviews (2,500 x 20). In addition, Page 18 Section 4.3.F states: “One (1) Full-Time Certified Coder for every 10,000 reviews annually (approximately five (5) full-time certified coders)”. Based on that assumption the annual workload would be 50,000 (10,000 x 5). Also, the Price Sheet states an annual volume of 40,080.

Bidders can expect upward to 50,000 claims annually.

Please refer to the Revised State-Supplied Price Sheet and the Revised Bid Solicitation Section 4.1.B, General Requirements for Utilization Review Contractor, as this section has been revised.

General Requirements for Utilization Review Contractor

Given the differences between bill audits and the utilization review audits described in [Bid Solicitation] Section 4.4.C-D, [Utilization Review,] would DMAHS be open to including bill audits in its price sheet as a separate line item?

No. Bill audits will not be included as a separate line item.

General Requirements for Utilization Review Contractor Please clarify if billing audits consist of a line-by-line review of the hospital charges for the inpatient stay compared to the medical record?

No, they do not. In Revised Bid Solicitation Section 4.1, General Requirements for Utilization Review Contractor, the Diagnosis Related Group (DRG) validation and billing audits mentioned consists of a comparison of the claim elements that impact DRG assignment to the medical record.

Contractor Qualifications "This section states, "B. Be approved by the State fiscal agent as an Electronic Data Interchange (EDI) submitter." Please confirm that bidders may be approved by the State fiscal agent as an EDI submitter after the bidder is awarded the contract."

Please see the answer to Question #20.

Staffing Requirements Question #1 - Could [the State] please confirm the final number of Full-Time Equivalent (FTE) positions required for both Medical Review Auditors and Certified Coders?

The State is unable to provide a specific number. The final number is based on the expected number of reviews per audit cycle.

Question #2 - Additionally, is there any flexibility to utilize part-time employees to fulfill any portion of the staffing requirements?

Yes, part-time employees can be utilized to fulfil any portion of the staffing requirements, unless the position is specifically stated per the Bid Solicitation to require a full-time employee.

Question #3 - Lastly, for full-time staff, are [Contractors] expected to provide medical and dental benefits, and should the associated costs be included in [the Bidder’s] pricing proposal?

Contractor employee benefits are not specified as a requirement under this Bid Solicitation, and as such are considered a decision between the Contractor and its employees.

The pricing provided by the Bidder must be firm-fixed pricing that is all-inclusive of direct cost and indirect costs, including, but not limited to, direct labor costs, overhead, fee or profit, clerical support, equipment, materials, supplies, managerial (administrative) support, all documents, reports, forms, travel, reproduction, and any other costs.

Staffing Requirements [Bid Solicitation Section 4.3.G, Staffing Requirements,] states "G. One (1) Statistician with all of the following qualifications:". Please confirm it would be acceptable whether MS or Ph.D."

The State confirms that both a Master of Science (MS) and PhD are acceptable; however, neither are required, and the Statistician must meet all other requirements listed in Revised Bid Solicitation Section 4.3.G, Staffing Requirements.

Staffing Requirements [Bid Solicitation Section 4.3.E, Staffing Requirements, states that the Contractor shall provide] "at least (1) Full-time Medical Review Auditor for every 2,500 reviews annually (approximately 20 full-time auditors) and Section F states [that the Contractor shall provide] one (1) Full-time Certified Coder for every 10,000 reviews annually (approximately five (5) full-time coders). This staffing suggests approximately 50,000 reviews annually. How does this compare with 35,000 claim audits in Bid Solicitation Section 4.1.B, [General Requirements for Utilization Review Contractor]?

Please see the answer to Question #48.

Staffing Requirements Does the State consider all [nine] (9) positions listed under Section 4.3, Staffing Requirements, as key personnel?

Yes, the State considers all positions listed under Revised Bid Solicitation Section 4.3, Staffing Requirements, as key personnel.

Staffing Requirements Due to the highly clinical nature of the audits (determination of medical necessity, coding, readmission, quality of care), would the State expand the requirement for the Audit Manager to include a Bachelor's…