Clinical Review Services

Inland Empire Health Plan (IEHP), a Medi-Cal and HMO D-SNP health plan serving over 1.5 million residents across Riverside and San Bernardino Counties, California, is seeking qualified vendors to provide Clinical Review Services through Request for Proposal 25-06803. The primary objective is to ensure IEHP meets regulatory turnaround times for physician-level review of prior authorizations, grievances, and potential quality incidents (PQIs). The vendor must provide board-certified, California-licensed physicians to conduct objective clinical reviews aligned with evidence-based medical guidelines, with demonstrated capacity to process approximately 1,375 prior authorization cases and 82 grievances monthly based on current utilization patterns. All vendor physicians must be physically located in the continental United States with no offshore services permitted, and must remain available during agreed coverage hours with particular emphasis on 1:00 p.m. to 6:00 p.m. weekday and weekend availability. Bidders must submit fully inclusive blended rates covering all project-related expenses including travel, administration, and training, with separate per-hour and per-review rates for authorization reviews, potential quality incident reviews, and grievance reviews. The RFP timeline requires bidder questions by May 1, 2026, with proposals due May 27, 2026, at 2:00 p.m. Pacific Time through the Bonfire portal; the initial contract term is one year with IEHP holding options to renew for up to four additional one-year periods. Evaluation criteria allocate 65 points to scope and company performance, 30 points to pricing, and 5 points for local preference; financial statements are required for proposals exceeding $200,000.

A local preference of 5 points is available to qualified businesses with fixed offices and staffing located in Riverside or San Bernardino Counties for at least six months prior to bid submission, with no formal disadvantaged enterprise set-asides identified in the procurement documents. All bidders must submit mandatory compliance documentation including Principal Certification, Certification of Non-Debarment, Non-Collusion Declaration, Workers' Compensation Certificate, W-9 Form, Certificate of Insurance, current business licenses, proof of corporate registration, and acknowledgment of non-negotiable contract terms; bidders must also complete comprehensive security assessments including the IEHP Data Sharing Assessment and Security Risk Assessment templates. The contractor will be designated a Subcontracted Delegate vendor and must comply with HIPAA Business Associate Agreement requirements, maintain professional liability insurance of at least $1,000,000 per occurrence, commercial general liability of $1,000,000 minimum, and cyber/privacy liability coverage if handling information technology services; cyber liability insurance requirements are tiered at a minimum of $3,000,000 for this health plan's size. IEHP retains the right to award the contract to multiple vendors, split awards among qualified bidders, negotiate terms with selected vendors, or reject all proposals; no incumbent vendor or current contract value is specified in the RFP documentation. Pricing shall be quoted F.O.B. Destination excluding applicable tax with firm pricing maintained for 120 days after the closing date, and IEHP is exempt from Federal Excise Tax but pays California Sales Tax on all applicable goods and services.