External Independent Third-Party Review (C6102)

The Commonwealth of Kentucky, Cabinet for Health and Family Services, Department for Medicaid Services is requesting proposals for External Independent Third-Party Review services to conduct independent reviews of managed care organization adverse decisions on Medicaid provider appeals regarding claim denials, with proposals due September 15, 2026 and written questions due August 17, 2026.

The contractor will review approximately 7,200 cases per year and staff the engagement with a Contract Manager, Process Supervisor, Operations Supervisor, Clinical Reviewer, and Certified Coder, all subject to DMS approval. The awardee must maintain Commercial General Liability Insurance of $1,000,000 per occurrence and $2,000,000 aggregate, plus Professional Liability Insurance of $1,000,000 per claim. As a Business Associate handling Protected Health Information under HIPAA and HITECH, the contractor must implement administrative, physical, and technical safeguards per 45 CFR Parts 160 and 164, report breaches within five calendar days, maintain records for six years beyond contract termination, and assume all costs and liability for breach notifications and any Department of Health and Human Services penalties resulting from non-compliance.

Pricing is submitted as an all-inclusive rate per rendered decision; the State will pay based on acceptable invoices submitted quarterly within thirty days of completion. The contract term runs from November 1, 2026 through June 30, 2028 (two fiscal years), with renewal options for up to two additional two-year periods. Performance-based penalties of up to five percent of the total contract amount may be assessed for non-performance. The contractor must provide monthly, quarterly, and annual reports tracking case processing and turnaround times in Excel format.

Evaluation allocates 1,000 points to technical proposals, 400 points to cost proposals, and up to 200 points for oral presentations if required; proposals scoring below 600 technical points are eliminated from consideration.