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 final decisions on Medicaid provider appeals, with proposals due September 30, 2026 at 2:00 PM Eastern Time under RFP 746.

The scope requires review and final decision issuance within specified timeframes: 30 calendar days for administrative and medical necessity reviews, 3 calendar days for pharmacy reviews, and 24 hours for expedited or urgent reviews. The contractor must comply with 907 KAR 17:035 and Kentucky Senate Bill 20. Anticipated annual case volume is approximately 7,200. The contractor must establish secure data transmission protocols, develop a comprehensive Standard Operating Procedure for clinician credentialing and assignment, and produce monthly, quarterly, and annual reports detailing case statistics, turnaround times, and performance metrics. Required staffing includes a Contract Manager, Process Supervisor, Operations Supervisor, Clinical Reviewer, and Certified Coder, each with specified qualification standards. The contractor must maintain Commercial General Liability Insurance with minimum limits of $1,000,000 per occurrence and $2,000,000 aggregate, plus Professional Liability Insurance with $1,000,000 minimum per claim, and assume all operational costs including business continuity, disaster recovery, and information security plans.

The cost proposal must provide an all-inclusive rate per rendered decision, with quarterly invoices due within 30 calendar days after quarter completion. The contract term runs from November 1, 2026 through June 30, 2028, with renewal options for two additional two-year periods subject to Finance and Administration Cabinet and Legislative Research Commission Government Contract Review Committee approval. Evaluation criteria allocate 1,000 points to the technical proposal, 400 points to cost, and up to 200 points for oral presentations or demonstrations, for a total of 1,600 possible points; proposals scoring below 600 points on technical evaluation are eliminated. Performance-based penalties of up to 5 percent of the total contract amount may be assessed for non-compliance. Written questions were due August 17, 2026.