Medical Care Utilization Review Services

The Missouri Department of Commerce and Insurance is requesting proposals for medical care utilization review services to be awarded to up to three responsive vendors, with proposals due September 16, 2026 at 2:00 PM Central Time. Contractors must be accredited or certified by a nationally recognized accrediting organization for health utilization management or as an independent review organization and hold current Missouri utilization review agent certification.

The scope encompasses external review of health insurance coverage denials under Missouri law (sections 376.1350-376.1399, RSMo), evaluating whether denied medical services meet standards for medical necessity, appropriateness, health care setting, efficacy, effectiveness, and level of care across 33 specialty areas. Standard external reviews must be completed within 20 calendar days of receipt; expedited reviews within 72 hours regardless of holidays and weekends. Historical case volume was 71 cases in 2025, averaging 2.8 hours for physician reviews and 3.2 hours for nurse reviews.

Required personnel include a Medical Director with an unrestricted medical license, at least two full-time registered nurse reviewers, and a minimum of two health care professionals in each specialty area with representation from different geographic locations and practice settings. Pricing is hourly-rate based for physician reviewers, registered nurse reviewers, and other health care professionals as specified in the proposal template. The state anticipates no minimum or maximum service guarantee.

The contract term is one year effective from authorization to proceed, with options to renew for up to four additional one-year periods. Invoices must be submitted within 60 business days of review completion and will be paid within 30 calendar days of approval. Travel expenses require prior written approval and are reimbursed at CONUS rates or the contractor's internal policy, whichever is lower. Contractors must execute a Business Associate Agreement addressing HIPAA compliance, including encryption of portable devices and electronic communications containing protected health information, workforce training, breach reporting within five calendar days, and record retention for a minimum of six years. Proposals must be submitted electronically through MissouriBUYS.