Medical Care Utilization Review Services

The Missouri Department of Commerce and Insurance, through the State of Missouri Office of Administration Division of Purchasing, is requesting proposals for medical care utilization review and external review services, with proposals due September 30, 2026 at 2:00 PM Central Time under RFP Amendment No. 01. The state anticipates awarding contracts to three vendors to ensure adequate coverage and meet service demand. Contractors must be accredited or certified by a nationally recognized independent review organization and certified as a utilization review agent under Missouri law (sections 376.1350–376.1399, RSMo) — the central eligibility filter.

The scope covers medical care utilization review and external review services for health insurance determinations subject to state regulation, including standard reviews to be completed within 20 calendar days and expedited reviews within 72 hours. Vendors must provide a Medical Director with an unrestricted medical license, at least two full-time registered nurse reviewers, and additional health care professionals spanning 33 specialty areas detailed in Attachment 1, with preference for Missouri-licensed providers. The contractor must maintain toll-free 24/7 phone service, quality assurance policies, conflict of interest procedures, secure web-based external review platforms, and submit annual reporting in Excel format. All work involves handling Protected Health Information under HIPAA; contractors execute a Business Associate Agreement and must implement administrative, physical, and technical safeguards with incident reporting required within five calendar days of discovery.

The contract term is one year with four optional one-year renewal periods. Pricing is firm and fixed on an hourly basis by medical personnel classification per Exhibit C. Historical case volume data indicates 71 cases referred in 2025, averaging 2.8 hours per physician review and 3.2 hours per nurse review; the state makes no guarantee regarding minimum or maximum service levels or work volume. Invoicing must be submitted within 60 business days of review completion, with payment due within 30 days of invoice approval. Vendors must register with "Approved" status in WebProcure/Proactis and "Spend Authorized" status in MissouriBUYS. Current incumbents operate under contract numbers CS220129001, CS220129002, and CS220129003.