Medical Care Utilization Review Services

The Missouri Department of Commerce and Insurance is requesting proposals for medical care utilization review services under RFP STATE 0000000557SL, with proposals due October 5, 2026 at 2:00 PM Central Time via MissouriBUYS. The state anticipates awarding contracts to three responsive vendors.

Contractors must be accredited or certified as an independent review organization by a nationally recognized health utilization management or independent review organization body and hold a Certificate of Registration as a utilization review agent under Missouri law. They must comply with HIPAA requirements via the attached Business Associate Agreement, including encryption of portable devices and electronic communications, maintenance of PHI records for six years, breach reporting within five to ten calendar days, and indemnification of the Department for Privacy and Security Rule violations.

The scope encompasses external review services for health plans regulated by Missouri under sections 376.1350–376.1399 RSMo, evaluating medical necessity, appropriateness, health care settings, efficacy, and level of care. Standard reviews must be completed within 20 calendar days of case receipt; expedited reviews within 72 hours. Historical case volume ranges from 13 cases in 2010 to 71 cases in 2025. Average processing times are 2.8 hours for physician reviews and 3.2 hours for nurse reviews.

Required personnel include a Medical Director with an unrestricted medical license, a minimum of two full-time registered nurses, and at least two health care professionals available in each of 33 specified medical specialty areas. Contractors must maintain written policies on conflicts of interest and quality assurance, provide 24/7 toll-free phone service, and use NAIC's State Based Services System for electronic case transmission.

Pricing is firm and fixed on an hourly basis by personnel classification (physicians, nurse reviewers, health care professionals). Invoicing occurs within 60 business days of case completion; payment within 30 calendar days. The contract period is one year from the effective date with four optional one-year renewal periods. The state assigns cases on a rotational basis and reserves the right to terminate for convenience with 30 days' notice or for material breach with ten business days to cure.