Medical Care Utilization Review Services

Missouri's Department of Commerce and Insurance is requesting proposals for medical care utilization review services with proposals due October 5, 2026. The contractor will conduct prospective, concurrent, and retrospective reviews of medical claims across 33 licensed medical specialties, including primary care, surgery, cardiology, oncology, psychiatry, substance use disorder treatment, and allied health disciplines such as chiropractic care and podiatry.

The scope requires pre-authorization reviews, concurrent reviews, and retrospective reviews of medical claims and procedures; clinical oversight and evidence-based assessment of treatment protocols; nurse reviewer support, physician advisor consultation, and case management coordination across inpatient hospital care, outpatient procedures, pharmaceutical services, and behavioral health treatments; development of review criteria; documented clinical justification for all determinations; establishment of timelines for review completion; detailed reporting on utilization patterns, trends, and review findings; and coordination with healthcare providers and insurers on medical necessity determinations. The contractor must maintain professional liability insurance, comply with HIPAA privacy requirements and Missouri insurance regulations, and implement administrative, physical, and technical safeguards to protect protected health information.

The initial contract term is two years with potential renewal options for up to three additional one-year periods. Pricing will be structured through negotiated rates based on the volume and complexity of reviews performed, with specific fee schedules to be detailed in the full request for proposal. Evaluation criteria emphasize experience in utilization review operations, quality assurance measures, turnaround times for review decisions, cost-effectiveness, and technological capabilities for claims processing and reporting. The Department will award the contract to a single vendor. A Business Associate Agreement revised December 29, 2025 governs the contractor's handling of protected health information and requires security incident reporting within five calendar days of discovery and maintenance of disclosure documentation for a minimum of six years.