Open Enrollment for Independent Review Organization Services, Medicaid & CHIP Services, Medical & UR Appeals

The Texas Health and Human Services Commission (HHSC) is conducting an Open Enrollment solicitation for Independent Review Organizations (IROs) to provide medical and utilization review appeal services for Medicaid and CHIP programs. The procurement seeks qualified organizations to perform independent clinical reviews of adverse healthcare decisions, focusing on medical necessity, appropriateness, and claims reimbursement. Contractors must have a minimum of 2 years relevant experience and employ personnel with 3 years of postgraduate direct patient care experience in the United States. Key deliverables include completing standard reviews within 20 business days and expedited reviews within 5 business days from assignment. The enrollment period opens February 1, 2025, and closes January 31, 2028, with an initial contract term of 3 years and a potential one-year extension. Evaluation criteria include demonstrated experience, personnel qualifications, insurance coverage, and submission of three references showing positive performance on similar contracts within the past two years.

The solicitation does not specify any set-aside designations for disadvantaged businesses or small enterprises. Contractors must be licensed in Texas and carry multiple types of insurance, including $1M professional liability, $1M commercial general liability, $2M umbrella liability, and $1M cyber liability insurance. There is no guaranteed minimum volume or compensation under the contracts, and pricing will be established through a fee schedule. Contractors must comply with extensive data security requirements outlined in the Data Use Agreement and maintain capabilities for handling protected health information and other sensitive data. The solicitation requires contractors to implement robust quality control measures, including Inter-Reviewer Reliability evaluations and monthly reporting on appeal activities. While no specific contract value is mentioned, the comprehensive requirements suggest a significant ongoing opportunity for qualified Independent Review Organizations to support Texas Medicaid and CHIP medical review processes.