Program Integrity Case Management (PICM) and Fraud Abuse Detection (FAD) Analytics Solution

The State of Nebraska's Department of Health and Human Services (DHHS) is seeking a comprehensive Program Integrity Case Management (PICM) and Fraud Analysis & Detection System (FADS) through a competitive Request for Proposal (RFP) process. The procurement aims to replace the current Medicaid program case management system with a cloud-based, modular software solution that supports fraud detection, case management, advanced analytics, and predictive modeling for approximately 340,000 Medicaid recipients. Key deliverables include a Software as a Service (SaaS) platform capable of tracking recoupments, identifying billing practice outliers, conducting retrospective drug utilization reviews, and referring suspected provider fraud cases to the state's Medicaid Fraud Unit. Mandatory vendor qualifications include having a current implemented PICM/FADS contract with another State Medicaid agency. The solicitation was released on May 28, 2025, with proposal responses due by July 10, 2025, at 2:00 p.m. Central Time, and an expected implementation date no later than October 31, 2026. Evaluation criteria will assess responses across three categories: Corporate Overview (25 points), Technical Response (60 points), and Cost Sheet (15 points), with a potential total of 100-120 points including potential oral interviews.

The RFP does not explicitly mention specific set-aside designations or restrictions for disadvantaged enterprises. The solution must integrate with existing state systems, including the Medicaid Management Information System (MMIS) and the Nebraska Family Online Client User System (N-FOCUS), utilizing an integration hub with batch processing and potential real-time integration protocols. Security requirements include TLS encryption, AES-256 data protection, role-based access control, and HIPAA compliance. The contract will have an initial five-year term with options to renew for two additional two-year periods. While specific total contract value is not disclosed, the cost sheet indicates the project will include multiple implementation phases, with the state allocating up to 500 vendor hours annually for system modifications at no additional cost. The project is eligible for enhanced federal financial participation (FFP), and the vendor will be responsible for supporting the Centers for Medicare and Medicaid Services (CMS) certification process, data migration, training, and ongoing maintenance and support.