RFP 2026-03 Second Pass Claims Editing System

CareOregon, Inc., a Oregon-based 501(c)(3) nonprofit health plan, is issuing Request for Proposals 2026-03 to procure a Second Pass Claims Editing System software solution designed to ensure payment accuracy and integrity by identifying coding and processing errors not caught by initial editing systems. The solution must integrate with the QNXT claims processing platform and support editing across facility, professional, ancillary/lab, behavioral health, pharmacy, and durable medical equipment claims. Key deliverables include implementation during June through October 2026 with go-live targeted for November 2026, followed by operational services from June 2026 through May 31, 2027, with two optional one-year renewal terms. Required qualifications include HIPAA compliance, SOC2/HITRUST certification or equivalent, 99.9% uptime guarantees, and specific service level agreements for claim processing timeliness (Medicare: 95% within 60 days; Medicaid: 90% within 30 days, 95% within 45 days, 99% within 60 days). The RFP evaluation criteria include proposer qualifications (30 points), scope of work capabilities (35 points), equity, diversity, and inclusion efforts (10 points), and fees (25 points). Proposal submissions are limited to 40 pages and must be received by April 9, 2026, at 2:00 PM Pacific Time, with a deadline for clarifying questions of March 26, 2026, at 5:00 PM Pacific Time.

The RFP does not identify any set-asides, restrictions on organization types, or incumbent vendors, meaning all qualified proposers are eligible to compete. CareOregon requires the selected vendor to execute a Professional Services Contract and maintain specific insurance coverage, including commercial general liability of $1,000,000 per occurrence, professional liability of $1,000,000 per occurrence, automobile liability of $1,000,000 per occurrence, and cyber liability of $7,000,000 per occurrence. Data must be stored and transmitted exclusively within the continental United States. CareOregon processed 8,998,405 total claims in 2025, with professional claims valued at $961,290,171.55, outpatient facility claims at $265,164,960.64, and inpatient facility claims at $295,070,459.47, serving 573,000 Medicaid members and 14,300 Medicare members. Proposers may submit fees using fixed fee, time and materials with not-to-exceed pricing, or contingency fee percentage of total savings from claims editing services bases, though no specific budget range is identified in the RFP.