T1683 - Independent Health Care Appeals Program: Independent Utilization Review Organization, DOBI

The New Jersey Department of Banking and Insurance (DOBI), on behalf of the State of New Jersey, is soliciting quotes for an Independent Utilization Review Organization to deliver managed care utilization review services for the Independent Health Care Appeals Program, with quotes due September 24, 2026. The state intends to award a single contract. A subcontracting set-aside requirement mandates good faith efforts to solicit New Jersey Small Business Enterprises and/or Disabled Veterans' Businesses as subcontractors, though the entire contract is not set-aside.

The contractor will conduct three review types: preliminary reviews (estimated 3,500 annually), full reviews (estimated 1,700 annually), and expedited reviews (estimated 1,700 annually). Preliminary reviews must determine whether appeals meet acceptance criteria within specified timeframes. Full reviews require analysis by board-certified consultant physicians to determine medical necessity of covered services. The contractor must maintain URAC external review accreditation throughout the contract term and comply with comprehensive data security, HIPAA, and privacy requirements. Key personnel include a licensed Medical Director who reviews and approves all determinations, and review agents consisting of registered nurses and board-certified physicians with a minimum of five years' managed care utilization review experience.

The contract term is three years with the possibility of two additional one-year extensions by mutual written consent. The contractor receives payment directly from carriers at the time written decisions are rendered, with bidders submitting all-inclusive firm fixed unit pricing for each review type per year of the contract through the state-supplied price sheet.

Bidders must complete a comprehensive state security due diligence questionnaire addressing thirty control areas, including data security categorization, cloud hosting, workforce screening, and compliance with New Jersey's Statewide Information Security Manual. Supporting documentation must include security plans, privacy policies, SOC2 Type II audit reports, and FedRAMP or StateRAMP authorizations if applicable.

An optional pre-quote conference was held July 23, 2026. Electronic questions were due August 6, 2026 (amended from August 3). Bidders must submit all required forms from the Standard Procurement Forms Packet, including Ownership Disclosure, Subcontractor Utilization Plan, MacBride Principles Form, and Iran/Russia/Belarus sanctions certifications. Quotes must be submitted exclusively through NJSTART; submissions through any other method will not be accepted.