Third Party Medical Reviews

The Kansas Department of Health and Environment (KDHE) is seeking competitive proposals for a third-party medical review service to provide an external, independent review process for Medicaid providers who have received service or payment denials from Managed Care Organizations (MCOs). The procurement aims to select a vendor capable of conducting specialized medical necessity and adverse payment claim reviews using specialty-matched clinicians. Vendors must complete each review within 30 calendar days and maintain a facility within five miles of Topeka, Kansas. The contract period will run from July 1, 2026, through June 30, 2029, with potential renewal options for two additional twelve-month periods. Key deliverables include monthly and annual reporting, strict adherence to HIPAA regulations, and comprehensive data security measures. Proposals are due by September 23, 2025, at 2:00 PM CST, and bidders must submit detailed documentation through the State of Kansas SMART Strategic Sourcing System. Evaluation criteria will likely focus on the vendor's ability to provide timely, specialty-specific medical reviews, compliance capabilities, and proposed review pricing.

The state encourages participation from diverse business types, including potential preference for Disabled Veteran Owned Businesses and Certified Businesses. Bidders must obtain a current Tax Clearance Certificate, comply with immigration reform laws, and submit additional forms such as a Boycott of Israel declaration and a Sexual Harassment form. While specific budget ranges are not explicitly detailed, vendors will be expected to provide comprehensive pricing for clinician reviews, indirect costs, administrative fees, and incidental expenses. The procurement includes provisions for liquidated damages in cases of non-compliance and requires vendors to implement robust information security measures, including vulnerability scanning. Potential bidders must demonstrate comprehensive knowledge of Kansas state and federal healthcare regulations, maintain appropriate clinical expertise, and have the technological infrastructure to support secure, confidential medical record reviews. The state emphasizes additional preferences for vendors with policies discouraging human trafficking and those capable of meeting stringent regulatory and operational requirements.