S & L - NC DHHS Due Process (Appeals) Clearinghouse - MRAS

The General Services Administration (GSA) is conducting market research on behalf of a State & Local agency to develop a comprehensive solution for managing Medicaid beneficiary appeals and grievances. This initiative stems from the requirements established under the 14th Amendment, federal regulations, and North Carolina state statutes, which mandate that Medicaid beneficiaries have the right to due process, including fair hearings. Since October 2008, the North Carolina Office of Administrative Hearings (OAH) has overseen Medicaid service denials or reductions. With the transition to Medicaid Managed Care initiated by Session Law 2015-245, the North Carolina Department of Health and Human Services (DHHS), through its Division of Health Benefits (DHB), now manages both Medicaid Direct and Managed Care programs.

The primary objective is to establish a secure, centralized web-based Clearinghouse Solution that complies with federal and state due process requirements for handling Medicaid appeals. The proposed system will collect, store, manage, analyze, and securely share documents related to adverse benefit determinations (NABDs), appeals, mediations, and State Fair Hearings. This platform must ensure timely access to information for all authorized agencies involved in the appeals process including OAH, Managed Care Organizations (MCOs), Utilization Review vendors, legal entities, and internal policy experts.

The solution must offer secure password-protected access while providing centralized electronic storage and reporting capabilities. It should support data analytics for financial tracking as well as daily or on-demand uploads from vendors and agencies. Additionally, it must confirm uploads or report errors within 24 hours while allowing authorized users to securely access, view, and export appeal files. The system needs to support expedited appeals requiring resolution within 72 hours.

Vendors are asked to provide detailed information regarding their solution architecture's integration with existing DHB Enterprise Architecture and Medicaid Integration Services platforms for data ingestion analytics and security services. They should also describe tools used for building operational functions automation while detailing business resources required by DHHS during implementation phases such as planning design development implementation testing training go-live stages along with cost models pricing structures expected timeframes completion phases annual software licensing maintenance fees cloud hosting costs basis estimates these fees.