Independent Review Organization for Medical Necessity review (IRO)

Background
The Maryland Department of Health (MDH) is issuing this Request for Proposals (RFP) to select an Independent Review Organization (IRO) to perform Medical Necessity reviews for Maryland Medicaid Managed Care Organization (MCO) claim denials. The goal of this contract is to provide independent reviews of Medicaid claim denials for medically necessary services delivered by healthcare providers to Maryland Medicaid recipients enrolled with MCOs. This process aims to ensure that providers have a fair recourse in overturning claim denials based on medical necessity, as established by prior state regulations.

Work Details
The selected contractor will be responsible for conducting case reviews of payment denials based solely on medical necessity. The contractor must adhere to the following responsibilities:

1. Conduct independent case reviews after providers have exhausted the MCO's internal appeal process.
2. Ensure that all case reviews are based on current clinical guidelines and evidence-based practices, utilizing at least three peer-reviewed citations per case.
3. Provide a secure electronic web portal for case submissions and management, including user-specific accounts with multifactor authentication.
4. Generate timely notifications and reports regarding case determinations, including detailed rationales for decisions made.
5. Maintain records of all cases for a minimum of ten years and ensure compliance with federal and state regulations regarding confidentiality and data protection.

Period of Performance
The contract will have a duration of five years, starting from the effective date upon contract award, with no option periods.

Place of Performance
The primary place of performance will be within the State of Maryland.

Bidder Requirements
Offerors must demonstrate a minimum of two years’ experience providing independent medical review determinations for a state Medicaid agency. Additionally, there are no minority business enterprise (MBE) or veteran small business enterprise (VSBE) subcontracting goals set for this RFP.