T2691 - NJFamilyCare Utilization Review Audits, DMAHS

Background
This Bid Solicitation is issued by the State of New Jersey, Department of the Treasury, Division of Purchase and Property on behalf of the Department of Human Services, Division of Medical Assistance and Health Services (DMAHS). The purpose is to solicit Quotes for conducting utilization reviews, quality of care audits, and Diagnosis Related Group (DRG) validation audits for inpatient hospital services provided to NJ FamilyCare clients. The State aims to award a contract to a responsible bidder whose quote is most advantageous considering price and other factors.

Work Details
The contractor will conduct various audits including:

1. Utilization Review (UR) audits to ensure medical necessity and appropriateness of inpatient services;
2. Quality of care audits focusing on readmissions and conditions not present on admission;
3. DRG validation audits for acute care hospitals;
4. Ad-hoc audits as assigned by DMAHS.

The contractor must maintain a database for generating reports, review medical records, identify underpayments/overpayments, prepare audit reports summarizing findings, create monthly performance report cards for providers, and ensure compliance with HIPAA regulations. Staffing requirements include a project manager, audit manager, medical director, medical review supervisor, auditors, certified coders, statistician, IT specialist, and provider relations representatives.

Period of Performance
The base term of the contract is four (4) years with an anticipated effective date starting from May 7, 2025. The contract may be extended for up to two (2) additional years upon mutual agreement.

Place of Performance
The contract will be performed in Trenton, New Jersey and may involve various hospitals across the state as part of the audit process.

Bidder Requirements
Bidders must meet small business set-aside requirements and disabled veteran-owned business set-aside requirements. They are required to have a valid Business Registration Certificate prior to contract award. Bidders must also submit proof of federal certification as a Quality Improvement Organization (QIO) or QIO-like entity from CMS. Additionally, bidders must comply with various forms including ownership disclosure forms and certifications regarding investment activities in Iran.