RFP 2026-03 Second Pass Claims Editing System
ID: S-X26083-00016311
• State: Oregon
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Description
Background
CareOregon, Inc. is a 501(c)(3) public benefit nonprofit organization founded in 1993, primarily funded through public programs such as Medicaid and Medicare. The organization aims to provide integrated managed care services to improve health outcomes for Oregonians, focusing on quality and equity in healthcare.
The RFP seeks a software solution for a Second Pass Claims Editing System to enhance payment accuracy and integrity in claims processing, aligning with regulatory requirements set by the Centers for Medicare and Medicaid Services (CMS) and the Oregon Health Authority (OHA).
Work Details
The selected Proposer must provide a second pass claims editing solution that integrates with QNXT, featuring functionalities such as:
- Identifying prepay issues not detected by existing systems, including duplicates, modifiers, bundling/unbundling, NCCI/MUE alignment, DRG/MS-DRG alignment, APC-related edits, site-of-service validations, age/sex checks, and specialty edits.
- Editing capabilities for various claim types: facility, professional, ancillary/lab, behavioral health (BH), pharmacy (Rx), and durable medical equipment (DME).
- Outcomes of edits including deny, pend, or informational activities.
- Customizability of edits and logic based on CareOregon's needs.
- Implementation of fraud detection functionalities and integration with prior authorization processes.
- Comprehensive reporting capabilities including provider-reported hours and cross-payer reporting.
Deliverables include a complete second pass claims editing solution integrated with QNXT and various reports as required by CareOregon.
Period of Performance
The contract will commence in June 2026 and continue through May 31, 2027. There is an option for two additional one-year renewal terms thereafter.
Place of Performance
The services will be performed primarily at CareOregon's facilities located in Oregon.
Bidder Requirements
Proposers must demonstrate experience providing similar services to nonprofit entities or Medicaid carriers within the past five years. They should also comply with specific insurance requirements including commercial general liability of $1 million per occurrence; professional liability of $1 million per occurrence; automobile liability; and cyber liability coverage of $7 million per occurrence.
Proposers are encouraged to include minority-owned business enterprises (MBE), women-owned business enterprises (WBE), service-disabled veteran-owned businesses (SDV), or emerging small businesses (ESB) in their proposals.
CareOregon, Inc. is a 501(c)(3) public benefit nonprofit organization founded in 1993, primarily funded through public programs such as Medicaid and Medicare. The organization aims to provide integrated managed care services to improve health outcomes for Oregonians, focusing on quality and equity in healthcare.
The RFP seeks a software solution for a Second Pass Claims Editing System to enhance payment accuracy and integrity in claims processing, aligning with regulatory requirements set by the Centers for Medicare and Medicaid Services (CMS) and the Oregon Health Authority (OHA).
Work Details
The selected Proposer must provide a second pass claims editing solution that integrates with QNXT, featuring functionalities such as:
- Identifying prepay issues not detected by existing systems, including duplicates, modifiers, bundling/unbundling, NCCI/MUE alignment, DRG/MS-DRG alignment, APC-related edits, site-of-service validations, age/sex checks, and specialty edits.
- Editing capabilities for various claim types: facility, professional, ancillary/lab, behavioral health (BH), pharmacy (Rx), and durable medical equipment (DME).
- Outcomes of edits including deny, pend, or informational activities.
- Customizability of edits and logic based on CareOregon's needs.
- Implementation of fraud detection functionalities and integration with prior authorization processes.
- Comprehensive reporting capabilities including provider-reported hours and cross-payer reporting.
Deliverables include a complete second pass claims editing solution integrated with QNXT and various reports as required by CareOregon.
Period of Performance
The contract will commence in June 2026 and continue through May 31, 2027. There is an option for two additional one-year renewal terms thereafter.
Place of Performance
The services will be performed primarily at CareOregon's facilities located in Oregon.
Bidder Requirements
Proposers must demonstrate experience providing similar services to nonprofit entities or Medicaid carriers within the past five years. They should also comply with specific insurance requirements including commercial general liability of $1 million per occurrence; professional liability of $1 million per occurrence; automobile liability; and cyber liability coverage of $7 million per occurrence.
Proposers are encouraged to include minority-owned business enterprises (MBE), women-owned business enterprises (WBE), service-disabled veteran-owned businesses (SDV), or emerging small businesses (ESB) in their proposals.
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Overview
Agency
Opportunity Type
Open Market
Opportunity ID
S-X26083-00016311
Response Deadline
April 9, 2026
Past Due
Date Posted
March 12, 2026
Source
Pre-Bid Conference
There will not be a pre-bid conference.
Est. Value Range
Experimental
$500,000 - $2,000,000
(AI estimate)
Agency Distribution
High
On 3/12/26 CareOregon, Inc. in Oregon issued Open Market Second Pass Claims Editing System with ID S-X26083-00016311 due 4/9/26.
Contacts
Documents
Posted documents for RFP 2026-03 Second Pass Claims Editing System
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AI Analysis
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Classifications
Opportunity Classification
X2608 - Procurement
Additional Details
Source Department
X2608 - Procurement