Open Enrollment for Independent Review Organization Services, Medicaid & CHIP Services, Medical & UR Appeals

The Texas Health and Human Services Commission (HHSC) is conducting an open enrollment to establish contracts with Independent Review Organizations (IROs) to support Medical and Utilization Review (UR) Appeals and Provider Resolution and Administrative Appeals. The primary objective is to engage professional reviewers to conduct appeal reviews of adverse decisions resulting from retrospective reviews of Medicaid claims, ensuring compliance with Texas Medicaid policies, the Texas Administrative Code, and clinical guidelines such as InterQual and MCG. The enrollment period is open from February 1, 2025, through January 31, 2028, with specific work assigned via individual work orders. Selected vendors must adhere to rigorous compliance and security standards, including the execution of a Data Use Agreement to protect Protected Health Information (PHI) and Personal Identifying Information (PII) in accordance with HIPAA. All contractor personnel must undergo comprehensive background checks through the Texas Department of Public Safety. Award decisions are made at the sole discretion of the HHSC Executive Commissioner based on a trade-off process that prioritizes compliance verification and past performance over a lowest-price model. Disqualification triggers include federal or state debarment, failure to maintain good standing with the Texas Franchise Tax, or unfavorable reports in the CPA Vendor Performance Tracking System. Administrative requirements mandate that all applications be submitted via email to the designated address, including signed affirmations and a detailed budget. Invoices are submitted electronically to the HHSC Accounts Payable department, and the contract expressly prohibits the reimbursement of travel or meal expenses. The agreement is governed by the HHS Uniform Terms and Conditions, which outline standard legal provisions for indemnity, confidentiality, and dispute resolution.