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

The Texas Health and Human Services Commission (HHSC) has issued an open enrollment solicitation titled "Open Enrollment for Independent Review Organization Services, Medicaid & CHIP Services, Medical & UR Appeals" (Solicitation Number HHS0015818). This contract opportunity invites qualified Independent Review Organizations (IROs) to provide clinical and administrative appeal review services for Medicaid fee-for-service and managed care claims in Texas. The IROs will assist HHSC Medical and Utilization Review Appeals and HHSC Operations Management Provider Resolution and Administrative Appeals by conducting independent reviews of adverse decisions derived from retrospective claim reviews, including audits such as OIG Hospital Utilization Reviews, Acute Care Surveillance, Targeted Query, and Recovery Audit Contractor reviews. The contract expects IROs to employ licensed professionals with expertise in medical record and billing documentation review, maintain robust quality control, including Inter-Reviewer Reliability evaluations, and provide comprehensive monthly and quarterly reporting on reviewer activities and credentials. Strong emphasis is placed on compliance with Texas Medicaid policies, adherence to reviewer qualifications, conflict of interest disclosures, and confidentiality protocols under state and federal privacy laws such as HIPAA. The contractual framework is governed by the Health and Human Services Uniform Terms and Conditions for Vendors (Version 3.4, effective November 2023), supplemented by a strict Data Use Agreement ensuring protection of sensitive health and confidential information. The contract obligates the contractor to safeguard Protected Health Information, respond to amendment or disclosure requests, and comply with breach notification and data destruction standards. Applicants must submit detailed organizational charts, resumes of key personnel, and affirm compliance with criminal background checks, ethical standards, and conflict-of-interest prohibitions. The solicitation requires electronic submission by email to the designated POC, Marticia Lee, with recommended file size limitations and specific allowable file formats to ensure accessibility. Award decisions hinge on meeting mandatory qualifications and disqualifying conditions such as unfavorable vendor performance records or state debarments rather than a scored multi-factor evaluation. No federal acquisition regulations (FAR) clauses apply as this is a state-level contract. The contract term is open with applications accepted from February 1, 2025, through January 31, 2028. Reimbursement specifics and pricing models are not publicly disclosed, indicating pricing is likely determined competitively or post-award. Overall, this contract enables HHSC to ensure independent, high-quality clinical and administrative review of appeals resolutions within Medicaid and CHIP programs, while safeguarding sensitive information and enforcing rigorous contractor performance standards.