Description
The California Department of Corrections and Rehabilitation (CDCR) seeks a contractor to provide comprehensive Pre‑Payment Claim Review (PPCR) and Post‑Payment Audit & Recovery (PPAR) services for health‑care claims related to incarcerated patients. The contractor will be responsible for all labor, travel, materials, and related expenses, and must deliver claim reviews, audit over‑payments, recover funds, and supply detailed reporting via a secure HIPAA‑compliant portal. Performance must meet strict timelines, including rapid response to inquiries, on‑time claim determinations, and adherence to extensive security, wage‑law, and DVBE/Small‑Business certification requirements. The contract runs from October 1 2026 through September 30 2029 with up to five one‑year extensions, and compensation is a percentage (up to 20 %) of actual recoveries, subject to reductions for various conditions.
• Conduct pre‑payment claim reviews to ensure medical necessity, correct coding, and compliance before payment.
• Perform post‑payment audits of up to 120 k claims per month, identify over‑payments, and recover funds within defined timeframes.
• Provide secure web‑portal and HIPAA‑compliant data exchange, monthly reporting, and maintain required staffing (licensed physicians, RNs, APRNs) throughout the contract.