Claims Prepay RFI

The Colorado Department of Health Care Policy and Financing is seeking information on advanced pre-payment solutions for Medicaid fee-for-service claims. The solutions should provide incremental savings and risk detection beyond the Department's existing editing and claims processing. The Department is interested in solutions that use artificial intelligence, rules-based analytics, and edits to evaluate claims prior to final payment. The solutions should also integrate with the Department's existing MMIS/CMES infrastructure and provide real-time or near real-time analytics on claims to identify potential fraud, waste, and abuse. Some key features of the desired solutions include: • Advanced pre-payment solutions that provide incremental savings and risk detection • Solutions that use artificial intelligence, rules-based analytics, and edits to evaluate claims • Integration with the Department's existing MMIS/CMES infrastructure • Real-time or near real-time analytics on claims to identify potential fraud, waste, and abuse • Solutions that minimize the need for skilled medical professionals to manually review claims • Solutions that provide explainability, provider-facing communications, and low-abrasion methods to improve first-pass accuracy