Description
The State of Missouri, through its Department of Commerce and Insurance, is seeking a qualified contractor to provide Medical Care Utilization Review Services for a one‑year period. The contractor will perform external medical necessity reviews, provide clinical opinions, and support the state’s regulatory functions under Missouri statutes. The work includes reviewing case files, producing written reports within statutory timelines, handling expedited reviews, and attending quarterly status meetings. Vendors must be certified as an Independent Review Organization (IRO) or hold equivalent accreditation, possess at least one year of relevant experience, and staff a Medical Director plus two registered nurse reviewers (and additional specialty clinicians as needed). All deliverables are to be submitted via a secure web‑based platform.
• Provide medical utilization reviews for health‑plan consumers under Missouri law.
• Deliver written external review reports within 20 calendar days (72 hours for expedited cases).
• Staff a Medical Director (licensed physician) and a minimum of two full‑time RN reviewers; additional specialty clinicians as required.
• Maintain IRO certification, conflict‑of‑interest policies, and OIG compliance.
• Submit all proposals electronically through MissouriBUYS; must be registered “Approved/Spend Authorized.”
• Attend optional quarterly status meetings (in‑person or virtual).
• Contract term: 1 year with possible renewal at State’s discretion.