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 contract. The contractor will perform external medical necessity reviews for health plan appeals, conduct expedited reviews, and supply medical expertise to support the agency’s regulatory functions. Required personnel include a Medical Director and at least two full‑time registered nurses (or equivalent health professionals) with appropriate licensure, and the contractor must hold certification as an Independent Review Organization (IRO) or equivalent. The work will be performed via a secure web‑based platform, with case volumes averaging roughly 200‑250 cases per year and an estimated 2.8‑3.2 hours of review time per case. The contract mandates compliance with Missouri statutes, conflict‑of‑interest policies, and various business‑compliance certifications.
• One‑year contract, effective upon award
• Review ~200‑250 external medical appeal cases annually
• Minimum staffing: 1 Medical Director + 2 RN reviewers (or equivalent) available at all times
• Required IRO or similar accreditation; proof of certification at proposal submission
• Secure web‑based case transmission (State’s NAIC SBS system)
• Experience: ≥1 year in utilization review, expedited review, and electronic case handling
• Mandatory compliance with Missouri health‑care statutes, OIG sanctions screening, and anti‑boycott certifications
• Submission through MissouriBUYS by 2:00 PM CT, Oct 5 2026