Claims Prepay RFI

The Colorado Department of Health Care Policy and Financing is issuing a Request for Information (RFI) to receive responses and information from vendor organizations that can provide advanced pre-payment solutions for Medicaid fee-for-service claims. The Department is interested in seeing solutions that address analytics, post-payment, and identification of billing errors, and provide a well-rounded solution for billing issues that cannot be addressed in a singular solution or may be more complex than a single edit. The solutions should align with federal Medicaid program integrity requirements and be adaptable to future federal regulatory changes without requiring significant system redesign. Some key features the Department is looking for in the solutions include: • Advanced pre-payment solutions that provide incremental savings and risk detection beyond the Department’s existing editing and FFS claims processing • Solutions that use artificial intelligence (AI) to evaluate FFS claims prior to final payment • Solutions that minimize the need for skilled medical professionals to manually review FFS claims prior to final payment • Solutions that integrate with the Department’s existing MMIS/CMES infrastructure to ingest FFS claims and return decisions without disrupting current operations • Solutions with explainability, provider-facing communications, and low-abrasion methods to improve first-pass accuracy.