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Prior Authorization and Utilization Management Services


Location
Indiana
Publication Date
10/31/2018 06:51 AM EDT
Closing Date
01/08/2019 03:00 PM EST
Issuing Organization
State of Indiana - Department of Administration
Solicitation Number
Description

Specifications include, but are not limited to: The purpose of this RFP is to select a Contractor to be responsible for working with Indiana Health Care Programs (IHCP) to manage the day-to-day operations of PA and UM services for all IHCP enrollees including Medicaid populations receiving care through the FFS mechanism and those enrolled in the managed care portion of the program for services that are carved-out of managed care. It is the intent of the FSSA OMPP to contract with a vendor that provides sound PA and UM decisions on a case-by-case basis. The OMPP seeks a Contractor to evaluate PA and UM cases involving Indiana Medicaid members receiving medical care through the FFS mechanism. The Contractor will also be responsible for specific managerial duties for the Right Choices Program (RCP), Single Case Agreements (SCAs), Special Case Considerations (SCCs), and Utilization Management Care Coordination Services (UMCC). The Contractor has a multitude of PA responsibilities and performance standards that must be met. They include: - Review, research, and analyze PA requests and appropriately make and send determinations in an expedient timeframe - Staff the PA function with medical professionals with clinical expertise - Deliver monthly, quarterly, semi-annual and annual reports, work plans, studies, and summaries to the State - Maintain adequately staffed PA phone lines and fax access - Interface with providers regularly to ensure that PA policies are in accordance with changing provider practices - Respond to state inquiries in a timely fashion - Design PA forms and purge old PA forms - Analyze internal processes, policies, and structure and make appropriate changes to any deficient areas of the business function - Represent the State in PA-related legal hearings - Review PA policy drafts and provide feedback on operational implications - Refer instances of fraud to the State - Meet with State leaders to ensure coordination - Coordinate with other State contractors on business processes

Source
https://www.in.gov/idoa/proc/bids/19-049/ (opens in a new window)

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