KDHE-DHCF is seeking competitive proposals from qualified vendors to provide retrospective utilization review services for the purpose of providing methods and procedures to assure "efficiency, economy and quality of care” as required by law pursuant to section 1902 (a)(30)(A) thru (B) of the Social Security Act (Act) and 42 U.S.C. §1320c et seq. Section 1902 (a)(30)(A) of the Social Security Act requires that state Medicaid Agencies provide methods and procedures to safeguard against unnecessary utilization of care and services and to assure “efficiency, economy and quality of care.” Under Section 1902 (d), a State can contract with a Quality Improvement Organization (QIO) or QIO-like entity to perform medical and utilization review functions required by law. The contracts must be consistent with the QIO legislation. Section 1903(a)(3)(C) of the Act specifies that 75% Federal Financial Participation is available for State expenditures for the performance of medical and utilization reviews or external quality reviews by a QIO, or by an entity which meets the requirements of section 1152 of the Act (i.e., “QIO-like entity”). The primary purpose of this component of the RFP is to solicit proposals leading to a contract with a Quality Improvement Organization (QIO) or QIO-Like Entity for the implementation and management of a statewide quality and utilization control program provided to Kansas Medicaid members in fee-for-service programs. The utilization review contractor will conduct retrospective utilization review services of fee-for-service inpatient hospital, inpatient psychiatric hospital, and ambulatory surgical center claims. This RFP Scope of Work will not include the Kansas Managed Care Program, KanCare. Per 42 CFR §456.3, a Contractor is sought who meets the requirements of a statewide utilization program to: 4.2.1. Safeguard against unnecessary or inappropriate use of Medicaid services and against excess payments; 4.2.2. Assess the quality of those services, identify key characteristics and measures of both adverse and superior quality; and 4.2.3. Provide for the control of the utilization of services.
