The vendor required to provide utilization management expert consulting services to equitable, high-quality, timely, and affordable health care within a stable health care delivery system.
- Provide expert guidance and recommendations in developing and implementing the reporting template and instructions
• Provide expert guidance and recommendations to the department to develop a reporting template for health plans to report data on prior authorization, including approvals, denials and modifications, approved by health plans or their delegated entities at a rate that meets or exceeds the threshold rate of 90 percent.
• Inform the development of reporting instructions to ensure health plans can complete the reporting template.
• Include guidance to users on the expected, appropriate and valid data values and information to populate in the reporting template.
• Provide expert guidance and recommendations to assist the department when responding to technical and operational inquiries from health plans on the implementation of the reporting template and instructions, and requirements for covered services subject to prior authorization.
- Provide expert guidance and recommendations on report analysis and evaluation
• Provide expert guidance and recommendations to the department in evaluating completed reporting templates filed by health plans.
• Guidance, at a minimum, shall include recommendations informed by industry best practices on groupings of service, treatment, drug and diagnosis and procedural codes for analysis.
- Provide expert guidance and recommendations on the development and publishing of the list of covered services for which health plans shall not impose prior authorization
• Provide expert guidance and recommendations to the department in developing and publishing a list of services for which health plans shall not impose prior authorization.
• Include the consideration of other factors, such as utilization practice standards and pairings of treatment, frequency and duration, service and drug codes, when recommending and determining the appropriateness of adding or removing a service subject to prior authorization, regardless of its approval percentage rate.
• Participate in stakeholder discussions regarding the list of covered services for which health plans and delegated entities shall cease requiring prior authorization.
- Draft a report regarding the impacts of the cessation of prior authorization requirements
• Provide expert guidance and recommendations to the department and draft a template for health plans to report the impacts of the cessation of prior authorization requirements, including effects on the:
o Volume of covered services subjected to prior authorization,
o Statistics on prior authorization requests and determinations,
o Administrative costs,
o Timely access to care,
o Enrollee health outcomes, and
o Data on reinstatements of prior authorization.
• Consider factors that ensure successful completion and recommendations of factors and metrics to ask health plans to understand the impacts of the cessation of prior authorization requirements.
• Include knowledge of current industry trends and current practices in utilization management that assist in contextualizing trends and anomalies observed in these reports.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: January 14, 2026
