Case Management Decision Support Tool

The vendor required to provide case management decision support software tool that supports appropriate patient status determinations, utilization review workflows, documentation, reporting, and payer audit readiness.
- The software must support compliant workflows, integration with agency systems, and regulatory alignment.
- The software must assist with evaluating inpatient, observation, and outpatient level of care determinations and must support regulatory compliance, payer audit defensibility, and standardized documentation.
1. Clinical criteria content requirements
•    Medical and surgical criteria
•    Emergency department utilization criteria
•    Behavioral health criteria
•    Pediatric criteria
•    Procedure‑ and condition‑specific criteria
2. Functional requirements of the software
•    Searchable criteria engine
•    Documentation tools for level‑of‑care determinations
•    User activity audit trails
•    Role‑based access controls
•    Administrative dashboards and usage metrics
•    Exportable reports for payer audits and internal compliance
3. Technical and integration requirements
•    Support single sign‑on (SSO)
•    Provide API or hl7 interoperability
•    Meet HIPAA security standards
4. Implementation and training requirements
•    Implementation timeline and milestones
•    Staff training plan
•    Configuration and testing approach
•    Ongoing support structure
5. Support, maintenance and update requirements
•    Annual criteria update process
•    Software release cycles
•    Help desk response standards
•    Escalation pathways
•    Disaster recovery
6. Performance standards and KPIs
•    System uptime ≥ 99.9%
•    Criteria updates within 30 days of release
•    Help desk response within 1 business day
•    High‑priority issue resolution within 72 hours
•    ≥ 90% user satisfaction
7. Compliance requirements
•    HIPAA standards
•    CMS conditions of participation
•    State confidentiality laws
•    Joint commission requirements
•    Agency internal data protection policies.

- Questions/Inquires Deadline: December 23, 2025