North Carolina Department of Insurance

The buyer is seeking qualified vendors to perform independent medical reviews of health plan coverage denials. Vendors will conduct external reviews of noncertifications and issue timely determinations. The buyer requires vendors to maintain a network of qualified clinical peer reviewers and implement quality assurance processes. Vendors must have systems in place to maintain case confidentiality and provide 24/7 phone service for inquiries. The contract will be for an initial two-year term with option to renew.

• 1/21/2025 - Submit Written Questions
• 1/28/2025 - Provide Response to Questions
• 3/4/2025 - Proposal Due Date
• 7/1/2025 - Contract Award

• Perform independent medical reviews of health plan coverage denials
• Issue timely determinations on standard and expedited review cases
• Maintain qualified clinical peer reviewer network
• Implement quality assurance program and plan
• Maintain confidentiality of case records
• Provide toll-free 24/7 phone service for external review inquiries
• Notify all required parties of review decisions
• Maintain records of all external review requests
• Screen cases for organizational and reviewer conflicts of interest
• Consult with NC-licensed physician on standards of practice