Kansas Department of Health and Environment

Buyer seeks a qualified vendor to provide retrospective utilization review services to ensure efficiency, economy, and quality of care for Kansas Medicaid fee-for-service programs. The contractor will conduct retrospective utilization review of hospital inpatient, psychiatric, and ambulatory surgical center claims. Reviews must safeguard against unnecessary utilization, assess quality of services, and provide for utilization control. The contractor will need to maintain a facility near Topeka and employ Kansas-licensed physicians familiar with standards of practice.

• 4/29/2025 - Questions Due
• 5/20/2025 - Proposal Due Date

• Must be a Federally Designated Quality Improvement Organization (QIO) or QIO-Like Entity
• Must be certified as corporation doing business in Kansas
• Must demonstrate high quality administrative and clinical leadership
• Must maintain facility within five miles of Topeka
• Must have capability to assume statewide responsibility

• Conduct retrospective reviews of inpatient hospital admissions
• Perform DRG validation to ensure proper diagnostic coding
• Review ambulatory surgical center claims
• Review inpatient psychiatric hospital claims
• Evaluate readmissions within 15 days of discharge
• Review hospital cost outliers
• Process claim adjustments in the MMIS system
• Handle reconsiderations and support administrative hearings
• Develop provider notification procedures for adverse determinations
• Create reports tracking review outcomes and financial impact