Medicaid Physician Review and Consulting Services

The Vermont Department of Vermont Health Access, located in Waterbury, Vermont, is seeking a contractor to provide Medicaid physician review and consulting services. The agency requires medical oversight, prior authorization case review, and medical necessity determinations within a Medicaid managed care environment. The selected provider will review medical services and procedures assigned by the state’s clinical operations unit director and render professional opinions using evidence-based literature, accepted medical standards of care, and expert medical opinion. The agency needs the contractor to collaborate with the state’s chief medical officer on utilization management activities. The contractor will also work alongside the state’s Medicaid clinical staff, including quality improvement, chronic care, program integrity, and pharmacy teams, to identify areas of concern in the utilization program. This initiative aims to ensure appropriate medical necessity decision-making and robust program oversight. Bidders must be onshore organizations based in the United States. The agency requires the performance of all work to occur offsite. The contract period will span one year, and the agency is currently looking for budget proposals to determine the cost of these services. The agency has set the deadline for all questions regarding this opportunity for June 5, 2026. Evaluation criteria and specific budget limits are not detailed in the initial solicitation, as the agency is seeking comprehensive proposals to evaluate suitability and cost.