Medicaid Physician Review, Prior Authorization, and Medical Necessity Consulting Services
- Client
- Department of Vermont Health Access
- Solicitation No.
- 03410-245-27
- Posted
- —
- Category
- Medical Services
- Budget
- Looking for Proposals
- NAICS
- —
- Set-aside
- —
- Contact
- —
Description
AI GeneratedThe agency is seeking Medicaid physician review and consulting services. The agency requires medical oversight for clinical needs, prior authorization case review, and medical necessity determinations within a Medicaid managed care environment. The project covers providing expertise in competencies, knowledge, skills, abilities, and subject matter. Excellent verbal and written communication skills are essential, as are advanced analytical skills for reviewing clinical data from various sources including claims, medical records, guidelines, literature, and policies. Advanced interpersonal skills are also required for relationship building, teamwork, motivation, consensus building, negotiation, persuasion, facilitation, conflict resolution, tact, sensitivity, and confidentiality. Eligibility is limited to onshore organizations located within the USA. The performance of the work will be conducted offsite. The agency is looking for proposals.
Key solicitation details
AI-extracted from DVHA Medical Director RFP 03410-245-27 (1).pdf, DVHA Medical Director RFP 03410-245-27.pdf. Confirm against the original documents before bidding.
The Department of Vermont Health Access is soliciting proposals from actively licensed physicians to provide medical oversight, prior authorization case reviews, and medical necessity determinations in a Medicaid Managed Care environment. Services are on an as-needed basis, not to exceed 10 hours per week per contractor, or up to 16 hours total across multiple physicians. Actively licensed physicians meeting Vermont Medicaid credentialing standards are eligible to bid.
- Issued by
- Department of Vermont Health Access
- ISSUE DATE
- July 10, 2026
- QUESTIONS DUE
- Ongoing
- STATE'S RESPONSE TO QUESTIONS
- Ongoing
- RFP RESPONSES DUE BY
- This RFP will remain open until filled
- SELECTION NOTIFICATIONS
- This RFP will remain open until filled
- PROPOSED START DATE OF CONTRACT
- This RFP will remain open until filled
- How to submit
- Electronic via email
- Submission details
- Submitted via email to the designated State Contact in a single email containing digitally searchable PDF attachments not exceeding 40 MB.
- Contract term
- Three years with an option to renew for up to two additional years
- Place of performance
- Vermont / Offsite
- Insurance and bonding
- Medical Malpractice and Professional Liability insurance coverage, and Certificate of Insurance per Attachment C, Section 8
- Funding
- Federal monies, Title 42, Part 400 of the Code of Federal Regulations
How proposals are evaluated
| Quality of Bidder's Experience | 40 points |
| TECHNICAL PROPOSAL & EXAMINATION APPROACH | 30 points |
| PROGRAM COST | 30 points |
Scope of work
- Review Prior Authorization requests for medical necessity based on clinical acumen, DVHA criteria, and national guidelines
- Support the Clinical Services Team in understanding clinical information submitted with requests
- Provide clinical support for review and adoption of clinical guidelines
- Review Non-Emergent Medical Transportation for medical necessity
- Assist Vermont Chronic Care Initiative nurse case managers with patient condition management questions
- Participate in monthly VCCI case reviews and prepare brief presentations on monthly topics
- Conduct Peer to Peer discussions with requesting providers regarding coverage determinations
- Participate in Appeals, Fair Hearings, and quality improvement activities as needed
Minimum qualifications
- Attainment of M.D. or D.O. degree
- Minimum of one-year primary care or general medicine internship
- Active license to practice medicine in Vermont in good standing
- Meets Vermont Medicaid credentialing standards
- Functional knowledge of Microsoft Office including Word, Excel, and PowerPoint
- Broadband internet connection
Documents to include with the bid
- Cover Letter
- Technical Response
- Price Schedule
- Signed Certificate of Compliance
- References (at least three)
- Sample reporting documentation
- Worker Classification Compliance Requirement Subcontractor Reporting Form
Verify important details
Document checkConfirm submission instructions and amendments with the issuing agency before responding.
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