Utilization Review (UR)

The State of Montana’s Department of Public Health and Human Services is seeking a qualified vendor to provide comprehensive Utilization Management and Review (UR) services for the Montana Healthcare Program (MHP). The contractor will perform level‑of‑care determinations, PASRR activities, functional assessments, prior authorizations, continued‑stay reviews, eligibility determinations, and special‑case reviews, while maintaining Qualified Intellectual Organization (QIO) status throughout the contract. The award will be a firm‑fixed‑price lump‑sum contract with a maximum term of ten years (including design‑development‑implementation and ongoing operations), payable Net 30. The effort requires compliance with federal Medicaid rules, state regulations, and extensive reporting and documentation requirements. • Perform full‑cycle utilization management for MHP beneficiaries, covering assessments, authorizations, and ongoing reviews. • Deliver a Business Rules Engine, data conversion, correspondence management, and robust data‑governance as defined in the detailed requirement matrix. • Must sustain QIO‑like status, meet HIPAA, NIST, FedRAMP, and WCAG 2.1 Level AA accessibility standards, and submit all required documentation through the eMACS portal.