Medical Care Utilization Review Services

The State of Missouri’s Department of Commerce and Insurance is seeking a qualified contractor to provide Medical Care Utilization Review Services for the state’s external review program. The contractor will review consumer‑initiated appeals of health‑plan adverse determinations, produce written medical opinions within statutory timeframes, and support the agency’s quality‑assurance and reporting requirements. The contract is for one year, with the possibility of renewal, and requires the contractor to maintain accredited utilization‑review status, employ a Medical Director and at least two registered‑nurse reviewers, and comply with extensive conflict‑of‑interest, data‑security, and reporting obligations. • Scope: review ~70 external cases per year (historical average), each requiring ~6 hours of clinical review. • Personnel: Medical Director (physician), minimum two full‑time RN reviewers, plus additional specialty clinicians as needed. • Deliverables: written external‑review reports within 20 calendar days (72 hours for expedited cases), quarterly status meetings, annual statistical reporting in Excel. • Compliance: IRO certification, Missouri utilization‑review agent registration, conflict‑of‑interest policies, anti‑boycott certification, E‑Verify, and other state‑mandated business‑compliance exhibits. • Submission: electronic only via MissouriBUYS by 2 PM CT on 16 Sep 2026. • Evaluation: based on experience, certifications, methodology, pricing, and past performance.