Medicaid Physician Review and Consulting Services

Background

The Agency of Human Services (AHS) through the Department of Vermont Health Access (DVHA) is soliciting proposals for Medicaid Physician Review and Consulting Services. The goal is to contract with actively licensed Physicians to provide medical oversight, prior authorization case review, and medical necessity determinations in a Medicaid Managed Care environment. These services are federally mandated for all State Medicaid Managed Care Organizations as outlined in Title 42, Part 400 of the Code of Federal Regulations.

Work Details

The Contractor will provide consultative services not exceeding sixteen (16) hours per week, according to a mutually agreeable schedule. Responsibilities include: - Supporting prospective, concurrent, and retrospective review processes; - Preparing recommendations based on comparisons of requests for medical services to treatment guidelines; - Reviewing specific requests for medical services as assigned; - Collaborating with the State’s Chief Medical Officer; - Submitting written reports within five (5) business days; - Maintaining records of activities; - Ensuring an active medical license in Vermont throughout the contract term. The Contractor will also be required to maintain a Windows Virtual Desktop account for secure electronic communication.

Period of Performance

The contract will be for a period of three years starting January 1, 2027, with an option to renew for up to two additional years.

Place of Performance

Services will be performed primarily in Vermont, with provisions for in-person work at State offices if required.

Bidder Requirements

Bidders must maintain an active license to practice medicine in Vermont. They must also submit a certificate of insurance and a current IRS Form W-9 prior to commencement of work. Additionally, bidders must comply with worker classification compliance requirements if the bid exceeds $250,000.