Open Enrollment: HHS0008368

Agency: HHSC
Procurement Number: HHS0008368
Procurement Name: Independent Review Organization Services
Program Name: Medicaid and CHIP Services
Release Date:
Submission Deadline: August 31, 2023 — 05:00 pm CDT

Executive Summary

The Health and Human Services Commission (HHSC) seeks to contract with one or more Independent Review Organizations (IROs) to conduct external medical reviews (EMRs) for: 1) Texas Medicaid managed care organization (MCO) or dental maintenance organization (DMO) benefit denials or reductions that are appealed by Medicaid members or their authorized representatives and subsequently are requested for review by a contracted IRO; and 2) eligibility decisions made by HHSC for a Medicaid program in which eligibility is based on a Medicaid applicant or recipient's medical or functional need. Initially, a contracted IRO will be responsible for reviewing eligibility decisions related to the denial of medical necessity Medically Dependent Children Program (MDCP) and STAR+PLUS Home and Community Based Services (HCBS) program. Eventually, other 1915 (c) waivers administered by HHSC will be phased into the program.