Colorado Department of Health Care Policy and Financing

The buyer is soliciting proposals for utilization management services for Colorado Medicaid. The contractor will perform reviews for hospital inpatient, outpatient, long-term care, and physician administered drugs. Key requirements include implementing a provider portal, conducting medical necessity reviews, providing analytics, and collaborating to improve health outcomes and reduce costs. The initial contract term is anticipated to be 5 years beginning July 2026.

• 3/14/2025 - Inquiry Deadline
• 4/8/2025 - Intent to Bid Notification
• 4/11/2025 - Proposal Due Date
• 6/1/2025 - Estimated Notice of Intent to Award

• Accreditation by NCQA or URAC
• Designation as a QIO or QIO-like entity
• Experience with federal and state Medicaid UM rules and regulations
• Experience utilizing nationally recognized Evidence-based criteria
• Experience with medical necessity reviews

• Perform utilization management services for hospital inpatient, outpatient, and long-term care reviews
• Conduct Physician Administered Drug (PAD) reviews
• Implement and manage a provider portal and call center
• Provide enhanced analytics and reporting on utilization patterns
• Develop evidence-based criteria for medical necessity reviews
• Conduct peer-to-peer consultations and reconsiderations
• Automate UM processes to reduce administrative burden
• Collaborate with Department to improve health outcomes and decrease costs
• Provide clinical expertise for specialized reviews
• Conduct annual review of HCPCS codes for benefit coverage recommendations