Starting easy — a quick program snapshot

• Tell me about the populations covered by your current Medicaid managed care program and any subgroups you track separately Options: Full Medicaid population, Children (CHIP overlap), Adults without children, Seniors and dual eligibles, Behavioral health high-need cohort, Long-term services and supports (LTSS) population, Other
• How many members does your program serve today, and which counties or regions are highest priority for access improvements
• When was the last time your team changed network adequacy rules or provider reimbursement models for Medicaid, and what prompted that change
• Which core outcome areas does your leadership prioritize this procurement, choose up to three Options: Reducing avoidable inpatient admissions, Improving behavioral health access, Lowering pharmacy spend, Better maternal and child health outcomes, Reducing ED utilization, Improving member experience, Other
• Who on your leadership team is accountable for each of those priority outcomes, list roles or offices

Where outcomes currently fail and why it matters

• If your current managed care approach stays unchanged for 24 months, which measurable outcome would you most likely miss and what would that cost the program
• Walk me through the last 12 months of trends for high-need members with serious mental illness or substance use disorder in your program Options: Admissions rising, Admissions stable, Admissions falling, Insufficient data to tell
• Describe the biggest operating frustration your program faces when coordinating care between physical health, behavioral health, and LTSS
• How often do data gaps or delays in claims and encounter feeds materially change your view of program performance Options: Weekly, Monthly, Quarterly, Rarely, We do not rely on those feeds
• Which single metric, if it improved by 10% in the next year, would make leadership declare the program a success

Who signs off and who pushes back

• Who on your team has veto authority over procurement awards and under what conditions would they block a contract
• Who on your team is responsible for provider network adequacy assessments and what evidence do they require to approve a network
• How many internal stakeholders routinely review vendor performance dashboards each month Options: None, 1-3, 4-7, 8-12, More than 12
• Which stakeholder group tends to be Most skeptical about new managed care models, and why (procurement, clinical leadership, finance, legal, members) Options: Procurement, Clinical leadership, Finance, Legal, Member advocates, Other
• If a compliance or quality trigger occurred under a new contract, who would be first to expect remedial action and what timeline do they consider reasonable Options: 30 days, 60 days, 90 days, Depends on issue

Risks that actually stop a procurement

• Which single operational or legal risk would cause you to pause award negotiations immediately Options: Insufficient provider network in rural areas, Unresolved data access or privacy concerns, Weak financial guarantees, Unclear reporting formats, Conflicts with existing contracts, Other
• Describe a recent procurement where an operational detail caused delay, what was the detail and how long did it delay award
• How do procurement timelines and fiscal year windows constrain the pace at which you can start a new contract Options: Fixed fiscal deadlines, Can be flexible within a quarter, Only at year-end, Depends on legislature
• To what extent does concern about vendor readiness for CMS reporting shape your short list Options: Critical factor, Important but manageable, Secondary factor, Not a factor
• If an integration or readiness gap were identified during negotiations, how quickly would you expect a remediation plan to be delivered Options: Within 2 weeks, Within 4 weeks, Within 8 weeks, Depends on scope

The other options you're weighing

• List the alternatives you are actively considering, including the incumbent, named vendors by role (vendor, broker, systems integrator), and any in-house options
• Which of the following describes an internal option someone has proposed to avoid bringing in an outside MCO Options: Expand state-run care management, Use a vendor for data only, Retain current incumbent with targeted fixes, Create a hybrid model, No internal option proposed
• What would have to be true about the incumbent or your internal option for you to keep that path instead of switching vendors
• Who on your evaluation panel favors staying with the incumbent or building internally, and what are their main reasons
• If a new vendor matched price but offered stronger rural network guarantees, how would that change your ranking of alternatives Options: Move to top of list, Move up one tier, No change, Need more evidence

Can you deliver on day one — integrations, data, and people

• Which integrations are nonnegotiable for go-live because they feed your core payment or quality systems Options: Claims processing, Eligibility directory, Encounter feeds, Pharmacy benefit manager (PBM) data, Clinical registry interfaces, Other
• How many owned APIs or data owners will the seller need to work with inside your agency to obtain the feeds needed for reporting Options: None, 1-2, 3-4, 5 or more, Unknown
• Describe the clearest data readiness gap you anticipate that would slow onboarding, for example missing member identifiers or delayed claims adjudication
• Who is the technical owner of your eligibility and enrollment system and how quickly can they grant integration access once a vendor is selected Options: Within 2 weeks, Within 4-6 weeks, 2-3 months, Longer than 3 months, Unknown
• Are there statutory, regulatory, or legislative approvals that must occur before certain integrations or program changes can proceed Options: Yes, major approvals required, Yes, minor notifications, No approvals required, Unknown

Success criteria that would make approval fast

• Assuming a six month pilot achieved its targets, what internal approvals or signoffs would be required to convert to a full contract Options: Executive health director approval, Finance committee approval, Procurement office signoff, Legislative notification, Other
• If the pilot demonstrated a 15% reduction in avoidable admissions among high-need members, what would stop you from awarding a contract immediately
• Which quantitative KPIs matter most for your award decision, pick up to four Options: Emergency department visits per 1,000 members, 30-day readmission rate, Total cost of care per member per month, Behavioral health access measure, Member grievance rate, Provider network sufficiency, Other
• How will you validate vendor-reported results during a pilot, which evidence or third party checks are required Options: State audit of claims, Independent evaluator, Third party data reconciliation, Internal validation only, Other
• What timeline from pilot close to contract award would be acceptable to your team Options: Within 2 weeks, Within 4 weeks, Within 8 weeks, Longer than 8 weeks

Procurement mechanics, finances, and guarantees

• If a vendor proposed performance guarantees tied to quality metrics, which guarantee structure would your procurement team prefer Options: Holdback with clawback, Bonus for overperformance, Milestone-based payments, Insurance-backed guarantees, No guarantees preferred
• How does your procurement team evaluate financial risk for capitated arrangements, for example required reserves or letters of credit
• Describe the one contract clause that historically causes the most negotiation friction with bidders
• Who in procurement manages rate modeling and how often do they expect revised models during negotiation Options: Once, Two rounds, Ongoing iterative, As needed
• If a vendor asked for a phased financial reconciliation schedule, would you accept it and under what conditions Options: Yes with oversight, Yes unconditionally, No, Need more details

Timing, dependencies, and a decisive next step

• If negotiations extended beyond your current fiscal window, which program deliverable or budget would be at risk Options: Provider rate increases, New program launches, Quality improvement funding, None, Other
• If we could remove the single biggest integration blocker within 30 days, how would that change your willingness to move to a pilot Options: Would run pilot immediately, Would move timeline up one quarter, No change, Need more evidence
• Which stakeholder needs a short demonstration or evidence package before they will support a pilot decision Options: Clinical leadership, Finance, Procurement, Legal, Member advocates, Other
• How soon can your team assemble a cross-functional pilot approval packet if a vendor meets baseline readiness Options: Within 2 weeks, Within 4 weeks, 1-2 months, Longer than 2 months
• What would constitute a reasonable first milestone for a pilot that, if met, would accelerate contract award Options: Data feed validated, Provider onboarding complete in pilots sites, Target KPI improvement met, Member outreach metrics met, Other

Final alignment — how we proceed together

• Walk me through the final internal step that must happen for this procurement to move from award to signed contract
• Which documents or deliverables would you need from the seller before you present an award package to leadership Options: Detailed implementation plan, Data sharing agreement, Sample reports and schemas, Provider network directory with contracts, Financial guarantee documents, Other
• Who should the seller engage next inside your organization to keep momentum, list roles and best contact path
• Realistically, when would you expect to make a final award decision if a vendor can meet the readiness checklist we've discussed Options: Immediately after pilot, Within 30 days, Within 60 days, Longer than 60 days
• Finally, what single remaining concern would cause you to delay awarding a contract even if all other pieces look good

• Solution Experience Session

• Confirm the current state and its cost
• You confirm that the demonstrated care pathway eliminates the transition and coordination gaps you described in Discovery.
• Seller to run a member-level cohort simulation on the buyer's top high-need cohort and deliver findings including projected reductions in inpatient days and required care manager FTEs.
• You confirm that the proposed network remediation approach addresses the rural and behavioral health shortfalls that drive avoidable cost.
• Show a live care pathway for a representative high-need cohort
• Seller to deliver an initial network remediation plan with specific provider types, geographic priority, and target onboarding timelines.
• Buyer to provide the top three high-need cohorts and the most recent 12 months of utilization data for those cohorts.
• You confirm that the reporting workflow produces the metrics and audit trail required for your procurement and regulatory needs.
• Demonstrate network implications and remediation plan
• Demonstrate reporting and compliance workflow
• You agree on the remaining evidence and timeline required for procurement evaluation.
• Buyer to confirm the state's procurement evaluation criteria and required reporting cadence for inclusion in the proof artifacts.
• Validate alignment with your needs
• Agree next evidence and decision steps

• Solution Experience Session
• Solution Experience Deck
• Solution Brief — Managed Care Outcomes for High-Need Populations

• meeting
• slides
• document

• Provider Network Contracting and Credentialing
• Rural and Underserved Provider Recruitment Programs
• High-Risk/High-Cost Case Management
• Serious Mental Illness Intensive Care Management
• Substance Use Disorder Care Coordination
• Pharmacy Benefits Management and Formulary Administration
• Long-Term Services and Supports Coordination
• Care Transitions and Hospital Discharge Management
• 24/7 Member Services Call Center Operations
• Member Grievance and Appeals Processing
• Population Health Analytics and Monthly Dashboards
• Quality Measure Reporting to State and CMS
• Community Health Worker Deployment in High-Need Areas
• Social Determinants of Health Screening and Referral Navigation

Provider Network Contracting and Credentialing

• How many contracted providers do you currently have by type (primary care, specialist, behavioral health, substance use disorder, long-term services and supports) within the contract geography? Options: Less than 500, 500-2,000, 2,001-10,000, More than 10,000, Prefer to provide exact counts
• Which network adequacy standard in the state contract must the roster meet (time/distance standard, appointment wait-time standard, provider-to-member ratio, other)? Options: State time/distance standard, Appointment wait-time standard, Provider-to-member ratio, Other (explain)
• What credentialing standard must be applied for provider enrollment and primary source verification (for example NCQA, state Medicaid credentialing manual, or specific PSV checklist)? Options: NCQA standard, State Medicaid credentialing manual, Medicare credentialing standard, Other (describe)
• When must a fully credentialed and contracted provider roster be delivered relative to the contract start date (for example 60 days before, 30 days before, by go-live)? Options: 60 days before go-live, 30 days before go-live, By go-live date, Phased delivery schedule
• What evidence will validate that provider credentialing and contracting meet state requirements (for example executed contracts, NPI roster with taxonomy and practice locations, primary source verification reports)? Options: Executed signed contracts and provider agreements, Primary source verification (PSV) reports and credentialing logs, NPI roster with taxonomy and practice addresses and hours, Other accepted evidence
• Who will own outreach to fill identified provider gaps (name or role) and what is their preferred contact method?

Rural and Underserved Provider Recruitment Programs

• Provide the list of counties or ZIP codes that the contract designates as rural or underserved for targeted recruitment.
• Identify the provider types prioritized for recruitment in those areas (primary care, OB/GYN, behavioral health, substance use treatment, durable medical equipment, home health). Options: Primary care, OB/GYN, Behavioral health, Substance use treatment, Home health / LTSS, Durable medical equipment, Other
• Specify any contract-required incentives or rate enhancements for rural provider recruitment (for example sign-on bonuses, enhanced capitation tiers, telehealth subsidies). Options: Sign-on bonuses, Higher reimbursement rates, Telehealth equipment/support, Loan repayment support, No incentives required, Other (describe)
• Indicate the target timeline to recruit and credential new providers in each designated county or ZIP code. Options: 30 days, 60 days, 90 days, Phased over 6 months
• List the documentation you expect as proof of recruitment and onboarding for an individual provider (signed contract, site visit report, credentialing packet, active NPI and taxonomy).
• How will improvement in provider coverage be measured for underserved areas (for example provider-to-member ratio by ZIP, appointment availability logs, claims volume growth)? Options: Provider-to-member ratio by ZIP, Appointment availability audits, Claims/provider visit volume by ZIP, Other

High-Risk/High-Cost Case Management

• List the risk stratification algorithm and enrollment thresholds you require for the high-risk cohort (for example top 5% cost, clinical risk score >X, multiple ED visits in 90 days).
• Who will be the primary point of contact on your side for case management program design and what is their role or title?
• Specify enrollment targets and outreach cadence for identified high-risk members (for example percent enrolled, contact within 7 days, number of outreach attempts). Options: Enroll 50% of identified members, Enroll 75% of identified members, Contact within 48 hours, Contact within 7 days, Custom cadence (describe)
• Provide the required care team composition for intensive cases (for example registered nurse care manager, licensed social worker, behavioral health clinician) and any required supervision ratios. Options: RN care manager + SW, RN + BH specialist, Multi-disciplinary team including pharmacist, Other (describe)
• Estimate the acceptable maximum caseload per care manager for the intensive program (for example 1:35, 1:50, 1:100). Options: 1:25-35, 1:36-50, 1:51-75, 1:76-100, Custom
• Which real-time or batched data sources must feed the case management workflow (for example real-time ED/ADT alerts, encounter/claims data, pharmacy fills, health information exchange feeds)? Options: Real-time ADT/ED alerts, Daily claims/encounter batch, Pharmacy refill feeds, HIE lab and clinical results, Other

Serious Mental Illness Intensive Care Management

• Specify the diagnostic codes, utilization patterns, or clinical criteria to identify Serious Mental Illness members for intensive management (for example ICD-10 code list, two or more psychiatric hospitalizations in 12 months).
• Describe which evidence-based program models you require for SMI management (for example Assertive Community Treatment, intensive case management) and any fidelity measures to be applied. Options: Assertive Community Treatment, Intensive Case Management, Critical Time Intervention, Other (describe)
• Who will be responsible for psychiatric medication management coordination and what is the expected workflow for prior authorizations for psychotropics?
• Indicate the target crisis response SLA for SMI members (for example mobile crisis dispatched within 2 hours, tele-psychiatry assessment within 24 hours). Options: Mobile crisis within 2 hours, Assessment within 24 hours, Assessment within 72 hours, Custom SLA (describe)
• Provide the training and certification standards required for SMI care managers (for example crisis intervention training, licensed clinical supervision, state CHW certification).
• Are community-based behavioral health providers required to be in-network for SMI services and which provider types should receive contracting priority (for example community mental health centers, community psychiatric providers)? Options: Yes - priority CMHCs, Yes - priority community psychiatry, No - backend referral allowed, Other (explain)

Substance Use Disorder Care Coordination

• Which levels of SUD care must be covered under the scope (for example outpatient medication-assisted treatment, intensive outpatient programs, residential treatment, withdrawal management)? Options: Outpatient MAT, Intensive outpatient, Residential treatment, Withdrawal management, Other
• Specify required MAT protocols and preferred agents, including prior authorization rules that must be implemented for buprenorphine, methadone, and naltrexone.
• Who will coordinate data sharing with state opioid treatment programs (OTPs) and what data elements are required (enrollment, dosing logs, urine drug screen results)?
• Indicate the expected referral turnaround time from identification to MAT initiation for high-priority cases. Options: Within 24 hours, Within 48 hours, Within 7 days, Custom timeline
• List the documentation required to confirm SUD program enrollment and ongoing engagement (consent, individualized treatment plan, urine drug screen records, attendance logs).
• Identify the metrics you will use to measure reduction in high-cost utilization related to SUD (for example ED visits related to overdose, overdose claims, MAT adherence rates). Options: ED visits for overdose, Overdose-related claims, MAT initiation and retention, Reduction in inpatient stays, Other

Pharmacy Benefits Management and Formulary Administration

• Which pharmacy benefit design must be supported (closed formulary, open formulary, preferred drug list) and do you have a current Preferred Drug List (PDL) to provide? Options: Closed formulary, Open formulary, Preferred drug list (PDL), I will provide current PDL
• Specify the prior authorization rules and step therapy protocols that must be implemented and where those policy documents are stored.
• Provide the expected turnaround service-level agreement for prior authorization decisions and pharmacy appeals. Options: 24 hours, 48 hours, 72 hours, Custom SLA
• List the claims adjudication feeds and NCPDP transaction versions required for integration with your pharmacy benefit system. Options: NCPDP SCRIPT, NCPDP Batch 5.1, Real-time eligibility (270/271 equivalent), Other
• Define the acceptance criteria that will confirm formulary and pharmacy benefits administration readiness prior to go-live (for example published PDL, PA criteria loaded, EDI test cases passed). Options: Published PDL and PA criteria, Successful EDI testing for claims and refills, Training completed for pharmacy operations, Other (specify)
• Who is the pharmacy operations contact for PBM reconciliation, rebate reporting, and formulary change management?

Long-Term Services and Supports Coordination

• List the specific LTSS programs in scope (for example home and community-based services, institutional care, personal care services, skilled nursing) and any population subgroups. Options: HCBS waiver services, Institutional nursing facility, Personal care assistance, Skilled nursing services, Other
• Specify whether 1915(c) waiver administration, level-of-care assessments, or PASRR workflows must be included in the scope. Options: 1915(c) waiver administration, Level-of-care assessments, PASRR workflows, None of the above
• Provide required timelines for LTSS service plan development and reassessment (for example number of days from authorization to service start and reassessment cadence). Options: Service plan within 7 days, Service plan within 14 days, Reassessment every 90 days, Custom timeline
• Identify documentation needed to authorize LTSS services (for example functional assessment, physician order, service plan) and the preferred file formats.
• Estimate the expected number of LTSS members and average monthly authorization volume to size care management resources. Options: Less than 500, 500-2,000, 2,001-5,000, More than 5,000
• Who will manage the interface with county long-term care caseworkers and which exchange method is required (secure file transfer, API, web portal)? Options: Secure file transfer, REST API, SFTP, Web portal, Other

Care Transitions and Hospital Discharge Management

• Describe the discharge notification feed requirements you need (real-time ADT, daily batch, HL7 v2, or other) and the receiving endpoint details. Options: Real-time ADT HL7 v2, Daily batch CSV/XML, API-based notifications, Other (describe)
• Identify the target post-discharge follow-up window for high-risk members and which role is responsible for the follow-up (for example RN care manager contact within 48 hours). Options: Contact within 24 hours, Contact within 48 hours, Contact within 7 days, Other
• List the transition-of-care documents required for exchange on discharge (discharge summary, medication reconciliation, after-visit summary). Options: Discharge summary, Medication reconciliation, After-visit summary, Follow-up appointment details, Other
• Specify the alerting thresholds for ED and inpatient utilizers that should trigger a care transitions workflow (for example 3+ ED visits in 90 days, inpatient within 30 days).
• Define acceptance criteria for successful discharge coordination (for example percent of discharges with documented follow-up within SLA, percent medication reconciliations completed). Options: >= 80% follow-up within SLA, >= 90% medication reconciliation completed, Other (specify)
• Who will serve as the hospital liaison and what is the escalation contact if a discharge is delayed?

24/7 Member Services Call Center Operations

• State required call center service levels for Medicaid member lines (for example speed to answer in seconds, abandon rate percentage, average handle time target).
• List the languages, TTY/TTD and video interpretation requirements specified in the contract for member services.
• Identify expected peak hourly call volumes and the number of concurrent agents you estimate will be required. Options: Less than 50 peak calls, 50-200 peak calls, 201-500 peak calls, More than 500 peak calls
• Specify integration points required for the contact center (IVR, CRM case creation, real-time eligibility checks, EHR lookup). Options: IVR integration, CRM case creation, Real-time eligibility API, EHR clinical lookup, Other
• When must enhanced after-hours nursing triage be available and under which protocol (for example 24/7 RN triage for high-risk members)? Options: 24/7 RN triage, Business hours RN only, 24/7 for specified populations, Other
• Name the KPIs you will use to accept call center readiness at go-live (for example answer rate, average speed of answer, quality assurance scores). Options: Answer rate, Average speed of answer, Average handle time, QA scores, Other

Member Grievance and Appeals Processing

• List the grievance and appeal timelines required by the state contract (for example acknowledgement, expedited review days, standard resolution days).
• Specify the tracking fields that must be captured on grievance and appeal records (for example member ID, issue category, resolution code, appeal level). Options: Member ID, Issue category, Resolution code, Appeal level, Other
• Identify the reporting cadence and file format required by the state for grievance and appeal summaries (for example monthly CSV, quarterly dashboard, per-incident reporting). Options: Monthly CSV, Quarterly dashboard, Per-incident reporting, Other
• Which internal roles must be represented on appeal review panels and what documentation must they complete for each decision?
• Specify measurable controls you expect to monitor appeal turnaround (for example percent within SLA, average days to resolution) and acceptable thresholds. Options: % within SLA, Average days to resolution, Backlog age distribution, Other
• Who will be the appeal coordinator and what is the escalation path for denied expedited appeals?

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Rate Schedule & Payment Terms
• Performance Guarantees & Withhold Schedule
• Reporting & Quality Metrics Schedule
• Data Use, Security & Business Associate Addendum (BAA)
• Procurement Deliverables & Readiness Conditions
• Provider Network Adequacy Exhibit
• Regulatory Compliance Addendum (Medicaid/CMS)
• Transition, Termination & Transition Services Agreement

• Go-live Health Check (Weeks 1-4)
• First Measurement Review (Weeks 4-10)
• Acceptance Gate Review (Day 90)
• Monthly Operational Compliance Review (Months 3-6)
• Quarterly Performance and Compliance Review

• Open targeted investigations for any unexplained spikes in grievance rate with a 10-business-day diagnostic timeline.
• Agree remediation items and a timeline for any conditional or failed criteria, with named owners.
• Record the formal acceptance decision and upload the acceptance evidence package to the shared workspace.
• Open remediation tickets for any failed or conditional criteria with deadlines tied to acceptance remediation timelines.
• Schedule the next operational compliance review to validate remediation progress against agreed dates.
• Monthly metric snapshot
• Confirm remediation tickets are closing on schedule and no unresolved items block regulatory compliance.
• Identify any new systemic causes for grievances or appeals delays and assign corrective tasks.
• Agree the status of enhancement requests that have compliance implications and set next steps.
• Update and circulate the issue tracker with current statuses and target close dates.
• Re-confirm success criteria and owners
• Document decisions on enhancement requests that affect reporting or compliance and schedule follow-up where required.
• Quarterly trend presentation
• Confirm whether quarterly trends for ED utilization and 7-day follow-up meet the contract targets recorded in Program Scope & Requirements.
• Ensure all regulatory reports are current and any corrective actions are underway with owners and dates.
• Prioritize enhancement requests that materially affect outcomes or compliance and allocate delivery windows for the quarter.
• Publish the quarterly performance packet with trend charts and regulatory report receipts to the shared workspace.
• Create prioritized delivery commitments for the top enhancement requests that affect compliance or targeted outcomes.
• Schedule the next monthly operational check-ins needed to validate any outstanding remediation items.
• All critical integrations and data feeds confirmed operational or assigned a remediation plan with dates.
• Baseline adoption signals documented with owners for follow-up at the first measurement meeting.
• All high-severity blockers have an open ticket and a target resolution date.
• Publish a go-live health summary capturing integration status, adoption baselines, and open blockers for the shared channel.
• Create remediation tickets for each high-severity blocker with target resolution dates.
• Share raw adoption logs and call-center volume exports ahead of the first measurement meeting.
• Present first-cycle data
• Determine whether early outcome metrics are trending toward the targets recorded in Program Scope & Requirements or require remediation.
• Document root-cause analysis for any metric gaps and assign corrective actions with dates.
• Confirm the data package and cut-off dates required for the acceptance gate review.
• Publish the first measurement report with raw data extracts and variance analysis to the shared channel.
• Open corrective action items for each out-of-tolerance metric with target remediation dates ahead of the acceptance gate.
• Deliver the curated data package for acceptance gate review by the agreed cut-off date.
• Restate acceptance criteria and numeric targets
• Produce a documented pass/conditional/fail result for each acceptance criterion recorded in Program Scope & Requirements.
• Capture the buyer's formal acceptance decision and the record of the buyer's designated signatory in the platform.
• Present outcome evidence for each criterion
• Compliance and reporting audit
• Deployment and integration validation
• Issue tracker burn-down
• Diagnose variances
• Grievance and appeals trend analysis
• Early adoption and operational signals
• Document pass, conditional pass, or fail per criterion
• Agree corrective actions and owners
• Grievances and appeals detailed review
• Enhancement request review
• Open issues and blockers triage
• Buyer acceptance decision and signatory capture
• Confirm data quality and reporting cadence
• Enhancement backlog and prioritization
• Immediate remediation actions
• Agree remediation plan for any failed or conditional items
• Next quarter commitments