Active SLED Opportunity · CALIFORNIA · CALOPTIMA HEALTH
AI Summary
CalOptima seeks a consultant for its Special Investigations Unit to conduct fraud, waste, and abuse investigations, provide improvement recommendations, and support related tasks. Proposals are due August 10, 2026, submitted electronically via Bidnet.
CalOptima is seeking proposals for a consultant to provide services to CalOptima’s Special Investigations Unit (SIU) and Fraud, Waste and Abuse Programs. The consultant will undertake various types of investigations to assist the SIU with its workload, will provide recommendations for improvement, and will undertake other tasks as requested by CalOptima. **Solicitation Type**: RFP - Request for Proposal (Formal) **Source ID**: PU.AG.USA.2797475.C21291376 **Piggyback Contract**: No **Question Acceptance Deadline**: 07/20/2026 04:00 PM EDT **Questions are submitted online**: Yes **Bid Submission Type**: Electronic Bid Submission **Additional Bidding Instructions**: All proposals must be submitted electronically using the Bidnet platform by the deadline date. Late submissions will not be accepted. Questions submitted by the question deadline via BidNet will be answered via the BidNet platform. Any questions received after the deadline will not be answered. All times indicated are Pacific Time. BidNet may change deadline times to match the user's location, depending on the user's preference. All deadlines are 1:00pm Pacific Time. It is the responsibility of the bidder to ensure deadlines are met. **Owner Organization**: CalOptima **Solicitation Number**: 27-004 **Reference Number**: 0000429930 **Pricing**: In attached document **Bid Documents List**: | Item Name | Description | Mandatory | Limited to 1 file | |---|---|---|---| | Bid Documents | Documents defining the proposal | Yes | No | **Questions and Answers**: | Question | Answer | |---|---| | Will vendor staff be provisioned access to CalOptima's case management, workflow, audit, and investigative systems, or is the consultant expected to perform the work within its own systems and submit results to CalOptima? | No, the vendor staff will not have access to CalOptima's systems. Rather, any CalOptima internal information the vendor needs will be supplied to the vendor for investigative considerations. | | Can CalOptima further clarify the expected volume and distribution of work across the various review, audit, investigation, appeals, and consulting activities identified in the Scope of Work? | The majority of the work will be in investigative support, such as coding and medical necessity reviews. The vendor may be asked to review provider appeals as a third-party consultant from the lens of potential FWA. | | Section 4.7.1 references 'Minimum Qualifications, using CalOptima forms if provided.' No Minimum Qualifications form was included in the solicitation documents. Please confirm whether proposers should provide a narrative attestation of compliance with the minimum qualifications identified in Section 1.6, or if CalOptima intends to provide a form. | No standard form is required to provide minimum qualifications. Please describe how your firm meets the minimum qualifications in your proposal. | | Section 3.5 states that certain forms and disclosures (e.g., W-9, litigation disclosures, audited financial statements, and insurance certificates) may be required from the successful proposer prior to contract execution. However, Section 4.7 appears to request some of these same items as part of the proposal submission. Could CalOptima please clarify whether these documents are required at the proposal stage, or only from the selected proposer following award? If proposal submission is required, please identify which specific documents must be included with the proposal. | Forms requested in section 4.6 are required at the time of proposal submission for proposal to be considered complete. Information listed in section 4.7 is applicable if requested in the Scope of Work. For example: the Scope of Work lists minimum qualifications. Please explain how your firm meets these. A W-9 form will be requested before an award can be made, but can be included with the proposal. | | The pricing proposals asks for estimated number of hours to perform each required task. For example, for Medical Reviews, is that number of hours to perform one review or should it reflect the number of hours to perform a particular volume of reviews? Can CalOptima provide estimated number of medical reviews, written reports, and mentoring/training volume/hours anticipated? | Within a one-year contract, we estimate approximately 40 FWA investigations which would involve written reports. The number of investigations depends on the audit scope (ranging from small to large). | | Under Scope of Work, Section 1.2. Consultant Services (Addendum No 1) could you provide any volume associated with the number of investigations, claim lines or reviews that CalOptima will need assistance with? Estimated monthly volume for investigations and medical review claim lines would be fine. | Within a one-year contract, we estimate approximately 40 FWA investigations which would involve written reports. The number of investigations depends on the audit scope (ranging from small to large). | | Will CalOptima staff be responsible for sample selection for each audit identified? | Yes, CalOptima staff will be responsible for sample selection for each audit identified. | | Will the consultant(s) receive access to the electronic health record (EHR) or will medical record documents be sent via secure methods? | Medical records will be obtained by CalOptima staff and sent to vendor via secure methods. | | What EHR is CalOptima utilizing? | Not applicable | | Scope of Work, 1.2. E: Could you provide an average percentage of medical reviews that are appealed / disputed? | The vendor may be asked to review provider appeals/disputes. This may be up to 20% of the workload. 80% of the workload will be on coding/clinical/investigative reviews. | | Section 1.4.A indicates that reports must be submitted for review no later than 30 days of request. Is this referencing the reports related to ongoing meetings with CalOptima? Or reports related to the coding review results? | 30 days for the coding or clinical reviews. The date may be extended if the audit scope happens to be unusually large. | | Can CalOptima confirm they will not accept modifications to the Business Associate Agreement? | No modifications to the Business Associate Agreement will be accepted. | | The procurement document states, "The consultant will undertake various types of investigations to assist the SIU with its workload". So to ensure we identify best qualified project staff, can CalOptima provide more details around the specific types of investigations expected to be assigned to the Contractor? | Each investigation will depend on the allegation type. The investigations will primarily be coding and clinical reviews. | | In Part A, RFP indicates that "Consultant will assist with full-scope investigative services..." Can you describe the breakdown of investigative responsibilities between CalOptima and Contractor? | CalOptima will conduct data analysis and determine the audit scope. CalOptima will request the medical records. The vendor will be responsible for the coding or clinical reviews of the medical records under investigation and providing a detailed report of the findings. | | Will the Contractor be responsible for completing investigations from start to finish, or will the contractor only be responsible for assigned portions of the investigation? | CalOptima will conduct data analysis and determine the audit scope. CalOptima will request the medical records. The vendor will be responsible for the coding or clinical reviews of the medical records under investigation and providing a detailed report of the findings. | | Part B lists criteria for medical records review to include CPT/HCPCS and/or clinical reviews to adhere to policy guidelines. Would CalOptima consider the utilization of clinicians (RN, LCSW, etc) to review against clinical guidelines and industry standards in lieu of non-clinical professionals with CFE/AHFI certifications? | If a coding review is needed, a certified coder or certified documentation specialist is required. If a clinical review is needed, a medical doctor, physician assistant, nurse practitioner of equivalent is required. On that note, if the investigation involves behavioral health services, the appropriate mental health practioner is required (e.g., BCBA, LMSW). Designated CFE/AHFI is preferred due to the vendor is supporting the FWA team. | | How many ongoing investigations would the Contractor be anticipated support on a monthly or annual basis? | Within a one-year contract, we estimate approximately 40 FWA investigations which would involve written reports. The number of investigations depends on the audit scope (ranging from small to large). | | Can CalOptima provide historical volumes of investigations, broken down by type(s) of services? | Within a one-year contract, we estimate approximately 40 FWA investigations which would involve written reports. The number of investigations depends on the audit scope (ranging from small to large). | | Can CalOptima provide historical data on the total number of investigations and appeals, or the % of findings appealed? | Within a one-year contract, we estimate approximately 40 FWA investigations which would involve written reports. The number of investigations depends on the audit scope (ranging from small to large). | | Please describe the appeal process for provider disputes, and the role envisioned for the Contractor. | Provide additional support (e.g., 2nd opinions) when a provider disputes FWA findings. | | How many training sessions would CalOptima expect to be provided by Contractor? | Minimal - this would be primarily virtual case discussions that may be considered as training. | | Does CalOptima have a preferred delivery method and/or cadence for training and mentoring sessions? | This would be primarily virtual case discussions that would be considered as training. | | Would CalOptima consider accepting Clinical Auditors (RN, LCSW, etc) with 5+ years of experience in lieu of, or in addition to, CFE / AHFI reviewers? | No, please review the minimum qualifications listed in the Scope of Work document. | | Is there any expectation as to the total number of anticipated project staff? | Project staff would need to encompass certified coders and clinicians, preferably with FWA experience. | | Given the uncertain volume of investigations and trainings, would CalOptima consider a unit-rate pricing model (for example, $100 per investigation, $150 per training), or a fixed fee based on multipliers established for all prospective bidders (for example, 100 reviews x $100 per rate = $1,000 fixed fee)? | Please use the included Attachment 2 - Price Proposal form. Additional pricing models can be included with a description of the model and reasoning in addition to the standard price proposal Attachment 2 included in the RFP document. | | To successfully deliver all aspects of this scope of work, we anticipate that clinical review staff will need to be supported by a project management team and other subject matter experts who can offer additional expertise on an as needed basis. In developing costs, should bidders delineate such hours and corresponding costs, or include them within an all inclusive hourly rate? | Please use the inclusive hourly rate on the Price Proposal form in Table 1. | **Addendums**: | Addendum | Date | Note | |---|---|---| | Addendum No. 1 | 07/08/2026 06:13 PM EDT | |
SLED stands for State, Local, and Education. These are solicitations issued by state governments, counties, cities, school districts, utilities, and higher education institutions — as opposed to federal agencies.
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