South Carolina Sfaa Sfaa #5400029593

Medicaid Recovery Audit Contractor (RAC) Services with Advanced AI/ML and Security Compliance for SCDHHS

The South Carolina Department of Health and Human Services (SCDHHS) is seeking a qualified contractor to provide Medicaid Recovery Audit Contractor (RAC) services, focusing on identifying and recovering improper Medicaid payments. - Government Buyer: - South Carolina Department of Health and Human Services (SCDHHS) - Office of Cybersecurity (OCS) involved for security deliverables - Scope of Services: - Operate a Medicaid RAC program to audit fee-for-service and managed care claims - Identify and recover overpayments and underpayments - Use advanced Artificial Intelligence (AI), Machine Learning (ML), and data mining tools - Maintain a secure provider portal and data systems - Provide provider education, fraud referral, and coordination with Managed Care Organizations (MCOs) - Key personnel required: Program Manager, Medical Director, Lead Certified Coding Specialist, Audit Manager - Security and Privacy Requirements: - Deliverables include System Security and Privacy Plan (SSPP), Information Security Risk Assessment (ISRA), Privacy Impact Assessment (PIA), Disaster Recovery and Business Continuity Plan (DR/BC), System Design Document (SDD), and Audit/Assessment/Testing Results with Plan of Action & Milestones - All deliverables must be updated annually and comply with federal, state, and SCDHHS security standards - If AI/ML is used, must comply with NIST AI Risk Management Framework, ensure human review of eligibility/claims decisions, and prohibit use of SCDHHS PHI/PII for AI/ML training unless authorized - Compensation: - Contingency-based on recovered funds - Notable Requirements: - Annual updates to all security and privacy documentation - Periodic disaster recovery testing - Use of SCDHHS-approved templates for all deliverables - OEMs and Vendors: - No specific OEMs or vendors are named; opportunity is open to qualified offerors - Place of Performance: - Primary location: 1801 Main Street, Columbia, SC 29201 - Office of Cybersecurity (OCS) for security deliverables

Description

This solicitation is issued by the South Carolina Department of Health and Human Services to procure services for a Medicaid Recovery Audit Contractor (RAC). The contractor will be responsible for auditing Medicaid claims to identify and recover improper payments, including overpayments and underpayments. The contract includes implementation, coordination, education, and operational readiness activities, with a focus on compliance with federal and state regulations. Proposals are due by May 18, 2026, with a pre-proposal conference scheduled for April 17, 2026.

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