Payment Integrity Validation and Oversight Tool

Location:

New Jersey, USA

Posted on:

Jan 10, 2026

Deadline:

Mar 8, 2026

Summary:

RFP for a tool to detect and prevent improper healthcare claims payments in New Jersey, featuring AI/ML, compliance, and reporting modules.

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(1) Vendor needs to provide payment integrity validation and oversight tool to proactively detect and prevent improper community care healthcare claims payments.– Improper payments may result from inaccurate coding, billing, unauthorized services, or non–compliance with agency or CMS reimbursement policies, including fraud, waste, and abuse.– The solution will enable systematic analysis of claims data, early detection of improper payments, and support cost containment strategies.• Rules Engine: Execute and agency compliance rules at scale, support configuration in sandbox, testing, pre–production, and production environments; rules library, version control, rollback, and audit logging.• Pattern Recognition Engine: Detect anomalies and suspicious billing behaviours using AI/ML, provide risk and confidence scoring and explainable AI outputs, enable continuous improvement through feedback loops, and AI–Recommended Rules.• Workload Module: Centralized interface for staff to review flagged claims, validate rule outcomes, manage approvals, and disposition cases with audit logging and performance tracking.• Dashboards & Reporting: Real–time dashboards, customizable reports, and export capabilities.• Security & Compliance: FedRAMP High baseline, HIPAA, FISMA compliance, role–based access control, and audit logging.(2) All questions must be submitted no later than January 23, 2026.

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Submit your next proposal, within 48 hours or less

Stay ahead with the latest advancement in proposal automation.

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Submit your next proposal, within 48 hours or less

Stay ahead with the latest advancement in proposal automation.