The State of Oregon is seeking proposals for a second pass claims editing system. The required software solution will enhance payment accuracy and integrity by ensuring claims are properly coded and processed. The system must be able to edit various claim types, identify prepay issues not flagged by the current system, and support multiple edit outcomes, such as denial, pending, and informational notices.

Further requirements include applying multiple procedure payment reductions, customizability for configuring edits and logic, and provider billing detection to monitor excess utilization at the provider level. The solution should support seamless data migration for members, providers, claim histories, and prior authorization data. Advanced functionalities for detecting fraud, waste, and abuse are essential, as is a clinical validation approach with quality assurance, audit processes, and credentials relevant to clinical/coding development. The platform must also support appeals and reconsideration procedures.