The State of Oregon is seeking a vendor to provide second pass data mining services for its claims processing operations, with a primary focus on identifying high-risk and suspect claims. The required solution must deliver a comprehensive second pass data mining system that integrates seamlessly with the existing claims processing infrastructure. This integration should be achieved with minimal effort, time, and cost, and must not disrupt ongoing regulatory claims processing.

The service must support integration at multiple stages of the claims workflow, from submission through adjudication, and should enable rapid assessment of provider risk while targeting specific claims of interest. Vendors are expected to utilize advanced, statistically robust data mining technologies — including link analytics and geospatial analysis — to evaluate both historical transaction data and external data sources. This includes connecting to third-party systems such as investigation databases, lists of excluded individuals/entities, vital records, land records, and criminal history databases.

The objective is to identify improper payments within medical and potentially pharmacy claims, analyze suspect relationships and patterns, and detect abnormal utilization and billing behaviors. Detailed analysis and auditing capabilities are required, including reporting on claim details, sources of error, and reasons for overpayment.