Opportunity Overview
Open now. The Texas Health and Human Services Commission (HHSC) is accepting applications from qualified Independent Review Organizations (IROs) to establish contracts supporting HHSC Medical and Utilization Review Appeals and Operations Management Provider Resolution and Administrative Appeals. The open enrollment was released February 1, 2025 and remains available through January 31, 2028 at 5:00 PM CST.
Scope and Compensation
This is a healthcare-services procurement rather than a fixed grant pool. Selected contractors conduct independent clinical and payment-related appeal reviews for Texas Medicaid and CHIP programs. The current Exhibit F fee schedule pays $325 per review for Admission Denial, Denied Days, DRG Revision, Outlier Days and Acute Care Surveillance reviews, and $150 per review for OIG Targeted Query retrospective payment reviews and Recovery Audit Contractor automated reviews.
The public solicitation does not state a guaranteed contract volume or total contract value. Applicants should therefore evaluate staffing and economics using the current fee schedule, Statement of Work, expected case mix and all controlling addenda rather than treating the opportunity as a guaranteed award amount.
Who Should Evaluate This Opportunity
This pathway is relevant to organizations that can satisfy the controlling Independent Review Organization qualifications and provide defensible medical-necessity, utilization, payment and administrative appeal determinations. Applicants should review the complete Open Enrollment package rather than assume that ordinary provider enrollment alone establishes eligibility.
Application Readiness
Prospective applicants should review the current Open Enrollment, Statement of Work, Solicitation Affirmations, Data Use Agreement, Fee Schedule and all addenda; confirm Independent Review Organization qualifications and qualified clinical-review capacity; document data-security and confidentiality controls; build workflows for timely, independent and well-supported review determinations; and submit the complete application before January 31, 2028 at 5:00 PM CST.
Atlas Analysis
Atlas Opportunity Score: 87/100. This is a credible long-horizon Texas Medicaid and CHIP contracting pathway for specialized clinical-review organizations. Its value is driven by the statewide program scope and multi-year open-enrollment window, while the absence of guaranteed review volume makes the ultimate contract value applicant-specific.
N9+ Direct Vendor Fit: 0/100. The verified scope is independent medical, utilization and payment appeal review. It does not establish a telehealth, connected-exam or clinical-device procurement path, so Atlas should not manufacture an N9+ use case.
Official source: Texas HHS — Open Enrollment HHS0015818.