The Department of Vermont Health Access, Clinical Operations Unit and the Clinical Integrity Unit, is seeking to establish service agreement(s) with one (or more) companies that can provide legally defensible and nationally recognized accepted evidence-based medical criteria for clinical reviews and utilization management activities. DVHA is required to have mechanisms in effect to examine health services and make decisions regarding coverage, unit limitations, place of service, length of stay, over and underutilization, and medical necessity of services in Vermont’s Medicaid programs. Vermont Medicaid has approximately 190,000 covered lives in the program. The daily responsibilities of coverage decisions are carried out by a team of licensed healthcare professionals who review, monitor, and coordinate the healthcare services provided to Medicaid members. DVHA staff use standardized clinical decision support tools and clinical criteria for making Utilization Review (UR) decisions that are objective and based on sound medical evidence

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