Payment Integrity Validation and Oversight Tool

The State of New Jersey is seeking a vendor to provide a robust payment integrity validation and oversight tool for community care healthcare claims. The primary objective is to proactively detect and prevent improper payments, which may result from inaccurate coding, unauthorized services, billing errors, or non-compliance with agency and CMS reimbursement policies, including instances of fraud, waste, and abuse.

The desired solution should incorporate advanced modules such as a rules engine for executing compliance rules at scale, complete with version control, rollback, a rules library, and audit logging capabilities. A pattern recognition engine leveraging AI and machine learning is required for anomaly detection, risk scoring, explainable AI outputs, and continuous improvement via feedback loops and AI-recommended rules. The system must also include a centralized workload module, allowing staff to efficiently review flagged claims, validate rule outcomes, manage approvals, and track case dispositions with detailed audit logs.

Additional features should include real-time dashboards, customizable reporting tools, export options, and compliance with security standards such as FedRAMP High baseline, HIPAA, and FISMA. Role-based access control and comprehensive audit trails are also required. Interested vendors should note that all questions regarding this solicitation must be submitted by January 23, 2026.