|Type of Government:||State & Local|
|Posted Date:||Mar 16, 2021|
|Due Date:||Apr 7, 2021|
|Bid Source:||Please Login to View Page|
|Contact information:||Please Login to View Page|
|Bid Documents:||Please Login to View Page|
Request for Proposal #CCHR2021-1 - Medical Benefits, Medical Management Administrative Services and Group Insured Medicare Advantage Programs
Download the RFP Document belowAddendum No. 1 - March 12, 2021
Please be advised that the above referenced RFP has been granted an extension for one week.
|Target Date||Event||Party Responsible|
|3/22/2021||Bidders deadline to present questions. Firm.||Vendors|
3:00 PM EST
|Full and complete proposal submitted by vendors to Premier. Firm.||Vendors|
|April/May 2021||Vendor proposal analysis presented to the Client.||Premier Consulting|
|May/June 2021||Finalist Presentations (finalists selected by the Client)||
Premier Consulting /
Vendor / The Client
|May/June 2021||Announcement of Selected Vendor.||The Client|
|10/01/2021||Proposed Implementation.||Premier Consulting / Vendor / The Client|
|01/01/2022||New vendor(s) effective.||Premier Consulting / The Client|
Medical Benefits, Medical Management Administrative Services and
Group Insured Medicare Advantage Programs
Request for Proposal #CCHR2021-1
Proposed Effective Date: January 1st, 2022
Premier Consulting Associates
1416 Sweet Home Road, Suites 5-6
Amherst, NY 14228
This Request for Proposal (RFP) and all information contained herein, any attachments or exhibits hereto, and all communications in whatever media form, in support of this document are proprietary to Cattaraugus County (“the Client”). Your firm acknowledges the proprietary nature of the aforementioned described information. Your use of such information for purposes other than a vendor relationship or the disclosure of such proprietary information to third parties (other than for the purpose of advancing the intent of the services contemplated by this document) will cause irreparable injury to Cattaraugus County. A breach of this covenant pertaining to the proprietary information will entitle Cattaraugus County to an automatic injunctive relief in addition to any and all other remedies available at law.
Table of Contents:
I. Introduction……………………………………………………………………….……………………….. 4
II. Background…………………………………………………………………………………….………….. 7
III. Overview and Summary of Current Plans…………………………………………….…..… 13
IV. Specifications……………………………………………………………………………..………………. 15
V. Information Sheets………………………………………………………………….…………………..17
VI. Medical Benefits Administration Agreements and Questionnaire…………………19
VII. Medical Management Administration Agreements and Questionnaire…………32
VIII. Group Insured Medicare Advantage Agreements and Questionnaire……………37
EXHIBIT A – MEDICAL PERFORMANCE GUARANTEES
EXHIBIT B - MEDICAL BENEFIT SUMMARIES
EXHIBIT C - MEDICAL CENSUS INFORMATION
EXHIBIT D - MEDICAL DATA & ELIGIBILITY INTEGRATION FIELD SPECIFICATIONS
EXHIBIT E – MEDICAL ADMINSITRATIVE QUOTE
EXHIBIT F – MEDICAL PROVIDER DISRUPTION
EXHIBIT G – MEDICAL PRICING ATTESTATION
EXHIBIT H – MEDICARE ADVANTAGE ADMINISTRATIVE QUOTE
EXHIBIT I – POST-65 RETIREE ELIGIBILITY, MEDICAL AND PRESCRIPTION DRUG CLAIMS YEAR TO DATE
EXHIBIT J – PRESCRIPTION DRUG BENEFIT COPAY SUMMARY
EXHIBIT K – POST-65 RETIREES PRESCRIPTION DRUG DATA FILE
NOTE: There are three proposals within this request – Medical Administration, Medical Management and a Group Insured Medicare Advantage Program. Vendors may respond to any or all of these proposals.
- Completion of Exhibit A as well as Exhibits D-G in this request are mandatory for consideration of your Medical Administration proposal.
- No exhibits are required for your response to the Medical Management Administration proposal (however, you must submit your own pricing proposal with this).
- Exhibit H in this request is mandatory for consideration of your Group Medicare Advantage Program proposal.
Failure to complete these listed Exhibits may result in the elimination of your proposal.
I. Introduction: Request for Proposal (RFP)
You are invited to submit your firm's proposal to provide medical benefits administration services and/or medical management administration (as detailed in this RFP) for Cattaraugus County.
Premier Consulting Associates (“the Consultant”) is requesting a self-funded proposal for the administration of medical benefits and medical management (utilization management and cost management as well as any other offerings) to Cattaraugus County (“the Client”). The response to this RFP will determine the vendor or combination of vendors best suited to assist Cattaraugus County (“the Client”).
Vendors may respond to any or all of the three proposals within this RFP.
If replying to any of the three proposals, you are to follow the RFP instructions and specifications as described (Pages 5-9 and 13-16). You will submit the Confidentiality Agreement (Page 2), respond to all bid specifications (Page 9-11), review the Consultant Rights and Completeness of a proposal submission (Pages 11-12) and respond to all applicable background information (Pages 17-18). For submission of the Medical Administration proposal, you must include all answers to the Medical Administration Questionnaire (Pages 19-31) as well as submit Exhibit A and Exhibits D-G. For submission of the Medical Management proposal, you must include all answers to the Medical Management Questionnaire (Pages 32-36). There will be no required Exhibits to submit for the Medical Management piece, but you are required to submit client-specific pricing details in your own format. For submission of the Group Insured Medicare Advantage proposal, you must include all answers to the Medicare Advantage Questionnaire (Pages 37-48) as well as submit Exhibit H.
The proposed effective date for this account is January 1st, 2022.
Submission of Proposals:
Please provide one (1) electronic copy (via email) of your proposal response and completed Exhibits to:
Premier Consulting Associates
Attention: Renee Golding
Asst. Marketing Manager
1416 Sweet Home Road, Suites 5&6
Amherst, NY 14228
The deadline for submitting proposals and all proposal attachments is 3:00 PM EST on Wednesday, March 31st, 2021.
If you have any questions, please contact Renee Golding at (716) 688-5600, ext. 253 or email@example.com.
If you will not be responding to this request, please notify Renee Golding at (716) 688-5600, ext. 253 or firstname.lastname@example.org.
Deliverable dates and proposed effective dates are as follows:
Bidders deadline to present questions. Firm.
3/31/2021 by 3:00 PM EST
Full and complete proposal submitted by vendors to Premier. Firm.
Vendor proposal analysis presented to the Client.
Finalist Presentations (finalists selected by the Client).
Premier Consulting / Vendor / The Client
Announcement of Selected Vendor.
Premier Consulting / Vendor / The Client
New vendor(s) effective.
Premier Consulting / Vendor / The Client
Medical Administration – Independent Health Association (IHA)
Medical Management Administration – Corporate Care Management (CCM)
Over Age 65 Retiree Medical and Prescription Drug Coverage – currently included in the self-funded health plan with IHA for medical administration and ProAct as the Pharmacy Benefit Manager; no current Group Insured Medicare Advantage plans in place
Objectives and Strategy
For medical benefits administration, the selected vendor must demonstrate a comprehensive provider network. By submitting a response to this proposal, it will be your firm’s responsibility to provide timely data, claim and eligibility file feeds to a third-party data warehousing vendor, and reports, both standard and ad-hoc, upon request. Your firm must be able to interface with a third-party enrollment vendor. Additionally, plan management/medical management components such as wellness, disease management, wrap around network repricing, claim negotiation, subrogation and large case management may be carved out of your firm’s administration.
For purposes of disease management, case management, stop loss and cost management, your firm will need to demonstrate its ability to integrate medical and pharmacy claims regardless of whether you are selected to administer one or all of these programs.
Cattaraugus County currently provides medical and prescription drug coverage to both under and over age 65 retirees. According to the terms of the collective bargaining agreements all retirees, regardless of age have the same medical and prescription drug benefit plan as the active employees. See Exhibit B, Exhibit J and Exhibit I for the medical and prescription drug benefits currently in place. Assume all Medicare eligible retirees are enrolled in Medicare Parts A and B.
The Client is seeking fully insured Group Medicare Advantage Plans that provides the same or greater benefits than what is currently being offered through the self-funded medical and prescription drug plans. The plan must provide access to providers both locally and nationally. The plan is looking for a two (2) year pricing commitment.
Please provide insured Group Medicare Advantage quotes for Medical only and a combined Medical/Prescription Drug plan. All plans must provide the same or greater benefits than what is currently in place, with a National PPO provider network.
The Client’s goal is in developing a long-term strategy that incorporates plan management opportunities with access to the most appropriate and cost-effective provider networks.
Primary requirements to meet this goal:
• Provide a strategy incorporating network reimbursement/managed care capabilities into new or existing programs.
• If the client retains third-party vendors for any line of business (such as pharmacy, medical management, etc.), the chosen vendor must be able to integrate and share data with these third-party vendors.
• Deliver accurate, responsive and timely claims payment.
• Provide effective and accurate member services.
• Provide timely, standard reporting and data file feeds to Premier and/or subcontracted vendors to assist the client in managing its plan.
The Client is looking to select and implement a claims administrator with plan management capabilities for self-insured medical programs. It is not the Client’s intent to implement more restrictive plan design features within their medical plans but to enhance the management of these programs through access to strong, quality-based networks. Therefore, this RFP will allow the Client to:
• Select an administrator with a well-developed provider network to ensure employee access to high quality care through network physicians, hospitals and providers.
• Maintain effective pre-admission certification, concurrent review and case management programs for all employees regardless of in or out-of-network access.
• Maintain freedom of choice for the employees to those providers best able to offer both the quality care and utilization controls necessary to meet benefits cost objectives.
• Maintain effective utilization management in all areas.
The vendor selected to provide the benefits specified will be required to provide competitive pricing. Key criteria in the vendor selection process are (some of these criteria applies to the medical benefits administration piece only):
1. Ability and willingness to deliver a pure pass-through arrangement with full and complete transparency where your revenue is exclusively in the form of an explicit administrative fee for both medical claims payment and administration. Where outside vendors are subcontracted for any services, please provide the fee based on hourly, percentage of savings or case rate. Please indicate administrator cost add-ons and explain how these additional costs are critical to plan administration.
2. Competitive and guaranteed financial terms including network access fees, discounts, pass-through revenue, etc.
3. Your delivery of the Client’s binding contract that supports your proposal with no contradictions or omissions.
4. Your ability to integrate prescription drug data with medical claims data and/or other third-party data feeds to set the Client up for success using data-driven medical management, predictive modeling, plan design decision making, etc. This will include your ability to send claims and eligibility files to the Consultant’s data warehouse vendor on a weekly basis (if Client utilizes the Consultant’s data warehouse).
5. If the client retains third-party vendors for any line of business (such as pharmacy, medical management, etc.), the chosen vendor must be able to integrate and share data with these third-party vendors. Any applicable fees should be noted in the Medical Administrative Quote (Exhibit E).
6. Ability to offer a large and comprehensive, seamless, national network of providers with competitive discounts.
7. Ability to demonstrate cost savings through claim management, network discounts, management of fees, efficacy of cost containment programs, etc.
8. Willingness to work with the Client’s plan and eligibility auditors based on criteria established by the Client.
9. A complete response to this RFP in the requested format and with all requested attachments/exhibits.
10. Demonstrated performance of high-quality claim administration and customer service.
11. Willingness and ability to prospectively collaborate with the Client regarding development and implementation of new benefit plans.
12. Fully integrated platforms and systems. Ability to respond rapidly to information technology (IT) and system requests.
13. Complete Medical Performance Guarantees (Exhibit A).
1. In responding to each specification, indicate “Confirmed” or “Bid specification not met.” If you indicate “Confirmed,” you will be deemed to comply 100% with all aspects of the specification. If your proposal deviates in any way from the specifications, you must indicate “Bid specification not met” and provide full and complete details (see #2 below).
2. Failure to meet any bid specifications must be detailed in your response. After an analysis of proposals submitted in response to this RFP, the Client reserves the right to modify the requirements and terms of this RFP and request resubmission of some, or all, items from any initial bidders.
3. Your proposal shall remain valid through January 1st, 2022.
4. All aspects of the client’s business to which you may have access as a result of this RFP are considered strictly confidential.
5. Nothing contained in this RFP creates, nor shall be construed to create, any contractual relationship between the Client and any vendor. The Client makes no commitment in or by virtue of this RFP to purchase any services or items from any vendor, nor does receipt of your proposal place the Client under obligation to enter into an agreement to purchase services from your organization.
6. Your proposal shall become the sole and exclusive property of the Client. The Client reserves the right to modify, reject, or use without limitation any or all of the ideas from the proposals. The Client will not disclose the pricing contained in any proposal to any party other than its attorneys, representatives, or the Consultant except as may be necessary to complete a blind analysis of responses provided to this RFP.
7. Vendors from whom proposals are solicited may not discuss this RFP with anyone outside their own organization other than the Consultant or the Client’s authorized personnel. If your organization is awarded the account, you may not advertise or publish the fact that the Client has selected your company as their partner without written permission from the Client. You are not allowed to use the Client’s name, trademark or any of its subsidiaries in any advertising or publication or other communication, other than in your proposal, without the prior written consent of an officer of the Client.
8. Expenses incurred in preparing and presenting a proposal to the Client is the sole responsibility of the vendor and may not be charged to the Client in any way. You must specifically agree that the Client shall have no responsibility or liability, whether in contract, tort or otherwise, for any loss, damage or liability for its actions in releasing this RFP, or rejecting, considering and choosing among the proposals.
9. Include with your response proposed contract, specific to the Client, which reflects your proposed pricing and terms.
10. You must agree to make available internal legal counsel with the authority to negotiate contract terms (on an unlimited basis) as needed to address any concerns or issues the Client may have with your proposed contract.
11. All claims and related data acquired as a result of any relationship with the Client will be deemed the property of the Client. You must agree to provide an electronic transfer of the Client data within 14 calendar days of any request by the Client. In the event of termination, the selected vendor will agree to provide all data and pertinent records required for program administration to the Client within thirty (30) days upon notification of termination. Data requested may include current eligibility information, full claim records detailing all claims transactions, prior authorization file for the previous twelve (12) months and case management notes and reporting at no additional cost to the Client.
12. Separate attachments which directly affect the quoted terms of your proposal are NOT permitted. A response to any specification, pricing assumption, underwriting caveat, or limitation on terms or quoted rates must be included where appropriate in your bid specification response.
The Consultant reserves the right to:
• Reject any proposal(s) received;
• Communicate or negotiate exclusively with one or more of the organizations invited to submit proposals;
• Request one or more of the quoting organizations to clarify its proposal, supply additional information, or expand upon its original submission;
• Enter into agreements or arrangements not specified herein;
• Base selection of the finalist(s) on factors such as adequacy of service personnel, claim adjudication services, cost management options, utilization review services, case management, reporting, IT capabilities and willingness to enter into a long-term relationship.
Your proposal must be complete and comply with all specifications.
The following important factors should be emphasized in your proposal:
• Administration, claim processing and service;
• Managed care capabilities, including scope and quality of existing provider networks;
• Medical management programs and services (Utilization Management, Case Management, Disease Management);
• Administrative charges and retention;
• Availability of reporting capabilities;
• Compliance with specifications as presented;
• Ability to provide data file feeds/ downloads to subcontracted vendors on a weekly basis;
• On-line capabilities, including web tools, employer portal with reporting and an online benefit eligibility management and employee portal;
• Ability to accept a direct feed from enrollment vendor;
• Performance Guarantees.
III. Overview and Summary of Current Plans
See Exhibit B.
Key Plan Requirements
• Fully review all plans presented;
• Identify all features of a plan that would require manual intervention or revision to be adjudicated by your claims system.
It is a requirement of this proposal to outline your firm's:
• Criteria used for claims denial;
• Appeal process; the selected vendor should be able to provide fiduciary responsibility for level two claims appeals;
• Services for outsourced claims appeals;
• Provide a sample Explanation Of Benefits (EOB), as well as sample messaging, such as participant advice, vendor directed inquiries, etc.;
• Dedicated service representative should be assigned to the Client for employer and member customer service and claims adjudication;
• Affordable Care Act (ACA)/Health Care Reform and other State or Federal compliance assistance;
• HIPAA compliance;
• Provide a sample member identification card;
• Bidding companies will be required to provide performance guarantees to the plan for specific member service, administration, claims adjudication services and accurate data file feeds performed on the Plan's behalf. See Medical Performance Guarantees, Exhibit A.
• Bidding companies are expected to provide toll-free access to claims and customer service personnel as follows:
o 8:00 AM – 8:00 PM (Eastern Standard Time) Monday through Friday, and;
o 24-hour provider access through voice response or member service is expected. Your proposal must address the provider service inquiry process you can provide on the plan's behalf.
• Provide employee communication materials for implementation of new administrator process and open enrollment meetings. Support client with employee communication materials for new plans or programs.
• Summary Benefit Comparisons (SBCs) must be created and provided for Open Enrollment.
Bidding company must outline:
• Vendor’s contractual position on “simple negligence” vs. “gross negligence”;
• Vendor’s contractual position on indemnification.
Managed Care Requirements
All programs should keep the following requirement in mind:
• Provide a detailed and complete description of the provider networks in existence at all employee locations.
• Provide specific information regarding the number and types of specialists available in your networks. Mental Health and Chemical Dependency providers must be included in the network offer to employees. This is an important consideration, so please include an analysis of the availability and accessibility of network physicians. A record of current member population by zip code is shown in Exhibit C.
• The Client may request that your company recruit ADDITIONAL physicians in certain specialties at major locations in response to employee request. The network must allow for this;
o Your proposal must explain how your network(s) will accommodate these requests. Include an explanation of your process and criteria for action and decision;
• Your firm must be able to provide an annual analysis of each network’s performance. Please include an explanation of your ability to add or change provider networks at the Client’s request.
• Provide pre-certification reporting and case management reporting on a monthly basis and upon request as needed by the stop-loss carrier, if applicable.
Contract Anniversary Date
The contract anniversary date is January 1st, 2022.
Guarantee all rates/fees for one (1) year from the plan's effective date. You can also provide rate/fee guarantees with two (2) and three (3) year options.
We request a minimum of one hundred twenty (120) day notice for any rate/fee change for renewal.
After the first year’s contract period, the Client reserves the right to terminate its contract without cause, provided such notification is given at least sixty (60) days in advance.
Rights and Access to Records
All claim records, eligibility data and associated files used by the carrier in its role, as claim administrator shall remain the property of the Client as Plan Sponsor and Plan Administrator.
Transfer of Records at Future Cancellation
The claims administrator must agree to transfer to the client, within thirty (30) days of notice of termination, all required data and records necessary to administer the plans. The transfer may be made electronically, based on the mutual agreement between the Client and the administrator.
Audit and Access Rights
It will be the right of the Client or its representative(s) to review and audit claims and administrative charges under the contract if awarded.
Designated Account Manager
Please provide information about the team that will provide service to the Client.
When printing is required (example: SPD, ID Cards, etc.), you must present a complete draft and subsequent proof to the Client for sign-off. The Client will not pay for any printed materials not specifically approved in writing.
V. Information Sheets
The following section will detail basic information regarding your organization.
Please answer each question clearly and completely. Responses should be concise and to the point. When responding, please state the question asked and then respond directly.
Please do not refer us to other source documentation. You are welcome to provide marketing materials; however, these materials should be used as support for a question and not as the response itself.
If you are unable to answer a part of this information request, please indicate why you cannot. If you are unwilling to disclose particular information requested please indicate your reasons.
If there is additional relevant information or documentation which you feel would aid the Client in the selection process, please provide that information separately and note specific page number references where appropriate.
1. Please provide a brief description of your organization.
2. Please provide an address for the locations below:
o Corporate headquarters;
o Ownership (Provide current description of any significant merger/acquisition activity and the impact there might be on service provided to the Client);
o Local service office;
o Claims office;
o Customer service office.
3. Provide a list of services and products offered by your organization. For purposes of this proposal, provide:
o Full name of primary contact;
o Work address of primary contact;
o Primary contact phone number;
o Primary contact fax number;
o Primary contact email address.
4. Have there been or are there pending legal actions against your firm in the past three (3) year period which may have a negative impact on the structure or financial stability of your organization? If yes, state the action and the possible impact to your operation and to this employer if a client.
5. How long has your present claims adjudication system been in place? What was the last date of major change or enhancement to the system? What advantages does your claims system provide to a self-funded or a high-deductible health plan?
Indicate Coverage Carried
Errors & Omissions*
*List covered parties for each and applicable coverage per entity (physicians, specialists, review organizations, employers, etc.)
For Medical Benefits Administration/Medical Management Administration - Please provide the client name, address, telephone number, email address and contact name for five (5) clients for whom you have administered self-funded medical programs. Of the (5) clients, please provide at least three (3) references from self-insured clients within the past twenty-four (24) months.
For Group Fully Insured Medicare Advantage Programs – Please provide the client name, address, telephone number, email address and contact name for (3) clients for whom you have successfully transitioned over age 65, Medicare eligible retirees to a fully insured group Medicare Advantage Plan(s) that provides national coverage.
For Medical Management Administration - Please provide the client name, address, telephone number, email address and contact name for three (3) clients for whom you have administered medical management programs. Of the (3) clients, please provide at least two (2) that fall within the past twenty-four (24) months.
VI. Medical Benefits Administration Agreements and Questionnaire
(not applicable if only submitting insured Group Medicare Advantage Administration and/or Medical Management Administration piece(s))
As the vendor for the Client’s program, you will be required to provide at least the following services under your full-service administration quotation. Your proposal should include these services, and appropriate pricing should be assumed in your response. In the event that you are unable to comply with one of the services requested, please specifically note that fact in your response.
The Claims Administrator agrees to provide an accurate claims data feed to a third-party claims and eligibility warehouse. If data is incorrect or missing, the Claims Administrator will be required to provide, correct, or replace the data within two (2) weeks of notification by the Plan or its designee. See Exhibit D for claims data field requirements.
Complete Exhibit E, Medical Administrative Quote, acknowledging any additional charges and the charge amounts. Note: The County may consider removing the over age 65 retiree population from the self-funded health plan and implementing an insured Medicare Advantage PPO. It is important that you provide pricing based on the current enrollment for the self-funded plan that includes all actives and retirees as well as for plan with the over age 65 retiree population removed from the self-funded health plan.
General account management services including the following:
• On-line enrollment capability (with an independent vendor);
• Direct claim verification of eligibility;
• Direct claims submission;
• Claim adjudication;
• HCRA Filing
• Customer Services (employer, provider or participant inquiries);
• Medical Management services and reports;
• Annual financial accounting reports;
• Banking transfer, reporting and reconciliation services;
• Communication services;
• Underwriting and actuarial services, including the following:
• Development of Costs/Benefits Analysis for existing as well as alternative Plan Designs (Example: Point of Service (POS) Program);
• Renewal services;
• Regulatory compliance services;
• Managed Network Services (to include adjudication of non-network claims);
• Utilization Review Services/Large Case Management
• Disease Management/Wellness Plans and reporting;
• Fiduciary responsibility for second level appeals;
• Network access; primary and wrap-around;
• SPD and SBC production, printing, distribution and updates;
• COBRA/HIPAA Administration;
• Stop loss reporting;
• Ad-hoc reporting;
• Download of data files to external vendors.
The Client will update eligible employees and dependents on a monthly basis. You will certify eligibility, with benefit payments being sent directly to the provider and/or employee, as appropriate. Your claim administration services must include:
• A dedicated claims supervisor (team leader) that will be assigned to the Client’s account;
• Receipt and maintenance of historical claim data and eligibility rosters (paper, electronic or tape) from the current vendor. Liaison with the current vendor as needed. Eligibility will be updated as required;
• All necessary forms, claim forms, EOBs and checks, etc., claim forms and ID cards may need to be printed with the company logo;
• ID cards (when applicable) to include pharmacy vendor information, even though pharmacy administration may not be provided by your company;
• Appropriate EOB, paid or denied. If a network discount is applied, the EOB must reference the patient is not responsible for the amount of the negotiated contract discount;
• Printed instructions for completing any necessary forms as well as a description of whatever documentation must accompany the claim for processing. Initially, claim kits may be provided;
• Review, adjudication, processing and payment of all claims including folding, stuffing, addressing (including postage) of all drafts, EOBs, and forms;
• “Clean claims” must be processed within ten (10) business days of receipt;
• A toll-free arrangement for employee and provider use in obtaining the following service:
• Proper administration of all Coordination of Benefits (COB), non-duplication, no fault and other subrogation provisions;
• Contact and communication with claimants and providers as required resolving problems or responding to questions. Provider “flagging” should be initiated when required due to ongoing submission of questionable claims.
• Claim investigation and analysis prior to payment. Outline your process and suspense procedure with regard to questionable claims, incomplete claims, or in an instance where a fee or charge is in excess of your reasonable and customary profile;
• Auditing, upon request, of medical claims in excess of $25,000;
• Performance of this important portion of your services will be subject to guarantees based upon the employees' satisfaction and adherence to plan guidelines.
Timely and accurate claim service and responsiveness to employee inquiries are important factors. Customer service capacities and guarantees will play an important role in the Client’s decision. Customer service expectations include:
• Dedicated customer service supervisor will be assigned to the Client;
• Dedicated customer service personnel will have easy access to claims processing personnel for information;
• Indicate how services will be subject to guarantees based upon timeliness, employee satisfaction and accuracy performance.
To provide a proper accounting for the ongoing and/or monthly management of the Plan, you must be able to provide the reports listed. Detailed quantitative analysis of a paid claims history package must include a claim breakdown of hospital utilization and major diagnostic category data. It is required that monthly or quarterly reports be available within thirty one (31) days following the end of that period. The reports generated must be able to reflect experience by line of coverage, split between the Plan, its operating units, employees, dependents and COBRA participants plus a total for all activity.
Describe and include samples of all management reports included within the quoted administrative expense. Include examples of the reporting package. Required management reports within your quoted administration fee include:
• Full population report (quarterly);
• Claims transaction report (weekly with a monthly summary);
• Detailed analysis of paid claim history by month (report package must include a claim breakdown by plan; location/branch and employee/dependent categories);
• General claim utilization report identifying claims submitted, claims eligible, deductible, coinsurance assessments, R&C cutbacks, COB applications, network/non-network expenses and savings by type of service and major procedure category every six (6) months;
• Monthly claim summary for active/COBRA population broken out by employee and dependent categories;
• Monthly network/non-network expense and savings report in addition to the six (6) month report;
• Claims turnaround/audit performance report;
• Customer service performance report;
• Claims denial/suspended report with explanation;
• Claims lag report for medical (monthly);
• Annual Incurred but Not Reported (IBNR) calculation/report to be provided prior to January 1st of each plan year;
• Utilization reports depicting activity (quarterly). Also quarterly Utilization Review (UR) reports must be available showing age, sex and case mix adjustments;
• Identify your firm’s capacity to produce reports to measure the experience in the following categories:
• Plan experience against similar plan designs on a national, regional or local level;
• Average length of stay;
• Average cost per hospital stay;
• Number of claims paid and number of transactions;
• Information by diagnostic related group;
• Information by specific physician provider and hospital provider;
• Information by line of coverage.
• Effectiveness of your managed care program including:
• Savings from utilization management;
• Savings from individual case management.
• Describe and provide samples of utilization and savings reports you are able to provide. With what frequency are these reports provided? What ad-hoc reporting capabilities are available for medical management?
• Ad-hoc reports for all claims and eligibility data (outline the process, time and cost associated with the development of ad-hoc reports.) Provide samples of capacities.
• Benchmarking report providing the Client’s data compared to regional or national benchmarks.
File Download to External Vendors
Describe capabilities to provide file feeds for eligibility and claims data as required to facilitate externally administered plan management services, including data warehousing of claims, integration with a third-party enrollment system as well as integration with a third-party case management and case utilization vendor, pharmacy and/or wellness. Specify in pricing proposal if there are any additional charges, including but not limited to, integration, data transfers and sharing clinical information.
Annual Financial Accounting Reports
It is required that you provide a year-end financial accounting for the Client’s program within three (3) months of the end of the plan year. This report must also provide a full disclosure of administrative costs, NYS Public Goods Pool Report, any ACA fees and other annual financial supportive data.
If you are awarded this program, it will be your responsibility to:
• Produce a detailed implementation calendar identifying dates, types of information required and responsibilities. Assume that you will be notified of vendor/administrator selection prior to August 31st, 2021 for a plan effective date of January 1st, 2022. Detail both pre-implementation and post-implementation strategies;
• Receive initial eligibility data and updates. The bidding company is required to audit the weekly in force census and reconcile discrepancies in the claim system eligibility record. Termination notices will be provided by the Client.
• Describe approach to administrating prior administrator’s run-out claims;
• Prepare, submit for approval, and print employee identification cards, which will be distributed to covered employees and their eligible dependents;
• Print claim forms that will be used by plan participants for the submission of claims for out-of-network plans;
• Review all plans, draft plan abstracts, and confirm plan provisions;
• Demonstrate tested benefit file for all plan designs;
• Provide all reasonable assistance as may be requested during the transition period, including participation at employee meetings.
Note: You will be responsible for drafting, printing and distributing required enrollment cards and related forms, ID cards, claim forms, claim instructive materials, claim envelopes and claim kits, SPDs and SBCs.
The carrier must administer applicable legal services, including:
• Preparing and filing all legal documents necessary to implement and maintain the plan, including policies, amendments, contracts and required state filings including HCRA filings;
• Necessary legal defense in the event of litigation, involving a managed care network and its providers and/or utilization review services;
• Monitoring federal and state legislation affecting the plans; and
• Preparing annual Schedule C forms as well as 5500 information, if applicable.
Managed Care Network and Utilization Review
The carrier is expected to maintain required managed care network and utilization review services for the Plan. Utilization review services including hospital pre-certification, concurrent review, discharge planning, second surgical opinions and individual case management should be quoted as a monthly rate per employee to be included in the rate exhibit (carefully review the sections of this RFP which address Preferred Provider, Utilization Review/Claim Management and Managed Prescription Drug services)....
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