Post Payment Claims Review Services

The Illinois Department of Central Management Services (CMS), Bureau of Benefits, has awarded a contract to SmartLight Analytics, LLC for post-payment claims review services across four state health insurance programs: State Employees Group Insurance Program (SEGIP), Teachers' Retirement Insurance Program (TRIP), College Insurance Program (CIP), and Local Government Health Plan (LGHP). The contract, valued at $498,000 for the initial three-year term, will provide comprehensive audit services to review 100% of self-insured medical, pharmacy, and dental claims processed by third-party administrators including Aetna, CVS Health, HealthLink, Blue Cross Blue Shield, and Delta Dental of Illinois.

The contract, designated as Open Market Competitive Sealed Proposal 25-416CMS-BENF4-P-84134, commenced on August 20, 2025, with a completion date of June 30, 2028. SmartLight Analytics will deliver per member per month (PMPM) claims review services, focusing on identifying fraud, waste, and abuse across approximately 242,073 covered lives. The scope includes real-time and retrospective claims audits, with the contractor required to provide analytical dashboards, data sharing capabilities, and conduct audit meetings with third-party administrators. The contract includes potential for a two-year renewal, with renewal rates capped at 3% or the Consumer Price Index Inflation factor, whichever is less.