122435 O5 - Attachment C - Questionnaire.xlsx
XLSX spreadsheet 60 KB Posted
- Attached to
- Administrative Support Services for the State of Nebraska Employee Health Care Medical Benefit Plans
- Solicitation number
- 122435 O5
- Issued by
- Lancaster County, Nebraska
About this file
This document is a comprehensive questionnaire (Attachment C) for a state government health plan contract opportunity in Nebraska, specifically targeting a state-wide group health insurance program. The solicitation (Number 122435 O5) seeks a medical administrator to provide comprehensive health plan services beginning July 1, 2026, with an initial contract term likely spanning multiple years. The questionnaire requires detailed responses across multiple sections including experience and references, account management, member services, claims processing, wellness programs, behavioral health services, network access, case management, and implementation strategies.
The document indicates the state is seeking a highly sophisticated health plan administrator with robust capabilities in areas such as member services, claims processing, utilization management, wellness programs, and technological integration. Key requirements include US-based member services, extensive provider networks across Nebraska, advanced digital platforms, comprehensive reporting capabilities, HIPAA compliance, and support for specialized programs like disease management, behavioral health, and transparent pricing. The questionnaire suggests the state is looking for an innovative partner with demonstrated experience in public sector health plan administration, with a strong emphasis on member experience, cost containment, and technological capabilities that can be customized to meet the state's specific needs.
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Instructions
| ATTACHMENT C - QUESTIONNAIRE | Bidder: | NAME |
| SOLICITATION NUMBER - 122435 O5 |
| Instructions for Completing this Questionnaire Workbook |
| • Provide succinct yet informative responses. |
| • Bidder should complete all questions in this Questionnaire. |
Questionnaire
| ATTACHMENT C - QUESTIONNAIRE | Bidder: | NAME |
| SOLICITATION NUMBER - 122435 O5 |
| Questionnaire Section | Section | Vendor Response | |
| A | EXPERIENCE AND REFERENCES | Experience | RESPONSE |
| A.1 | Provide three (3) current customer group health plan references. For at least one (1) of these references, Bidder should provide a reference for their largest (based on total group membership) Public Sector group health plan client. This reference should cover at least 15,000 Public Sector group health plan members. For at least one (1) reference, Bidder should provide a reference for their longest standing Public Sector group health plan client, based on continuous years of service. The reference for largest client and longest standing client may be the same reference. The State is interested in working with carriers that have experience with, and a history of, providing benefit services to public sector plans of similar size. Provide the following for each reference: | Experience | |
| a. Reference #1 | Experience | ||
| a. Customer name | Experience | ||
| b. Length of time serviced | Experience | ||
| c. Number of covered members (lives) | Experience | ||
| d. Description of services | Experience | ||
| e. Name of contact | Experience | ||
| f. Contact title | Experience | ||
| g. Contact phone number | Experience | ||
| h. Contact email | Experience | ||
| i. Contact address | Experience | ||
| b. Reference # 2 | Experience | ||
| a. Customer name | Experience | ||
| b. Length of time serviced | Experience | ||
| c. Number of covered members (lives) | Experience | ||
| d. Description of services | Experience | ||
| e. Name of contact | Experience | ||
| f. Contact title | Experience | ||
| g. Contact phone number | Experience | ||
| h. Contact email | Experience | ||
| i. Contact address | Experience | ||
| c. Reference #3 | Experience | ||
| a. Customer name | Experience | ||
| b. Length of time serviced | Experience | ||
| c. Number of covered members (lives) | Experience | ||
| d. Description of services | Experience | ||
| e. Name of contact | Experience | ||
| f. Contact title | Experience | ||
| g. Contact phone number | Experience | ||
| h. Contact email | Experience | ||
| i. Contact address | Experience | ||
| A.2 | Provide this same information for two (2) customers terminated within the last 24 months. Include the reason the engagement was terminated. | Experience | |
| a. Reference #1 | Experience | ||
| a. Customer name | Experience | ||
| b. Length of time serviced | Experience | ||
| c. Number of covered members (lives) | Experience | ||
| d. Description of services | Experience | ||
| e. Name of contact | Experience | ||
| f. Contact title | Experience | ||
| g. Contact phone number | Experience | ||
| h. Contact email | Experience | ||
| i. Contact address | Experience | ||
| j. Reason for termination | Experience | ||
| b. Reference # 2 | Experience | ||
| a. Customer name | Experience | ||
| b. Length of time serviced | Experience | ||
| c. Number of covered members (lives) | Experience | ||
| d. Description of services | Experience | ||
| e. Name of contact | Experience | ||
| f. Contact title | Experience | ||
| g. Contact phone number | Experience | ||
| h. Contact email | Experience | ||
| i. Contact address | Experience | ||
| j. Reason for termination | Experience | ||
| A.3 | Based on number of covered members (lives), list your organization’s five (5) largest client groups., Include name of entity, number of covered members, and sort by group size (largest to smallest). | Experience | |
| A.4 | For the entire book of business, provide the national group membership (number of lives) for which you provide medical administration services and indicate how many of these are in Nebraska. Provide statistics for Public Sector clients: | Experience | |
| a. National Groups - Total Covered Members (Lives) | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| 2022 | Experience | ||
| b. Nebraska Groups - Total Covered Members (Lives) | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| 2022 | Experience | ||
| c. Public Sector Covered Members (Lives) | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| 2022 | Experience | ||
| d. Number of Employer Groups | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| 2022 | Experience | ||
| e. Number of Public Sector Groups | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| 2022 | Experience | ||
| f. Number of Public Sector Groups with 15,000+ Covered Members (Lives) | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| 2022 | Experience | ||
| B | ACCOUNT MANAGEMENT | Acct Mgmt | RESPONSE |
| B.1 | Provide an organization chart, including names and titles, of Account Team and key personnel that will be responsible for the State account. | Acct Mgmt | |
| B.2 | Confirm the Account Team will attend all quarterly and account meetings at the Bidder’s expense. | Acct Mgmt | |
| B.3 | Confirm that you will respond to all inquiries from the State's Benefits staff within one (1) business day. | Acct Mgmt | |
| B.4 | How do you assess the Account Team’s performance and quality of service? Provide a sample of an annual score card or template used. | Acct Mgmt | |
| C | MEMBER SERVICES | Mbr Svcs | RESPONSE |
| C.1 | Please provide the geographic location of the proposed Member Services units. The State requires the service unit to be US based. | Mbr Svcs | |
| C.2 | At a minimum, Member Services staff must be available from 7:00 a.m. to 8:00 p.m., CST, Monday through Friday. Confirm your organization can meet this requirement. | Mbr Svcs | |
| a. Will the member services toll-free line be dedicated to the State of Nebraska? | Mbr Svcs | ||
| b. Will this service be outsourced? If so, to whom? | Mbr Svcs | ||
| C.3 | Confirm that the dedicated Member Services line will produce performance-reporting specific to the State of Nebraska only. | Mbr Svcs | |
| C.4 | Describe what steps must be taken by members to reach a live representative after first reaching the interactive voice response (IVR) unit when calling Member Services. How quickly will the member be connected to a live representative? | Mbr Svcs | |
| C.5 | Describe the process of handling calls "after hours" of operation? Is there a voicemail system or capability for callers to leave messages after normal business hours? | Mbr Svcs | |
| C.6 | Describe the system by which the Member Services unit tracks and documents calls. Describe the process to review the findings of the call tracking and documentation process with the State. | Mbr Svcs | |
| C.7 | Member Services Metrics: In reference to member services, state your performance stats for 2024 and 2023. | Mbr Svcs | |
| a. Call Volume (calls/day) | Mbr Svcs | ||
| 2024 Target/Actual: | Mbr Svcs | ||
| 2023 Target/Actual: | Mbr Svcs | ||
| b. Call Abandon Rate (%): | Mbr Svcs | ||
| 2024 Target/Actual: | Mbr Svcs | ||
| 2023 Target/Actual: | Mbr Svcs | ||
| c. Average Speed of Answer (in seconds): | Mbr Svcs | ||
| 2024 Target/Actual: | Mbr Svcs | ||
| 2023 Target/Actual: | Mbr Svcs | ||
| d. Average Wait Time (in seconds): | Mbr Svcs | ||
| 2024 Target/Actual: | Mbr Svcs | ||
| 2023 Target/Actual: | Mbr Svcs | ||
| C.8 | Can the MSRs access claim status online in real-time? How many months of claims history are available to MSRs? Can MSRs make adjustments to claims during a call in real-time? | Mbr Svcs | |
| C.9 | Confirm whether your member website (or secure portal) and member smartphone app include the following capabilities: | Mbr Svcs | |
| a. Accurate provider directory and provider search (physician, hospital, pharmacy, and ancillary providers) | Mbr Svcs | ||
| b. Physicians accepting new patients | Mbr Svcs | ||
| c. Physician and hospital quality and outcomes data | Mbr Svcs | ||
| d. Physician and hospital pricing data by procedure by provider | Mbr Svcs | ||
| e. Physician and hospital reviews from other members | Mbr Svcs | ||
| f. Treatment cost estimator | Mbr Svcs | ||
| g. Information about diseases and conditions | Mbr Svcs | ||
| h. Ability to see a summary of the State’s plan design and review the State’s plan documents | Mbr Svcs | ||
| i. Ability to review the State’s appeals process and file an appeal online | Mbr Svcs | ||
| j. Ability to review the waste, fraud and abuse notification process | Mbr Svcs | ||
| k. Contact information for the State, its other vendors, and links to their websites | Mbr Svcs | ||
| l. On-line access to forms | Mbr Svcs | ||
| m. Ability to review claim payment status online | Mbr Svcs | ||
| n. Ability to review a history of claim payments, including deductible status, out-of-pocket maximum status | Mbr Svcs | ||
| o. Ability to review or print out a health statement with a history of claim payments | Mbr Svcs | ||
| p. Ability to print ID cards and request replacement cards | Mbr Svcs | ||
| q. Dependent information | Mbr Svcs | ||
| r. Ability to contact member services online | Mbr Svcs | ||
| s. Other | Mbr Svcs | ||
| C.10 | Confirm a State of Nebraska specific website and mobile app will be functional by Feb 1, 2027 (so the State may test and review). | Mbr Svcs | |
| C.11 | Describe your ability to customize the web site and mobile app for the State’s membership. | Mbr Svcs | |
| C.12 | Describe transparency tools available to members for evaluation of cost and/or quality of healthcare providers. | Mbr Svcs | |
| C.13 | Can your plan/benefit decision tool be customized to evaluate all State plan options - including consideration of FSA/HSA and the impact these funds have on overall member cost? | Mbr Svcs | |
| C.14 | During the last 12 months, how many times and what percent of time has your system been "down"? System down-time percent is determined by the ratio of planned system availability when inquiry operators could not access the system to perform their functions, to the total planned system availability time. Disregard down-time for planned system maintenance. | Mbr Svcs | |
| C.15 | Confirm you will notify the State, in writing, immediately upon identifying system-related issues. This may include but is not limited to, issues with programming, data transfers, telephone systems. Confirm you will also make every effort to resolve the issue(s) within 48 hours regardless of the time or date, to minimize any disruption to members. | Mbr Svcs | |
| C.16 | Confirm that your information and communication technology, including websites, mobile applications, and member portals: | Mbr Svcs | |
| a. Is in compliance with Standards under Section 508 of the Rehabilitation Act of 1973, as amended, and implementing regulations. | Mbr Svcs | ||
| b. Conforms to Web Content Accessibility Guidelines (WCAG) 2.1, as updated from time to time. | Mbr Svcs | ||
| c. Conforms to Title II of the Americans with Disabilities Act and implementing regulations. | Mbr Svcs | ||
| C.17 | Describe your website accessibility program and how it complies with Section 508, Title II, and the WCAG 2.1 standards. | Mbr Svcs | |
| C.18 | Describe future plans/timeframes for enhancements to your website or mobile app. | Mbr Svcs | |
| C.19 | Describe the escalation process for Member Services satisfaction and complaints. | Mbr Svcs | |
| C.20 | Describe how you monitor member satisfaction and improve the quality of service. Describe the information captured in your organization's member satisfaction surveys and your process for collecting survey data. | Mbr Svcs | |
| C.21 | Confirm you will send a mutually agreed member satisfaction survey to the entire State membership. If not, please describe the percentage of the State membership targeted in your survey. | Mbr Svcs | |
| C.22 | Describe any member advocacy, navigation services, or programs you offer in addition to the traditional core member services center including outcomes achieved. | Mbr Svcs | |
| C.23 | Confirm your nurse line staff is available 24 hours a day, 365 days a year. | Mbr Svcs | |
| C.24 | Is your 24-hour nurse line service in-house or subcontracted? | Mbr Svcs | |
| C.25 | What is the average wait time to speak with a registered nurse? | Mbr Svcs | |
| C.26 | Does the nurse line associate a member to a contact history allowing a current inquiry to be addressed within the context of previous calls? | Mbr Svcs | |
| D | CLAIMS PROCESSING | Claims | RESPONSE |
| D. 1 | What is your definition of a "paid" claim, a "clean" claim, and a "suspense" claim? State the time frames required to process the claims under each of the categories mentioned. If you have additional categories, list them and state the time frames for processing those categories of claims. Include a claim form, if applicable. | Claims | |
| D. 2 | With regard to the claim offices that will be used, complete the following table: | Claims | |
| a. Location | Claims | ||
| b. Hours of operation | Claims | ||
| c. Annual claim volume | Claims | ||
| d. Average claims per processor per day | Claims | ||
| e. Number of staff | Claims | ||
| f. Average years of claims administration experience with your organization | Claims | ||
| g. Average Years of Claims Administration Experience with Your Firm | Claims | ||
| h. Annual Turnover (%) | Claims | ||
| i. Work remotely /from home (%) | Claims | ||
| D. 3 | Confirm that the claims processing system is integrated with the eligibility and Member Services system. | Claims | |
| D. 4 | Confirm your system will automatically adjudicate the current schedule of benefits for the State’s plans that have been provided with this proposal. | Claims | |
| D. 5 | Describe protocol and use of proper quality control testing for any benefit or program changes prior to live release. Include in your response the standard number of tests and applicable test areas. | Claims | |
| D. 6 | Describe how you monitor denied claims for trends and patterns to timely determine if outreach is needed to a provider's office for educating/training on proper filing and codes so the provider may submit a clean and accurate claim. | Claims | |
| D. 7 | Describe the outreach made to providers and the education/training provided in the event a provider needs to be contacted because of trends and patterns related to denied claims. | Claims | |
| D. 8 | Describe your appeal process for denied PAs and medical pre-certifications. | Claims | |
| D. 9 | Confirm that if any unapproved, non-medically necessary procedure is paid by the Medical Administrator, the Administrator will take full financial responsibility for the expense and reimburse the State for the charges. | Claims | |
| D. 10 | Describe your process to review claims for billing irregularities by provider (such as regular overcharging, unbundling of procedures, upcoding or billing for inappropriate care for stated diagnosis). Include savings figures resulting from these procedures. | Claims | |
| D. 11 | Bidders are required to credit overpaid claims within 7 – 10 business days of discovery of overpayment. This does not include actual recovery of funds that were the result of Bidder error. Describe your overpayment process. | Claims | |
| D. 12 | Do you agree to return 100% of all recovered monies from overpayments or duplicate payments (without a recovery fee) to the State? | Claims | |
| D. 13 | Provide the following information regarding internal claims audit(s): | Claims | |
| a. What are the current standards for internal claim audits? | Claims | ||
| b. How often are claim processors audited? | Claims | ||
| c. When an error is found, what is the time period for correction of the claim? | Claims | ||
| d. Are reports monthly, quarterly, semi-annual? | Claims | ||
| e. What claims do you consider for high dollar audits? | Claims | ||
| f. Are high dollar audit claims handled internally? | Claims | ||
| g. How are criteria determined for internal audits? What triggers do you utilize? | Claims | ||
| h. What percent of claims are audited internally? | Claims | ||
| i. What is the ratio of quality reviewers to claim processors? | Claims | ||
| D. 14 | On average, what percentage of all claims that are internally audited are then adjusted in some way as a result of the audit? Describe your procedure for adjusting the claim including any contact with the provider. | Claims | |
| D. 15 | Provide actual (achieved) performance measurements for the claims office that will handle the State account. | Claims | |
| a. Member Satisfaction Survey (% satisfied) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| b. Claim Accuracy (percentage) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| c. Financial Accuracy (percentage) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| d. Claims Turnaround Time (days) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| e. Overpayment recoveries (number of days to send check for overpayment) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| f. Telephone call response time (seconds) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| g. First call resolution rate (percentage) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| h. Closure time for open inquiries (number of days) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| i. Timeliness of responding to web inquiries (number of days) | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| j. Timeliness of resolution for grievances, complaints, and appeals | Claims | ||
| 2024 Target/Actual: | Claims | ||
| 2023 Target/Actual: | Claims | ||
| D. 16 | Provide in detail the procedure for processing claims based on benefit exceptions of denied claims as determined by the State. | Claims | |
| D. 17 | Define “medical necessity.” What guidelines are used to determine medical necessity? | Claims | |
| D. 18 | The State requires that claims history be maintained on-line for a minimum of ten (10) years. Describe how this will be met and/or exceeded. | Claims | |
| D. 19 | Describe how usual, customary and reasonable charges are determined for out-of-network medical, surgical and anesthesia. | Claims | |
| D. 20 | Describe your out-of-network reimbursement methodology. What data sources are used? How frequently are your data sources updated? | Claims | |
| D. 21 | Provide sample Claim Submission and Explanation of Benefits (EOB) forms. | Claims | |
| D. 22 | What procedures are used to administer COB provisions? | Claims | |
| D. 23 | Describe your subrogation recoveries process. Are any subrogation services subcontracted? Identify the subcontractor. | Claims | |
| D. 24 | What are your gross subrogation recovery fees? If you have a shared savings model, please describe how it works. | Claims | |
| D. 25 | What are your average subrogation rates of return for 2023 and 2024? | Claims | |
| D. 26 | Confirm understanding that any subrogation claim that is less than 100% of the State’s loss, and all settlements, require the State’s approval. | Claims | |
| D. 27 | Provide a description of premium or administrative fee billing procedures, including information on the timing of billing and billing-payment reconciliations. | Claims | |
| D. 28 | Complete the table below on your Medical PPO group book of business statistics on appeals and grievances. Provide additional explanation for these statistics as needed. | Claims | |
| a. Total 2024 Member Medical Appeals | Claims | ||
| Total Dismissed | Claims | ||
| Total Overturned | Claims | ||
| Total Upheld | Claims | ||
| b. Total 2024 Provider Medical Appeals | Claims | ||
| Total Dismissed | Claims | ||
| Total Overturned | Claims | ||
| Total Upheld | Claims | ||
| c. Total 2024 Member Grievances | Claims | ||
| D. 29 | Confirm your understanding the State reserves the right to accept or decline the following at no additional cost to the State: | Claims | |
| a. proposed service centers | Claims | ||
| b. proposed claims processors | Claims | ||
| c. proposed changes to claims processing systems | Claims | ||
| E | AUDIT RIGHTS | Audits | RESPONSE |
| E.1 | Indicate whether or not you agree with the following statements regarding audits. | Audits | |
| a. Confirm you agree to extend audit rights to the State and cooperate with any outside audit firm the State selects to perform an operations and claim administration audit. This might include the provision of space and system terminals for a reasonable period of time to accomplish the audit objectives. | Audits | ||
| b. Confirm you agree to the following provision: Audits may include, but are not limited to, implementation audits, claims and operations audits, clinical audits. | Audits | ||
| c. Confirm you have provided a copy of your current standard audit agreement with your proposal response. | Audits | ||
| c. Confirm you will not charge for services rendered in conjunction with the audit. | Audits | ||
| d. Confirm that if problems are discovered, the cost of follow-up audits will be paid by your organization. | Audits | ||
| E.2 | Confirm the State, via its designated auditor, has the right to perform multiple audits having differing scopes, at different times during the contract year. | Audits | |
| E.3 | Confirm the State, via its designated auditor, has the right to perform additional audits during the year of similar scope if performed as a follow-up to ensure significant/material errors found in a previous audit have been corrected and are not recurring or if additional information becomes available to warrant further investigation. | Audits | |
| E.4 | Confirm the State, via its designated auditor, has the right to audit claims and operations after the contract has terminated. | Audits | |
| E.5 | Confirm your organization will provide a response to all findings received within 30 days of audit, or at a later date if mutually determined to be more reasonable based on the number and type of findings. | Audits | |
| E.6 | Confirm you will allow Segal, or any other party selected by the State, to audit all provisions governed by the contract. | Audits | |
| E.7 | Confirm you agree not to charge the State for EOBs/claims issued as corrections due to audits. | Audits | |
| E.8 | Bidder will guarantee the State or its appointees the right to reasonable inspection of facilities, equipment, and system support operations to ensure the continued ability of the Offeror to support the plan; failure to comply with a reasonable request to inspect will result in a penalty; failure to respond to a finding from an inspection within 30 calendar days will result in a penalty. | Audits | |
| E.9 | The State will not be held responsible for time or miscellaneous costs incurred by the Administrator in association with any audit process including all costs associated with provision of data, audit finding response reports, or systems access, provided to the State or its designee by the Administrator during the life of the contract. Note: This includes any data required to transfer the business to another vendor and money collected from lawsuits and internal audits. | Audits | |
| E.10 | Bidder will correct any errors that the State, or its representative, brings up to the Bidder’s attention whether identified by an audit or otherwise. Describe the process that the Bidder will undergo to correct the error and make the appropriate payments to the member and/or the State, if applicable. | Audits | |
| E.11 | Confirm you have provided a document outlining the Audit Rights and Procedures. Indicate the name of the Attachment | Audits | |
| F | BEHAVIORAL HEALTH | Behavioral H | RESPONSE |
| F.1 | Provide a brief overview of your program and address how your behavioral health interventions are integrated with your medical interventions. | Behavioral H | |
| F.2 | Do you have a clinically integrated delivery system that coordinates behavioral health services with medical services to improve the quality of care? Please describe. | Behavioral H | |
| F.3 | Describe any efforts used to educate members of available behavioral health services. Also describe education efforts to medical providers and facilities of your behavioral health services so that members who could benefit from those services can be referred if presenting at a medical provider. | Behavioral H | |
| F.4 | Which, if any, behavioral health services are subcontracted? Identify the program, the subcontractor, and background on your organization's relationship with them. | Behavioral H | |
| F.5 | Describe the process for plan participants to access behavioral health services in a primary care setting, during chronic condition case management, during an acute inpatient episode, and during post-discharge follow up. | Behavioral H | |
| F.6 | Are specialty case managers used to manage Mental Health/Substance Use Disorder cases? What are their credentials? | Behavioral H | |
| F.7 | Does the same case manager handle the member's care through all levels of care? For example, inpatient, intermediate, and outpatient? | Behavioral H | |
| F.8 | How long is a patient monitored after discharge? | Behavioral H | |
| F.9 | What guidelines do you use to ensure appropriateness of treatment (utilization and duration for relevant medications and services)? | Behavioral H | |
| F.10 | Confirm you offer a comprehensive behavioral health network that includes a variation of providers such as Psychiatrists (MDs), Psychologists, Therapists, Counselors, Social Workers, DEA waiver providers, ABA Paraprofessionals. | Behavioral H | |
| F.11 | Describe your (or your behavioral health subcontractor's) philosophy for best practice treatment for members with opioid addiction needing inpatient substance use services. | Behavioral H | |
| F.12 | Describe how the size and caliber of your network will effectively meet the State's behavioral health needs. | Behavioral H | |
| F.13 | Complete the following chart for in-network mental health and substance use disorder providers. If services for a particular provider specialty are not provided, please indicate N/A: | Behavioral H | |
| a. Psychiatrists (MDs) | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| b. Psychologists | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| c. Therapists | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| d. Licensed Professional Counselors | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| e. Social Workers | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| f. DEA waiver providers | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| g. ABA Paraprofessionals | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| h. Other | Behavioral H | ||
| Included in network? | Behavioral H | ||
| Percent accepting new patients | Behavioral H | ||
| Avg wait time to get appointment? | Behavioral H | ||
| Total appointments provided in 2024 | Behavioral H | ||
| Total appointments provided in 2023 | Behavioral H | ||
| F.14 | What is the process for making an assessment and/or referral for Behavioral Health services? | Behavioral H | |
| F.15 | What percentage of your in-network behavioral health providers are accepting new patients? | Behavioral H | |
| F.16 | Describe the process for scheduling appointments through the Behavioral Health provider network. | Behavioral H | |
| F.17 | How do you prioritize appointments based on urgency, and what strategies are in place to reduce wait times? | Behavioral H | |
| F.18 | How do you manage appointment availability during high-demand periods or for specialized treatment needs? | Behavioral H | |
| F.19 | Provide details regarding the average wait time for scheduling appointments for both virtual and in-person mental health and substance use treatment services. Specifically: | Behavioral H | |
| a. What is the typical wait time for a new patient to schedule an initial appointment for both virtual and in-person consultations? | Behavioral H | ||
| b. Are there any differences in wait times between virtual and in-person services? | Behavioral H | ||
| c. Do you offer same-day or next-day appointment availability, and if so, under what circumstances? | Behavioral H | ||
| F.20 | How are crisis intervention services and support features made accessible and understood by all eligible members of an employee’s family? | Behavioral H | |
| F.21 | What is your average response time to emergency calls? | Behavioral H | |
| G | ELIGIBILITY AND MEMBERSHIP | Eligibility | RESPONSE |
| G.1 | Confirm you can accept and receive weekly data transfers utilizing standard HIPAA 834 file format and process within one (1) business days of receipt. | Eligibility | |
| G.2 | Confirm that you will provide direct same day confirmation that the eligibility file was received, properly loaded, processed, and that this confirmation will include the date of receipt. | Eligibility | |
| G.3 | Describe your process to update a member’s eligibility information after a file is uploaded, including the process of working error reports generated. | Eligibility | |
| G.4 | How does your organization handle manual updates to eligibility? | Eligibility | |
| G.5 | Describe if eligibility is processed in real time with the claims system. | Eligibility | |
| G.6 | Describe your best practice of eligibility reconciliation. | Eligibility | |
| G.7 | Confirm all Administrator's coding errors will be resolved within two business days. | Eligibility | |
| G.8 | Describe your eligibility verification services for complete dependent eligibility audits of the dependent(s) enrolled on employee health plans that are required by the State. Confirm your ability to perform these services. Will these services be subcontracted? If so, identify the subcontractor. | Eligibility | |
| H | NETWORK ACCESS AND MANAGEMENT | Ntwk | RESPONSE |
| H.1 | Provide a network access report using the access standards below. The submitted access report (mapping and accessibility analysis) must demonstrate provider availability for EACH provider type listed below. In the production of the reports, please note the following: |
• Must utilize Optum®, GeoAccess®, GeoNetworks or comparable software.
• Must indicate those participants with access and those without access according to provider network access standards above, by county.
• Access must be based on driving distance from the center of the participants' home zip codes.
• The access reports should include providers under contract as of June 1, 2025 and may also include providers that have entered a legally binding letter of intent or letter of agreement with the Bidder.
| Ntwk | |||
| URBAN: Count of EEs/RETs WITH access and count WITHOUT access | Ntwk | ||
| Facilities: | Ntwk | ||
| Hospital - 1 in 25 miles | Ntwk | ||
| Ambulatory Surgical Centers - 1 in 25 miles | Ntwk | ||
| Urgent Care Facilities - 1 in 25 miles | Ntwk | ||
| Free-Standing Imaging Centers - 1 in 25 miles | Ntwk | ||
| Free-Standing Rehabilitation Facilities - 1 in 25 miles | Ntwk | ||
| Skilled Nursing Facilities - 1 in 25 miles | Ntwk | ||
| Inpatient Behavioral Health Facilities - 1 in 25 miles | Ntwk | ||
| Primary Care: | Ntwk | ||
| General/Family Practitioner (includes Internal Medicine, Family Practice, General Practice and Family Nurse Practitioner) - 2 in 10 miles | Ntwk | ||
| Specialists: | Ntwk | ||
| Allergist - 2 in 25 miles | Ntwk | ||
| Anesthesiologist - 2 in 25 miles | Ntwk | ||
| Cardiologist - 2 in 25 miles | Ntwk | ||
| Chiropractor - 2 in 25 miles | Ntwk | ||
| Dermatologist - 2 in 25 miles | Ntwk | ||
| Endocrinologist - 2 in 25 miles | Ntwk | ||
| Gastroenterologist - 2 in 25 miles | Ntwk | ||
| General Surgeon - 2 in 25 miles | Ntwk | ||
| Hematologist/Oncologist - 2 in 25 miles | Ntwk | ||
| Neurologist - 2 in 25 miles | Ntwk | ||
| OB/GYN (female members, age 12 and older) - 2 in 10 miles | Ntwk | ||
| Orthopedist - 2 in 25 miles | Ntwk | ||
| Pediatrician (members, birth through age 18) - 2 in 10 miles | Ntwk | ||
| Psychiatrist/Psychologist - 2 in 25 miles | Ntwk | ||
| Pulmonologist - 2 in 25 miles | Ntwk | ||
| Radiologist - 2 in 25 miles | Ntwk | ||
| Urologist - 2 in 25 miles | Ntwk | ||
| Other Specialists - 2 in 25 miles | Ntwk | ||
| RURAL: Count of EEs/RETs WITH access and count WITHOUT access | Ntwk | ||
| Facilities - 1 in 35 miles | Ntwk | ||
| Hospitals | Ntwk | ||
| Ambulatory Surgical Centers | Ntwk | ||
| Urgent Care facilities | Ntwk | ||
| Free-Standing Imaging Centers | Ntwk | ||
| Free-Standing Rehabilitation Facilities | Ntwk | ||
| Skilled Nursing Facilities | Ntwk | ||
| Inpatient Behavioral Health Facilities | Ntwk | ||
| Primary Care - 2 in 25 miles: | Ntwk | ||
| General/Family Practitioner (includes Internal Medicine, Family Practice, General Practice and Family Nurse Practitioner) - 2 in 25 miles | Ntwk | ||
| Specialists - 2 in 50 miles: | Ntwk | ||
| Allergist | Ntwk | ||
| Anesthesiologist | Ntwk | ||
| Cardiologist | Ntwk | ||
| Chiropractor | Ntwk | ||
| Dermatologist | Ntwk | ||
| Endocrinologist | Ntwk | ||
| Gastroenterologist | Ntwk | ||
| General Surgeon | Ntwk | ||
| Hematologist/Oncologist | Ntwk | ||
| Neurologist | Ntwk | ||
| OB/GYN (female members, age 12 and older) | Ntwk | ||
| Orthopedist | Ntwk | ||
| Pediatrician (members, birth through age 18) | Ntwk | ||
| Psychiatrist/Psychologist | Ntwk | ||
| Pulmonologist | Ntwk | ||
| Radiologist | Ntwk | ||
| Urologist | Ntwk | ||
| Other Specialists | Ntwk | ||
| H.2 | Please provide a general description of how you establish your organization's networks and the corresponding financial arrangements. | Ntwk | |
| H.3 | If a network gap or deficiency is identified, either in the above analysis or if the State brings one to your attention, how will the need for additional providers be addressed? | Ntwk | |
| H.4 | Indicate whether the network proposed for the State is leased or owned or a combination. If a combination, indicate what percent is leased and what percent is owned. If any portion of the network is leased, provide the name of network lessee. | Ntwk | |
| H.5 | Confirm you notify the State immediately if the network or any part thereof, loses any accreditation, licenses or liability insurance coverage, security or bonding. | Ntwk | |
| H.6 | The State requires that when a member or dependent enrollee is admitted in one of the Contractor’s network facilities at the time the group contract terminates, the normal/usual discount still applies for the entire period of admittance, as if the program had not terminated. | Ntwk | |
| H.7 | What is your current book-of-business in-network utilization percentage? | Ntwk | |
| H.8 | What is your average in-network utilization by service type (Professional, Outpatient, Inpatient, and Other) based on claims paid for 2024 and 2023, for clients located in Nebraska? | Ntwk | |
| a. Professional | Ntwk | ||
| 2024 | Ntwk | ||
| 2023 | Ntwk | ||
| b. Outpatient | Ntwk | ||
| 2024 | Ntwk | ||
| 2023 | Ntwk | ||
| c. Inpatient | Ntwk | ||
| 2024 | Ntwk | ||
| 2023 | Ntwk | ||
| d. Other | Ntwk | ||
| 2024 | Ntwk | ||
| 2023 | Ntwk | ||
| H.9 | Provide your network provider turnover rate. | Ntwk | |
| 2024 | Ntwk | ||
| 2023 | Ntwk | ||
| H.10 | In the event that a network physician refers a member to a non-network specialist or utilizes a non-network laboratory, confirm that you will adjudicate the non-network claim as a network claim. | Ntwk | |
| H.11 | When a qualified network provider is not available, what is your process for approving the use of non-network providers? Describe your ability to negotiate favorable reimbursements on behalf of the State and the members. Confirm that the State can require prior approval in such instances. | Ntwk | |
| H.12 | How are benefits applied in those service areas where your networks do not meet the State’s access standards? | Ntwk | |
| H.13 | What percent of current contracted facilities/physicians in the following metro areas are not currently accepting new patients? | Ntwk | |
| a. Omaha | Ntwk | ||
| b. Lincoln | Ntwk | ||
| H.14 | Are there any services or specialists that are not available in your physician networks in the service areas where there are plan participants? If yes, please identify them and explain what provisions are made for patients requiring these services. | Ntwk | |
| H.15 | How much notice is a provider contractually required to give if they elect to terminate a contract with your network(s)? How much notice will the State be provided when providers are added to or leave a network? How will the State be notified of such change(s)? How will members be notified? | Ntwk | |
| H.16 | How do you monitor non-network utilization and what steps do you take to contract with these providers? | Ntwk | |
| H.17 | Check off those elements that are included in the provider selection process and provide the estimated percentage of network providers that satisfy the following selection criteria elements: | Ntwk | |
| a. Require unrestricted state licensure | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| b. Review malpractice coverage and history | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| c. Require full disclosure of current litigation | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| d. Require current DEA registration | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| e. Review adherence to state and community practice standards | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| f. Onsite review of office location | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| g. Review hours of operation and capacity | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| e. Board eligibility | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| f. Review practice patterns and utilization results | Ntwk | ||
| In Selection Process (Y/N) | Ntwk | ||
| % of Providers | Ntwk | ||
| H.18 | What is the average time to credential and add an individual physician? What is the average time to credential and add a medical group? | Ntwk | |
| H.19 | Provide detailed information on how often provider directories are updated. Both hard copy and on-line provider directories must be made available to the State. | Ntwk | |
| H.20 | Describe your Centers of Excellence (COE) services, programs, and how members access care for each of the conditions and needs listed in the table below: | Ntwk | |
| a. Bariatric surgery | Ntwk | ||
| b. Burns | Ntwk | ||
| c. Cancer | Ntwk | ||
| d. Cardiovascular | Ntwk | ||
| e. HIV | Ntwk | ||
| f. Joint Replacement | Ntwk | ||
| g. Cardiac Surgery and Intervention Procedures | Ntwk | ||
| h. Disease Management | Ntwk | ||
| i. End Stage Renal Disease | Ntwk | ||
| j. Transplants (including bone marrow, heart, lung, kidney and other transplants) | Ntwk | ||
| k. Wellness | Ntwk | ||
| l. Any other Centers of Excellence | Ntwk | ||
| H.21 | Indicate ongoing provider quality monitoring activities. | Ntwk | |
| H.22 | Describe the support you provide members that reside in lower income zip-codes and disadvantaged minority communities | Ntwk | |
| H.23 | Describe the criteria used to select hospitals and other health care facilities to participate in the network. | Ntwk | |
| H.24 | Indicate if any hospitals or other medical facilities have been terminated or dropped from the network in the past five (5) years. Identify the hospital/medical facility and for what reason(s). | Ntwk | |
| H.25 | Confirm your understanding of the following State requirement: When a member or dependent enrollee is admitted in one of the Administrator’s network facilities at the time the group contract terminates, the normal/usual discount still applies for the entire period of admittance, as if the program had not terminated. | Ntwk | |
| H.26 | Describe your in network reimbursement methodology. What data sources are used? How frequently are your data sources updated? | Ntwk | |
| H.27 | Describe your out-of-network reimbursement methodology. What data sources are used? How frequently are your data sources updated? | Ntwk | |
| H.28 | Complete the table below on your value-based contracting (VBC) practices. | Ntwk | |
| a. How many VBC offerings/contracts do you currently have in Nebraska? Indicate the type of contracting such as ACO (Accountable Care Organizations), EOC (Episodes of Care), APM (Alternative Payment Models). How many do you expect to have on July 1, 2026 | Ntwk | ||
| b. Please list the entities in Nebraska under such contracts. | Ntwk | ||
| c. What is the average medical cost PMPM from these VBC offerings compared to your typical PPO/POS network in Nebraska? | Ntwk | ||
| d. Are additional fees required? (e.g., cost containment program fees, network fees, attribution fees, provider performance fees) | Ntwk | ||
| e. Are members required to select PCPs? If so, what is the selection process? | Ntwk | ||
| f. Describe the reporting capabilities for your VBC offerings. Include sample reports. | Ntwk | ||
| g. Describe any other value-based contracting (VBC) practices you have in place both nationally and in Nebraska | Ntwk | ||
| h. Describe how these arrangements influence physician behavior and utilization and discuss how this has led to client savings. | Ntwk | ||
| What are your capabilities to provide actual physician outcome quality data to members so that they can make wiser choices regarding where they seek care and in turn realize better and lower cost outcomes for the Plan? | Ntwk | ||
| I | MEDICAL CASE MANAGEMENT AND DISEASE MANAGEMENT | CM/DM | RESPONSE |
| GENERAL | CM/DM | ||
| I.1 | Describe in detail all programs and services, such as wellness programs, disease management programs, case management programs, dieticians, social workers, engagement rates. you will offer with this plan that may control costs. Please explicitly note if you utilize third party vendors for such programs and services. | CM/DM | |
| I.2 | Describe your approach to large case management and complex care, including any specialty programs that are included in your proposal. Describe any special programming for High cost/high risk, Oncology, Transplant, Maternity, Fertility, NICU, ESRD/CKD, Musculoskeletal, Cardiovascular, Behavioral Health (mental health/substance use). | CM/DM | |
| I.3 | Describe how your program design enhances quality of care, including how you engage targeted individuals and how you improve health status and clinical outcomes. | CM/DM | |
| I.4 | Describe your organization's approach to identifying and closing gaps in care. | CM/DM | |
| I.5 | Describe how your organization monitors and measures outcomes. | CM/DM | |
| I.6 | What are your standard business hours and days of operation? Please provide time zones. If your hours are not 24/7/365 how do you respond to calls that are urgent or emergent? | CM/DM | |
| I.7 | Confirm you will notify the State within three (3) business days of an inpatient case that is expected to be above $100,000. | CM/DM | |
| DISEASE MANAGEMENT | CM/DM | ||
| I.8 | Describe how enrollees are identified for a disease management program, how frequently the process occurs and stratification processes. What data sources are utilized? How are comorbidities handled? | CM/DM | |
| I.9 | Once identified for the program, is enrollment into the program automatic or must action be taken to enroll (i.e., is the program opt-in or opt-out)? | CM/DM | |
| I.10 | Provide a timeline from identification of the enrollee to point of contact. Do all identified members receive outreach and what is the communication method. Please describe if communication methods differ by acuity level. | CM/DM | |
| I.11 | Describe your process to engage program enrollees. Describe your process to re-engage members that have opted out of the program. | CM/DM | |
| I.12 | How do you define engagement? What strategies and incentives have you used in the past to achieve the most continuous engagement? Provide a case study on what you define as successful client engagement. | CM/DM | |
| I.13 | Do you provide any third party therapeutic disease management point solutions? If so, describe below. | CM/DM | |
| a. Weight Management | CM/DM | ||
| Point Solution Provided? | CM/DM | ||
| Vendor Partner? | CM/DM | ||
| Type of Fee Arrangement? | CM/DM | ||
| Included in the Current Proposal? | CM/DM | ||
| b. Physical Therapy | CM/DM | ||
| Point Solution Provided? | CM/DM | ||
| Vendor Partner? | CM/DM | ||
| Type of Fee Arrangement? | CM/DM | ||
| Included in the Current Proposal? | CM/DM | ||
| c. Wellness (lifestyle modifications) | CM/DM | ||
| Point Solution Provided? | CM/DM | ||
| Vendor Partner? | CM/DM | ||
| Type of Fee Arrangement? | CM/DM | ||
| Included in the Current Proposal? | CM/DM | ||
| d. Musculoskeletal | CM/DM | ||
| Point Solution Provided? | CM/DM | ||
| Vendor Partner? | CM/DM | ||
| Type of Fee Arrangement? | CM/DM | ||
| Included in the Current Proposal? | CM/DM | ||
| e. Other | CM/DM | ||
| Point Solution Provided? | CM/DM | ||
| Vendor Partner? | CM/DM | ||
| Type of Fee Arrangement? | CM/DM | ||
| Included in the Current Proposal? | CM/DM | ||
| I.14 | Demonstrate how your Disease Management programs have achieved savings for your clients. Please include specific savings and achieved health outcomes in your examples. | CM/DM | |
| CASE MANAGEMENT | CM/DM | ||
| I.15 | How do you define Case Management? | CM/DM | |
| I.16 | Describe your organization's philosophy of case management and the model under which it currently operates. Describe how the case management program integrates with other care management programs such as utilization review and quality management. | CM/DM | |
| I.17 | Indicate which of the following Case Management components are offered by your organization: | CM/DM | |
| a. Pre-admission outreach | CM/DM | ||
| b. In-patient confinement outreach | CM/DM | ||
| c. Discharge planning | CM/DM | ||
| d. Post-discharge outreach | CM/DM | ||
| e. Catastrophic/long-term Case Management | CM/DM | ||
| f. Episodic/short-term Case Management | CM/DM | ||
| g. End-of-life program identification and transition | CM/DM | ||
| h. Other | CM/DM | ||
| I.18 | What percentage of a typical client population do you identify for case management? Of the identified population, what percentage do you anticipate engaging in your programs (express on a unique member, annualized basis)? | CM/DM | |
| a. % of typical client population identified for case management | CM/DM | ||
| b. % of part a. anticipated to engage in programs | CM/DM | ||
| I.19 | Demonstrate how your Case Management program has achieved savings for your clients. Please include specific savings and achieved health outcomes in your examples. | CM/DM | |
| I.20 | Once a member is selected for case management, describe your outreach procedures to engage members. How many attempts are made? What services or efforts are used to obtain updated contact information? Describe any follow-up procedures are there for case management? | CM/DM | |
| I.21 | How do you define engagement? What strategies and incentives have you used in the past to achieve the most continuous engagement? Provide a case study on what you define as successful client engagement. | CM/DM | |
| I.22 | The State desires a robust and aggressive Case Management program. Confirm your willingness to work with the State to develop/customize a more flexible identification process for case management protocols, with the goal of optimizing care while eliminating excess cost that will be specific to the State and the State's needs. | CM/DM | |
| I.23 | Describe identification and selection criteria for individual case management. | CM/DM | |
| I.24 | Describe your process when members decline case management. | CM/DM | |
| I.25 | It is important to the State that members are consistently informed of discharge planning activities, denials related to post discharge levels of care and educated on the criteria necessary to be admitted to post hospital facilities. Communication with hospital discharge planners and case managers is critical to achieving this goal. How will your case management program achieve this? | CM/DM | |
| I.26 | What is your process for post discharge outreach? | CM/DM | |
| I.27 | Do you have the capability to customize authorization letters to include the contact information of the carrier's case manager managing the case? | CM/DM | |
| I.28 | Do you have the capability to customize denial letters to include the contact information of the carrier's case manager managing the case? | CM/DM | |
| I.29 | Do you have hospital based on-site case managers? How many do you have? What are their locations? How many are in Nebraska? Please specifically outline how many on-site case managers are in Nebraska and their locations. | CM/DM | |
| I.30 | Describe the criteria and process for case management referrals to the Medical Director, specialty programs, and community resources including how you address social drivers of health. | CM/DM | |
| I.31 | What outcomes are measured in your standard clinical management programs? | CM/DM | |
| I.32 | Describe in detail the methodology and policy for calculating case management savings. | CM/DM | |
| UTILIZATION MANAGEMENT | CM/DM | ||
| I.33 | Describe your organization's programs and options related to utilization management, pre-service review process, concurrent review, retroactive review, appeals, and cost containment. Include a description of Medical Director involvement on clinical review, peer-to-peer, denials, and appeals. | CM/DM | |
| I.34 | Describe how your program design enhances quality of care, including how you engage targeted individuals and how you improve health status and clinical outcomes. | CM/DM | |
| I.35 | Include final net savings figures resulting from these programs and list by program type. | CM/DM | |
| I.36 | Describe your processes for inpatient care management and post-acute transitions including items such as: | CM/DM | |
| a. Prior approval of inpatient status if any | CM/DM | ||
| b. Clinical workflow process and timely information exchange with inpatient care management team | CM/DM | ||
| c. Peer-to-peer discussions during case reviews | CM/DM | ||
| d. Inpatient care managers in the facilities for care coordination | CM/DM | ||
| e. Monitoring of recent case decisions including turn-around times, short-term and long-term clinical results | CM/DM | ||
| f. Hospitalized members | CM/DM | ||
| g. Members in treatment | CM/DM | ||
| h. Maternity members | CM/DM | ||
| I.37 | Respond to the following Utilization Management questions: | CM/DM | |
| a. What do you require prior authorization for? Is it customizable and is there a fee? | CM/DM | ||
| b. Describe what you perform concurrent review on and how often. | CM/DM | ||
| c. Do you offer Retrospective Review? | CM/DM | ||
| d. Describe any automated utilization management or Artificial Intelligence procedures your system utilizes for the following, as well as any other automated system quality assurance/claim appropriateness controls you employ and feel would be beneficial to the State. | CM/DM | ||
| · Medical necessity | CM/DM | ||
| · Pre-certifications | CM/DM | ||
| · Claim accuracy | CM/DM | ||
| e. How do you achieve cost savings and what is your methodology? Do you use a third party to validate any of your savings or ROI? | CM/DM | ||
| f. Do you agree to redirect pre-certification requests to in-network providers? | CM/DM | ||
| g. Describe any customized, rigorous preservice programs for any specific medical procedures in place currently. | CM/DM | ||
| h. Do you perform Discharge Planning as part of Utilization Management? Describe discharge planning as part of your UM process. | CM/DM | ||
| i. How many on-site (in facility) and remote case managers do you propose at the various facilities statewide to serve the State membership to minimize as much as possible any disruption during the discharge or transition of care process. | CM/DM | ||
| j. List any medical services categories your organization carves out on utilization management (e.g., high-tech imaging, oncology, spinal fusion, onsite clinical review). | CM/DM | ||
| I.38 | Describe your methods for internally monitoring and evaluating the performance of utilization management activities. If an issue is discovered, describe the corrective actions you would implement to resolve it. | CM/DM | |
| I.39 | What process is used to provide training and education for providers regarding Utilization Management issues? How are non-compliant providers identified and educated and/or sanctioned? | CM/DM |
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