2-2026-076 Medical TPA PBM Services Workbook.xlsx
XLSX spreadsheet 7 MB Posted
- Solicitation number
- RFP 2026-076
- Issued by
- Bexar County, Texas
About this file
This is a Medical Third-Party Administrator (TPA) and Pharmacy Benefit Management (PBM) Services workbook for Northside Independent School District (NISD) in San Antonio, Texas. The District is soliciting sealed bids for comprehensive medical TPA and PBM services to replace the expiring RFP 2023-024, which previously covered fully-insured and self-funded managed health and consumer-driven health plans. This new RFP (2-2026-076) represents a mandatory solicitation for all vendors currently doing business with the District, as failure to respond to this new RFP will impact continued business opportunities. The contract term extends through December 31, 2026, with all proposals required to include shipping and handling costs to the District's San Antonio location.
The workbook serves as the detailed pricing and specification document for evaluating vendor proposals for medical TPA and PBM services. All vendors are required to submit complete responses addressing the services outlined in the workbook, which includes detailed cost structures, service delivery requirements, and administrative capabilities. The existing contract expiration date of December 31, 2026, establishes the timeline for contract transition and implementation of the new vendor arrangement.
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References
| Instructions: Enter the carrier name in the header. Provide a list of three (3) current and former clients/groups with 500+ employee lives (local government references preferred). We will contact the carrier prior to contacting any references. Reference checks will only be conducted for finalists. |
| CURRENT |
| Client/Group Name: |
| Contact Name: |
| Phone Number: |
| Email: |
| Effective Date: |
| Services: |
| Client/Group Name: |
| Contact Name: |
| Phone Number: |
| Email: |
| Effective Date: |
| Services: |
| Client/Group Name: |
| Contact Name: |
| Phone Number: |
| Email: |
| Effective Date: |
| Services: |
| FORMER |
| Client/Group Name: |
| Contact Name: |
| Phone Number: |
| Email: |
| Service Dates: |
| Termination Date & Reason: |
| Client/Group Name: |
| Contact Name: |
| Phone Number: |
| Email: |
| Service Dates: |
| Termination Date & Reason: |
| Client/Group Name: |
| Contact Name: |
| Phone Number: |
| Email: |
| Service Dates: |
| Termination Date & Reason: |
Carrier _________________________
References
INPUT
| Client Name | Northside Independent School District | ||
| RFP # | 2026-076 | ||
| Client Address | 510 W. 9th Street | ||
| SIC Code | 9111 | ||
| Type of Client | K-12 School | ||
| Full-Time Employees | 14,700 | ||
| Products Requested | Medical TPA and Pharmacy Benefit Management Services | ||
| Requested Effective Date | 1/1/27 | ||
| RFP Release Date | 4/14/26 | ||
| Vendor Questions Due | 4/23/26 | ||
| RFP Due Date | 05/06/2026 @ 2PM CST | ||
| BAFO Due Date | It is not guarranteed that there will be a BAFO round. We ask that you provide your best response. | ||
| Vendor Interviews Date(s) | 05/14/2026, if required | ||
| Award Date | Earliest - June 2026 | ||
| Benefit Admistration System | Bswift | ||
| Alliant Contact Names | John Shores | ||
| Alliant Contact Emails | John.Shores@alliant.com | ||
| Internal Only - Special Instructions for RFP Team i.e. set carriers to include which reps to utilize etc. | |||
| Group Background/History for Carriers | Northside Independent School District (Northside ISD) is a school district headquartered in Leon Valley, Texas. With nearly 98,000 students and 13,000 employess across 133 schools, it is the largest school district in the San Antonio area and the fourth largest in the State of Texas. | ||
| Products Requested | Requested Proposals | ||
| Medical | ASO | ||
| Stop Loss | NO | ||
| Medical TPA | |||
| General | Response | ||
| Current TPA | UHC | ||
| With Carrier Since | 1/1/16 | ||
| Requested Contract Length | 3 years w/ 2 optional renewal years there after | ||
| Current Funding | ASO | ||
| Enrolled | 9700 | ||
| Retiree Coverage | 5 Retirees are grandfathered into the plan | ||
| Eligibility | 20 hours per week | ||
| Waiting Period | |||
| ER Contribution Strategy | Aggregate 70% | ||
| Current Broad Network | UHC Choice, Choice Plus and NexusACO | ||
| Current High Performance / HMO | NexusACO | ||
| Traditional PPO Plans # | 3 | ||
| High Performance / HMO Plans # | 1 | ||
| HDHP Plans # | 2 | ||
| Requested Networks | NISD plans include a choice of network options. NISD expects a robust perferred provider network with focus on physicians and facilities within Bexar and surrounding counties for active employees, as well as a satisfactory network for out of area dependents, as aligned with the current plan options in force today. | ||
| Requested Plan Designs | Please reference the Plan Design tab where the current plan designs are included. We request that you match current plan designs. | ||
| Allowances/Credits | Response | Details | |
| Annual Allowance - Wellness | YES | $650,000.00 | |
| Annual Allowance - Communications | YES | $100,000.00 | |
| Credit - Implementation | YES | $210,000.00 | |
| Credit - Technology | NO | ||
| Commission | NO | 0% | |
| Onsite - Account Management | YES | This is not currently in place. Please quote this on an a la carte basis. | |
| Onsite - Wellness Coordinator | NO | This is not currently in place. Please quote this on an a la carte basis. | |
| Clinic | NO | There is currently an onsite clinic managed by Memorial Hermann. This will continue into future plan years. Employees are not charged for use of the Clinic. | |
| Carrier Requests | Response | Details | |
| Repricing | YES | File Provided | |
| Carrier Provided Discounts | YES | File Provided | |
| Discount Guarrantee | YES | Carrier Standard | |
| Claim Target Guarrantee | YES | Carrier Standard | |
| Trend Guarrantee | YES | Carrier Standard | |
| Performance Guarrantee | YES | Carrier Standard | |
| Program Requests | Program Name | Current Vendor | Details / Request |
| Program 1 | Wellness | UHC | Rally - Optum Engage |
| Program 2 | Maternity | Maven through UHC | Runs through claims wire |
| Program 3 | Biometric Screenings | UHC | UHC arranges on-site biometric screenings in partnership with Quest Diagnositics |
| Program 4 | Behavioral Health | UHC | Runs through claims wire |
| Program 5 | |||
| Program 6 | |||
| Program 7 | |||
| Program 8 | |||
| Data | Response | ||
| Data Included in RFP | |||
| Special Instructions | This is a public bid request. As a result, it is critical that you comply with public bid requirements and submit your formal proposal through the procurment portal provided. We ask that you provide as many services as possible on an a la carte basis in your proposal. We also ask that you clearly differntiate between fixed fees and costs that will be billed through the claim wire in your proposal. |
| Vendor Exhibits | Response |
| Exhibit 1 | Completed Workbook |
| Exhibit 2 | Proposal |
| Exhibit 3 | Details on all vendor guarrantees (can be included in proposal) |
| Exhibit 4 | Provider Disruption Report |
| Exhibit 5 | Claims Repricing File |
| Exhibit 6 | Sample Reporting |
| Exhibit 7 | Third Party Validation Studies (where applicable) |
| Exhibit 8 | |
| Reinsurance | |
| General | Response |
| Carrier | |
| With Carrier Since | |
| ISL Contract | |
| ISL Deductible | |
| Aggregating ISL | |
| ASL Contract | |
| ASL Corridor | |
| Current Lasers | |
| No New Lasers | |
| 2nd Year Rate Cap | |
| Mirror Plan Document | |
| Commission |
mailto:John.Shores@alliant.com Cover Page
ERROR:#REF!
The information in this document is submitted solely for internal evaluation purposes, with the express understanding that it will not be disclosed, reproduced or used for any purpose other than internal evaluation, without the prior express written consent of Alliant.
© 2025 Alliant Insurance Services, Inc. All rights reserved. Alliant Employee Benefits, a division of Alliant Insurance Services, Inc. CA License No. 0C36861 Northside Independent School District 1/1/2027 Plan Effective:
RFP Released:
Tim Brown <Tim.Brown@alliant.com> Wayne Levitt <Wayne.Levitt@alliant.com>
Medical Overview
| Northside Independent School District | |||
| January 1, 2027 | |||
| Medical Plan Information | |||
| General Information | |||
| Group Name | Northside Independent School District | ||
| Requested Effective Date | January 1, 2027 | ||
| Requested Contract Length | 3 years w/ 2 optional renewal years there after | ||
| Current Funding | ASO | ||
| Requested Funding | ASO | ||
| Enrolled Lives | 9700 | ||
| Current Networks | |||
| Current Broad Network | UHC Choice, Choice Plus and NexusACO | ||
| Current High Performance / HMO | NexusACO | ||
| Requested Networks | NISD plans include a choice of network options. NISD expects a robust perferred provider network with focus on physicians and facilities within Bexar and surrounding counties for active employees, as well as a satisfactory network for out of area dependents, as aligned with the current plan options in force today. | ||
| Current Plan Designs | |||
| Traditional PPO Plans # | 3 | ||
| High Performance / HMO Plans | 1 | ||
| HDHP Plans | 2 | ||
| Total Plans | 6 | ||
| Requested Plans | Please reference the Plan Design tab where the current plan designs are included. We request that you match current plan designs. | ||
| Requested Commissions | |||
| Medical Commission | NO | ||
| Amount | 0.0% | ||
| Requested Allowances | |||
| Annual Allowance - Wellness | $650,000 | ||
| Annual Allowance - Communications | $100,000 | ||
| Credit - Implementation (One-Time) | $210,000 | ||
| Annual Audit Allowance | $30,000 | ||
| Requested Resources | Notes | ||
| Onsite - Behavioral Health | NO | This is not currently in place. Please quote this on an a la carte basis. | |
| Onsite - Wellness Coach | No | This is not currently in place. Please quote this on an a la carte basis. | |
| Requested Programs / Solutions | Current Vendor | Notes | |
| Wellness | UHC | Rally - Optum Engage | Rally - Optum Engage |
| Maternity | Maven through UHC | Runs through claims wire | Runs through claims wire |
| Biometric Screenings | UHC | UHC arranges on-site biometric screenings in partnership with Quest Diagnositics | UHC arranges on-site biometric screenings in partnership with Quest Diagnositics |
| Behavioral Health | UHC | Runs through claims wire | Runs through claims wire |
| Requested Guarrantees | |||
| Discount Guarrantee | YES | Carrier Standard | |
| Claim Target Guarrantee | YES | Carrier Standard | |
| Trend Guarrantee | YES | Carrier Standard | |
| Performance Guarrantee | YES | Carrier Standard | |
| Additional Information | |||
| Additional Notes | This is a public bid request. As a result, it is critical that you comply with public bid requirements and submit your formal proposal through the procurment portal provided. We ask that you provide as many services as possible on an a la carte basis in your proposal. We also ask that you clearly differntiate between fixed fees and costs that will be billed through the claim wire in your proposal. |
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Medical Admin Pricing
| Northside Independent School District | |
| ASO Medical Pricing Sheet | |
| Company Legal Business Name: | <<INSERT YOUR COMPANY NAME HERE>> |
In order to ensure we're measuring all financial elements correctly, please clearly outline your proposed solutions for this project. Please also ensure you line up network / costs as it compares to Northside Independent School District's current plan offerings to ensure we accurately capture your proposed intent.
| Vendor Name | UHC | Proposing Vendor Name | Proposing Vendor Name |
| Proposed Network | UHC Choice, Choice Plus & NexusACO | ||
| Base Administration Fee | |||
| Current | $46.59 | ||
| RX Admin Fee credit | $0.00 | ||
| Net Fee | $46.59 | ||
| 2027-2028 Plan Year (PEPM) | |||
| 2028-2029 Plan Year (PEPM) | |||
| 2029-2030 Plan Year (PEPM) | |||
| 2030-2031 Plan Year (PEPM) | |||
| 2031-2032 Plan Year (PEPM) | |||
| Notes | Please show the base admin berfore any discounts/credits have been applied. RX credits will be captured in the RX tab and factored into the overall analysis. If you are a point solution bidding only on a specific management program. Please list your fees in the "additional program" section below. | ||
| Additional Programs/Service Fees | |||
| Enhanced Member Services Program | |||
| Network Access Fee | |||
| Disease Management - Congestive Heart Failure | |||
| Disease Management - Chronic Obstructive Pulmonary Disease | |||
| Disease Management - Diabetes | |||
| Disease Management - Asthma | |||
| Utilization Management | |||
| Behavioral Health Solutions | |||
| Weight Loss/Management | |||
| Wellness with rewards tracking | |||
| Behavioural Health | |||
| Claim Fiduciary | |||
| Second Opnion Services | |||
| Maternity Program | |||
| Buy-Up Case Management Program | |||
| MSK Program | |||
| Telemedicine | |||
| Non-Network Claim Negotiation Services | |||
| Transplant COE network/negotiation | |||
| Fraud, Waste, Abuse Management Program | |||
| Subrogration Services | |||
| Credit Balance Recovery | |||
| Injury Coordination Coverage | |||
| Focused Claim Review | |||
| Hospital Bill Audit Program | |||
| EAP | |||
| COBRA Administration | |||
| SBC & SPD Creation | |||
| Enter Additional Program | |||
| Enter Additional Program | |||
| Enter Additional Program | |||
| Enter Additional Program | |||
| Enter Additional Program | |||
| Enter Additional Program | |||
| Additional Programs | Please show all programs possible as a la carte expenses. If unable to offer a program a la carte from the base fee, please list it as "included" in the fee section above. Please include claim fiduciary as an additional program above. If there are claim wire expenses please outline those in the appropriate program cell. | ||
| Integration Fees | |||
| Third Party Pharmacy PBM Eligibility Fees | NA | ||
| Third Party Pharmacy PBM Accumulator Fees | NA | ||
| Third Party Reinsurance Integration Fees | NA | ||
| Third Party Reinsurance Integration Fees | NA | ||
| Benefit Administration EDI/API feeds | No |
| Allowances Included | |
| Wellness $ | $650,000 |
| Confirm Wellness Allowance is annual (each year of contract) | YES |
| Communications $ | $100,000 |
| Confirm Communications Allowance is annual (each year of contract) | YES |
| Implementation $ | $210,000.00 |
| Audit $ | $30,000 |
| Confirm Communications Allowance is annual (each year of contract) | YES |
| Notes | Please reference "Medical Overview" tab for requested allowances. Those listed above reflect current. |
| Onsite Resources | |
| Service Respresentative | Included |
| Wellness Coordinator | Not currently included. Please quote a la carte. |
| Onsite Resources | Please outline how onsite resources will be expensed. Please break this out by position. |
| Guarrantees | |
| Claim Target Guarantee / Penalty Corridor (PEPM) | Go to Additional Guarantees tab |
| Network Discount Target Guarantee / Penalty Corridor (Discount %) | Go to Additional Guarantees tab |
| Performance Guarrantee | Go to Additional Guarantees tab |
| ALL FIXED PROGRAM COSTS MUST BE DISCLOSED ON THIS SPREADSHEET. |
Vendor - General
| Northside Independent School District | ||
| January 1, 2027 | ||
| Proposal Specifications | ||
| General | ||
| Category | Question | Vendor Response |
| Organization | Enter vendor name in the response cell | |
| Organization | In what year was your organization founded. | |
| Organization | Describe the ownership structure of your company. | |
| Organization | What is the total number of employer clients that you have for the services you are proposing? What is the average size of your client as well as the largest? | |
| Organization | What is the name of your parent organization if you have one? | |
| Organization | How many local goverment institutions do you provide similar services for? | |
| Organization | Please provide the number of employees in your organization. | |
| Organization | Please provide the ratings of your company (A.M. Best, Moody's, Standard & Poor's). | |
| Organization | If you plan on using any third-party organizations please provide a detailed list of who will participate in the execution of the services you will provide as a part of your proposal response (name, nature of relationship, length of affiliation). | |
| Organization | To the extent applicable, are you now and will you remain duly licensed and in full compliance with all federal and state statutory administrative requirements? | |
| Organization | Are you able to offer your services in all 50 states? If not, please clarify where you are unable to do business. | |
| Administration | Do you require a deposit or imprest claims? If so, how much do you require? | |
| Administration | Your proposal will become part of the final contract by reference. Indicate your agreement to this requirement. | |
| Administration | Describe your client billing process. | |
| Administration | Please confirm that your organization will handle disabled dependent verification. If there is an additional charge please outline the charge. | |
| Administration | With respect to ID cards: | |
| Administration | Do you charge a fee for card preparation? | |
| Administration | Do you charge for replacement cards? | |
| Administration | Can you put the plan sponsor name and logo on the ID cards? Is there an additional cost for this? | |
| Administration | Can you do a combination medical / Rx card (if the PBM is carved-out currently or in the future)? Is there an additional cost for this? | |
| Administration | Describe your eligibility file feed process. Do you charge additional fees for API/EDI integrations? If so, please outline those charges. | |
| Administration | How often is membership updated? | |
| Administration | Can you maintain membership by employee and dependent? | |
| Administration | What media types do you accept for plan enrollment? | |
| Administration | You are in compliance with all HIPAA Privacy, Electronic Data Interface (EDI) and Security Regulations and will use HIPAA 834 (ASC X12N 834) for the file transmission layout. | |
| Administration | Does your organization currently interface with Workday as a benefit administration sytem? If so, please confirm your ability and experience working to integrate eligibilty feeds with this system. | |
| Administration | Please address how your firm handles HIPAA and security breaches. Please include the number of HIPAA and security breaches your firm has experience in the past 5 years including the number of individuals impacted by each breach. | |
| Administration | Do you allow outside claim audits? Describe any limitations. | |
| Administration | Briefly outline your standards/procedures for quality control in your claims processing center. | |
| Administration | Will claims funding be handled on a checks issued, or checks cleared basis. | |
| PBM Integration | Should the City choose another carrier to manage their Pharmacy Benefits Plan, will you be willing and able to work with another vendor? What preferred prescription vendors do you currently work with? Will there be a cost for data integration? | |
| PBM Integration | If the Pharmacy Benefit Manager services are placed with another carrier, will your organization be capable of including the prescription plan information (including logos) on the Medical ID cards? | |
| Contract | Please confirm your organization will be ready to begin services on the effective date confirmed in this RFP. | |
| Contract | Please confirm the length of the contract you are offering. | |
| Contract | Please confirm the termination terms of the contract you are proposing. Please clarify specifically any financial penalties that may be incurred for a termination of the contract by the group. | |
| Contract | The vendor will be responsible for producing the Summary Plan Description. The group reserves the right to review / revise the SPD prior to final printing. | |
| Contract | You have reviewed and accept the Plan’s eligibility provisions. | |
| Contract | Vendor agrees to comply with the Performance Guarantees, and penalties for non-compliance, as provided in this RFP. | |
| Contract | Vendor has specifically listed all deviations from the RFP and coverage requirements. NOTE: Deviations MUST be listed; vendors cannot simply make “general” references to the proposal. | |
| Contract | Vendor agrees to provide a dedicated reporting contact for the Client and its Consultant. This person would be responsible for running ad hoc reports at the client's and/or its Consultant’s discretion, at no additional cost to the Client. | |
| Contract | The group intends to include your RFP responses as part of the overall Contract. Please acknowledge you understand and agree to this expectation. | |
| Implementation | Please provide a sample implementation timeline assuming the initial kickoff call is April 27, 2026. | |
| Implementation | What is the normal lead-time required to implement a group? | |
| Implementation | How many team members will be dedicated to implementing this group if selected? | |
| Implementation | Have you included an implementation allowance for the group? If so, please describe how the group will access that i.e. credit after providing an invoice etc? Please also describe any limitations around accessing this allowance. | |
| Reporting | Please confirm that you will not charge for ad hoc reporting. | |
| Reporting | Please describe, in detail, the reporting that will be made available to the group. Please include the frequency this reporting will be provided. | |
| Service | Please provide the name and title of the executive sponsor that will be assigned to this account. | |
| Service | How many individuals will be assigned to this account? | |
| Service | Please provide the titles of the individuals that will be assigned to this account. | |
| Service | Where will the service team that manages this account be located? | |
| Service | Please confirm that you will plan a minimum of quarterly, onsite, utlization meetings with the group. | |
| Service | Please confirm that the service team can attend bi-weekly service calls with the client. | |
| Service | Where is the member services call center located that would service this account. | |
| Service | Are there any employees contractors or otherwise that will service member needs on this account that are located outside of the US? If so, please explain. | |
| Service | Are there any employees contractors or otherwise that will access data related to this account that are located outside of the US? If so, please explain. | |
| Service | Will any of this groups employer data or member data be stored outside of the US? If so, please explain. | |
| Service | Vendor agrees to provide benefit summaries SBCs within 90 days ahead of annual enrollment meetings starting. | |
| Service | Vendor agrees to provide all plan communication materials in electronic (pdf) format. |
Medical - Standard Network
| Northside Independent School District | ||
| January 1, 2027 | ||
| Network Contractual | ||
| Category | Question | Vendor Response |
| Organization | Enter vendor name in the response cell | |
| Network | We are requesting a Disruption report BY plan/network. The Muncipality has three different plans, with varying networks. Disruption reports for each plan must be on a 'PAID' claims basis and total number of provider matches. Each line item must note the match (Yes/NO) and a summary report on the two criteria noted must be included. Use your proposed network for each plan to match against each plan individually. | |
| Network | Conffirm your organization has online capabilities in the following areas: |
1) Provider selection – tools that will help members select reputable and effective providers
2) Quality comparison – tools that will help members compare quality outcomes of providers and facilities
3) Price comparison – tools that will allow members to compare the price for services of various providers.
| Network | Please provide some commentary regarding your organizations approach to Centers of Excellence networks, as well as your efforts to ensure Providers and Facilities in your networks meet or exceed all HEDIS measures? |
| Network | Please CONFIRM you have listed any and all capitations and/or any other fees that would be going through the claims funding ACH account in the ASO Pricing Sheet tab and Shared Savings Tab. |
| Network | Describe how out-of-network providers are reimbursed by your organization. Provide an overview of your process, including discussion on initiatives to negotiate single case provider contracts. |
| Network | Discuss your ability to offer “navigating tools” and strategies to direct patient care to lower cost procedural codes like OP X-Ray and Lab services. |
| Network | Provide details on how your plan handles out-of-area dependents, specifically as it relates to limited-network plans. |
| Network | How are out of network allowable amounts determined? Please explain methodology and any partnerships or vendors used in the determination of reasonable and customary. |
| Network | Describe the following: |
| Network | Provider Selection Process |
| Network | Credentialing Process |
| Network | Recredentialing Process |
| Network | Please confirm if your behavioural health in-network providers fall under a capitated or fee-for-service model. |
| Network | Does your broad network option have "preffered" provider desginations within it? If so, please explain. |
| PCP Refferals | Do you any of your network plans require a PCP selection and/or referrals to specialists? If so, please elaborate. |
| PCP Refferals | Please confirm how long it would take a member to switch to a different designated PCP in the middle of the plan year. |
| PCP Refferals | Please confirm your process if a member does not elect a PCP i.e. auto-assignment, delayed care etc. |
| PCP Refferals | If the group chooses to elect a set provider group as the auto-selection for the initial PCP selection when a member does not select a PCP, can your system administer this arrangement? |
| PCP Refferals | If the group chooses to select their employer health clinic as the auto-selection for the initial PCP selection when a member does not select a PCP, can your system administer this arrangement? |
| Retail Clinics | Does your network include clinician-staffed clinics in a retail setting? (e.g. RediClinic, etc.) Please elaborate. |
| Shared Savings | Discuss your Claim subrogation process and recovery fees charged to the plan. |
| Shared Savings | Discuss internal quality assessment programs; internal audit procedures including additional protocols in place for ICD-10 accuracy. |
| Shared Savings | Discuss fraud and abuse programs. |
| Shared Savings | Please confirm your proposals do not include this. If so, please clearly outline below when Shared Savings Arrangements would be applied and clearly outline any fees/costs associated with such programs. |
| Shared Savings | For each situation listed below please confirm if you will be utilizing a rental network, repricing using a Medicare fee scheudle or clarify how you will reprice claims. If a portion of the negotiated savings is to be retained for this non-network claim negotiation please confirm what that would be. |
| Shared Savings | Voluntary Non-Network: Member had alternatives that were in-network but chose not to use them. |
| Shared Savings | Involuntary Non-Network: Member had no decision to make i.e. Radiology, Pathology, Anesthesiology, or Emergency. |
| Shared Savings | Confirm if you organization is able to administer adjudicating ALL non-network claims as a % of medicare established by the group. |
| Shared Savings | Confirm if you organization is able to administer adjudicating only voluntary (a member was not in an emergency or RAP provider scenario ) non-network claims as a % of medicare established by the group. |
| Shared Savings | How would non-network air ambulance claims be adjudicated under your standard administrative service agreement? |
| Shared Savings | Is there a potential that you would utilize a network arrangement that you do not own/operate i.e. rental network for any claims as the administrator of this plan? If so, please clarify the scenarios in which this would take place. Please also clarify how network fees are accessed to access this rental network. |
| Specific Providers | There are several key health systems that the group would like to confirm are in-network as well as the length of your current contract agreement. For each network quoted please confirm the date your current agreement terminates and where negotiations currently sit. |
| Specific Providers | Ascension Seton Health System |
| Specific Providers | Ascension - Dell Childrens Medical Center |
| Specific Providers | St. Davids Health System |
| Specific Providers | Baylor Scott & White Health System |
| Specific Providers | Austin Regional Clinic |
| Specific Providers | Austin Diagnostic Clinic |
| Specific Providers | Texas Childrens Medical Center - (Austin and Houston) |
| Specific Providers | MD Anderson Cancer Center |
| Specific Providers | Airrosti |
Med - High Performance Network
| Northside Independent School District | If quoting multiple High Perofrmance Networks please breakout your response specific to each network. | |
| January 1, 2027 | ||
| Network Contractual | ||
| Category | Question | Vendor Response |
| Organization | Enter vendor name in the response cell | |
| Organization | How long has this High Performance Network product been offered in the client's immediate geography? | |
| Organization | How many public entity clients do you currently have that utlize the High Performance Network(s) that you are proposing. | |
| Organization | How many enrolled members do you currently have that utlize the High Performance Network(s) that you are proposing. | |
| Organization | What is the average size employer group enrolled in the High Performance Network(s) that you are proposing. | |
| Organization | Is your High Performance Network offered in partnership with a set healthcare provider group or system? If so, which group(s)? | |
| Organization | If your High Performance Network is with a set healthcare system i.e ACO arrangement, when does the current contract between your organization and this system end if not renewed? | |
| Administration | Will your organization manage utlization and case management on the High Performance Plans? If not, please clarify. | |
| Administration | Please clarify how the providers participating in the High Performance Network have "skin-in-the game" when it comes to both finacial performance and quality measures. | |
| Administration | Does your plan have the ability to administer either a 3 tier plan design (HPN / Broad Network / Non-Network), two tier plans design (HPN / Broad Network), or one-tier network (HPN providers only)? | |
| Administration | Do you require plan designs to set cost share arrangements with set differentials inside of the plan design i.e. the HPN deductible must be $X higher than the non-HPN tier? | |
| Administration | Are there any carrier provided programs or services that are mandated as part of the High Performance Network i.e. Disease Management, PBM Carved-In etc? If so, please clarify which programs are required. | |
| Administration | Would the group be prohibited from using a third-party Telemedicine vendor for members that enroll in the High Performance Network. If so, please clarify. | |
| Administration | Please confirm that your organization would be willing to offer the High Performance Network as a plan option alongside one or multiple broad network options allowing members to choose the plan that fits them best. If so, do you have any cost-share or member premium differential requirements between plans? | |
| Administration | In scenarios where the High Performance Network is offered alongside Broad Network plans, please confirm if there are enrollment minimums in the High Performance Network. | |
| Communications | Are your standard network search capabilities inclusive of the High Performance Network as an option for members to search for a provider? | |
| Communications | What additional tools will be used/available to help members utilize a smaller High Performance Network in order to avoid ending up out-of-network? | |
| Contracting | Describe how your organization prices out-of-network claims and the measures you take to ensure the District's overall costs are being minimized when Out-of-Network utilization occurs. | |
| Disruption | Please confirm that you have included the High Performance Networks in the disruption report that was requested. | |
| Financial | According to you book of business, what is the average % savings achieved when comparing your High Performance Network to your main Broad network option in this market. If you are proposing multiple High Performance network options, please break this out for each one. | |
| Financial | Are you achieving a true "unit cost" concession from the providers inside fo the High Performance Network that you are proposing or is the negotiated rate with the providers in the HPN network the same as broad network? | |
| Financial | Are there any in-network providers under the High Performance Network proposed i.e. behavioral health that would not fall under either a capitated arrgangement or be considered part of the ACO provider group? If so, how are their claims adjudicated and would they be removed from consideration when calculating a potential performance payment? | |
| Financial | Does your High Performance Network(s) include capitiation or attribution payments to providers that participate within the network? Please answer YES or NO. | |
| Financial | How often are attribution or capitiation payments made to the High Performance Network Providers? | |
| Financial | Can the client be responsible for additional provider or vendor "performance" payments to the High Performance Network(s) providers if certain metrics are achieved? | |
| Financial | How often are provider performance payments calculated and when would they be calculated for this client? | |
| Financial | If peformance payments are part of your arrangement will the client's payment be individually calculated based solely on their plans performance OR will they be pooled with other customers to determine if the performance payment is due? | |
| Financial | If performance payments are part of your arrangement is there a potential for the provider to lose or payback money if they do not meet the set performance metrics? If so, please clarify how the client's payback would be calculated and payment made. | |
| Financial | Please provide the formula that is utilized to identiy the prior year "claims baseline" that current year claims are being compared to in order to determine year-end financial performance. | |
| Financial | What Medical and RX trend is being currently utlized to compare potential claims spend vs actual claims spend in the year-end financial performance calculation. | |
| Financial | Are RX claims a component of your year-end financial performance payment calculation or reporting? | |
| Financial | Are provider performance payments tied to quality metrics in addition to financial results. If so, which metrics are used? | |
| Financial | How many quality metrics can a provider group "miss" on before they see financial penalties. How are those financial penalties determined? | |
| Financial | Are the quality metrics that are utilized to determine a performance based solely on the groups results OR are thay based on a pool of customers? | |
| Financial | If your arrangement includes a capitation or attribution payment how is a member "attributed" to a set provider group? For example, would the member start being attributed once they designate a PCP or upon having their first visit with the provider group? | |
| Network | If a member has covered childre(n) that live outside of the service area of the High Performance Network how are those claims adjudicated? | |
| Network | If a member has medical claims that take place outside of the service area of the High Performance Network how are those claims adjudicated? | |
| Network | If there is a center of excellence that is outside of the High Performane Network but needs to be utilized, how will those claims be adjudicated? | |
| Network | Is your High Performance Network specific to certain counties? If so, please confirm the counties within the group's immediate geography of the group that are eligible. | |
| Network | Can your High Performance Network plans be offered to members that live outside the service area but work inside the service area i.e. Live/Work rule? | |
| Network | Please confirm the number of providers that are part of your High Performance Network group broken out by each category below. | |
| Network | PCPs | |
| Network | Specialists | |
| Network | Urgent Care Centers | |
| Network | Emergency Rooms | |
| Network | Outpatient Surgical Centers | |
| Network | Outpatient Imaging Centers | |
| Network | Inpatient Facilities | |
| PCP Refferals | Does the High Performance Network you proposed mandate a member get refferals from a PCP in order to see a specialist? | |
| PCP Refferals | Please confirm how long it would take a member to switch to a different designated PCP in the middle of the plan year. | |
| PCP Refferals | Please confirm your process if a member does not elect a PCP i.e. auto-assignment, delayed care etc. | |
| PCP Refferals | If the group chooses to elect a set provider group as the auto-selection for the initial PCP selection when a member does not select a PCP, can your system administer this arrangement? | |
| Retail Clinics | Does your High Performance Network(s) include clinician-staffed clinics in a retail setting? (e.g. RediClinic, etc.) Please elaborate. | |
| Shared Savings | For each situation listed below please confirm if you will be utilizing a rental network, repricing using a Medicare fee schedule or clarify how you will reprice claims. If a portion of the negotiated savings is to be retained for this non-network claim negotiation please confirm what that would be. | |
| Shared Savings | Voluntary Non-Network: Member had alternatives that were in-network but chose not to use them. | |
| Shared Savings | Involuntary Non-Network: Member had no decision to make i.e. Radiology, Pathology, Anesthesiology, or Emergency. | |
| Shared Savings | Confirm if you organization is able to administer adjudicating ALL non-network claims as a % of medicare established by the group. | |
| Shared Savings | Confirm if you organization is able to administer adjudicating only voluntary (a member was not in an emergency or RAP provider scenario ) non-network claims as a % of medicare established by the group. | |
| Shared Savings | How would non-network air ambulance claims be adjudicated under your standard administrative service agreement? | |
| Shared Savings | Is there a potential that you would utilize a network arrangementthat you do not own/operate i.e. rental network for any claims as the administrator of this plan? If so, please clarify the scenarios in which this would take place. Please also clarify how network fees are accessed to access this rental network. | |
| Specific Providers | Specific to the HPN networks proposed, please confirm if the providers listed below are in-network providers. For each network quoted please confirm the date your current agreement terminates and where negotiations currently sit. | |
| Specific Providers | Ascension Seton Health System | |
| Specific Providers | Ascension - Dell Childrens Medical Center | |
| Specific Providers | St. Davids Health System | |
| Specific Providers | Baylor Scott & White Health System | |
| Specific Providers | Austin Regional Clinic | |
| Specific Providers | Austin Diagnostic Clinic | |
| Specific Providers | Texas Childrens Medical Center - (Austin and Houston) | |
| Specific Providers | MD Anderson Cancer Center | |
| Specific Providers | Airrosti |
UM-CM
| Northside Independent School District |
| January 1, 2027 |
| Case/Utilization Management | ||
| Category | Question | Vendor Response |
| Organization | Enter vendor name in the response cell | |
| Organization | What is your liability coverage for pre-admission review? Do you agree that the Client will be held harmless in any suit filed by a subscriber against the company? | |
| COB | What are your normal COB procedures? | |
| COB | How are COB savings tracked in the system? | |
| Pre-certification | Is Utilization or Case Management managed by an outside vendor for any services? If so, please clarify. | |
| Pre-certification | Do you have a standard pre-certification requirement for any of the following: |
(Respond YES / NO)
| Pre-certification | Hospitalizations |
| Pre-certification | Outpatient Surgery |
| Pre-certification | Specified Diagnosis Procedures |
| Pre-certification | Durable Medical Equipment |
| Pre-certification | Corrective Appliances / Prosthetics |
| Pre-certification | Skilled Nursing Facility |
| Pre-certification | Home Health Care |
| Pre-certification | Musculoskeletal Services (e.g. chiropractic) |
| Pre-certification | Medical Services (e.g. physical therapy) |
| Pre-certification | Inpatient Mental Health / Substance Abuse |
| Pre-certification | Outpatient Mental Health / Substance Abuse |
| Pre-certification | Other |
| Pre-certification | Does precertification include the analysis and determination of any of the following: |
| Pre-certification | Appropriate level of care (e.g., IP vs. OP) |
| Pre-certification | Reasonable length of stay of IP confinement |
| Pre-certification | Actual medical necessity & appropriateness of surgery or service being requested (e.g., does service require performance?) |
| Pre-certification | Necessity for the services of an assistant surgeon with each operative procedure analysis |
| Pre-certification | Necessity for a proposed preoperative hospital day |
| Pre-certification | Necessity for a proposed 23-hour observation stay following OP surgery |
| Pre-certification | Other (Explain) |
| Pre-certification | Within the past twelve months, in what percentage of all precertification cases was a letter of noncertification (denial) for Medical Necessity / Appropriateness for the procedure/service issued? |
| Peer-to-Peer Review | What percentage of ALL pre-service reviews requires your physician advisor review for decision making? |
| Peer-to-Peer Review | What is your Medical Director to Member Ratio? |
| Concurrent Review | Does your organization perform concurrent review services? |
| Communications | Describe your Advocacy process of transitional care form in-hospital to out-patient settings. |
| Staffing | Please advise the following for the concurrent review staff (should total 100%): |
| Staffing | % of Full-time employees of the UM team |
| Staffing | % of Part-time employees of the UM team |
| Staffing | % Subcontracted/Consulting reviewers (e.g., on-call only, registry, home health agency personnel) |
| Savings | Indicate your standard method of reporting savings from the review of IP hospitalization. |
| Savings | Indicate your standard method of reporting savings from the review of OP hospitalization. |
| Bill Review Audits | Does your organization perform hospital bill audits? If yes, describe the program and the basis of your compensation. |
Disease Management
| Northside Independent School District |
| January 1, 2027 |
| General Disease Management | ||
| Categtory | Question | Vendor Response |
| Organization | Enter vendor name in the response cell | |
| Organization | Please confirm the number of clients you have that you currently manage general disease management services for. | |
| Organization | Please confirm the number of covered members that you currently utilize your general disease manaegment programs. | |
| Organization | Please confirm the number of current covered members that would be eligible to have access to your program(s) should they become eligible based on program requirements. | |
| Organization | Is your DM program developed internally, or provided through an outside vendor? If an outside vendor, please indicate the name(s) of the firm(s). If you have models are are both in-house and outside partnerships, please elaborate on those programs. | |
| Financial | Is there an implementation fee for your services? If so, please clarify. | |
| Financial | Are there fees to integrate with third party TPAs and/or benefit administration systems? If so, please clarify. | |
| Financial | Please confirm your fees / pricing | |
| Financial | Can your pricing change if the group enrollment or headcount changes during the contract period? If so, please clarify. | |
| Financial | Do you have third party validated program outcomes? If yes provide details and verification report(s). | |
| Financial | Is your pricing based on a PEPM, Per Participant Per Month, or Claim Charge. If there are multiple options please list out all options. | |
| Financial | What additional charges can arise that are outside of the charges you have illustrated? | |
| Financial | Specific to DM, are you willing to guarrantee return on investment (ROI)? If yes, please describe terms and conditions in detail. | |
| Financial | Does your proposal include any allowances for communication, implementation, etc specific to your program? If so, please outline them. | |
| Financial | Describe how your organization establishes a claims baseline to evalaute the effectiveness of an engaged member in one of your DM programs. | |
| Financial | Please provide savings / cost avoidance formula used to illustrate annual savings back to your clients. | |
| Prevention | Describe how your DM team gets involved before the standard pre-certification and utilization review procedures for inpatient and outpatient surgical procedures. | |
| Administration | Which medical TPA's are you currently able to integrate with and have current customers in which you do so. | |
| Administration | Discuss the integration capabilities of your managed behavioral healthcare programs with other programs/plans subject to the Mental Health Parity Act, such as EAP and utilization management treatment plans. | |
| Administration | Discuss in detail the integration of all the various data components that feed your predictive model and note any vendors that are outsourced and their function. | |
| Administration | Please explain how your DM program integrates with any other point solution / cost containment programs you may be proposing in this RFP. | |
| Administration | Describe the incentives and rewards that are available through your platform. | |
| Services | Does your organization provide any 24/7 "Nurse Lines"? If so, please provide some commentary regarding this service. | |
| Services | Does your organization provide focused disease management treatment groups? Please provide list each disease state covered in your program. If it varies by tier of your program please outline the variations, by program tier. | |
| Staffing | Please confirm your DM Nurse/Advocate to Member ratio. If it varies by program tier/option please provide the breakout. | |
| Staffing | Are the DM Nurse/Advocates that would support members located in a common office? If not, please explain how the team would be dispersed geographically. | |
| Engagement | Please explain, in detail, what you consider an "engaged/enrolled" member for the purpose of reporting and fees. | |
| Engagement | What is your organizations current BOB engagement rate specific to the DM program(s) being proposed. If it varies by program tier please break it out accordingly. | |
| Engagement | What is the criteria for a member to go from being considered to an "un-engaged" to "engaged" member i.e. X days without contact etc. | |
| Communications | Describe the navigation tools available for increasing member advocacy as a consumer such as OP lab, imaging, ER, Urgent care, etc. | |
| Communications | Discuss your communication efforts and campaigns to engage members identified as high-risk? | |
| Communications | Does your organization offer a mobile app? | |
| Reporting | Please confirm the level of reporting that is available specific to your DM programs. Please provide sample reporting and confirm the frequency in which these reports will be available. | |
| Reporting | How often are you able to provide the group with utilization reporting? | |
| Second Opinion Services | Please confirm if your second opinion services are offered through your organizaiton directly or through a third party partnerhsip. If a third party, please confirm the name of the vendor and how long the partnership has been in place. | |
| Second Opinion Services | Please confim the cost for second opinion services and how your organization bills the client for services. | |
| Second Opinion Services | Specific to Second Opinion Services, are you willing to guarrantee return on investment (ROI)? If yes, please describe terms and conditions in detail. | |
| Second Opinion Services | Please provide an overview of the second opinion services provided in your proposal. | |
| Second Opinion Services | Please confirm the conditions that your second opinion services can manage. | |
| Second Opinion Services | Has your second opinion services results been validated by an independent third party. If so, please provide those results. | |
| Second Opinion Services | Please confirm the number of MDs that are employed by your second opinion service | |
| Second Opinion Services | Please describe how your second opinon service team identifies eligible claims/members. Is your program based on self-refferal or is there outreach to members. |
Wellness
| Northside Independent School District |
| January 1, 2027 |
| General Wellness | ||
| Categtory | Question | Vendor Response |
| Organization | Enter vendor name in the response cell | |
| Organization | Please confirm the number of clients you have that you currently manage general Wellness services for. | |
| Organization | Please confirm the number of covered members that you currently utilize your Wellness programs. | |
| Organization | Please confirm the number of current covered members that would be eligible to have access to your program(s) should they become eligible based on program requirements. | |
| Organization | Is your Wellness program developed internally, or provided through an outside vendor? If an outside vendor, please indicate the name(s) of the firm(s). If you have models are are both in-house and outside partnerships, please elaborate on those programs. | |
| Financial | Is there an implementation fee for your services? If so, please clarify. | |
| Financial | Please confirm your fees / pricing | |
| Financial | Can your pricing change if the group enrollment or headcount changes during the contract period? If so, please clarify. | |
| Financial | Are there fees to integrate with third party TPAs and/or benefit administration systems? If so, please clarify. | |
| Financial | Is your pricing based on a PEPM, Per Participant Per Month, or Claim Charge. If there are multiple options please list out all options. | |
| Financial | What additional charges can arise that are outside of the charges you have illustrated? | |
| Financial | Are you willing to guarrantee return on investment (ROI)? If yes, please describe terms and conditions in detail. | |
| Financial | Please provide savings / cost avoidance formula used to illustrate annual savings back to your clients. | |
| Financial | Does your proposal include any allowances for communication, implementation, etc specific to Wellness? If so, please outline them. | |
| Administration | Which medical TPA's are you currently able to integrate with and have current customers in which you do so. | |
| Administraton | Discuss in detail the integration of all the various data components that feed your predictive model and note any vendors that are outsourced and their function. | |
| Administraton | Please explain how your Wellness program integrates with any other point solution / cost containment programs you may be proposing in this RFP. | |
| Staffing | Please confirm your Wellness Advocate to Member ratio. If it varies by program tier/option please provide the breakout. | |
| Staffing | Are the Wellness Nurse/Advocates that would support members located in a common office? If not, please explain how the team would be dispersed geographically. | |
| Staffing | Are Wellness coaches a component of your proposal? If so, please confirm the Wellness coach to member ratio across your book of business. | |
| Staffing | Will your company provide a Wellness coordinator / consultant for the City assigned to their account? If so, please confirm the title of this individual. | |
| Engagement | Please explain, in detail, what you consider an "engaged/enrolled" member for the purpose of reporting and fees. | |
| Engagement | What is your organizations current BOB engagement rate specific to the Wellness program(s) being proposed. If it varies by program tier please break it out accordingly. | |
| Engagement | What is the criteria for a member to go from being considered to an "un-engaged" to "engaged" member i.e. X days without contact etc. | |
| Engagement | Describe how your Wellness team gets involved before the standard pre-certification and utilization review procedures for inpatient and outpatient surgical procedures. | |
| Engagement | What data is your Wellness team utilizing to make outreach to high-risk members? | |
| Financial | Do you have third party validated program outcomes? If yes provide details and verification report(s). | |
| Financial | Describe how rewards are billed: |
Is prefunding required? Does the client get reimbursed for rewards that were payed for but not cashed out by employees?
| Communications | Provide sample communication material available on your Wellness programs. |
| Communications | Describe the navigation tools available for increasing member advocacy as a consumer such as OP lab, imaging, ER, Urgent care, etc. |
| Communications | Discuss your communication efforts and campaigns to engage members identified as high-risk? |
| Member Tools | Describe your health risk assessment and any unique features. |
| Member Tools | Describe how you integrate with trackers and devices: |
Do you offer an in-house device/tracker?
| Member Tools | Does your organization offer a mobile app? |
| Member Tools | Can you organization build a custom Wellness microsite for the group? If so, is there an additional cost associated? |
| Reporting | Please confirm the level of reporting that is available specific to your Wellness programs. Please provide sample reporting and confirm the frequency in which these reports will be available. |
| Reporting | How often are you able to provide the group with utilization reporting? |
| Savings | Describe how your organization establishes a claims baseline to evalaute the effectiveness of an engaged member in one of your Wellness programs. |
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