5-Dental and Vision Services RFP final .pdf

COOK COUNTY HEALTH (CCH)

REQUEST FOR PROPOSAL

(RFP) NO. H26-25-140

FOR

Dental and Vision Benefit Management Services

GENERAL DESCRIPTION: Cook County Health’s CountyCare Health Plan is seeking to identify competitive, qualified proposers to contract for providing Dental and Vision Benefit Management Services for Medicaid Enrollees. References to Cook County Health (CCH) should not be understood as an offer for services beyond CountyCare.

Date Issued: April 1, 2026

Pre-Proposal Conference/Field Inspection: None

Vendor Questions: Any questions regarding this RFP should be submitted via Bonfire.

Questions submission deadline: April 16, 2026, by 2 p.m. Central Time (CT)

Proposal / Response Due Date:

Proposals are due no later than 2 p.m. CT on May 13, 2026

Proposal Must be Uploaded to:

https://cookcountyhealth.bonfirehub.com/portal/?tab=openOpportunities

LATE PROPOSALS WILL NOT BE CONSIDERED

COOK COUNTY HEALTH

Erik Mikaitis, MD, MBA Charles A. Jones

Chief Executive Officer Chief Procurement Officer

Commented [RC1]: SCM please add number

RFP H6-25-140

Table of Contents

1. Hospital System Background

2 Award

3 Schedule

4 Scope of Services

4.4 HIPAA and Regulatory Compliance

4.5 Compliance Requirements

5 Subcontractor Services

6 Submission of Proposal

6.1 Instructions for Submission

6.1.1 Electronic Submission

6.1.2 Time for Submission

6.1.3 Late Proposals

6.1.4 Schedule of Revisions to RFP Schedule

6.1.5 Complete Proposals

6.2 Submission Requirements

6.2.1 Cover Letter

6.2.2 Executive Summary

6.2.3 Qualifications of the Proposer

6.2.4 Proposed Plan of Action, Implementation and Solution

6.2.5 Key Personnel

6.2.6 MBE/WBE Participation

6.2.7 Financial Status

6.2.8 Conflict of Interest

6.2.9 Contract, Master Service Agreement (MSA)

6.2.10 Legal Actions

6.2.11 Confidentiality of Information

6.2.12 Economic Disclosure Statement

6.2.13 Addenda

6.2.14 Price Proposal

7. Evaluation and Selection Process

7.1 Proposal Assessment

7.1.1 Responsiveness Review

7.2 Evaluation Process

7.3 Selection Process

7.4 Consideration for Contract

8 General Evaluation Criteria

8.1 Responsiveness of Proposal

9 Instructions for Proposers

9.1 Pre-Proposal Conference (if Applicable)

9.2 Availability of Documents

9.3 Questions and Inquiries

9.4 Submitting the Proposal Package

9.5 Uniformity

9.6 Proposal Material

9.7 Addenda

9.8 CCH RFP Format

9.9 Pricing

9.10 Period of Firm Proposal

9.11 Alteration/Modification of Original Documents

9.12 Cost of Proposer Response

9.13 Proposer’s Responsibility for Services Proposed

9.14 RFP Interpretation

9.15 Specifications and Special Conditions

9.16 Errors and Omissions

9.17 Confidentiality and Response Cost and Ownership

9.18 Awards

9.19 CCH Rights

9.20 Cancellation of RFP; Requests for New or Updated Information

10 Definitions

11 List of Attachments

11 Appendix 1-Instructions for Submitting an Electronic Bid/Proposal/Qualification

Request for Proposal (RFP) # H26-25-140

1. Hospital System Background

1.1 Cook County Health

Cook County Health (CCH) provides a wide range of health care services and operates the John H. Stroger, Jr. Hospital of Cook County, a tertiary acute care hospital, and Provident Hospital of Cook County, a community acute care hospital. Cook County Health is also comprised of:

• More than a dozen community health centers offering primary and specialty care and diagnostic services,

• The Cook County Department of Public Health (CCDPH), a certified local public health department serving most of suburban Cook County,

• Cermak Health Services of Cook County, which provides health care services to the detainees in the Cook County Sheriff’s Department of Corrections and to the residents of Cook County’s Juvenile Temporary Detention Center,

• The Ruth M. Rothstein CORE Center, a comprehensive care center for patients with HIV and other infectious diseases, and

• CountyCare, the largest Medicaid managed care plan in Cook County and one of the largest in the northeast region of the state.

CCH’s history and mission to care for all, regardless of their ability to pay, dates to 1835. Since then, CCH has cared for millions of people, trained thousands of doctors and conducted important research that has contributed to modern-day practices in hospitals. We have centers of excellence in trauma, burn and emergency care, oncology, endocrinology, infectious disease and other areas.

We have long been the safety net to the safety net when it comes to caring for the uninsured, a mission that remains today.

CCH is one of the largest public health systems in the United States. As a provider of care, CCH sees approximately 300,000 unique patients annually through more than 1 million outpatient visits and more than 20,000 admissions, including 77,000 detainees at the Cook County Department of Corrections and residents of the Juvenile Temporary Detention Center. We are the largest provider of HIV care in the Midwest and one of the largest in the nation. On an average day, CCH fills 20 times as many outpatient prescriptions as the average commercial pharmacy.

CCDPH is a state- and nationally certified public health authority serving the majority of suburban Cook County.

1.2 Health Plan Services

Health Plan Services (HPS) is a department within CCH that manages CountyCare, a Medicaid managed care plan serving Cook County. In 2013, CCH launched CountyCare as a demonstration project through the Centers for Medicare and Medicaid Services (CMS) 1115 Waiver granted to the State of Illinois’ Medicaid agency to enroll eligible low-income ACA adults in Cook County into a Medicaid managed care program. In July 2014, CountyCare transitioned from the federal waiver authority and subsequently became a Medicaid managed care plan under the State’s County Managed Care Community Network (2018 County MCCN) rules. This transition allowed CountyCare to expand beyond the newly eligible ACA adult population to include traditional Medicaid populations in Family Health Plans (FHP), Managed Long-Term

Services and Supports (MLTSS), Special Needs Children (SNC) and Integrated Care Program

(ICP).

CountyCare receives a capitated per-member (enrollee), per-month (PMPM) rate for every enrollee in its health plan. CountyCare currently has over 386,000 Medicaid enrollees. The CountyCare provider network includes all CCH facilities, every Federally Qualified Health Center (FQHC) in Cook County and more than seventy hospitals. As it develops and grows, CountyCare continues to prioritize innovation, member experience and health equity while establishing itself as a pioneering, provider-led and governed health plan.

2 Award

a. Term of Services The term of services shall be for thirty-six (36) months, with two (2), two- (2) year extension options, if project deliverables are met and at the discretion of HPS.

b. Basis of Award The basis of award shall be to a single or multiple Proposers based on the highest-rated Proposal(s) offering the best value to CCH and meeting the specifications, terms and conditions in accordance with the evaluation criteria set forth in this RFP.

3 Schedule CCH anticipates the following schedule.

Activity Estimated Date

RFP posted to the CCH website April 1, 2026

Pre-Proposal Conference / Site Visit None

Proposer Inquiry Deadline April 16, 2026, by 2p.m. CT

Response to Inquiries (Tentative) Week of April 27, 2026

Proposal Due Date May 13, 2026, by 2 p.m. CT

4 Scope of Services

4.1 Minimum Qualifications

Proposers must meet the below minimum qualifications to be considered for the award.

Proposers should explicitly address the below qualifications in their response to section 4.1.

Please provide comments and additional details in fewer than ten (10) pages single-spaced on how your organization meets the minimum qualifications. If Proposer does not describe how they meet the qualifications, CCH will not reach out for clarification, and Proposer will not be considered for award.

Minimum Qualifications Response (Y/N)

1 A minimum of five (5) years of experience in providing dental and vision services for Medicaid plans.

Proposer’s Response:

2 A provider network that includes providers in the following specialties:

pediatrics, adult, orthodontist and endodontist

3 Cyber Liability Insurance: Proposer has cyber liability insurance with minimum limit of $10,000,000 aggregate and no sub limits under $1,000,000. Provide evidence of insurance.

4 Proposer will not offshore any portion of the proposed services.

Proposer’s Response:

5 Completion of a 2025 SOC 2 Type 2 audit. Proposer must provide report upon submission of RFP proposal. Bridge Letter and schedule is acceptable if SOC 2 is in progress.

6 Evidence of third-party penetration testing in 2025.

4.2 Preferred Qualifications

In addition, successful Proposers will meet some of the following preferred qualifications.

Proposer should explicitly address the qualifications below in their response to section 4.2.

Please provide comments and additional details in fewer than ten (10) pages single-spaced on how your organization meets the preferred qualifications.

Preferred Qualifications Response (Y/N) and narrative

1 Experience partnering with public sector organizations for similar scopes of work. Please name those organizations.

2 Experience providing services in Illinois’ Medicaid managed care market. If you mark “Y” for this preferred qualification, please name the organizations in the Illinois Medicaid managed care market that your organization has worked with. You must provide services for at least one of your required references.

3 Industry-recognized accreditation and/or certifications (please list).

Proposer’s Response:

4 National Committee for Quality Assurance (NCQA) or Utilization

Review Accreditation Commission (URAC) accreditation

4.3 Requirements and Specifications

For each of the scope questions listed below, describe in detail the Proposer’s solution.

Proposers should include and explicitly address how Proposer will meet or why Proposer cannot meet each of the below requirements in their response to this RFP. Please use the corresponding response codes listed below in Proposer’s RFP response. Responses with “T” in any of the below requirements should explicitly provide the names of the organizations that will be providing that service on Proposer’s behalf. Proposers should articulate their responses in a succinct and direct manner. The responses should refrain from statements not related to the question, and general statements should be supported by factual proof points. Responses to section 4.3 shall not exceed one hundred and fifty (150) pages.

Respons e code

Category Description

Y Demonstrated (operational today). This response indicates that the process/technology described is in use by the Proposer for that product. If requested by CCH, Proposer can provide outcomes and/or examples of how the process/technology is currently deployed. If the Proposer is leveraging another organization’s expertise, process or technology, then a “T” should be used.

D Under Development. This response indicates that the process/technology described is currently under development and/or designed but is not yet operational in any of the Proposer’s operational markets.

M Modify. This response means that the Proposer is willing to develop the process/technology. Any cost of this enhancement to CCH should be itemized and included in the Proposer’s projected cost of implementation.

T Third Party. This response means that the functionality is available from a third-party partner of the vendor. If third-party products are proposed, please include an itemized list in the projected costs along with any projected costs chargeable to CCH. Additionally, indicate the name of the vendor that is performing that service.

N This response indicates the Proposer does not have an applicable process/technology.

Mandatory Requirements Response code (Y/D/M/T/N)

1 Proposer’s account manager will respond to CCH calls/emails within one business day.

Proposer’s Response:

2 Proposer will monitor, implement and inform the Plan of any fee schedule changes.

Proposer’s Response:

3 Proposer will not change members of the account team without prior approval of CCH.

Proposer’s Response:

4 Capacity to receive and process claims, as well as provide payments to contracted network providers compliant with current American National Standards Institute (ANSI) standards.

Network providers may include those contracted directly with Proposer or those contracted directly by CountyCare (e.g. FQHCs with onsite dental and optical services).

5 Manage the appeals, grievance and state fair hearing process.

6 Has an effective corporate compliance program.

Proposer’s Response:

7 Proposer agrees to use only United States-based resources to support the activities outlined in this RFP.

8 Proposer will not allow any enrollee data to be transmitted, used, accessed or maintained outside of the United States or its territories.

9 Proposer agrees to provide all information necessary for completion of CCH, state or federal audits.

10 Proposer agrees to provide access to systems housing CountyCare activity.

Proposer’s Response:

11 Proposer will be able to accept updates and apply revised information to the provider network database within one business day of receipt.

12 Proposer agrees to provide a monthly report detailing the number and types of calls received according to date and time, as well as response call dates and times and calls abandoned.

13 Proposer agrees to provide required Medicaid deliverables and reports.

Proposer’s Response:

14 Proposer agrees, upon termination of the relationship (regardless of which party terminates), to provide all information required for successful transition files at no additional cost.

15 Proposer agrees upon termination of the contract to continue to provide run-out processing and customer service to members for a period of six (6) months at no charge to CCH. In addition, all financial reports must continue to be provided at the established schedule, and the performances guarantees for accuracy and timeliness will still apply.

16 Proposer agrees to provide all policies and procedures related to the execution of the dental/vision services to CCH.

17 Proposer confirms that secure firewalls within the Proposer’s systems, processes and personnel are established to avoid the sharing of proprietary information from CCH with Proposer’s other clients.

18 Proposer confirms it will be responsible for payment of any monetary fines levied against CCH by any authority as a result of an action by the Proposer that incurred the citation.

19 Proposer will only contract with providers that have ADA-compliant locations.

Proposer’s Response:

20 Proposer agrees to process prior authorizations 24/7.

Proposer’s Response:

21 Proposer agrees to maintain a member and provider call center staffed by “live” persons from 8 a.m. to 5 p.m. CT on business days.

22 Proposer agrees, during non-business hours, to support member and provider access through an automated call distributor (ACD) supported by interactive voice response (IVR) 24/7.

23 Proposer agrees to allow CCH access to its policies and procedures for delegated functions and to ensure that services provided meet necessary standards of practice and contractual and regulatory obligations.

24 Proposer shall retain any books, contracts, records and documents related to CCH’s contract with CMS for a period of ten (10) years from the final date of the Contract period or completion of any audit, whichever is later.

25 Proposer shall provide CCH with the information necessary to fully respond to any CMS inquiries and requests for information no later than the date required by CMS or a different date specified by CCH.

26 Proposer shall report the loss of protected health information without delay and no later than five (5) days after discovery.

27 Proposer shall abide by any corrective action plan (CAP) provisions and shall provide required information to CCH or CMS no later than the date specified by the party.

28 Proposer agrees to give written notice of termination of a provider as soon as practicable, but in no event later than a) two (2) days after issuance of a termination notice by contractor to a provider OR b) receipt of a termination notice from a provider that has provided services to one hundred (100) or more unique enrollees within the past twelve (12) months.

29 Proposer agrees to provide reports accurately and in a timely manner according to contractual and state requirements.

30 Proposer agrees that all providers obtain a signed “Agreement to Pay” form from the member prior to receiving services that are not covered or exceed the members benefit limit.

31 Proposer shall meet all provider directory requirements under 305 ILCS 5/5-30.3 and 42 CFR §438.10.

32 Proposer agrees to confirm with contracted providers who have not submitted claims in the past six (6) months if they intend to remain in the network and correct any incorrect provider directory information as necessary.

33 Proposer shall manage the prior authorization process.

Proposer’s Response:

34 Proposer has the capability to send all mailed member letters in a digital format, if requested.

Proposer’s Response:

DENTAL SERVICES

Value-Added Services

35 Provide a description of any value-added services the Proposer plans to offer in addition to the required Medicaid services. Any proposed value-added services shall be included as part of the proposed PMPM rate for Medicaid dental services.

Network Management

36 Describe the Proposer’s network management processes and solutions, including:

• Provider engagement activities

• New provider orientation and ongoing provider education

• Cultural competency training

• Provider call center

• Process for resolving and reporting member grievances and appeals

37 Describe the Proposer’s secure web portal functionality

Proposer’s Response:

38 Provide a sample provider satisfaction survey and outline areas that can be customized.

Proposer’s Response:

39 Describe how the Proposer will develop a network that meets the Medicaid dental provider network adequacy requirement and appointment availability requirements.

40 The Proposer’s contracted dental network must include providers within all dental specialties and sub-specialties and all of Cook County’s safety-net providers delivering dental care and must have experience with Illinois’ Medicaid dental benefits administration. How will the Proposer contract with the required providers?

41 Describe any gaps the Proposer’s proposed network has in meeting the requirements.

Proposer’s Response:

42 Describe how you will remediate the gaps prior to go-live. Proposer must provide its proposed network as an attachment to Proposer’s response.

43 Describe how the Proposer will coordinate with the Illinois Department of Healthcare and Family Services (HFS)’ IMPACT credentialing system, including reviewing complaints, investigating grievances and handling appeals during the contracting process.

44 Describe how the Proposer will accept claims from non-network providers for dental services provided in a school-based setting for enrollees under age twenty-one (21).

45 Describe how the Proposer will ensure that routine preventive care is available within five (5) weeks from the date of request of such care and within two (2) weeks from the date of request for infants under age six (6) months.

46 Describe how the Proposer will ensure that urgent but not emergent care is available within three (3) days from the date of request for such care.

47 Describe how the Proposer will ensure that emergency care is available within one (1) day from the date of request for such care.

48 Describe how the Proposer will ensure that network providers shall offer hours of operation that are no less than the hours of operation offered to persons who are not enrollees/members. Network provider contracts shall provide coverage for their respective practices twenty-four (24) hours a day, seven (7) days a week and have a published after-hours telephone number; voicemail alone after hours is not acceptable.

Benefit Determination, Utilization Review & Peer Review

49 Describe the Proposer’s utilization management accreditation, if any.

Proposer’s Response:

50 Describe how the Proposer ensures clinical guidelines are updated, followed and applied consistently.

51 Describe how the Proposer’s utilization-review/peer-review policies and procedures meet the requirements of Illinois Medicaid.

52 Describe the Proposer’s prior authorization program processes, including how prior authorization is integrated with the claims system.

53 Provide the Proposer’s prior authorization timeliness statistics for the past three (3) years.

Include data on appeals. (Four (4) days turnaround time for standard requests and forty-eight

(48) hours for expedited requests.)

Proposer’s response:

Measure CCH Standard 2023 2024 2025 # of prior authorization requests

NA

Medicaid Standard authorization request turnaround time

100% of requests completed within four (4) calendar days

Medicaid Expedited authorization request turnaround time

100% of requests completed within forty-eight (48) hours (two [2] days)

54 Describe the Proposer’s process on provider outreach and education on prior authorization process.

55 Describe how often the Proposer completes inter-rater reliability reviews on all review staff.

Proposer’s response:

56 Describe the Proposer’s percentage of prior authorizations that go to second-level review.

Proposer’s response:

57 Describe clinical guidelines that Proposer utilizes.

58 Describe Proposer’s new-hire utilization management training and retraining.

Member Communications

59 Describe the Proposer’s call center.

Proposer’s Response:

60 Provide the last three (3) years of Proposer’s call center Statistics.

Proposer’s response:

Measure Cook County

Standard 2023 2024 2025

# of calls N/A Average hold time

< 30 seconds

Call abandonment rate

< 5%

Average speed to answer

< 30 seconds

61 Describe other means for the Proposer to provide information to members, including digital media.

62 Describe the Proposer’s ability to offer interpretation services and materials in alternative formats, including email.

63 Describe how the Proposer ensures member materials are written at no higher than a sixth-grade reading level.

64 Describe the Proposer’s health education programs and innovative offerings and how these programs will improve the member experience.

65 Provide a sample member satisfaction survey and outline areas that can be customized.

Proposer’s Response:

66 Describe the Proposer’s process for receiving and acting on Health Plan directives for member outreach and describe any limitations or exceptions

Claims/Encounters Processing

67 Describe the Proposer’s claims adjudication and payment system.

Proposer’s Response:

68 Describe the Proposer’s capacity to perform the minimum:

• Receive the electronic daily 834 membership file;

• Provide the electronic 835 claims file to providers;

• Provide the electronic 837 payment file to CCH and the contracted third-party administrator (TPA) vendor;

• Adjudicate within contracted rates and CountyCare’s approved benefits design;

• Adjudicate within State’s claims submission requirements;

• Coordinate benefits and third-party liabilities.

69 Provide the Proposer’s claims payment timeline statistics for the last three (3) years.

Proposer’s response:

Measure CCH Standard 2023 2024 2025 # of claims processed - Medicaid

NA

Standard turnaround time – Medicaid

NA

% of clean Medicaid claims processed within thirty (30) days

90% of clean Medicaid claims processed and paid within thirty

(30) days

99% of clean Medicaid claims processed and paid within ninety

(90) days

70 Describe the Proposer’s ability to submit encounter data to CCH’s TPA vendor and HFS

71 Describe the Proposer’s ability to load and process encounter remittances received from HFS and CCH’s TPA vendor.

72 Describe the Proposer’s ability to meet a 95% encounters acceptance score, including the Proposer’s ability to review, correct and resubmit encounter rejections.

Quality Assurance Program (QAP)

73 Describe how the Proposer’s QAP meets the requirements in Appendix F. Provide two specific examples of quality improvement activities performed in the last three (3) years. Provide outcomes data, if available, to illustrate the effectiveness of improvement activities.

74 Describe what metrics and reporting are utilized to monitor and evaluate dental services rendered, including frequency of reporting and monitoring of related metrics.

75 Describe the Proposer’s process for identifying, reporting, investigating and addressing critical incidents and quality-of-care grievances/concerns.

Delegated Subcontractors

76 Identify any delegated subcontractors and complete the following table for each delegated vendor.

Required Information

Details

Name of Subcontractor

Name of Contact Person

Telephone Email Address Services to be Delegated

VISION SERVICES

Value-Added Services

77 Provide a description of any value-added services the Proposer plans to offer in addition to the required Illinois Medicaid services. Any proposed value-added services shall be included as part of the proposed PMPM rate for Medicaid optical services.

78 Describe the Proposer’s network management processes and solutions including:

• Provider engagement activities

• New provider orientation and ongoing provider education

• Cultural competency training

• Provider call center

• Process for resolving and reporting member grievances and appeals

79 Describe the Proposer’s secure web portal functionality

Proposer’s Response:

80 Provide a sample provider satisfaction survey and outline areas that can be customized.

Proposer’s Response:

81 Describe how the Proposer will contract with a network of optometric providers that adheres to the following criteria:

• An optometrist who holds a valid Illinois (or state of practice) license and is duly enrolled in the HealthChoice Illinois IMPACT system to practice optometry is eligible to be considered for enrollment to participate in HFS’ Medical Programs.

• Optometrists holding non-teaching administrative or staff positions in schools or other institutions may be approved for participation in the provision of direct services if they maintain a private practice.

• Teaching optometrists who provide direct services may be approved for participation, provided that salaries paid by schools or other institutions do not include a component for treatment services.

• No license is required for enrollment as an optician or optical company, but the provider must be in compliance with relevant federal and state laws in the state in which he or she is doing business.

• The provider must be enrolled in the specific category of service for which charges are to be made. The categories of service for which an optometrist may enroll are:

o Category 001 – Physician Services o Category 003 – Optometric Services o Category 045 – Optical Materials. Opticians and optical companies may only enroll for Category of Service 045 – Optical Materials.

• Meets network adequacy requirements and appointment availability requirements.

82 Describe how the Proposer will coordinate with HFS’ IMPACT credentialing system, including reviewing complaints, investigating grievances and handling appeals during the contracting process.

83 Describe how the Proposer will develop a network that meets the Medicaid optical provider network adequacy requirements: Other specialist Provider access. Contractor shall ensure an enrollee has access to at least one (1) specialty services Provider within a sixty (60)-mile radius of or sixty (60)-minute drive from the enrollee’s residence. If an enrollee lives in a rural area, the enrollee shall have access to at least one (1) specialty services Provider within a ninety (90)-mile radius of or ninety (90)-minute drive from the enrollee’s residence.

84 Describe any gaps the Proposer’s proposed network has in meeting the requirements outlined in this section. Describe how the Proposer will remediate the gaps prior to go-live.

The Proposer must submit a proposed network as an attachment to the Proposal response.

85 Describe how the Proposer will ensure that routine preventive care is available within five (5) weeks from the date of request of such care and within two (2) weeks from the date of request for infants under age six (6) months.

86 Describe how the Proposer will ensure that urgent but not emergent care is available within three (3) days from the date of request for such care.

87 Describe how the Proposer will ensure that emergency care is available within one (1) day from the date of request for such care.

88 Describe how the Proposer will ensure that network providers shall offer hours of operation that are no less than the hours of operation offered to persons who are not enrollees/members. Network provider contracts shall provide coverage for their respective practices twenty-four (24) hours a day, seven (7) days a week and have a published after-hours telephone number; voicemail alone after hours is not acceptable.

Benefit Determination, Utilization Review & Peer Review

89 Describe the Proposer’s utilization management accreditation, if any.

90 Describe how the Proposer ensures clinical guidelines are updated, followed and applied consistently.

91 Describe how the Proposer’s utilization-review/peer-review policies and procedures meet the requirements of Illinois Medicaid.

92 Describe the Proposer’s prior authorization program processes, including how prior authorization is integrated with the claims system.

93 Describe how the following services and materials may be provided only with prior approval:

• Contact lens/lenses and related services

• Custom-made artificial eye

• Low-vision devices

• Polycarbonate eyeglass lenses for adults, age 21 and over

Proposer’s Response:

94 Describe how the services/materials not otherwise identified on the schedule of procedures for optical services and supplies may be approved.

95 Provide the Proposer’s prior authorization timeliness statistics for the past three (3) years.

Include data on appeals.

Measure CCH Standard 2023 2024 2025 # of prior authorization requests

NA

Medicaid Standard authorization request turnaround time

100% of requests completed within four (4) calendar

Medicaid Expedited authorization request turnaround time

100% of requests completed within forty-eight (48) hours (two [2] days)

96 Describe the Proposer’s process on provider outreach and education on prior authorization process.

97 Describe how often the Proposer completes inter-rater reliability review on all review staff.

Proposer’s response:

98 Describe the Proposer’s percentage of prior authorizations that go to second-level review.

Proposer’s response:

99 Describe clinical guidelines that Proposer utilizes.

Proposer’s response:

100 Describe Proposer’s new-hire utilization management training and retraining.

Proposer’s response:

Member Communications

101 Describe the Proposer’s call center.

Proposer’s Response:

102 Provide the last three (3) years of Proposer’s call center statistics.

Proposer’s response:

Measure Cook County

Standard 2023 2024 2025

# of calls N/A Average hold time

Call abandonment rate

< 5%

Average speed to answer

103 Describe other means for the Proposer to provide information to members, including digital media.

104 Describe the Proposer’s ability to offer interpretation services and materials in alternative formats, including email.

105 Describe how the Proposer ensures member materials are written at no higher than a sixth-grade reading level.

106 Describe the Proposer’s health education programs and innovative offerings and how these programs will improve the member experience.

107 Provide a sample member satisfaction survey and outline areas that can be customized.

Proposer’s Response:

108 Describe the Proposer’s process for receiving and acting on Health Plan directives for member outreach and describe any limitations or exceptions.

Claims/Encounters Processing

109 Describe the Proposer’s claims adjudication and payment system.

Proposer’s Response:

110 Describe the Proposer’s capacity to perform the minimum:

• Receive the electronic daily 834 membership file;

• Provide the electronic 835 claims file to providers;

• Provide the electronic 837 payment file to CCH and the contracted third-party administrator (TPA) vendor;

• Adjudicate within contracted rates and CountyCare’s approved benefits design;

• Adjudicate within State’s claims submission requirements;

• Coordinate benefits and third-party liabilities.

111 Provide the Proposer’s claims payment timeline statistics for the last three (3) years.

Proposer’s response:

Measure CCH Standard 2023 2024 2025 # of claims processed - Medicaid

NA

Standard turnaround time – Medicaid

NA

% of clean Medicaid

90% of clean Medicaid claims claims processed within thirty (30) days processed and paid within thirty

(30) days

99% of clean Medicaid claims processed and paid within ninety

(90) days

112 Describe the Proposer’s ability to submit encounter data to CCH’s TPA vendor and HFS.

113 Describe the Proposer’s ability to load and process encounter remittances received from HFS and CCH’s TPA vendor.

114 Describe the Proposer’s ability to meet a 95% encounters acceptance score, including the Proposer’s ability to review, correct and resubmit encounter rejections.

115 Describe how the Proposer will maintain updates to HFS-covered services and fee schedule updates

Quality Assurance Program (QAP)

116 Describe how the Proposer’s QAP meets the Illinois Medicaid requirements. Provide two specific examples of quality improvement activities performed in the last three (3) years.

Provide outcomes data, if available, to illustrate the effectiveness of improvement activities.

117 Describe what metrics and reporting are utilized to monitor and evaluate vision services rendered, including frequency of reporting and monitoring of related metrics.

118 Describe the Proposer’s process for identifying, reporting, investigating and addressing critical incidents and quality-of-care grievances/concerns.

Delegated Subcontractors

119 Identify any delegated subcontractors and complete the following table for each delegated vendor.

Required Information

Details

Name of Subcontractor

Name of Contact Person

Telephone Email Address Services to be Delegated

DENTAL AND VISION SERVICES

Member and Provider Portals

120 Describe the Proposer’s ability to host member portal and provider portal functionality.

Include a summary of existing portal functionalities.

121 Provider Portal:

• Eligibility and benefits verification

• Claims submission and claims status

• Prior authorization submission and status review or single sign-on (SSO) capabilities to existing portal

• Access to remittance advice and payment information

• Secure messaging with health plan representatives

• Provider data management and demographic updates

122 Describe the Proposer’s member portal. Please outline whether the Proposer can allow clients to brand the portal and the cost associated with the branding. Include a detailed description of all features, functionalities and restrictions. What information is available to members?

Attach screenshots that represent the home page and key features, including accessibility features.

123 Describe the Proposer’s provider portal. Please outline whether the Proposer can allow clients to brand the portal and the cost associated with the branding. Include a detailed description of all features, functionalities, as well as any restrictions. What information is available to providers? Attach screenshots that represent the home page and highlight key features.

124 Please describe your ability to support Single Sign-On (SSO) integration with the Health Plan’s existing member and provider portal. Specifically, indicate whether users (members and providers) can seamlessly access your dental and vision portals using their existing Health Plan portal credentials without requiring a separate login. Include details on supported authentication standards, security protocols, user experience, and any implementation requirements or limitations.

Appeals, Utilization Review, and Grievances

125 Describe in detail Proposer’s appeals and grievances process, specifically how Proposer documents, investigates and resolves all appeals and grievances and addresses state fair hearings.

126 Describe how the Proposer ensures member prior authorization and appeal decision letters are compliant with NCQA or other regulatory requirements. Provide any auditing tools or checklists used. Provide a sample of prior authorization and appeal decision letters that are compliant with all Illinois Medicaid requirements.

127 Submit policies and procedures related to specific processes for member and provider grievances.

128 Supplement the narrative with a flow chart describing the process.

129 Include appeals and grievances timeliness performance metrics for the past twenty-four (24) months by quarter.

Measure CCH

Standard Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

# of complaints NA

% of encounter s that generate a complaint

NA

# of appeals

NA

Average complaint resolution time (days)

Thirty (30) business

Average appeal resolution time (days)

Fifteen (15)busin ess days

% of appeals resolved in favor of the enrollee

NA

130 Include the leadership and reporting structure along with the number of individuals assigned to this area and identify the subset of individuals who will be dedicated to the Medicare and Medicaid Health Plan.

131 Proposer’s Response:

Describe any formal committees or workgroups designed to oversee plan member grievance and appeal processes, include the committee or workgroup charter, frequency of meetings and membership with roles/titles of each member.

132 Proposer’s Response:

Describe the CMS Complaint Tracking Module (CTM) processing and analysis and how that information will be shared with CCH.

133 Describe how the Proposer monitors compliance with provider directory requirements and actions taken to close gaps. Please provide any tools used for monitoring/auditing.

134 If Proposer already participates in the Illinois Medicaid managed care market, please submit your current provider roster counts, including (1) total number of contracted providers, (2) total number of providers by specialty and (3) total number of providers that can perform endodontic services.

Customer Service

135 Provide details on staffing model, including total number of agents, supervisor ratios and approach to scaling during peak call volumes or open enrollment periods.

136 Describe training programs for customer service representatives, including onboarding, ongoing training and specific training related to Medicaid populations, cultural competency and health equity.

137 Explain your quality assurance (QA) and performance-monitoring processes, including call recording, evaluation criteria and continuous improvement practices.

138 Proposer agrees to provide call center scripts and touchpoints as requested.

Proposer’s Response:

139 Detail language-access services, including availability of bilingual representatives, interpreter services and devices for hearing impairments (e.g., TTY/TDD).

140 Describe your call center operations, including hours of operation, days of service and availability of extended or 24/7 support for members and providers

4.4 HIPAA and Regulatory Compliance

The Selected Proposer may have access to confidential information, including protected health information (PHI), to perform the functions, activities or services for or on behalf of CCH as specified in this RFP. The Proposer must acknowledge that, if awarded, there is a high likelihood that the Selected Proposer may have access to PHI, in paper or electronic form, and thus, it must sign a Business Associate Agreement with CCH. As a Business Associate, the Selected Proposer will agree to comply with all federal and state privacy, confidentiality and security laws and regulations, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA), Health Information Technology for Economic and Clinical Health Act (HITECH), Medicare Confidentiality Regulations, as defined herein, and all other applicable rules and regulations. The Proposer must commit to requiring all staff and subcontractors to complete HIPAA training upon hire and no less frequently than annually thereafter. CCH reserves the right to review and accept the training program prior to implementation or require the Selected Proposer to use HIPAA materials or training sessions supplied by CCH.

4.4.1 Describe how the Proposer’s company is HIPAA compliant.

4.4.2 Has the Proposer had a third-party (independent) company confirm and certify the

Proposer as HIPAA compliant? If yes, which company provided the certification, and when was the certification obtained? Please provide the certificate(s) and any relevant SOC or HITRUST reports (or similar).

4.4.3 Provide a listing of Proposer’s current HIPAA Privacy, Security and Breach Notification policies and procedures, including date of creation and date of last revision.

4.4.4 Describe the Proposer’s staff training programs for privacy and security awareness, including frequency of training completion and how training completion is tracked.

4.4.5 List out and provide short descriptions of all software and/or applications used by Proposer that will create, receive, access, use, disclose, maintain and transmit CountyCare PHI.

4.4.6 List the number of HIPAA incidents reportable to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) during the past five (5) years. Please include the aggregated incident count and the associated individual count by year. Has Proposer’s company been cited or fined or been notified of pending citation or financial penalties within the last five (5) years for federal or state privacy law violations and/or failure to implement privacy regulations? If yes, explain in detail.

4.4.7 What is the Proposer’s defined process for transmitting and storing PHI, and how does it comply with both the content requirements and disclosure restrictions of all applicable state and federal public health laws? Provide documentation.

4.4.8 Provide a summary of any cyber insurance policies held by Proposer, including information regarding minimum or aggregate limits and sublimits.

4.4.9 Provide an explanation of whether Proposer and/or its subcontractors access, use, store, maintain or transmit CountyCare PHI, documents, data, claims, guidelines, protocols, programs, financial analyses, performance measures or other information at or to any offshore location, including a description of any Proposer services that will be performed by offshore operations and any contracted services. Include Proposer’s processes for review, auditing and monitoring its offshore staff or subcontractors and the frequency of review and/or auditing and monitoring activities.

4.4.10 Provide an explanation of how Proposer will ensure that any vendor or subcontractors utilized by the Proposer will comply with applicable HIPAA privacy and security requirements, including those outlined in the Business Associate Agreement between CCH and the Proposer.

4.4.11 How does the Proposer stay updated on current laws, compliance issues and HFS and/or CMS changes to the Medicaid program, including those related to communication requirements and guidelines? How does Proposer implement any necessary changes throughout the organization and ensure accuracy and timeliness? How does the Proposer communicate these changes to clients and work with clients to update processes as needed?

4.4.12 Has Proposer’s company been cited or fined or been notified of pending citation or financial penalties within the last five (5) years for federal or state law violations and/or failure to implement regulations? If yes, explain in detail.

4.5 Compliance Requirements

Compliance Requirements are intended to demonstrate the Proposer’s capability to adhere to the detailed compliance requirements that CCH, through its Medicaid health plan, CountyCare, must follow. Each respondent must demonstrate implementation of an effective compliance program that meets the regulatory requirements set forth in the CMS Medicaid Managed Care Program Integrity requirements (42 CFR 438.608), in addition to requirements for operating an health maintenance organization (HMO) in Illinois.

Note: Failure to complete the section in its entirety will disqualify your Proposal. This section is specific to the corporate compliance requirements of a health plan and its vendors; it does not address contract compliance requirements referenced elsewhere within this RFP.

4.5.1 Compliance Program

Proposer must provide an explanation, along with tangible examples and/or submitted collateral material, of the Proposer’s compliance program, including how its compliance plan incorporates the seven elements of an effective compliance program as mandated by the CMS Medicaid Managed Care Program Integrity requirements. Policies, procedures or other documentation submitted may include the Proposer’s code of ethics/code of conduct, Proposer’s compliance plan, a listing of compliance policies or procedures and Proposer’s organization chart with the reporting or relationship hierarchy included for the compliance program.

4.5.2 Written Policies, Procedures and Code of Ethics.

Proposer must submit a description of current compliance-related policies, procedures or other documentation, where available, including a description of how Proposer disseminates its code of ethics, policies and procedures to all personnel, agents, subcontractors and delegated vendors. The explanation should include the frequency of the dissemination of materials and the methodology for tracking receipt.

4.5.3 Compliance Officer and Compliance Oversight Committee(s) If available, Proposer should provide two (2) organizational charts, the first demonstrating the organizational hierarchy with the compliance officer, privacy officer and security officer. A second organizational chart should demonstrate the reporting structure of the compliance program team, including staffing numbers and roles in addition to HIPAA privacy and security personnel.

4.5.4 Effective Training and Education

Proposer must describe the initial and continuing (i.e., annual) compliance and privacy education/training programs that are completed by staff and vendors, including specific detail on the following topics:

• Code of ethics/compliance program,

• HIPAA privacy and security,

• Fraud, waste and abuse (FWA)

• Critical incident/abuse, neglect and exploitation training (as applicable); and

• Cultural competency.

For each of the training topics listed above:

4.5.4.1 Identify the audience for training completion.(e.g., personnel, agents, providers, subcontractors and first tier, downstream and related entities (FDRs))

4.5.4.2 Specify the modality for delivering each training topic above, the frequency of training delivery and the mechanism used to track training completion.

Additionally:

4.5.4.3 Provide a summary of how Proposer ensures that personnel, agents, providers, subcontractors and delegated vendors complete training as mandated by regulatory and contractual obligations.

4.5.4.4 Provide record retention policy and procedure for maintaining training records.

4.5.5 Effective Lines of Communication

4.5.5.1 Provide an explanation of Proposer’s expectations for reporting concerns related to compliance, integrity, FWA and financial misconduct by employees and vendors.

4.5.5.2 Describe the Proposer’s compliance hotline. Include the days and hours of operation and whether the Proposer manages the hotline internally or externally through a third party. If a third party is used, identify the vendor. Delineate the intended recipients of the hotline (e.g., members, personnel, agents, providers, subcontractors, vendors).

4.5.6 Disciplinary Standards

4.5.6.1 Identify ramifications for failure to report a violation. Provide supporting policy or procedure documentation on sanctions and describe the levels of disciplinary action.

4.5.6.2 Describe how violations of the code of ethics or policies and procedures will result in disciplinary action or sanctions and provide policy and procedure explaining the process.

4.5.7 Monitoring, Auditing and Identification of Compliance Risks

4.5.7.1 Describe Proposer’s compliance program for monitoring, auditing and identification of compliance-related risks.

4.5.7.2 Describe the process for tracking and documenting compliance efforts.

4.5.7.3 Describe in detail audits or monitoring schedules of vendors, subcontractors, agents and providers used by Proposer to ensure compliance with contractual and regulatory requirements. Include the frequency of the activity.

4.5.7.4 Provide an explanation and/or policy that addresses how Proposer will ensure full cooperation with any review, audit or investigation conducted by the CCH compliance program or its designee (including those related to readiness activities) or any regulator/oversight entity (HFS, HHS Office of the Inspector General (OIG), etc.).

4.5.8 Prompt Responses to Detected Offenses

Describe how Proposer has established and implemented methods and programs that encourage personnel, subcontractors, vendors, agents and providers to report program non-compliance and potential compliance issues without fear of retaliation.

4.5.9 Reporting Compliance Concerns

4.5.9.1 Describe how Proposer supports a safe, non-threatening environment where individuals may ask questions about integrity and compliance, FWA and financial misconduct matters and report their concerns.

4.5.9.2 Delineate the methods of how concerns may be submitted from personnel, providers, agents and members and describe the tracking system and the resolution process.

4.5.9.3 Identify how reporters are protected from retaliation and harassment.

4.5.10 Exclusion Screening

4.5.10.1.1 Describe how Proposer avoids employing, engaging, contracting, reimbursing or agreeing with any individual or entity who is excluded or “sanctioned” from participation in a federal or state health care program or who is debarred from participation in federal or state procurement or non-procurement programs for the provision of goods or services.

4.5.10.1.2 Describe the system Proposer has in…