Addendum 1 - Medical Claims Audit RFP #270-20250414MCA.pdf

Proposal Number: 270-20250414MCA Vendor: _______________________________________

ADDENDUM 1 Page 1 of 4

Date: April 23, 2025

RFP Number: 270-20250414MCA

RFP Description: Medical Claims Audit Services – Operation Services

Addendum Number: 1

Using Agency: The North Carolina State Health Plan for Teachers and State Employees

Purchaser: Kimberly Alston

Opening Date / Time: May 16, 2025 @ 10:00 AM ET

INSTRUCTIONS:

1. This Addendum is issued in response to questions submitted.

2. Return one executed copy of this Addendum Number 1 with your Technical Proposal.

Failure to sign and return this Addendum Number 1 may result in the rejection of your proposal.

Execute Addendum Number 1, RFP Number 270-20250414MCA:

Vendor: _______________________________

Authorized Signature: _______________________________

Name and Title (Print): _______________________________

Date: _______________________________

ADDENDUM 1 Page 2 of 4

No. Reference Vendor Question Answer

1. Section 3.4

EVALUATION

CRITERIA, page 16

As the RFP specifies a 50/50 split between Technical and Cost Proposals, could the Plan clarify if there are any minimum threshold scores required in either component to remain eligible for award consideration?

There is no minimum threshold of points for the for technical or cost components. The Vendor must meet each of items included in the Minimum Requirements;

otherwise, the technical requirements will not be evaluated, and the Vendor will not be eligible for the Contract.

2. Section 4.16.(a), CONFLICT OF

INTEREST, page 22

Would an existing business relationship with an entity that could be perceived as a competitor or in conflict with the Plan restrict our eligibility to participate in this RFP?

An existing business relationship with an entity that could be perceived as a competitor or in conflict with the Plan does not restrict a Vendor’s eligibility to participate in this RFP.

Section 4.16.a) only requires that a Vendor disclose such a relationship to the Plan as part of its Proposal.

3. Section 4.16.(e), CONFLICT OF

INTEREST, page 22

The RFP requests information on litigation and regulatory actions from the past five years. Could the Plan confirm if only material or performance-impacting matters should be disclosed, or should all matters—including resolved minor cases—be included? If there is any current legal issue, the Plan restrict our eligibility to participate in this RFP?

Under Section 4.16.e), Vendors are only required to disclose lawsuits or regulatory compliance actions that are material to the performance of the duties in the RFP.

Current legal issues do not preclude participation in the RFP, but the Plan may consider those current legal issues in making an award to a Vendor.

4. Section 5.1.2

MINIMUM

REQUIREMENTS,

Regarding the requirement for a client with more than 250,000 covered lives, would the Plan consider a client relationship serviced through a third-party administrator (TPA) under our management, or must the engagement be directly contracted?

The engagement has to be directly contracted.

ADDENDUM 1 Page 3 of 4

5. Section 5.3.B.1

STANDARD AUDIT,

Could the Plan confirm whether vendors may propose an alternative stratification methodology—provided it meets or exceeds the statistical validity of a 95% confidence level with ±2% precision?

The Plan is open to, and Vendors may propose other alternative stratification methodologies.

6. Section 5.3.B.3

STANDARD AUDIT,

Will the Plan facilitate direct access to TPA systems and provider contracts, or is the vendor required to work through scheduled remote sessions only?

The TPA contract includes requirements for the TPA to share data with the Plan’s auditors.

The Plan will facilitate either direct access to TPA systems and provider contracts or through remote access.

7. Section 5.3.B.3

STANDARD AUDIT,

How many provider contracts will your vendor be required to review?

All facility claim provider contracts in your sample should be reviewed.

8. Section 5.3.B.5 (f)

STANDARD AUDIT,

In Section 5.3.B.5(f), the RFP states that the vendor must ensure "no hidden fees" are included. Could the Plan define what constitutes a hidden fee in this context or provide past examples?

“Hidden fees” are unexpected charges that are not displayed on the claim or cannot be explained. There should be no TPA administrative fees attached to the claims.

9. Section 5.3.B.6

STANDARD AUDIT,

Can you please clarify what "out-of-sample claim errors" mean and what are your expectations for your vendor regarding these errors?

These are claim audit samples that are not part of the standard 250 audit sample and focused 750 audit sample. If you find an error on a member as a part of your standard and focused audit, you are expected to pull claims that are not a part of the audit samples on that same member.

10. Section 5.3.B.9

Will the Plan provide a framework for root cause analysis or corrective action reporting, or should the vendor utilize its internal methodology?

The Vender should utilize its own methodology.

ADDENDUM 1 Page 4 of 4

11. Section 5.3.B.10

Regarding vendor responsibility for monitoring the TPA’s collections process (Section 5.3.B.10), can the Plan clarify the expected level of involvement? Is the vendor expected to independently track recoveries or rely on reporting from the TPA?

The Vendor would be responsible for validating that the TPA has recovered all overpayments identified as errors in the quarterly audits.

12. Section 5.4.B.1

FOCUSED AUDIT,

For the 750-claim Focused Audit sample, will the Plan provide criteria for sample, or is the vendor expected to independently define sample logic based on risk analysis?

Section 5.4.B.(1) outlines some of the criteria. The Plan may offer additional criteria when applicable.

13. Section 5.4.B.1

FOCUSED AUDIT,

Can the Plan confirm whether Standard and Focused Audits may overlap in scope (e.g., COB, duplicate claims audits, and eligibility audits), or should vendors ensure mutually exclusive findings between the two?

It is possible that there could be some overlap.

14. Section 5.5

ADDITONAL AUDITS,

Plan refers to custom or ad hoc audits. Could the Plan provide an example of a previously requested additional audit type or an expected timeline for initiating such efforts?

The Vendor should respond based on its capabilities. If this tool is not available and the Vendor does not want to build it, the Vendor should respond with the statement “Not Confirmed.”

15. Section 5.6.A.5

AUDIT REPORTS,

MEETINGS AND

COMMUNICATION,

Is providing an electronic portal or dashboard for the Plan staff to access, non-negotiable? Our team provides electronic project status updates to each client, throughout the duration of the audit. Will our status notification process satisfy this request?

The Vendor should respond based on its capabilities. If this tool is not available and the Vendor does not want to build it, the Vendor should respond, “Not Confirmed.”

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