Addendum 1 Post Payment Claims Review Services RFP.docx

Post Payment Claims Review Services RFP

#25-416CMS-BENF4-B-46745

Addendum 1

The Illinois Department of Central Management Services (CMS) is issuing Addendum 1 to amend the original Request for Proposal (RFP) for the above referenced project as issued by this office on March 25, 2025, and is now considered a part thereof.

This addendum is to be acknowledged in accordance with the RFP, Subsection C.6, Offeror Questions and Agency Response. Vendors are instructed to read the entire package before attempting to complete the information required therein. All other terms and conditions of the RFP shall remain in full force and effect, unchanged except as amended hereby. At this time the Agency is choosing to extend the bid opening date to May 6, 2025.

This addendum answers questions received by CMS on or before April 10, 2025.

Questions contained in this addendum are repeated word-for-word exactly as they were received.

25-416CMS-BENF4-B-46745 Post Payment Claims Review Services

1. Seeking clarification regarding the scope of this RFP. Based on the Trading Partner Agreement, it appears to be focused on Eligibility/COB services. However, certain sections of the RFP suggest the state is requesting investigative work, such as identifying overpayments (e.g., medical record reviews for DRG downgrades), pricing adjustments, and identifying anomalies that may indicate fraud, waste, and abuse within the Program’s claims data.

Answer: The scope of the services will focus solely on the work identified in the solicitation. The Trading Partner Agreement is a standard agreement documenting how the vendor will accept eligibility data, accepted uses of that data, and HIPAA compliance. Responsive vendors only need to confirm their abilities regarding investigative work including identifying overpayments and anomalies that may indicate fraud, waste, and abuse.

2. Additionally, for clarification on the bid page, does “Bid Price” refer to the cost unit minus any applicable discounts multiplied by the membership?

Answer: The agency is requesting a monthly Per Member Per Month (PMPM) fee for these services. Offeror shall input their price in the unit cost on the line item in Bidbuy for each contract year. If applicable, the Offeror can input a total discount amount within the line item entries.

3. Has CMS hired a contractor to perform a 100% claim review in the past, and if so, can you identify the contractor(s) and provide copies of any reports that were generated?

Answer: No. This procurement for Post Payment Claims Review Services is a new initiative for the Agency.

4. If CMS has hired a contractor to perform these services in the past, can you share the amount of fees awarded?

Answer: N/A

5. Has CMS conducted any other types of health plan audits / reviews in the past, and if there have been reports generated, can you share those?

Answer: On behalf of the Agency, our contracted vendors perform claims audits to ensure claims are processed accurately financially and according to plan design. These audits are only completed on 3-5% of claims, however, and the data sets are not shared with the Agency.

6. Would CMS entertain more than one vendor to complete these audits?

Answer: The Agency intends to make one award for these services.

7. Can you confirm the estimated covered lives in all self-insured plans as of 7/1/2025 broken down by self-insured plan?

Answer: The below figures are estimates. The Agency will have a more detailed enrollment structure after the completion of our Benefit Choice period ending 6/2/2025.

8. Can you share the annual spend for your medical, pharmacy, and dental plans for each self-insured plan?

Answer: The approximate annual claims spend for medical, pharmacy and dental plans are as follows:

Pharmacy: $350,000,000 Aetna PPO & CDHP: $395,000,000

BCBS OAP: $170,000,000

HealthLink OAP: $391,000,000 Aetna OAP: $320,000,000 Dental: $135,000,000

9. Can you share who is your current benefit consultant?

Answer: The Agency’s current benefit consultant is Deloitte Consulting.

10. Can you share your current Administrative Services Agreements for each self-insured plan?

Answer: The Agency cannot share the requested Administrative Service Agreements without a formal FOIA request.

11. Can you define “retrospective” claims reviews and “real-time” claims reviews as contemplated in this RFP?

Answer: Retrospective claims analysis will be performed on claims processed in prior plan years for the State of Illinois. The Agency desires to audit claims looking backward 3 plan years (7/1/2022 – 6/30/2025). Real-time claims analysis will be performed on claims processing in the current benefit year (starting 7/1/2025).

12. Can you confirm that real-time claims reviews are post payment reviews?

Answer: Confirmed. Real-time reviews will be performed on a post payment basis.

13. Can you confirm that there is no pre-bid conference for this RFP?

Answer: Confirmed, The Agency will not conduct a pre-bid conference.

14. With respect to pricing, can you confirm that the cost proposal is to be entered into the BidBuy Bid Solicitation page only?

Answer: Offerors shall enter their Per Member Per Month cost into the “unit cost” field in Bidbuy.

15. Can you confirm that the cost proposal must be submitted on a per member per month basis, and will CMS entertain any other pricing basis?

Answer: Pricing must be submitted on a per member per month basis. The Agency is not considering any other pricing options.

16. Can you clarify the meaning of the figure “200,000” under the heading “Qty” and can you clarify the meaning of “EA-Each” under the heading “Unit Cost” found on the BidBuy Bid Solicitation page?

Answer: The 200,000 figure is the estimated number of members, “EA-each” represents “Member”.

17. Is there any other guidance you can give to ensure that an Offeror provides a cost proposal in a format that meets the RFP requirements?

Answer: Please review the solicitation document in its entirety, all requirements are addressed within. Offeror must provide their unit cost in the line items in Bidbuy.

18. We have not found any Terms & Conditions document on the portal. Only below listed documents we found in portal. Please advise is there anything other than these.

Answer: Terms and Conditions document link can be found in section C.12 TERMS AND CONDITIONS of the solicitation.

https://cpo-general.illinois.gov/solicitation-and-contract-templates.html.

19. We are not able to see any content in the attached document. Kindly advise on this or share the updated file.

Answer: The attached document is the Request for Proposal Offer to the State of Illinois, intentionally left blank as it is intended for the Offeror to complete. The file titled Post Payment Claims Review Services RFP Final~4.docx is the Agency’s completed solicitation document with all requirements and information contained within.

20. Relating to third party liability, and other health insurance coverage, what sources and methods has the plan/State utilized in the past to identify other primary coverage opportunities within this population and what has been the incidence of other primary coverage being identified (i.e. have you found that 10%/5%/1% etc.) has had other primary coverage?

Answer: The Agency currently uses the other insurance and third-party liability resources provided by its health, pharmacy, and dental carriers.

20.1. Would the plan/State be open to running a free test file with DRG Claims to identify the current opportunity?

Answer: No. The Agency is not interested in running a free test file.

21. For Inpatient claims, what are the reimbursement methods? DRG? Per diem?

Answer: The Agency utilizes the pricing reimbursement methodologies utilized by the contracted health plan carriers.

22. Skilled Nursing Facility, what are the reimbursement methods? PDPM? RUGS? Per diem?

Answer: The Agency utilizes the pricing reimbursement methodologies utilized by the contracted health plan carriers.