Addendum 2 - Medical Claims Audit RFP.final.docx

This document is Addendum 2 for a Medical Claims Audit Request for Proposal (RFP) issued by the North Carolina State Health Plan for Teachers and State Employees. The RFP (Number 270-20250414MCA) seeks comprehensive medical claims audit services, with proposals due on May 16, 2025, at 10:00 AM ET. The contract will have an initial term from September 2, 2025, to December 31, 2028, with services commencing January 1, 2026, and options for two additional one-year renewal terms through December 31, 2030. The scope includes performing quarterly Standard Audits of 250 stratified claims and Focused Audits of 750 targeted claims, with key objectives of measuring claims accuracy and identifying potential errors or improper payments.

The current incumbent for these medical claims audit services is Healthcare Horizons, Inc., whose contract began January 1, 2019, and expires December 31, 2025. The current third-party administrator is Aetna Life Insurance Company. The evaluation will follow a 50/50 split between technical and cost proposals, with vendors expected to demonstrate expertise in auditing self-funded health plans and provide comprehensive security and HIPAA compliance documentation. The Plan serves approximately 578,000 self-funded members and expects vendors to validate prior authorizations, allowed charges, provider network status, coordination of benefits, and payment accuracy. While no specific budget range is disclosed, the addendum indicates the Plan is seeking a vendor that can provide both automated and human-involved audit processes, with an emphasis on thorough claims processing review.