Addendum 3 - Medical Claims Audit RFP #270-20250414MCA.pdf
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- Solicitation number
- Doc1534198159
- Issued by
- North Carolina
About this file
Addendum 3 is a document issued by the North Carolina State Health Plan for Teachers and State Employees related to RFP #270-20250414MCA for Medical Claims Audit Services. This addendum replaces Addendum 2 and addresses additional vendor questions that could not be previously posted due to technical difficulties. The RFP seeks a vendor to perform medical claims audit services, with proposals due on May 16, 2025, at 10:00 AM ET. Vendors are required to return an executed copy of this addendum with their technical proposal, and failure to do so may result in proposal rejection.
The addendum provides insights into the current contract environment, revealing that Healthcare Horizons, Inc. is the incumbent vendor for Medical Claims Audit Services, with a contract spanning from January 1, 2019, to December 31, 2025. The State Health Plan indicates satisfaction with the current vendor and confirms that all contract extension options have been exercised. The document also clarifies key aspects of the audit requirements, such as expectations for both automated and human-involved audit processes, and specifies that the standard audit must be a random sample while targeting potential errors. The Plan is not open to extending the RFP timeline or conducting a second round of questions, maintaining a structured procurement process.
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Other files
| File | Type | Posted |
|---|---|---|
| Medical Claims Audit RFP Final.pdf | ||
| Addendum 1 - Medical Claims Audit RFP #270-20250414MCA.pdf | ||
| Addendum 2 - Medical Claims Audit RFP.final.docx | DOCX document |
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Text version
Proposal Number: 270-20250414MCA Vendor: _______________________________________
ADDENDUM 2 Page 1 of 3
Date: April 30, 2025
RFP Number: 270-20250414MCA
RFP Description: Medical Claims Audit Services – Operation Services
Addendum Number: 3
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. Addendum 3 replaces Addendum 2 and is issued in response to additional questions submitted.
These questions were submitted timely, but due to internal technical difficulties, the State Health Plan was unable to post the additional questions received.
2. Return one executed copy of this Addendum Number 3 with your Technical Proposal. Failure to sign and return this Addendum Number 3 may result in the rejection of your proposal
Execute Addendum Number 3, RFP Number 270-20250414MCA:
Vendor: _______________________________
Authorized Signature: _______________________________
Name and Title (Print): _______________________________
Date: _______________________________
ADDENDUM 2 Page 2 of 3
No. Reference Vendor Question Answer
16. General Would the Plan consider allowing a 2nd round of questions to enable vendors the opportunity to ask questions after solutioning?
No, there will not be a second round of questions.
17. General Who is the incumbent, and how long has the incumbent been providing the requested services?
Healthcare Horizons, Inc.
is the Plan’s incumbent for the Medical Claims Audit Services. The contract began January 1, 2019, and expires December 31, 2025.
18. General Please describe your level of satisfaction with your recent vendor(s) for the same purchasing activity, if applicable.
The current vendor is meeting Plan expectations.
19. General Did the recent contract(s) go full term?
Yes, initial term of the current contract expired and all options to extend the contract have been exercised.
20. General Have all options to extend the current contract been exercised?
Yes, all options to extend the contract have been exercised.
21. General
What estimated or actual dollars were paid last year, last month, or last quarter to any incumbent(s)?
The incumbent was paid in accordance with the contract for services provided over the relevant time frame.
22. General Would the Plan consider a 2-3 week extension to allow vendors an opportunity for a more detailed and comprehensive response?
No, the RFP timeline will not be extended.
23. General Would the Plan allow for automated audits, where the vendor’s platform is configured to the Plan and TPA specifications?
The Plan expects certain aspects of the audit would be automated, but the Plan also expects a level of human involvement to do such things as review medical policies, payment policies and provider contracts to confirm claims were processed appropriately. The scope of work is outlined in the
RFP.
ADDENDUM 2 Page 3 of 3
No. Reference Vendor Question Answer
24. RFP Sections 5.0-
5.7, pages 23-30 Would the State of North Carolina be open to an ongoing review of 100% of their medical and pharmacy claims, as close to real-time as possible? Although this would be much different than the current isolated claims audit (250/quarterly), the cost savings that would be generated would be increased for the State of North Carolina. This would also strengthen your position as a prudent fiduciary of the plan.
The scope and requirements of this Contract are outlined in the RFP. As noted in Section 5.5, the Plan may engage the Vendor in additional audits at some later date, but those will not be considered at Go-Live.
25. RFP Sections 5.0-5.7, pages 23-30
If we would bid on this project as presented, would we be able to select the highest materiality claims for the 250 claims audit completed quarterly? If not, how would these claims be selected and by whom?
The Standard Audit must be a random sample, but in Section 5.4.b.(1), the Plan directs the Vendor to target the sample to potential Errors.
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