Addendum_HCPS_Attachment_B_Medical_Questionnaire_12.1.25.xlsm
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- Medical/Rx
- Solicitation number
- 25598-RFP-DST
- Issued by
- Hillsborough County, Florida
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Medical Questions
| Request for Proposal (RFP) for The School Board of Hillsborough County, FL - ATTACHMENT B |
| Medical RFP |
To Proposer: Use Column G to provide a brief explanation. However if the length of the explanation is greater than 400 characters, you must use the "Explanation" worksheet to provide your detail explanation.
| MEDICAL RFP | Answer Format | Response | Explanation |
| Proposer confirms that all requirements set forth in the RFP will be met, including mandatory minimums within the Specifications Document and attached all items on the Retired Submittal Checklist therein. | drop down box | ||
| Minimum Qualifications | |||
| Must have at least three (3) years experience in providing medical benefit plan services including claims administration and provider network services as of the date of the effective date of this contract. | drop down box |
Yes/No Must be authorized to do business in the State of Florida. drop down box Yes/No Must propose a network that includes at least 90% overall match. drop down box Yes/No Must be able to work with HCPS's benefit administrator (currently Alight) drop down box Yes/No Must agree to fund wellness program provided by HCPS's Wellness vendor (i.e. pay the vendor directly on HCPS's behalf; including incentives/rewards, biometric screenings, and other costs associated with the plan. drop down box Yes/No
| I. | General Proposer Information | ||||
| General Information | Answer Format | Response | Explanation | ||
| 1. | Proposer Brand Name | text | |||
| 2. | Parent Co. Legal Entity Name | text | |||
| 3. | d/b/a (Name in Marketplace) | text | |||
| 4. | Year Established/Incorporated | Month Day, Year | |||
| 5. | NAIC Code | numeric | |||
| 6. | Industry Classification | text | |||
| 7. | FEIN (Federal Employer Identification Number) | text | |||
| 8. | Tax Status | text | |||
| 9. | Public or Privately-Held | drop down box |
Public/Privately-Held
| 10. | Ownership/Controlling Interest Structure, including whether your company is owned by a private equity firm or part of a larger national insurance carrier. | text |
| 11. | Does your company have any plans or intentions for a sale, merger, or change in ownership within the next five years? If yes, how would such a change impact your clients? | text |
| 12. | Describe how your organization’s ownership and fee structures allow for greater flexibility and prioritization of client needs compared to competitors. | text |
| 13. | Location(s) where employees will be assigned to provide services described in this RFP. | text |
| 14. | List the number and percentage of employers of similar size to HCPS that your organization currently contracts with directly for Self-Funded Medical | text |
| 15. | List the number and percentage of primary education employers that your organization currently contracts with directly for Self-Funded Medical. | text |
| 16. | Are you authorized to do business in the State of Florida? | drop down box |
Yes/No
| 17. | How many subcontractors will provide administrative services should your organization be awarded this business? | numeric |
| 18. | Please include a list of subcontractors used for customer service, claims administration, network access, disease management, and any other services within an Exhibit titled "[Proposer] Subcontractors" in your response that includes the following information: |
* Year Established/Incorporated
* NAIC Code
* Specify services to be provided drop down box Included/Not Included
| 19. | Home Office Location | text | |
| a. | Address Line #1 | text | |
| b. | Address Line #2 | text | |
| c. | City | text | |
| d. | State | text | |
| e. | Zip | text | |
| f. | Web Address | text | |
| 20. | All claim records and eligibility data used by the carrier in its role as claim administrator shall remain the property of HCPS as Plan Sponsor and Plan Administrator. | drop down box |
Confirmed/Not Confirmed
21. Proposer agrees to monitor federal and state legislation affecting the delivery of medical benefits under the plan and to report to HCPS on those issues in a timely fashion prior to the effective date of any mandated plan changes. drop down box Agree/Disagree
22. When customized printing is required, the health plan must present a proof to HCPS for approval. drop down box Agree/Disagree
| 23. | Your company will pay for printing costs for: | ||
| a. | ID Cards | drop down box |
Agree/Disagree
b. Booklets drop down box Agree/Disagree
c. Certificates drop down box Agree/Disagree
d. SBCs (Summary of Benefits and Coverage) drop down box Agree/Disagree
24. Your company agrees that no external communications material that mentions HCPS benefit plans may be circulated without prior written approval from HCPS. drop down box Confirmed/Not Confirmed
25. HCPS reserves the right to accept or decline the designated service centers. drop down box Agree/Disagree
26. HCPS reserves the right to decline the designated Account Manager. drop down box Agree/Disagree
27. HCPS reserves the right to accept or decline designated claims processors. drop down box Agree/Disagree
| 28. | Indicate whether the following functions are centralized or decentralized and provide the location where the functions will be performed in the Explanation column. | ||
| a. | Claims Administration | drop down box |
Yes/No
b. Member Services drop down box Yes/No
c. Network Management drop down box Yes/No
d. Disease Management drop down box Yes/No
e. Utilization Review drop down box Yes/No
f. Underwriting Services drop down box Yes/No
g. Handling of Premiums drop down box Yes/No
h. Eligibility Services drop down box Yes/No
| 29. | For the entity that will be providing medical claims administration services, provide your most recent financial ratings or filings and effective dates of the ratings from each of the following agencies: | ||
| Comment: Indicate whether your organization has received a financial rating for each of the rating agencies listed below by using the drop down box in the response cell to the right of each agency's name. Do not respond by providing information about your organization's credit ratings. | |||
| a. | A.M. Best: Financial Rating Status | drop down box |
Yes/No Financial Rating (do not report credit rating) drop down box Yes/No Financial Rating Modifiers (if applicable) drop down box Yes/No
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | |
| b. | Standard & Poor's: Financial Rating Status | drop down box |
Yes/No Financial Rating (do not report credit rating) drop down box Yes/No Financial Rating Modifiers (if applicable) drop down box Yes/No
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | |
| c. | Moody's: Financial Rating Status | drop down box |
Yes/No Financial Rating (do not report credit rating) drop down box Yes/No
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | |
| d. | Fitch: Financial Rating Status | drop down box |
Yes/No Financial Rating (do not report credit rating) drop down box Yes/No
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | ||
| 30. | Proposer's financial rating change within the past 12 months: | ||
| a. | A.M. Best | drop down box |
Yes/No
b. Standard & Poor's drop down box Yes/No
c. Moody's drop down box Yes/No
d. Fitch drop down box Yes/No
| II. | Contacts | Answer Format | Response | Explanation | ||
| Please indicate your company contact, should there be any questions concerning submitted responses. | ||||||
| 1. | Primary Contact | |||||
| a. | Name | text | ||||
| b. | Title | text | ||||
| c. | Address | text | ||||
| d. | City | text | ||||
| e. | State | text | ||||
| f. | Zip | text | ||||
| g. | Phone Number | text | ||||
| h. | Fax Number | text | ||||
| i. | E-mail Address | text | ||||
| 2. | Secondary Contact | |||||
| a. | Name | text | ||||
| b. | Title | text | ||||
| c. | Address | text | ||||
| d. | City | text | ||||
| e. | State | text | ||||
| f. | Zip | text | ||||
| g. | Phone Number | text | ||||
| h. | Fax Number | text | ||||
| i. | E-mail Address | text |
| III. | Respondent Approach |
| 1. | Please describe how you are responding to this RFP. |
• Are you proposing an ASO or TPA model?
• Are you matching current plans or proposing a different solution?
| • Are you proposing pharmacy as well as medical? Will it be carved-out or carved-in? | text | |||
| If you are proposing a different solution, please also complete questions #2-10: | ||||
| 2. | Can your solution be offered alongside a traditional ASO option (i.e. as a dual option or on a "slice" basis)? | text | ||
| 3. | Please describe how your solution is unique in the market and list 3 differentiators. Please share if there are competitors or other similar solutions and how they differ from yours. | text | ||
| 4. | How does your solution address or mitigate barriers to care, such as access limitations, rising costs, and other social determinants of health? | text | ||
| 5. | How does your solution mitigate or reduce claims costs? Provide actual BoB results and results for one client (of your choosing) who is similar to HCPS. | text | ||
| 6. | How do you work with clients to design flexible networks and plans that align with their clinical priorities and how do your claim administration options improve program efficiency? | text | ||
| 7. | What type and level of disruption should HCPS expect when implementing your solution? | text | ||
| 8. | How much administrative lift is required for the HCPS benefits team with your solution? Outline what would be required of HCPS for a successful implementation. | text | ||
| 9. | Please describe how your solution would integrate with HCPS's current benefits ecosystem and if there would be any additional fees to share data with other vendors (wellness, data warehouse, etc.). | text | ||
| 10. | All solutions have potential pain points or challenges - what are some examples you've seen with this solution and how is your company working to overcome them? | text | ||
| 11. | Please provide your proposed 5-year plan for HCPS, be clear on the strategies you would employ to bring claims costs down. | text |
| IV. | LEGAL/CONTRACTUAL CONSIDERATIONS | Answer Format | Response | Explanation | |
| 1. | Proposer has complied with all state insurance departments regulatory requirements for all products and services being offered in this quote in which HCPS has employees. | drop down box |
Yes/No
| Comment: Be sure to review the census data included as part of this RFP. | |||
| a. | If the answer to the preceding question is "no", for all products and services quoted in this RFP for which the required state insurance department regulatory requirements have not been met, please specify the applicable product. | text | |
| 2. | Proposer maintains a fidelity bond as required by ERISA. | drop down box |
Yes/No
3. Proposer maintains professional liability insurance that exceeds $5 million per claim and $20 million aggregate. drop down box Yes/No
| a. | If not, please explain amount of coverage. | text | |
| 4. | Liability insurance covers: | ||
| a. | Medical management decisions | drop down box |
Yes/No
b. Professional malpractice drop down box Yes/No
c. Provider contracting drop down box Yes/No
| 5. | Please describe any judgment or settlement during the past three years or pending litigation that could result in judgments or settlements in excess of $100,000. | text |
| 6. | Proposer will act as plan fiduciary, if requested. | drop down box |
Agree/Disagree
| 7. | Your organization carries a fiduciary bond as any arrangements where you serve as fiduciary. Provide details on the fiduciary bond that you carry. | text |
| 8. | Your company will act as the final claims appeal fiduciary for the plans of HCPS. If not, describe why you would be unwilling to agree to this request | drop down box |
Agree/Disagree/Not Applicable
9. Proposer agrees to prepare and file all legal documents necessary to implement and maintain the plan, including policies, amendments, contracts, and required state filings. drop down box Agree/Disagree
10. Proposer agrees to provide necessary legal defense in the event of litigation related to claims processing and adjudication disputes, including all costs incurred. drop down box Agree/Disagree
11. Proposer agrees to indemnify and hold HCPS harmless as defined within the Specifications Document. drop down box Agree/Disagree
12. January 1, 2027 is to be the contract effective date. drop down box Yes/No
13. The contract will be issued in Florida. drop down box Yes/No
14. Your company agrees not to appoint any agent, general agent, or broker, nor authorize payment of any kind to a party not approved in writing by HCPS. drop down box Agree/Disagree
15. The administrator must administer benefits on a discontinuance and replacement basis (sometimes referred to as a "no loss/no gain" basis) for eligible employees (and dependents) participating in the current plans on the effective date and to unconditionally provide continuous coverage to all participants enrolled on the program effective date. drop down box Agree/Disagree
16. Any participants not actively at work due to disablement, sickness or illness on the program effective date will be covered. drop down box Agree/Disagree
17. Your company will adhere to the proposed plan design(s) and match as closely as possible and note all deviations. drop down box Agree/Disagree
18. Your company has provided an alternative, innovative plan design or plan structure that you believe can help drive claims savings. drop down box Agree/Disagree
19. Proposer is fully compliant with the Genetic Information Nondiscrimination Act (GINA). drop down box Yes/No
20. Please confirm all fees and charges including capitation are disclosed in your response. Any fees including capitation not disclosed will be viewed as a breach of contract. All cost containment reports will be requested annually. drop down box Agree/Disagree
21. Please confirm medical rebates will pass through to HCPS. If there are additional costs associated with pass-through rebates, please provide the cost. drop down box Agree/Disagree
| 22. | Please confirm if you negotiate rebates amount directly manufacturers or if you leverage another carrier/PBM's agreements. | text |
| 23. | Your plan will accept liability for claim processor negligence or fraud. | drop down box |
Agree/Disagree
24. Upon notice of termination, your company shall either return, keep or destroy all PHI (Private Health Information) received without prior approval from HCPS, or created or received by your company on behalf of HCPS, and which your company still maintains in any form. In the event all companies related to Vendor including all Affiliates retains such PHI, it shall do so in compliance with HIPAA Privacy and Security Standards and provisions of the BAA. The parties acknowledge that it is not feasible to return or destroy PHI maintained in the Company's databases and electronic applications. Accordingly, the terms and provisions of the BAA shall survive termination and such PHI shall be used or disclosed solely for such purpose or purposes that prevented the return or destruction of such PHI. Penalties shall be enforced if breached. drop down box Agree/Disagree
25. Will your company agree to assist with the compliance of the provisions of the Affordable Care Act (ACA) and the associated fees related to ACA, if applicable? drop down box Agree/Disagree
| V. | Privacy and Confidentiality | Answer Format | Response | Explanation | |
| 1. | Your company adopts and implements written confidentiality policies and procedures in accordance with applicable law to ensure the confidentiality of member information used for any purpose. | drop down box |
Agree/Disagree
2. Your company will not use or further disclose protected health information (PHI) other than as permitted or required by the Business Associate Agreement or as required by law. drop down box Agree/Disagree
3. Your company agrees to use appropriate safeguards to prevent the unauthorized use or disclosure of the PHI. Proposer agrees to report to the plan sponsor any unauthorized use or disclosure of the PHI. drop down box Agree/Disagree
4. Your company agrees to mitigate, to the extent practicable, any harmful effect that is known to Proposer of a use or disclosure of PHI by Proposer in violation of the requirements of the federal privacy rule. drop down box Agree/Disagree
5. Your company agrees to ensure that any agent, including a subcontractor, to whom it provides PHI received from, or created or received by your company agrees to the same restrictions and conditions that apply to Proposer with respect to such information and agrees to penalties if breached. drop down box Agree/Disagree
6. Your company agrees to document such disclosures of PHI and information related to such disclosures as would be required to respond to a request by an individual for an accounting of disclosures of PHI in accordance with 45 CFR §164.528. drop down box Agree/Disagree
7. Your company agrees to (i) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI that it creates, receives, maintains, or transmits, (ii) report to the plan sponsor any security incident (within the meaning of 45 CFR § 164.304) of which Proposer becomes aware, and (iii) ensure that any Proposer employee or agent, including any subcontractor to whom it provides PHI received from, or created or received by your company agrees to implement reasonable and appropriate safeguards to protect such PHI. drop down box Agree/Disagree
8. Is your company compliant with the final HIPAA privacy regulations issued by the Dept. of Health and Human Services and any comparable state laws not preempted under HIPAA? drop down box Yes/No
9. Will your company enter into a business associate contract and/or agreement with HCPS, as plan sponsor, to comply with the HIPAA Privacy Rule and Security Standards? drop down box Yes/No
| VI. | Network Access/Management | ||||
| Network Management | Answer Format | Response | Explanation | ||
| 1. | Please confirm if there are multiple networks quoted and if so what networks align to each current plan? Networks quoted should match networks provided in disruption analysis. | text | |||
| 2. | What network management services will be delivered by a subcontractor, wholly owned subsidiary or other outside organization? (Include any leased network arrangements.) | text | |||
| 3. | If you use leased networks to service this account, are the leased discounts loaded into your claims system? | drop down box |
Yes/No
| 4. | What is your network's physician to patient ratio in Hillsborough County Service Area as provided through your network proposed? | text | |
| 5. | In Hillsborough County Service Area, what has been your average network turnover rate within the last twenty-four (24) months for each of the following categories of providers: | ||
| a. | PCP's (defined as Family/General Practitioner and Internist) | text | |
| b. | Pediatricians | text | |
| c. | Specialist (including ObGyn) | text | |
| d. | Hospitals | text | |
| 6. | How often will you notify members of changes in your provider network? How will members be notified? | text | |
| 7. | What percent of a network provider's case volume is reviewed for quality and appropriateness each year? | text | |
| 8. | How are network provider cases selected for review? | text | |
| 9. | Describe how your network will provide access and accommodation for retired members that reside outside of the local Hillsborough County service area. | text | |
| 10. | How frequently do you credential providers? | text | |
| 11. | How often are provider directories updated online? | text | |
| 12. | Do you foresee any significant provider contracts coming up for negotiation in the next five years based on HCPS locations? | drop down box |
Yes/No
| 13. | What are your current arrangements and incentives for directing members to ACOs (Accountable Care Organizations) and Patient Centered Medical Homes in the Hillsborough County Service Area? | text |
| 14. | If employees are incented to receive services at High Performance Network providers, ACOs (Accountable Care Organization), or PCMHs (Patient-Centered Medical Home), are such provider types delineated in the provider directory search functionality? | drop down box |
Yes/No
| 15. | Will full provider claim discounts that your firm has negotiated be passed through to HCPS or will some of these be retained, for example, as a network access fee? | text |
| 16. | Confirm that your firm will allow HCPS to designate and tier benefits directly within the In Network benefit if care is received at certain facilities. For example, offer lower copay for ER visits at Facility X, whereas ER copay is different and higher at all other facilities | drop down box |
Yes/No
17. Confirm that your firm will allow HCPS to contract different pricing for certain care at designated facilities and that your firm will administer this direct contracting pricing outside of your normal PPO network pricing. drop down box Yes/No
| 18. | Explain what actions your firm is taking to be proactive and manage provider practices that may be producing the same care, but resulting in higher charges to the plan. Examples include: billing of outpatient services under inpatient TIN, providing Urgent Care services but billing under ER TIN, or ER services that result in observation stay and are billed under inpatient TIN/services | text |
| 19. | Describe any specialized networks that your firm may have in place relative to high quality, evidence-based behavioral health. | text |
| VII. | High Performance Network (HPN) | Answer Format | Response | Explanation | |
| 1. | In the Hillsborough County Service Area, does your organization offer high-performance networks? If so, provide a brief description. | drop down box |
Yes/No
| 2. | In the Hillsborough County Service Area, how are specific providers/facilities identified for inclusion in a high-performance network? | text |
| 3. | In the Hillsborough County Service Area, what percentage of your standard PPO network is included in your HPN? | text |
| 4. | In the Hillsborough County Service Area, what types of providers are included in your HPN-i.e. primary care, specialists, hospitals? | text |
| 5. | In the Hillsborough County Service Area, how is ongoing provider performance measured? | text |
| 6. | For the Hillsborough County Service Area, provide a detailed description of your High Performance Network and future strategy for this network. How could this HPN be applied for HCPS membership? | text |
| 7. | Does your firm have the ability to include two levels of copayments with lower copayments for network physicians in a high performance network? | text |
| IIX. | Administration Requirements | Answer Format | Response | Explanation | |
| 1. | A five year fee cap shall be required. Please confirm you agree to these terms. | drop down box |
Confirmed/Not Confirmed
2. Please confirm that you are willing to draft the Certificates of Coverage and SBCs (Summary of Benefits and Coverage) accurately and in compliance with ACA by the HCPS specified date for Open Enrollment. drop down box Confirmed/Not Confirmed
3. To the extent permitted under state law, no fault auto insurance, governmental plans coordination and negligent third party subrogation will be administered. drop down box Agree/Disagree
| 4. | What rights do clients have to audit your fee structures, claims processing practices, and network access agreements to ensure transparency and alignment with contractual terms? | text |
| 5. | Please confirm you agree to work with HCPS's chosen claims payment integrity vendor to audit claims on a pre-pay and post-pay basis. | drop down box |
Agree/Disagree
6. Will you agree to fund a preimplementation audit and quality review of plan design to be loaded in the claims system prior to implementation? Please use the drop down to indicate your agreement to pay the cost of this review up to $100,000 as the selected vendor. drop down box Agree/Disagree
7. Will you agree to fund a claims audit for year two up to the cost of $50,000? drop down box Agree/Disagree
8. Do you agree to a coordination of efforts and monthly reconciliation with HCPS Benefit team? This requires vendor to provide data on a monthly basis. drop down box Agree/Disagree
9. Please confirm you will provide 240 days notice in the event of termination. drop down box Agree/Disagree
| IX. | Suspect Claims Measures | Answer Format | Response | Explanation | |
| 1. | What actions are taken to stop or eliminate fraud activity at the point it is first discovered in network? Out of Network? | text | |||
| 2. | What is the dollar amount claim threshold, number of claims per member per day or per condition in network that would automatically pend or deny an in network claim? | text | |||
| 3. | What is the dollar amount claim threshold, number of claims per member per day or per condition out of network that would automatically pend or deny an out of network claim? | text | |||
| 4. | Does your company purchase or access a national data bank to check legitimate providers prior to paying a claim out of network ? | drop down box |
Yes/No 5 If a wrap or supplemental network is utilized out of network, are the providers credentialed by the wrap or supplemental network? Use Explanation tab for details. drop down box Yes/No
6. When your company pays out of network claims, do you require the provider to display their National Provider Identifier (required by federal law)? Please explain. drop down box Yes/No
7. Do you have documented policies and procedures in place for identification and investigation of potential and/or actual fraud, waste and abuse for the following areas: underwriting operations, financial operations, electronic data gateways, eligibility, claims processing, network provider credentialing? drop down box Yes/No
8. Do you check Federal or State Inspector General Health Care Fraud prosecution sites to identify providers who have been convicted of fraud, waste, or abuse? drop down box Yes/No
9. Do you review your commercial book of business claims experience to determine if convicted providers have improperly received reimbursement under any of your accounts? drop down box Yes/No
10. Does your provider application ask about any health care facility or healthcare business arrangements in which the provider may have full or partial ownership or own shares? drop down box Yes/No
11. Do your provider contracts limit or prohibit referrals to practices and/or facilities in which the provider has a financial interest? drop down box Yes/No
12. Is Fraud, Waste, and Abuse management managed in a specific unit or group in your organization? drop down box Yes/No
13. Do you employ or retain legal counsel with expertise in fraud, waste and abuse? drop down box Yes/No
14. Are you a member of the National Health Care Fraud Anti-Fraud Association (NHCAA)? drop down box Yes/No
15. Is the NHCAA database of active investigations utilized in your investigations? drop down box Yes/No
16. Under what circumstances is an employer made aware of fraud, waste or abuse on their account? Under what circumstances is an employer made whole before recovery is accomplished? text
| X. | Claims Administration | Answer Format | Response | Explanation | ||
| 1. | Describe process for updating claims system (e.g., real time or batch)? If batch, how often is the system updated? Please highlight both the process and timing for manual updates of all systems. | text | ||||
| 2. | How many different systems and platforms will be used for HCPS? Are the claim payment system(s) developed internally or externally? | text | ||||
| 3. | Do you anticipate making any major changes to the claim payment system or implementing a new system before/after implementation date? If yes, please describe the changes. | text | ||||
| 4. | Please answer the following questions as they relate to claim adjudication: | |||||
| a. | What percent of claims received electronically are automatically adjudicated? | percent | ||||
| b. | What is your organization's target percent for automatic adjudication? | percent | ||||
| c. | Are claim forms required for any services incurred with a participating provider? If so, please describe. | drop down box |
Yes/No
d. Are there any provisions that cannot be auto-adjudicated by your system? If so, what provisions? drop down box Yes/No
5. Are claims incurred with participating and nonparticipating providers adjudicated by the same processors? drop down box Yes/No
| 6. | What claim adjudicator processing authority limits do you have in place? | text |
| 7. | Do you have the claims and appeals process documented for member reference and DOL requirements? | drop down box |
Yes/No
| 8. | Please describe your claims and appeals process. | text |
| 9. | For any service where coinsurance or copays apply, is the discount calculated before or after the reduction for the copay/coinsurance? | text |
| 10. | How long is claim history maintained online? | text |
| 11. | What procedures are not subject to reasonable and customary by your organization? | text |
| 12. | How often are the reasonable and customary profiles updated? | text |
| 13. | What R&C (Reasonable & Customary) percentile do you standardly apply? | text |
| 14. | Your company agrees to provide access to PHI in a "designated record set" in order to meet the requirements under 45 CFR §164.524. | drop down box |
Agree/Disagree
15. Your company agrees to make any amendment(s) to PHI in a "designated record set" pursuant to 45 CFR §164.526. drop down box Agree/Disagree
16. Please describe your claims coordination capabilities and procedures with other payers. text
| XI. | System Security | Answer Format | Response | Explanation | |
| 1. | Please describe your system security policy and how data will be secured. | text | |||
| 2. | What is your standard user id and password policy? Can you force password resets? If so, how often? | text | |||
| 3. | Are you able to recognize pre–authentication for single sign-on recognition? | drop down box |
Yes/No
| 4. | Describe your firm’s disaster recovery procedures. | text |
| 5. | In the event of a data breach that resulted from a non-HCPS error, what efforts would your firm undertake to cover this risk? | text |
| XII. | Open Enrollment | Answer Format | Response | Explanation | |
| 1. | Please confirm that all eligibility information will be entered into the system within three (3) business days of data receipt. | drop down box |
Confirmed/Not Confirmed
2. Please confirm that health plan identification cards (ID cards) are issued to participants within five (5) business days of receipt of data and prior to January 1 for the 2027 plan year. drop down box Confirmed/Not Confirmed
3. Please confirm if ID cards will only be sent to current members if a change is made in subsequent annual enrollments. drop down box Confirmed/Not Confirmed
4. Please confirm that you are willing to assist HCPS with the preparation and attendance of benefit fairs during their scheduled open enrollment and all other events as needed throughout the year. drop down box Confirmed/Not Confirmed
5. Please explain your capabilities and commitments related to training HCPS staff during implementation. text
| XIII. | Account Management | Answer Format | Response | Explanation | |
| 1. | Please confirm you agree to provide 3 full-time onsite representatives to work at HCPS office to be available during HCPS's work schedule for the term of the contract. | drop down box |
Agree/Disagree
2. You agree that the HCPS Benefits team will have the opportunity to interview the selected candidate(s) and provide final approval prior to placement at HCPS. drop down box Agree/Disagree
3. Please describe your approach with the account management team and if the Account Executive will be dedicated or designated. How will the team and the Account Executive meet HCPS’s service expectations around technical support, customer service, medical reporting, and financials? drop down box Yes/No
| 4. | What percent of the Account Manager's time will be dedicated to HCPS during the implementation? | text |
| 5. | What strategies do you employ to ensure that account managers and account executives can effectively manage their caseloads? | text |
| 6. | How do you maintain high service levels when there is turnover? | text |
| 7. | Please confirm you will provide HCPS with unlimited access to a local medical director to work directly with HCPS. Confirm if the Nurse/Claims analyst will be dedicated or designated and how HCPS's service expectations will be met. | drop down box |
Confirmed/Not Confirmed
8. Prepare a detailed schedule and time frame to implement this program by the effective date. Please indicate the implementation responsibilities of your organization and HCPS. Name the file: [Proposer]_Implementation. drop down box Attached/Not Attached
| 9. | Indicate your willingness to provide the following services, if required: | ||
| a. | Design, submit for HCPS approval, and print forms with HCPS logo for claims submission, where required. | drop down box |
Yes/No
b. Load, audit and insure clean eligibility data at least 5 days prior to program effective date. drop down box Yes/No
c. Meet deadlines set forth in Implementation Schedule. drop down box Yes/No
d. Produce and distribute ID cards prior to effective date with accuracy equal to data provided by HCPS. drop down box Yes/No
e. Appropriate members of account team to perform a service and operational audit for HCPS within the first three months of the program and provide audit results within 60 days. drop down box Yes/No
f. Provide HCPS with a renewal by April 15th of each year prior to the renewal effective date. drop down box Yes/No
g. Meet or exceed HCPS subjective assessment of satisfaction with program implementation. drop down box Yes/No
10. Please confirm your approach with the implementation manager and if they will be dedicated or designated. How will their time will be managed and HCPS's service expectations met? drop down box Confirmed/Not Confirmed
11. Please confirm that your company shall effectively manage program implementation and resolve any issues identified with implementation in a timeframe mutually agreed to by HCPS and the Account Executive. drop down box Confirmed/Not Confirmed
12. Please confirm all implementation fees are included in your proposal. drop down box Confirmed/Not Confirmed
| XIV. | Customer Service | Answer Format | Response | Explanation | ||
| 1. | Indicate which of the following teams supporting HCPS will be a dedicated service team (supporting only HCPS). If they are not dedicated, please explain how their time will be managed and HCPS's service expectations met. | |||||
| a. | Customer Service | drop down box |
Yes/No
b. Claims Processing drop down box Yes/No
c. Wellness Program drop down box Yes/No
| 2. | Please provide the location (city/state) of each of the following functions as they would relate to HCPS account. | ||
| a. | Customer Service Center | text | |
| b. | Claims Processing Center | text | |
| 3. | Please specify the hours of operation for each of the following. | ||
| a. | Customer Service Center | text | |
| b. | Claims Processing Center | text | |
| 4. | How are after-hour phone calls handled? | text | |
| 5. | Are you able to assign a dedicated customer service team within your call center to service HCPS? | drop down box |
Yes/No
| 6. | For the customer service team proposed to serve HCPS, provide the following information for the customer service representatives. | ||
| a. | Ratio of staff to members | text | |
| b. | Minimum qualifications | text | |
| c. | Average years of service | text | |
| 7. | For the claims processing team proposed to serve HCPS, provide the following information for the claim adjudicators. | ||
| a. | Ratio of staff to members | text | |
| b. | Minimum qualifications | text | |
| c. | Average years of service | text | |
| 8. | Please answer the following questions as they relate to Customer Services. | ||
| a. | Can customer service representatives access information related to a specific claim online? | drop down box |
Yes/No
b. Do customer service representatives also process claims? drop down box Yes/No
c. Confirm the onsite representatives have the ability to update eligibility as directed by HCPS. drop down box Yes/No
| 9. | Provide the following statistics for the customer service center that will handle the HCPS account. We are requesting actual results for the proposed customer service center; therefore, standards should not be provided. Please provide explanations for any results that are unusually out of the norm. | ||
| a. | Average customer service telephone response time (seconds) : Prior Plan Year | number | |
| b. | Average customer service telephone response time (seconds) : Current Plan Year | number | |
| c. | Call abandonment rate (%) : Prior Plan Year | number | |
| d. | Call abandonment rate (%) : Current Plan Year | number | |
| e. | Percentage of incoming calls that are recorded : Prior Plan Year | number | |
| f. | Percentage of incoming calls that are recorded : Current Plan Year | number | |
| g. | Length of hold time : Prior Plan Year | number | |
| h. | Length of hold time : Current Plan Year | number | |
| i. | First call resolution percentage : Prior Plan Year | number | |
| j. | First call resolution percentage : Current Plan Year | number | |
| k. | Percentage of incoming calls that are logged : Prior Plan Year | number | |
| l. | Percentage of incoming calls that are logged : Current Plan Year | number | |
| m. | Percentage of outbound calls that are logged : Prior Plan Year | number | |
| n. | Percentage of outbound calls that are logged : Current Plan Year | number | |
| 10. | What percent of calls are mandated to be documented in your organization's system? | number | |
| 11. | Indicate your process for documenting member calls. | ||
| a. | Representatives cannot close the calls unless the event is documented. | drop down box |
Yes/No
b. Representatives document calls using standard system generated reason codes. drop down box Yes/No
| 12. | Please answer the following questions as they relate to Claims Processing (we are requesting actual results) | ||
| a. | Claim payment accuracy (number of correct payments divided by number of payments) : Prior Plan Year | text | |
| b. | Claim payment accuracy (number of correct payments divided by number of payments) : Current Plan Year | text | |
| c. | Claim processing accuracy (number of claims processed with 100 percent accuracy divided by number of claims) : Prior Plan Year | text | |
| d. | Claim processing accuracy (number of claims processed with 100 percent accuracy divided by number of claims) : Current Plan Year | text | |
| e. | Financial accuracy (dollars paid correctly divided by total dollars paid) : Prior Plan Year | text | |
| f. | Financial accuracy (dollars paid correctly divided by total dollars paid) : Current Plan Year | text | |
| g. | Average turnaround time (x% in x business days) : Prior Plan Year | text | |
| h. | Average turnaround time (x% in x business days) : Current Plan Year | text | |
| i. | Non-Medicare COB (Coordination of Benefits) savings as a percentage of paid claims : Prior Plan Year | text | |
| j. | Non-Medicare COB (Coordination of Benefits) savings as a percentage of paid claims : Current Plan Year | text | |
| k. | Average number of days claims are pended : Prior Plan Year | text | |
| l. | Average number of days claims are pended : Current Plan Year | text | |
| 13. | Do you have a voice response system (automated) that allows members to check the status of their claims, deductibles, out-of-pocket maximums, etc.? | drop down box |
Yes/No
| 14. | What other services are made available through telephonic interface (i.e., IVR)? | text |
| 15. | Can you comply with primary and secondary payer requirements for Medicare? | drop down box |
Yes/No
16. Please describe your multi-lingual capabilities. text
| XV. | System Integration | Answer Format | Response | Explanation | |
| 1. | Are all of your internal systems integrated? (e.g., claims payment, eligibility, enrollment, customer service, utilization management, case management and disease management) | drop down box |
Yes/No
2. Please confirm you agree to interface with (e.g., sending to and/or receiving from) the contracted COBRA Administrator of HCPS at no additional cost. drop down box Confirmed/Not Confirmed
3. Please confirm you agree to interface with (e.g., sending to and/or receiving from) the contracted Data Warehouse vendor of HCPS at no additional cost. drop down box Confirmed/Not Confirmed
4. Please confirm you agree to interface with (e.g., sending to and/or receiving from) the contracted FSA vendor of HCPS at no additional cost. drop down box Confirmed/Not Confirmed
5. Please confirm you agree to interface with (e.g., sending to and/or receiving from) the contracted Benefits Administrator of HCPS at no additional cost. drop down box Confirmed/Not Confirmed
6. Please confirm you agree to interface with (e.g., sending to and/or receiving from) the contracted Wellness vendor of HCPS at no additional cost. drop down box Confirmed/Not Confirmed
7. Please confirm you agree to interface with (e.g., sending to and/or receiving from) the contracted 2nd Opinion vendor (Teladoc) of HCPS at no additional cost. drop down box Confirmed/Not Confirmed
8. Please confirm you agree to interface with (e.g., sending to and/or receiving from) the contracted Telemedicine vendor (Teladoc) of HCPS at no additional cost. drop down box Confirmed/Not Confirmed
9. Please confirm you agree to send/receive data feeds to other vendors of HCPS at no additional costs. drop down box Confirmed/Not Confirmed
| 10 | What is the time lag between the eligibility and enrollment claims systems? Are all systems updated in real time? | text |
| 11. | Describe how your system handles eligibility and enrollment history and retroactive coverage changes. | text |
| XVI. | Offshoring | Answer Format | Response | Explanation | |
| 1. | Does your organization use any offshore assets that have access to HCPS data including Customer Service Centers, mail handling facilities, software development centers, data storage or Debt Collection Services? | drop down box |
Yes/No
2. HCPS insists on no offshoring services, can you comply? drop down box Yes/No
3. If your organization does have services offshore, can you provide proof that these entities are in full compliance with Office of Foreign Assets Control ("OFAC") regulations? drop down box Yes/No
| 4. | What safeguards does your organization have in place to ensure that PHI and other private information is not compromised due to offshoring? | text |
| 5. | Does your organization provide any customer facing operations offshore? If so, please indicate. | drop down box |
Yes/No
| XVII. | Vendor Integration | Answer Format | Response | Explanation | |
| 1. | Describe your process for referring members to other programs such as EAP and 2nd Opinion Medical Services Providers. | text | |||
| 2. | Do you warm transfer to other vendors? | drop down box |
Yes/No
3. Do you accept inbound warm transfers from other vendors? drop down box Yes/No
4. Do you send referrals to other vendors via fax or secure email with member content? drop down box Yes/No
5. Indicate if you accept inbound referrals via fax, secure email or shared databases and provide outreach to members based on the referral. drop down box Yes/No
6. Do you develop a hierarchy for program outreach with other programs as applicable? drop down box Yes/No
| XVIII. | Website Capabilities | Answer Format | Response | Explanation | ||
| 1. | Please identify which of the following services are currently available on your website for members. | |||||
| a. | Update eligibility or change/add dependents. | drop down box |
Available/Not Available
b. Request additional or replacement ID cards. drop down box Available/Not Available
c. Print ID cards directly from site. drop down box Available/Not Available
d. Access historical health data. drop down box Available/Not Available
e. Take a health risk assessment. drop down box Available/Not Available
f. Provider directories (standard). drop down box Available/Not Available
g. Provider quality information. drop down box Available/Not Available
h. Provider cost information. drop down box Available/Not Available
i. Provider selection where users enter search criteria. drop down box Available/Not Available
j. Rx formularies with definitions and directions drop down box Available/Not Available
k. Prior Authorization drop down box Available/Not Available
l. Plan design information. drop down box Available/Not Available
| 2. | Please specify the tools available to HCPS via the employer portal of your organization's website. | ||
| a. | Real-time secure access to information for HCPS. | drop down box |
Available/Not Available
b. On-line eligibility maintenance. drop down box Available/Not Available
c. Access to claims data. drop down box Available/Not Available
d. Access to member-specific coverage information. drop down box Available/Not Available
e. Account level delegate rights. drop down box Available/Not Available
f. Eligibility verification. drop down box Available/Not Available
g. Request ID cards. drop down box Available/Not Available
| 3. | Describe your transparency tool that is available to members and confirm it includes the following: | text | |
| a. | Hospital Quality | drop down box |
Included/Not Included
b. Cost of Services from hospitals and free-standing facilities drop down box Included/Not Included
c. Physician Quality drop down box Included/Not Included
d. Cost of Services from physician or medical groups drop down box Included/Not Included
4. Describe any additional web tools/functionality you want to highlight that is not listed in questions 1-3. text
| XIX. | Communications | Answer Format | Response | Explanation | |
| 1. | Briefly describe the types of standard communication materials available and whether there are charges for those materials. | text | |||
| 2. | Can HCPS's "branding" be added to communication materials at no additional charge? Please explain in the Explanation column. | drop down box |
Yes/No
3. Can communication materials be customized at no additional charge? Please explain in the Explanation column. drop down box Yes/No
| 4. | List languages other than English in which communication materials are available. Are they available at no additional charge? | text |
| 5. | Briefly describe any innovative communication materials that you offer which differentiate you from your competitors (e.g. transparent stickers, video clips, etc.). | text |
| 6. | Do you provide an allowance for member communication? | drop down box |
Yes/No
| a. | How much is it? | text | |
| b. | Is it one-time or annual? | text | |
| 7. | Please report on your company’s process to provide the following communication materials and information. | ||
| a. | Member ID Cards | text | |
| b. | Master Contract | text | |
| c. | Certificates of Coverage | text | |
| d. | Ongoing Certificate of Coverage changes | text | |
| e. | Summary of Benefits and Coverage (SBC) | text | |
| f. | Ongoing SBC Changes | text | |
| g. | Enrollment Communications | text | |
| h. | Ongoing Member Engagement Communications | text | |
| i. | Medical Management Communications | text |
| XX. | Reporting Capabilities | Answer Format | Response | Explanation | |
| 1. | You will provide monthly paid claims and enrollment reports by group and plan type to HCPS as part of your standard reporting package. Costs for standard reports should be included in the quote provided. If you disagree, please explain | drop down box |
Agree/Disagree
2. You will meet with HCPS on a quarterly basis (at minimum) to review claim experience, plan progress, service-related issues, etc. The medical director and nurse shall also attend these meetings. Review will include an Executive Summary and plan recommendations based on HCPS utilization. If you disagree, please explain. drop down box Agree/Disagree
| 3. | What platform is utilized for your organization's reporting? | text |
| 4. | Do you provide online access to reporting tools for HCPS and any authorized vendors (e.g. actuarial consultants)? | text |
| 5. | If the relationship is terminated, do you have the ability to provide HCPS with a detailed report of the status of each participant, to transition these participants to another health plan? | drop down box |
Yes/No
| 6. | List the name, description and frequency of each standard report that would be provided to HCPS. | text |
| 7. | List the key drivers that you track to assess improved outcomes and lower costs. | text |
| 8. | Please confirm you provide ACA reporting and filing? HCPS will request a full list of employees receiving the 1095-B from vendor for their documentation purposes. | drop down box |
Yes/No
9. Can you provide ad hoc reports at no additional cost? If so, provide average turnaround time. drop down box Yes/No
10. Please provide an electronic copy of each report within the standard reporting package (use sample data). Name the file: [Proposer] Sample Reporting Package" drop down box Yes/No
| XXI. | Reports | Answer Format | Response | Explanation | ||
| 1. | Confirm you provide reporting containing the following information and provide frequency (monthly, quarterly, annually) in the explanation. | |||||
| a. | Paid Claims by Plan | drop down box |
Yes/No
b. Capitation/Cost Containment (if applicable) drop down box Yes/No
c. Administrative/Network Fees (if applicable) drop down box Yes/No
d. Premiums (if applicable) drop down box Yes/No
e. Claims exceeding $50,000 with diagnosis drop down box Yes/No
f. Medical rebates drop down box Yes/No
g. Monthly enrollment counts by Plan drop down box Yes/No
h. Electronic eligibility listing drop down box Yes/No
i. Runout and reserves drop down box Yes/No
j. IBNR reporting drop down box Yes/No
k. Claims paid by $ amount increments (claim stratification report) drop down box Yes/No
| 2. | General claim utilization reports by major line of coverage identifying: | ||
| a. | Claims submitted | drop down box |
Yes/No
b. Claims eligible drop down box Yes/No
c. Deductible and coinsurance application drop down box Yes/No
d. Payment reductions due to network negotiated rates drop down box Yes/No
e. R&C (Reasonable & Customary) cutbacks and savings drop down box Yes/No
f. COB (Coordination of Benefits) savings drop down box Yes/No
g. Ineligible expenses drop down box Yes/No
h. Net benefits paid by Plan in and out of network drop down box Yes/No
| 3. | Claim utilization report will show separate experience for: | ||
| a. | Employees | drop down box |
Yes/No
b. Dependents drop down box Yes/No
c. COBRA Participants drop down box Yes/No
d. Retirees- Pre-65 and Post-65. Confirm ability to separate pre- and post-65 age groups. drop down box Yes/No
4. Electronic format of claims data. drop down box Yes/No
5. Employee-contested claims separated by denial reason. drop down box Yes/No
6. Claim lag report. drop down box Yes/No
7. Network savings reports for each plan and network offered. drop down box Yes/No
8. Most-utilized hospitals and physicians reports. drop down box Yes/No
9. Utilization of High Performance Networks, ACOs, and PCMH drop down box Yes/No
| XXII. | Med/Utilization Management | Answer Format | Response | Explanation | ||
| 1. | What criteria do you use for determining medical necessity? Do these criteria vary by region? | text | ||||
| 2. | What is your current mix of case managers? | |||||
| a. | Registered Nurses (RN): Percent of Case Managers. | percent | ||||
| b. | Licensed Practical Nurses (LPN): Percent of Case Managers. | percent | ||||
| c. | Dieticians: Percent of Case Managers. | percent | ||||
| d. | Mental Health Practitioners: Percent of Case Managers. | percent | ||||
| c) | Dieticians: Percent of Case Managers | percent | ||||
| d) | Mental Health Practitioners: Percent of Case Managers. | percent | ||||
| e. | Social Workers: Percent of Case Managers. | percent | ||||
| f. | Physicians: Percent of Case Managers. | percent | ||||
| g. | Other: Percent of Case Managers. | percent | ||||
| 3. | Provide a description of the services listed below. What differentiates your organization's utilization management services? |
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