Appendix 2. Rx Claims Monitoring Questionnaire.docx

APPENDIX 2

PHARMACY BENEFIT CLAIMS MONITORING

General Vendor and Staffing Information

Vendor Name d/b/a (Name in Marketplace)

Primary Contact for Proposal

Title of Primary Contact

Vendor Address (Street, City, State, Zip)

Telephone Number

Fax Number

E-mail Address

Vendor Web Address

Is Vendor publicly or privately held?

Parent company legal entity name

Year established/incorporated

Vendor brand name

State Vendor’s ownership/controlling interest structure (wholly-owned, subsidiary, part of a joint venture, etc.). Provide information on all organizations with more than a 7.5% stake in the Vendor, including legal and financial arrangements with these organizations. Specify in which lines of your business such investments exist.

State any significant organizational structure changes including:

a. Significant organizational changes that were implemented during the past 24 months.

b. Any anticipated changes in ownership or business developments, including but not limited to mergers, stock issues, and the acquisition of new venture capital.

c. Mergers acquisitions, spin-offs, etc. that have occurred or are expected to occur within the next 12 months.

d. Changes that might be expected to impact services requested in the RFP or the level of service provided to the Commonwealth including changes in business operations, technologies, partnerships, or staffing.

Is the Vendor willing to provide two years’ of audited financial statements?

Please provide a copy of your most recent annual investor prospectus, investor presentation, or annual report (Form 10-K if publicly traded).

Is the Vendor, or does the Vendor intend to be during the term of the contract issued by this RFP, affiliated by a common parent company or holding company that shares any common members of the board of directors or managers in common with: (An affirmative answer to a. through d. below will disqualify the Vendor from consideration.)

Provide a brief history of Vendor’s organization.

Indicate Vendor’s years of experience performing the analysis of pharmacy benefit claims to validate Accuracy of the Claims and identify Errors in Near Real Time. An answer indicating less than five (5) years’ experience will disqualify the Vendor from consideration.

Indicate the Vendor’s experience providing other services, if any. State the type of service and years’ experience for each type of service.

Provide a brief summary of Vendor’s experience in performing the analysis of pharmacy benefit claims to validate Accuracy of the Claims and identify Errors in Near Real Time for clients such as the KEHP.

Provide the number and percentage of Vendor’s employer clients that the Vendor currently contracts with directly to perform the analysis of pharmacy benefit claims to validate Accuracy of the Claims and identify Errors in Near Real Time. Provide numbers and percentages based on the size of the employer group as follows:

a. <750

b. 750-999

c. 1,000-2,499

d. 2,500-4,999

e. 5,000-9,999

f. 10,000-24,999

g. 25,000-49,999

h. 50,000-99,999

i. 100,000+

Provide the number and percentage of government clients similar in size to the Commonwealth that your organization currently contracts with directly to perform the analysis of pharmacy benefit claims to validate Accuracy of the Claims and identify Errors in Near Real Time.

Provide the following information on the five largest clients for which the Vendor performs the analysis of pharmacy benefit claims to validate Accuracy of the Claims and identify Errors in Near Real Time.

a. Client Name, Address, City, State

b. Industry

c. Total number of employees

d. Number of employees enrolled in the group health plan

e. Services Vendor provides to the group health plan, including the annual prescription claim volume.

f. The number of years the contract has been in place with each client listed.

How do you differentiate your capabilities from other Vendor’s that perform the analysis of pharmacy benefit claims to validate Accuracy of the Claims and identify Errors in Near Real Time?

Confirm that Vendor is able to meet all minimum mandatory requirements and Vendor responsibilities outlined in the Scope of Work section (Section 2.00) of the RFP.

Provide the number of Vendor’s employees located in Kentucky and nationally.

Provide the location(s) of Vendor’s company offices.

Does Vendor offshore any business functions? If so, describe what functions the vendor performs.

a. Name of Subcontractor

b. Effective Date of Subcontract

c. Services Subcontracted

Vendor Capabilities

Describe, in step-by-step detail, the process the Vendor uses to perform the analysis of pharmacy benefit claims to validate the Accuracy of the Claims and identify Errors in Near Real Time. In the description, provide the following:

b. How does the Vendor access the data and files required to perform the services outlined in this RFP?

c. List the sources of the data and files required by the Vendor to perform the services required by this RFP, including which entity supplies each file or data set.

d. Identify all other information, data, and files needed to perform the services required by this RFP and the sources of all other information, data, and file.

e. The steps required to perform the analysis required by this RFP.

f. The process the Vendor uses to validate the Accuracy of the Claims and identify Errors in Near Real Time.

g. The Vendor’s ability to analyze one hundred percent (100%) of pharmacy invoices or claims submitted for payment to the KEHP by Caremark or any future PBM with which Personnel Cabinet may contract in the future while the contract awarded pursuant to this RFP is in effect.

i. The Vendor’s ability to identify and correct errors in pharmacy benefit claims in order to avoid or reduce erroneous overpayments or underpayments by KEHP through the KEHP Contracted Entities. Describe the process.

j. The Vendor’s ability to identify underpayments made by the KEHP Contracted Entities. Describe the process.

k. The Vendors ability to identify inappropriate or erroneous fees imposed by a KEHP Contracted Entity. Describe the process.

l. Other than the documentation listed in Section 2.00 of the RFP that will be provided by the Personnel Cabinet, describe any other resources that the Vendor will require from the Personnel Cabinet, whether it be documentation, staff, data, or any other resource.

For your claims accuracy book of business, provide the ratio of total number of claims initially flagged for errors to the number of claims actually approved and recovered for the preceding calendar year.

In the event the Vendor identifies an Error, describe the process used by the Vendor to negotiate the resolution of the identified discrepancy with the KEHP Contracted Entities.

Reporting

Standard Reports:

a. Describe the Vendor’s reporting capabilities and any suite of reports the Vendor can provide to the Vendor’s clients at no additional cost.

b. List the name, description, and frequency of each standard report that the Vendor provides to its clients.

c. What is the preferred delivery frequency of standard reporting?

d. What platform is utilized for the Vendor’s reporting?

Will the Vendor comply with the statutory mandate to submit a report to the Personnel Cabinet and the Legislative Research Commission quarterly, which shall include the following: (A negative answer to any of the report contents below will disqualify the Vendor from consideration.)

Is Vendor able to provide customized or ad hoc reports at the request of the Commonwealth? Explain any limitations to providing customized reports. Are there additional charges (please state “yes” or “no” and describe generally)? (Do not list any information applicable to the Cost Proposal here)

Integration and Implementation Plan

KEHP is a covered entity and therefore obligated to comply with HIPAA. As such, the Vendor, as a Business Associate of KEHP, is obligated to comply with HIPPA. Vendor shall be willing to enter into a Business Associates Agreement, attached to this RFP as Appendix 1, with KEHP for the protection of personal health information and shall procure Business Associates Agreements with all subcontractors performing services under the contract on behalf of the Vendor. Affirm Vendor’s willingness to meet this minimum mandatory requirement. The Vendor’s failure to affirm this requirement will disqualify the Vendor from consideration.

List the type of data from the KEHP or the KEHP’s other vendors that the Vendor will need in order to provide the services required by this RFP.

Please provide a detailed Implementation Plan and timeline. Label the plan “[Vendor’s Name] Implementation Plan”.

“[Vendor’s Name] Implementation Plan” attachment

Compliance – Privacy & Confidentiality

You agree you will not sell Commonwealth/DEI's pharmacy data without prior written approval and notice from Commonwealth/DEI.

You will adopt and implement written confidentiality policies and procedures in accordance with applicable law to ensure the confidentiality of member information used for any purpose.

You will not use or further disclose protected health information (PHI) other than as permitted or required by the Business Associate Agreement (BAA) or as required by law. The BAA for KEHP is attached within Attachment A.

You will use appropriate safeguards to prevent the unauthorized use or disclosure of the PHI, including but not limited to best practices for health industry cybersecurity (e.g.., compliance with Cybersecurity Act of 2015, Section 405(d)), and obtain security audits and certifications as appropriate under best practices for the industry (e.g., SOC 2 Type 2, HITRUST). You will report to Commonwealth/DEI and any unauthorized use or disclosure of the PHI.

You will mitigate, to the extent practicable, any harmful effect that is known to you of a use or disclosure of PHI by your firm in violation of the requirements of the federal privacy rule.

You will provide access to PHI in a "designated record set" in order to meet the requirements under 45 CFR §164.524.

You will make any amendment(s) to PHI in a "designated record set" pursuant to 45 CFR §164.526.

You will 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.

You will (i) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI that your firm creates, receives, maintains, or transmits, (ii) report to Commonwealth/DEI any security incident (within the meaning of 45 CFR §164.304) of which you become aware, and (iii) ensure that any employee of your firm or agent, including any subcontractor to whom you provide PHI received from, or created or received by your firm agrees to implement reasonable and appropriate safeguards to protect such PHI.

End Appendix 2