CTR076720_Cigna_-_ASRS_Group_Dental_Services.pdf

Part 2A:

SCOPE OF WORK ARIZONA STATE

RETIREMENT SYSTEM

3300 N Central Ave

14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

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Any reference to “Participant”, “Subscriber” or “Per Subscriber Per Month” within the Scope of Work shall have the meaning defined in the Special Terms and Conditions. All terms not defined herein shall have the meaning given to them in the Uniform Terms and Conditions.

Unless specifically stated, all Scope of Work items will apply to both fully insured and self-insured plans

1. GENERAL REQUIREMENTS

Contractor shall:

1.1. Have the capability and requisite experience and expertise to provide services to the Arizona State Retirement

System (“ASRS”) for the ASRS Group Dental Program (“the Program”) in accordance with the provisions and requirements set forth herein.

1.2. Offer such services in conformance with federal and state laws, regulations and ordinances.

1.3. Act on behalf of ASRS in a timely, skillful, professional, and workmanlike manner using personnel with the requisite skill, experience, and qualifications, who will exercise care, skill, and diligence consistent with accepted industry practices for clients of similar size and characteristics as ASRS.

1.4. Provide coverage to all eligible Participants, as determined by ASRS. Participation in the Program is 100% voluntary and at the sole discretion of the individual; Contractor shall not invoke any minimum enrollment requirements.

1.5. Administer any changes to plan design, benefit additions as stipulated in the current or future plan description, including but not limited to: network models, specific benefit changes to deductibles, co-insurance, and lifetime maximums.

1.6. Cover all available benefits from the effective date of the Contract such that no Participant will suffer a loss of coverage by virtue of a change in contractor other than by a change in plan design (such as applicable copayments, deductibles, lifetime maximums, etc.). No Participant shall lose benefits involuntarily because of transition issues.

1.7. Be responsible for all business expenses associated with providing services for the Program including but not limited to: auditing actions, education and communication resources, and enrollment and annual open enrollment expenses. Where specifically required, partner with other ASRS contractors to share and cover associated costs.

1.8. Maintain secure systems capabilities to accommodate timely and accurate sharing/transmission of data between eligibility, claims, billing and reporting.

1.9. Provide any information and assistance that is necessary for the effective administration of the Program and make recommendations, as needed, for changes or amendments due to changes in law or industry practices.

2. SPECIFIC REQUIREMENTS

2.1 Account Management

2.1.1 Establish and maintain throughout the term of the Contract an account management team, and adjust staffing as required and if acceptable to the ASRS, in accordance with Section 4 (Key Personnel) of the Special Terms and Conditions.

2.1.2 Designate a qualified Account Manager to be assigned to the ASRS account who will perform the following services, including but not limited to:

RETIREMENT SYSTEM

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14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

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2.1.2.1 Act as the principal contact for the ASRS with the primary responsibilities of managing all account activities, coordinating Contractor’s staff to resolve issues, and overseeing all aspects of any project management, including operational and information system requirements.

2.1.2.2 Participate in frequent meetings and/or conference call with ASRS to review and discuss claim issues.

2.1.2.3 Participate in a minimum of two (2) per fiscal year face-to-face meetings in Arizona with ASRS to review utilization and performance of the ASRS Program.

2.1.2.4 Monitor industry and legislative information for potential application to the ASRS Program.

2.1.3 In accordance with Section 4 (Key Personnel) of the Special Terms and Conditions, Contractor shall provide dedicated on-site customer service representative(s) at an ASRS place of businesses, or as directed by the ASRS, as follows:

2.1.3.1 The on-site representative(s) shall:

2.1.3.2 Serve as the day-to-day contact for ASRS and should have the ability to make certain decisions on behalf of Contractor, including accepting enrollments, discussing with Participants processes of the Program, and resolving issues related to eligibility.

2.1.3.3 Participate in educational meetings for Participants, as requested by ASRS. Outside of Open Enrollment. ASRS typically offers one educational meeting per month.

2.1.3.4 Correspond with ASRS on Participant issues by using ASRS communication and workflow systems.

2.1.3.5 ASRS will provide office space and supplies and ASRS-required equipment. Contractor will be responsible for providing a personal computer, internet access and any software required for the representative to utilize Contractor’s claims management and eligibility system(s).

2.1.3.6 Respond to ASRS calls/emails within 16 business hours.

2.1.3.7 On-site representative requirements in the ASRS Phoenix office:

2.1.3.7.1 One (1) full-time on-site customer service representative for up to the first 50,000 enrolled Subscribers.

2.1.3.7.2 Two (2) full-time on-site customer service representatives when the enrolled Subscriber count is greater than 50,000 but less than 80,000 enrolled Subscribers.

2.1.3.7.3 Three (3) full-time on-site customer service representatives when the enrolled Subscriber count is greater 80,000 enrolled Subscribers.

2.1.3.7.4 The requirement for on-site customer service representatives is not optional and the cost associated with the services must be included within the Contractor’s pricing.

2.1.4 Respond to ASRS regarding account or Participant issues within one (1) business day and shall include in its response a plan to resolve the issue and a timeframe established to do so.

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14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

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2.1.5 Conduct an annual survey on account management to measure satisfaction on Contractor’s staffing levels, responsiveness and expertise.

2.1.6 Take immediate corrective action and provide a written corrective action plan within thirty (30) days, as requested by ASRS, should ASRS identify any deficiencies in the performance of the Contract, including missed performance guarantees or audit findings. No fees shall be charged in the recovery or reimbursement of any funds identified. The corrective action plan shall include, at a minimum:

2.1.6.1 Reference to the specific error or finding, summary of overall impact error, financial and/or Participant impact;

2.1.6.2 Casual factor(s);

2.1.6.3 Name and title of the person accountable for implementing and overseeing the corrective action plan;

2.1.6.4 Corrective action items including:

2.1.6.4.1 Specific deliverables including but not limited to impact records

2.1.6.4.2 The anticipated completion date(s)

2.1.6.4.3 The reason the corrective action is not necessary, if applicable;

2.1.6.4.4 Disclosure of metrics used to measure the success of each deliverable;

2.1.6.4.5 Participant notification process, if applicable;

2.1.6.4.6 Notification upon completion of issue resolution.

2.1.7 As requested by ASRS, Contractor shall provide a qualified point of contact with the expertise to meet the following requirements:

2.1.7.1 Support the ASRS in the efficient management of dental benefits, operations, plan design, and achieving best practices clinical decisions, where appropriate.

2.1.7.2 Partner with ASRS on strategic issues related to network, plan management, and provider relations and contracts.

2.1.7.3 Resolve all IT-related issues that may arise.

2.2 Implementation

2.2.1 Upon award, Contractor shall provide a team of individuals dedicated to implementing the provisions of this Contract. The implementation team shall include, but not be limited to, a project manager, an account manager, a network contracting manager, programmers, enrollment specialists, claims specialists, and customer service staff.

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14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

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2.2.1.1 The implementation/transition team shall expedite all Contract requirements, as outlined and prioritized by the ASRS, to ensure complete continuity, without exception, of all functions, deliverables, and objectives by dates established by ASRS.

2.2.1.2 Contractor must develop a written plan that establishes key activities, milestones, and deliverables to ensure operational and financial readiness.

2.2.1.3 The project manager must continue to provide support to ASRS for a minimum of forty-five (45) calendar days after completion of implementation at no additional cost to ASRS.

2.2.2 Contractor will work together with ASRS in the development of communications, administration, and procedures.

2.2.3 Contractor’s implementation plan must include a detailed process for the transition of care to ensure continued authorization of dental services.

2.2.4 Contractor shall meet the following specific requirements for the implementation:

2.2.4.1 A customer call center and website are available no less than sixty (60) calendar days before the implementation date of January 1, 2026 (unless otherwise specified by ASRS) for transitioning and potential new Participants to access information.

2.2.4.2 Comprehensive claim system testing and a quality assurance audit is completed ninety (90) calendar days prior to the implementation date. Contractor shall report detailed system testing and audit results to ASRS. These audits shall be provided at no additional cost to ASRS.

2.2.4.3 New Participant Welcome Kits, ID Cards and Plan Descriptions are distributed within ten (10) calendar days of receiving the eligibility data.

2.3 Network/Provider Management

Contractor shall:

2.3.1 Provide access to a network of providers with sufficient capacity to provide timely access for and quality care to Participants.

2.3.1.1 Contractor shall complete a GeoAccess Report as requested by ASRS to ensure appropriate access to providers in various regions.

2.3.1.2 For the purposes of this section and performance guarantees, Contractor shall provide access according to the following criteria:

Provider Type Urban/Suburban Rural

General and Family Dentist 2 providers within 10 miles 2 providers within 20 miles

Periodontist 2 providers within 15 miles 2 providers within 30 miles

Prosthodontist 2 providers within 15 miles 2 providers within 30 miles

Endodontist 2 providers within 15miles 2 providers within 30 miles

Oral and Maxillofacial Surgeon 2 provider within 15 miles 2 provider within 30 miles

Orthodontist 1 provider within 10 miles 1 provider within 20 miles

2.3.2 Own all contracts and take responsibility for all subcontracted networks/providers offered by the Contractor, and must

2.3.2.1 Warrant that all participating providers meet the requisite credentialing requirements.

2.3.2.2 Conduct monitoring and evaluation of all types of provider performance.

RETIREMENT SYSTEM

3300 N Central Ave

14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

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2.3.2.3 Ensure that in-network providers are not allowed to balance bill Participants.

2.3.3 Develop, maintain and publish annually a directory of participating providers of services.

2.3.3.1 Such directory must be available online at the Contractor’s website and easily accessible by enrollees.

2.3.3.2 Contractor shall have and execute a plan for updating provider lists and communicating changes to benefits administrators and enrollees.

2.3.4 Notify the ASRS in writing at least ninety(90) calendar days in advance if the following situations should occur:

2.3.4.1 A network’s ability to serve Participants is impacted because of significant change (more than 5% of provider terminations in a specific county) in providers.

2.3.4.2 Contractor loses its certificate of authority.

2.3.5 When requested by ASRS in writing, Contractor will provide ASRS access to its most recent dental provider contract template(s) for audit purpose only.

2.4 Claim Administration

Contractor, with or without subcontractors, shall provide the following services, including but not limited to:

2.4.1 Establish written policies and procedures, including plan authorizations for coverage exceptions, practice guidelines, and payment policies that will allow for decisions.

2.4.2 Claim Processing and Management:

2.4.2.1 Receive, maintain, and process Participant eligibility files – including retroactive enrollments - in a secure, accurate and timely manner and in a format and time frame established by the ASRS.

ASRS will provide a file on a scheduled basis. Contractor must notify the ASRS of any errors or discrepancies.

2.4.2.2 Upon receipt of a claim, Contractor shall undertake all necessary tasks to properly process and resolve issues, including but not limited to verify eligibility, verify participation status of provider of services, review claim history to determine whether services covered and necessary, ensure coordination of benefits, and provide dental/clinical professional review of claims, as applicable, prior to adjudication.

2.4.2.3 Provide timely notification to Participants to request missing information that delays or prevents payment of a claim.

2.4.2.4 Contractor is responsible for documenting and processing claims according to all specific procedures or parameters outlined in the plan description and to apply all provisions consistently to all Participants.

2.4.2.5 Provide claims investigations and record these investigations. ASRS shall receive a report of these activities on a quarterly basis to show the number of investigations conducted and the outcome.

For self-insured plan

2.4.2.6 Provide the ASRS with access to real-time claim information and claim history, including denial reasoning and prior authorization.

2.4.2.7 ASRS shall have the capability to override and shall be the final decisive authority on all special, unanticipated, unusual, or new enrollment determinations when new legislation or policy changes occur throughout the plan year.

2.4.3 Claim Payment

2.4.3.1 Accurately calculate benefits payable in accordance with the benefit plan; investigate claims when charges are unusual.

RETIREMENT SYSTEM

3300 N Central Ave

14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

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2.4.3.2 Issue payments directly to Participants or providers. In accordance with Arizona Revised Statute § 20-464, Contractor is required to make a benefit payment for covered services directly to an out-of-network dental provider within the United States, if the Participant assigns the benefit payment to the out-of-network dental provider.

2.4.3.3 Generate an Explanation of Benefits (EOB) and provide to Participant.

2.4.3.4 Apply claim control and systematic procedures to trigger reviews and identify when Participants or providers have been overpaid.

2.4.3.5 Follow an established process to recover all overpayments. ASRS reserves the right to instruct Contractor how to process overpayment recoveries when an error in claims processing has occurred.

For self-insured plan

2.4.3.6 Provide a paid claim list and invoice in a form acceptable to ASRS on an established basis as stipulated during implementation.

2.4.3.7 ASRS shall have the ability to establish how recognized charges for Out of Network claims are determined.

2.5 Claim Appeals

Contractor shall provide the following services, including but not limited to:

2.5.1 Institute a procedure for responding to and resolving complaints, disputes, and appeals regarding the appropriateness of treatment, utilization review decisions, problems with provider access, requests for change of providers, requests to obtain second opinions on dental determinations, and other matters concerning quality of care.

2.5.1.1 Inform Participants about the availability of the appeals process and provide the forms with which to report issues requiring resolution

2.5.1.2 Provide a designated contact to the Participant for resolution

2.5.1.3 Respond to all complaints, grievances and appeals promptly, according to Contractor’s established best practices and standards established by the Arizona Department of Insurance and Financial Institutions, as reviewed and agreed upon by the ASRS/ Complaints, grievances and appeals about dental treatment should be acknowledged within seven (7) business days after filed.

2.5.2 Provide the necessary structure and resources, including the use of an independent reviewer, required to review all types of claims using accepted review standards at no additional cost to the ASRS.

For self-insured plan

2.5.3 Support the process established by ASRS in the review and final determinations of appeals.

2.5.4 Allow ASRS to review, edit and customize appeal templates used for ASRS Participants to ensure compliance and consistency with established ASRS procedures.

2.5.5 Provide all copies of claim and appeal documents to ASRS, as requested, and for all appeals that reach the ASRS level of review.

2.6 Customer Service

Contractor shall provide the following services, including but not limited to:

2.6.1 A toll-free number or other free telephone service that is staffed with live customer service representatives from at least 8 a.m. to 5 p.m., Monday to Friday (excluding State of Arizona holidays) Arizona time, to assist Participants with eligibility, claim filing, and dental care questions.

RETIREMENT SYSTEM

3300 N Central Ave

14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

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2.6.1.1 Customer service representatives shall have the ability to view information regarding claims and be trained to explain claim status and provider resources.

2.6.1.2 Calls outside of these hours shall be handled by voice mailbox, or equivalent system, and calls shall be returned by a knowledgeable staff member by the end of the following business day.

2.6.1.3 Contractor’s designated customer service team shall be trained on ASRS benefits under this Contract.

2.6.1.4 Contractor shall list the designated telephone number on Contractor’s website and on all communication materials.

2.6.1.5 Contractor shall accept “warm transfers” from the ASRS call center to Contractor’s call center(s).

2.6.1.6 Contractor shall ensure that ASRS and its Participants who are deaf or hearing impaired have access to communications services that enable them to use phone lines.

2.6.1.7 Document/record all ASRS Participant service calls. ASRS reserves the right to access all call logs at any time. Upon request from the ASRS, Contractor shall provide documents/recordings within a mutually agreed upon time frame.

2.6.1.8 Contractor shall notify ASRS immediately upon determination and identification of system-related problems that impact Participants’’ access to customer service assistance. Contractor shall make every effort necessary to correct such problems immediately in order to minimize any negative impact to Participants and to maintain continual operation of the Dental Plan.

2.6.2 A dedicated pre-enrollment public website for Participants to access plan documents, search for providers and self-educate regarding plan details.

2.6.3 A secure online/mobile tool for Participants to:

2.6.3.1 Review provider information including but not limited to: contracting status; licensing; specialty designation; education and background; acceptance of new patients; address; phone number.

2.6.3.2 Obtain general plan and dental procedures information, as necessary and as may be directed by

ASRS.

2.6.3.3 Access self-service capabilities to obtain current and historical claim information to track claim status.

2.6.3.4 Communicate with Contractor regarding specific claim or treatment information.

2.6.4 Contractor must certify that all systems are secure and information sent via email or provided online to Participants is protected.

2.6.5 Contractor shall provide appropriate level of access to ASRS, as allowed under privacy regulations.

2.7 Written Inquiries

2.7.1 Respond to all written inquiries/correspondence (not including appeals) within three (3) business days.

2.8 Participant Communication

2.8.1 Prepare, produce, and distribute Participant communications materials and administrative forms, including but not limited to: enrollment forms, enrollment brochures, newsletters, claim forms and checks, certificates of insurance, Participant booklets, identification cards, provider directories, announcement forms and any other forms required for proper administration.

2.8.2 Contractor shall not automatically enroll the ASRS in any programs that involve any type of communications with Participants without express written consent from ASRS.

2.8.3 Contractor agrees that ASRS must review and approve, and may edit or customize, all materials prior to distribution to Participants. Notwithstanding that Contractor must adhere to approval and notification procedures established by state and federal agencies, Contractor shall provide written verification of any

RETIREMENT SYSTEM

3300 N Central Ave

14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

Page federal or state authority that prohibits changes requested by ASRS within seven (7) business days of the requested changes.

2.8.4 Contractor will be responsible for any and all related costs of communications, including but not limited to development, printing (if any), and postage. The ASRS shall not reimburse the Contractor for any enrollment and communication costs.

2.8.5 Contractor shall supply draft articles for the quarterly ASRS retiree newsletters as requested.

2.8.6 Conduct an annual survey at Contractor’s expense to measure Participant satisfaction. The Contractor shall obtain approval of the survey instrument from ASRS.

2.9 Enrollment

2.9.1 Open Enrollment

Participating with other ASRS contractors and as coordinated by the ASRS, Contractor shall:

2.9.1.1 Within time frames specified by ASRS prior to the start of Open Enrollment, provide material for distribution, review guides and forms for accuracy and detail of all contract plans, and provide feedback.

2.9.1.2 Provide sufficient on-site knowledgeable staff to assist in all Open Enrollment activities annually, for as long as is required to manage the enrollment and reconciliation process. Dates will vary according to the ASRS Open Enrollment time schedule. These positions are in addition to any other on-site personnel employed by Contractor.

2.9.1.3 Provide Contractor representation at group monthly Enrollment Education meetings for Participants.

The representative(s) of the Contractor shall be responsible for making a brief presentation and answering questions.

2.9.1.4 Contractor shall cover the cost of Open Enrollment activities related to the Dental program.

Expenses may include, but are not limited to printing, telephone, temporary staffing, computers, and travel expenses. The Open Enrollment and communications funding must be viewed by the Contractor as a marketing and advertising business expense included in the Contractor’s Pricing Schedule, as accepted by the ASRS. The ASRS shall not reimburse the Contractor for any enrollment and communication costs. While specific costs may vary, the annual cost associated with Open Enrollment activities should be less than $10,000.

2.9.2 All Enrollments

Contractor shall:

2.9.2.1 Approximately 90% of enrollees are eligible through the ASRS, and 10% are eligible through pension plans administered by the Public Safety Personnel Retirement System. The Contractor is required to process enrollments, collect premiums, and provide required support services for the systems separately.

2.9.2.2 Ensure the Participants receive identification cards no later than the first ten (10) calendar days following the effective date of coverage. For Participants with family coverage, a minimum of two cards shall be provided. In cases where immediate enrollment is required, Contractor shall issue a temporary identification card that will be accepted by providers.

2.9.2.3 Provide a Welcome Kit, Plan Description, education information regarding available resources and tools, as appropriate.

2.9.2.4 Recognize the rights of Participants to engage in mid-year plan election changes consistent with qualifying life event and plan change rules.

2.9.2.5 Ensure orderly transitions for all Participants at life event changes and between plan years.

2.10 Reporting

RETIREMENT SYSTEM

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2.10.1 Provide a complete and comprehensive administrative reporting package to the ASRS on a defined schedule, according to the content of the report, and in a format acceptable to the ASRS. Reporting will include at a minimum plan demographics, premium dollars, total billed claims, provider discounts, total claims, ineligible charges, plan loss ratios, and direct pay Participant delinquencies.

2.10.2 Provide comprehensive utilization data to inform/guide policy and plan design decisions.

2.10.3 Submit reports in a secure manner, as appropriate for the content.

2.10.4 On a semi-annual basis, provide a comprehensive analysis of the ASRS Dental Program, providing an overview of key statistical outcomes, achievements, industry trends and practices, and recommend appropriate changes.

2.10.5 Prepare customized reports on a timely basis, on an ad hoc basis and as requested by the ASRS, to assist ASRS in effective cost management of the Program at no additional cost.

2.10.6 At the direction of the ASRS, provide claims data files to a third party of the ASRS’s choosing.

For self-insured plan

2.10.7 Provide a detailed record for funding claim payments, including the key data fields identified as necessary for the ASRS to process/utilize/interface with its computer systems and processes. The required data and format are subject to change as required by the ASRS.

2.10.8 Provide a detail of monthly bank account transactions.

2.11 Financial Management

2.11.1 Contractor shall perform any and all administrative functions necessary to ensure appropriate financial control.

2.11.2 Contractor shall provide for monthly billing for, and premium collection of, direct pay Participants. ASRS shall not be responsible for any direct pay shortfall.

2.11.2.1 No direct pay Participant should have an outstanding balance greater than three (3) months.

2.11.2.2 Contractor shall inform the ASRS ten (10) calendar days before terminating a Participant’s enrollment for non-payment.

2.11.2.3 As of September 30, 2024, the ASRS had six hundred seventy-five (675) DPPO Subscribers and one hundred thirty-five DHMO subscribers that require monthly premium billing and collection. This number is subject to change.

For fully insured plan

2.11.3 The Contractor agrees that ASRS will pay premiums on a self-billed basis.

For self-insured plan

Contractor, with or without subcontractors, shall provide the following services, including but not limited to:

2.11.4 Establish a bank account, based on the ASRS’s requirements, for the purpose of paying ASRS dental claims in the absence of a bank account established by the ASRS. ASRS reserves the right to establish its own bank account to pay claims.

2.11.4.1 Contractor established bank account shall not be required to have an imprest amount.

2.11.4.2 Establish appropriate procedures for accurate payment of claims and monthly reconciliation reporting, including issued, cleared, and stop payments and stale checks.

2.11.4.3 Transmit to the ASRS a report, in a file format acceptable to the ASRS, of all proposed claims to be paid in the time frame stipulated during implementation prior to the mutually agreed upon scheduled payment date.

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2.11.4.4 Have the capability to accept the electronic transfer of funds on regular intervals. The ASRS will wire transfer sufficient dollars to fund the account as appropriate prior to the scheduled payment date.

2.11.4.5 Contractor shall absorb any costs for the printing and issuance of any checks.

2.11.4.6 Provide escheatment services, as determined by ASRS.

2.11.4.7 Not charge banking, including late/penalty fees, to ASRS.

2.11.5 Establish a clear billing process for established administrative fees and approved expenses.

2.11.5.1 Costs/fees shall be billed to the ASRS on a monthly basis according to the format and content of the Pricing Schedule, as accepted by the ASRS. Invoices shall also reflect any reductions or discounts and include appropriate and acceptable documentation to validate the services performed as a basis for such costs.

2.11.5.2 Any additional costs/fees for any services that may be incurred by Contractor must be identified in writing and agreed to by the ASRS in advance.

2.11.5.3 Any savings gained by Contractor in utilizing subcontractors or by operational efficiencies must be reported to the ASRS.

2.11.5.4 ASRS reserves the right to offset any premiums, fees or other remittances due to Contractor to collect performance penalties or other identified and mutually agreed upon errors or adjustments.

2.11.6 Provide to ASRS any recovery monies within thirty (30) calendar days from the date of the recovery, including any interest that has been included in the recovery.

2.11.6.1 ASRS reserves the right to offset any premiums, fees, or other remittances due to Contractor in order to collect overpayments resulting from incorrect calculations, eligibility adjustments, incorrectly paid claims, or other errors or adjustments identified by ASRS internal audit, operational review, financial analysis, external audit, or other means. ASRS reserves the right to specify the method of payment of such amount.

2.12 Audit and Accounting

Consistent with Section 3.8 (Books and Records) of the Special Terms and Conditions, Contractor shall:

2.12.1 Be responsible for all costs associated with any investigation and/or audit necessary to ensure that claims are adjudicated properly.

2.12.2 Conduct internal audits at the request of ASRS should Participant service issues, regulatory changes, or failure to meet performance guarantees require ASRS to seek an intermittent audit of process or procedures.

2.12.3 Furnish a full annual accounting to the ASRS within sixty (60) calendar days of the end of the plan year showing all plan activity.

2.12.4 On an annual basis, provide a report of an operational audit (e.g. SSAE-18), conducted by an independent certified firm. Contractor shall be responsible for any expenses related to such audits.

2.13 Performance Guarantees

2.13.1 Contractor shall offer the following Performance Guarantees for which Contractor takes full financial risk for unsatisfied guarantees:

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Fully Insured Plan Performance Guarantees Service

Performance Standards

Measurement Performance Guarantee

Frequency of Measurement Weight Frequency of

Assessment

Eligibility Processing

% of updates to eligibility or enrollment records made within two (2) business days after receiving the file.

100% Quarterly 0.1% Annually

% eligibility determinations processed accurately 98% Quarterly 0.1% Annually

Claim Processing % claims processed within ten

(10) calendar days (paid, denied, or pended) of receipt.

95% Quarterly 0.1% Annually

Claim Processing

% of claims processed within fifteen (15) business days (paid, denied, or pended) of receipt.

98% Quarterly 0.1% Annually

Claim Processing Accuracy

% claims processed or coded with no errors. 98% Quarterly 0.1% Annually

Claim Calculating Accuracy

% of claim dollars submitted for payment calculated correctly (random sample audit of 2% of approved claims for the period).

98% Quarterly 0.1% Annually

Customer Satisfaction

Average overall satisfaction on Participant satisfaction surveys.

90% Annually 0.4% Annually

Account Management

% that the response time to ASRS calls/emails is within 16 business hours

100% Quarterly 0.2% Annually

Call Answer Speed Average seconds for a customer service representative to answer a call

30 Quarterly 0.3% Annually

Call Abandonment Rate

% time the abandonment rate is 2.5% or less 100% Quarterly 0.2% Annually

Network Access % access to Participants on plan(s) based on GeoAccess criteria

99% Annually 0.3% Annually

Renewal Reports

% time meets the date for delivering renewals (see Section 3.5 (Contract Amendments) of the Special Terms and Conditions)

100% Annually 0.1% Annually

Total Assessment 2.0% Annually

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Self-Insured Plan Performance Guarantees Service

Performance Standards

Measurement Performance Guarantee

Frequency of Measurement Weight Frequency of

Assessment

Eligibility Processing

% of updates to eligibility or enrollment records made within two (2) business days after receiving the file.

100% Quarterly 0.5% Annually

% eligibility determinations processed accurately 98% Quarterly 0.5% Annually

Claim Processing

% claims processed within fourteen (14) calendar days (paid, denied, or pended) of receipt.

94% Quarterly 0.5% Annually

% claims processed within thirty (30) calendar days (paid, denied, or pended) of receipt.

99% Quarterly 0.5% Annually

Claim Processing Accuracy

% claims processed or coded with no errors. 98% Quarterly 2.0% Annually

Claim Calculating Accuracy

% of claim dollars submitted for payment calculated correctly (random sample audit of 2% of approved claims for the period).

98% Quarterly 2.0% Annually

Customer Satisfaction

Average overall satisfaction on Participant satisfaction surveys.

90% Annually 2.0% Annually

Account Management

% that the response time to ASRS calls/emails is within 16 business hours

100% Quarterly 1.0% Annually

Call Answer Speed Average seconds for a customer service representative to answer a call

30 Quarterly 2.0% Annually

Call Abandonment Rate

% time the abandonment rate is 2.5% or less 100% Quarterly 2.0% Annually

Network Access % access to Participants on plan(s) based on GeoAccess criteria

99% Annually 2.0% Annually

Total Assessment 15.0% Annually

2.11.2. For all performance guarantees in aggregate, Contractor shall place at risk the following:

2.11.2.1. For a fully insured plan, a total of a minimum of two percent (2%) of the premiums per quarter measured, and

2.11.2.2. For a self-insured plan, a total minimum of fifteen percent (15%) of total annual administrative Per Subscriber Per Month fees.

2.11.3. Performance standards shall be measured by Contractor on an account-specific basis for the ASRS.

RETIREMENT SYSTEM

3300 N Central Ave

14th Floor Phoenix, AZ 85012

Group Dental Services Solicitation Code: BPM006502 Part 2 of 3 - Scope of Work

Page

2.11.4. On the frequency of measurement basis outlined for each guarantee, Contractor shall document and provide reports to ASRS to show actual results for the current period, results from prior periods, and the guaranteed standard within sixty (60) calendar days after the end of each measurement period.

2.11.4.1. Contractor’s failure to timely report the results of any individual Performance Guarantee shall be considered a failure to meet that Performance Guarantee and Contractor will be assessed a penalty for missing that guarantee.

2.11.5. Penalty assessments associated with performance guarantees shall be calculated and reviewed by ASRS within ninety (90) calendar days of the end of each Contract year and collected annually, as required.

2.11.5.1. Assessment amounts are payable to ASRS within thirty (30) calendar days of receipt of a finalized assessment.

2.11.6. The ASRS may request the inclusion of additional Performance Guarantees, a change in total percent at risk, or to reallocate the percent at risk for each performance standard. Any additional Performance Guarantees shall be mutually agreed upon through written Contract Amendment.

2.11.7. ASRS reserves the right to audit Contractor’s performance records and standards. Contractor shall cooperate with auditors and provide records, as requested, at no cost to the ASRS.

Offeror Name Completed By Title Contact Phone # Contact Email

Comments

Complete the grid. ASRS prefers to have the cost for lab work included in the member copay.

CDT Code Description Requested ----------------------------

Member Copay

Member Copay

GD

Member Copay Specialist

Lab Included (Yes/No)

Appointments None Office visit - during regularly scheduled hours $5.00

D0120 Periodic Oral Exam-Established Patient No Charge $0 $0 Yes D0140 Limited Oral Evaluation-problem focused No Charge $0 $0 Yes D0145 Oral Evaluation-Pt Under 3 Years/Counseling No Charge $0 $0 Yes D0150 Comprehensive Oral Evaluation - new or established patient No Charge $0 $0 Yes D0160 Detailed & Extensive Oral Evaluation - problem focused, by report No Charge $0 $0 Yes D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) No Charge $0 $0 Yes D0171 Re-evaluation - post-operative office visit No Charge $0 $0 Yes D0180 Comprehensive Periodontal Evaluation - new or established patient $43.00 $43 $43 Yes

DIAGNOSTIC

D0210 Intraoral - complete series (including bitewings) No Charge $0 $0 Yes D0220 Intraoral - periapical first film No Charge $0 $0 Yes D0230 Intraoral - periapical each additional film No Charge $0 $0 Yes D0240 Intraoral - occlusal film No Charge $0 $0 Yes

D0250 X-rays extraoral – 2D projection radiographic image created using a stationary radiation source, and detector

No Charge $0 $0 Yes

D0251 Extra-oral posterior dental radiographic image (limit 1 per calendar year) No Charge $0 $0 Yes D0270 Bitewing - single film No Charge $0 $0 Yes D0272 Bitewings - two films No Charge $0 $0 Yes D0273 Bitewings — three films No Charge $0 $0 Yes D0274 Bitewings - four films No Charge $0 $0 Yes D0277 Vertical Bitewings - 7 to 8 films No Charge $0 $0 Yes D0310 Sialography No Charge #N/A #N/A #N/A D0330 Panoramic Film No Charge $0 $0 Yes D0350 2D oral/facial photographic images obtained intra-orally or extra-orally Not Covered $0 $0 Yes D0351 3D photographic image Not Covered #N/A #N/A #N/A

D0364

Cone beam CT capture and interpretation with limited field of view – Less than one whole jaw (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year)

Not Covered Not Covered Not Covered Not Covered

D0365

Cone beam CT capture and interpretation with field of view of one full dental arch – Mandible (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year)

Not Covered Not Covered Not Covered Not Covered

D0366

Cone beam CT capture and interpretation with field of view of one full dental arch – Maxilla, with or without cranium (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year)

Not Covered Not Covered Not Covered Not Covered

DHMO COPAYS

Cigna Healthcare Niki Logan Senior Strategic Account Executive

(623) 271.3108 Niki.Logan@CignaHealthcare.com

Title Contact Phone # Contact Email

Comments

Complete the grid. ASRS prefers to have the cost for lab work included in the member copay.

CDT Code Description Requested ----------------------------

DHMO COPAYS

Cigna Healthcare Niki Logan Senior Strategic Account Executive

(623) 271.3108 Niki.Logan@CignaHealthcare.com

D0367

Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium (only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year)]

Not Covered Not Covered Not Covered Not Covered

D0368 Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; only covered in conjunction with Temporomandibular Joint (TMJ) evaluation)

$240.00 $240 $240 Yes

D0415 Collection of Microorganisms for Culture and Sensitivity Not Covered Not Covered Not Covered Not Covered D0425 Caries Susceptibility Tests Not Covered Not Covered Not Covered Not Covered

D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

$50.00 $50 $50 Yes

D0460 Pulp Vitality Tests $14.00 $14 $14 Yes D0470 Diagnostic Casts No Charge $0 $0 Yes D0472 Pathology report – Gross examination of lesion (only when tooth related) No Charge $0 $0 Yes D0473 Pathology report – Microscopic examination of lesion (only when tooth related) No Charge $0 $0 Yes

D0474 Pathology report – Microscopic examination of lesion and area (only when tooth related) No Charge $0 $0 Yes

D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report

Not Covered Not Covered Not Covered Not Covered

PREVENTIVE

D1110 Prophylaxis - adult No Charge $0 $0 Yes

Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year

$45.00

D1120 Prophylaxis - child No Charge $0 $0 Yes Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year

$30.00

D1206 Topical Fluoride Varnish No Charge $0 $0 Yes Additional topical application of fluoride varnish in addition to any combination of two (2) D1206s (topical application of fluoride varnish) per calendar year

$15.00

D1208 Topical application of fluoride - Excluding varnish No Charge $0 $0 Yes Additional topical application of fluoride - Excluding varnish - In applications of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year

$15.00

D1310 Nutritional Counseling for Control of Dental Disease No Charge $0 $0 Yes D1320 Tobacco counseling for the control and prevention of oral disease Not Covered Not Covered Not Covered Not Covered D1330 Oral Hygiene Instructions No Charge $0 $0 Yes D1351 Sealant - per tooth (1 series per 24 months to age 16. Perm.1st & 2nd molars only) $17.00 $17 $17 Yes D1352 Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth $17.00 $17 $17 Yes D1353 Sealant repair – Per tooth $11.00 $11 $11 Yes D1354 Interim caries arresting medicament application No Charge $0 $0 Yes D1510 Space Maintainer - fixed - unilateral $110.00 $110 $110 Yes D1515 Space Maintainer - fixed - bilateral $170.00 #N/A #N/A #N/A D1516 Space Maintainer – fixed – bilateral, maxillary $170.00 $170 $170 Yes

Title Contact Phone # Contact Email

Comments

Complete the grid. ASRS prefers to have the cost for lab work included in the member copay.

CDT Code Description Requested ----------------------------

DHMO COPAYS

Cigna Healthcare Niki Logan Senior Strategic Account Executive

(623) 271.3108 Niki.Logan@CignaHealthcare.com

D1517 Space Maintainer – fixed – bilateral, mandibular $170.00 $170 $170 Yes D1520 Space Maintainer - removable - unilateral $110.00 $110 $110 Yes D1525 Space Maintainer - removable - bilateral $170.00 #N/A #N/A #N/A D1550 Recementation of Space Maintainer No Charge #N/A #N/A #N/A D1555 Removal of fixed Space Maintainer No Charge #N/A #N/A #N/A D1575 Distal shoe space maintainer – Fixed – Unilateral $121.00 $121 $121 Yes

RESTORATIVE

D2140 Amalgam-one surface, primary or permanent $17.00 $17 $17 Yes D2150 Amalgam-two surfaces, primary or permanent $22.00 $22 $22 Yes D2160 Amalgam - three surfaces, primary or permanent $28.00 $28 $28 Yes D2161 Amalgam - four or more surfaces, primary or permanent $35.00 $35 $35 Yes D2330 Resin-based Composite - one surface, anterior $22.00 $22 $22 Yes D2331 Resin-based Composite - two surfaces, anterior $29.00 $29 $29 Yes D2332 Resin-based Composite - three surfaces, anterior $35.00 $35 $35 Yes D2335 Resin-based Composite - four or more surfaces or involving incisal angle (anterior) $88.00 $88 $88 Yes D2390 Resin-based composite crown, anterior $115.00 $115 $115 Yes D2391 Resin-based composite - one surface, posterior $47.00 $47 $47 Yes D2392 Resin-based composite - two surfaces, posterior $59.00 $59 $59 Yes D2393 Resin-based composite - three surfaces, posterior $82.00 $82 $82 Yes D2394 Resin-based composite - four or more surfaces, posterior $115.00 $115 $115 Yes D2510 Inlay - metallic - one surface $430.00 $430 $430 Yes D2520 Inlay - metallic - two surfaces $430.00 $430 $430 Yes D2530 Inlay - metallic - three or more surfaces $430.00 $430 $430 Yes D2542 Onlay - metallic - two surfaces $490.00 $490 $490 Yes D2543 Onlay - metallic - three surfaces $490.00 $490 $490 Yes D2544 Onlay - metallic - four or more surfaces $490.00 $490 $490 Yes D2610 Inlay - porcelain/ceramic one surface Not Covered Not Covered Not Covered Not Covered D2620 Inlay - porcelain/ceramic two surfaces Not Covered Not Covered Not Covered Not Covered D2630 Inlay - porcelain/ceramic three or more surfaces Not Covered Not Covered Not Covered Not Covered D2642 Onlay – Porcelain/ceramic, 2 surfaces Not Covered Not Covered Not Covered Not Covered D2643 Onlay – Porcelain/ceramic, 3 surfaces Not Covered Not Covered Not Covered Not Covered D2644 Onlay – Porcelain/ceramic, 4 or more surfaces Not Covered Not Covered Not Covered Not Covered D2650 Inlay – Resin-based composite, 1 surface Not Covered Not Covered Not Covered Not Covered D2651 Inlay – Resin-based composite, 2 surfaces Not Covered Not Covered Not Covered Not Covered D2652 Inlay – Resin-based composite, 3 or more surfaces Not Covered Not Covered Not Covered Not Covered D2662 Onlay – Resin-based composite, 2 surfaces Not Covered Not Covered Not Covered Not Covered D2663 Onlay – Resin-based composite, 3 surfaces Not Covered Not Covered Not Covered Not Covered D2664 Onlay – Resin-based composite, 4 or more surfaces Not Covered Not Covered Not Covered Not Covered D2710 Crown - Resin-based composite (Indirect) $260.00 $260 $260 Yes D2712 Crown - 3/4 resin-based composite (indirect) $370.00 $370 $370 Yes D2720 Crown - Resin with high noble metal $380.00 $380 $380 Yes D2721 Crown - Resin Based with Predominantly Base Metal $335.00 $335 $335 Yes D2722 Crown - Resin with noble metal $355.00 $355 $355 Yes

Title Contact Phone # Contact Email

Comments

Complete the grid. ASRS prefers to have the cost for lab work included in the member copay.

CDT Code Description Requested ----------------------------

DHMO COPAYS

Cigna Healthcare Niki Logan Senior Strategic Account Executive

(623) 271.3108 Niki.Logan@CignaHealthcare.com

D2740 Crown - porcelain/ceramic substrate $515.00 $515 $515 Yes D2750 Crown - porcelain fused to high noble metal $470.00 $470 $470 Yes D2751 Crown - porcelain fused to predominately base metal $415.00 $415 $415 Yes D2752 Crown - porcelain fused to noble metal $440.00 $440 $440 Yes D2780 Crown – 3/4 cast high noble metal $480.00 $480 $480 Yes D2781 Crown – 3/4 cast predominantly base metal $425.00 $425 $425 Yes D2782 Crown – 3/4 cast noble metal $450.00 $450 $450 Yes D2783 Crown - 3/4 Porcelain/Ceramic $515.00 $515 $515 Yes D2790 Crown - full cast high noble metal $480.00 $480 $480 Yes D2791 Crown - full cast predominately base metal $425.00 $425 $425 Yes D2792 Crown - full cast noble metal $450.00 $450 $450 Yes D2794 Crown-titanium $480.00 $480 $480 Yes D2799 Provisional Crown $135.00 $135 $135 Yes D2910 Recement Inlay, Onlay or Partial Coverage Restoration $43.00 $43 $43 Yes D2915 Recement Cast or Prefabricated Post and Core $43.00 $43 $43 Yes D2920 Recement Crown $43.00 $43 $43 Yes D2929 Prefabricated porcelain/ceramic crown - Primary tooth $155.00 $155 $155 Yes D2930 Prefabricated Stainless Steel Crown - primary tooth $105.00 $105 $105 Yes D2931 Prefabricated Stainless Steel Crown - permanent tooth $105.00 $105 $105 Yes D2932 Prefabricated Resin Crown $130.00 $130 $130 Yes D2933 Prefab. Steel Crown w/ Resin Window $155.00 $155 $155 Yes D2934 Prefabricated Esthetic Coated Stainless Steel Crown (primary tooth) $155.00 $155 $155 Yes D2940 Protective restoration $15.00 $15 $15 Yes D2941 Interim therapeutic restoration - Primary dentition $15.00 #N/A #N/A #N/A D2950 Core Buildup, including any pins $105.00 $105 $105 Yes D2951 Pin Retention, per tooth in addition to restoration $23.00 $23 $23 Yes D2952 Cast Post/Core In Add to Crown, Ind Fab $165.00 $165 $165 Yes D2953 Ea Add Indirect Fab Post-Same Tooth Not Covered Not Covered Not Covered Not Covered D2954 Prefabricated Post and Core in Addition to Crown $140.00 $140 $140 Yes D2957 Each additional prefabricated post - same tooth Not Covered Not Covered Not Covered Not Covered D2960 Labial veneer (resin laminate) – Chairside $105.00 $105 $105 Yes

D2971 Additional procedures to construct new crown under existing partial denture framework Not Covered Not Covered Not Covered Not Covered

D2980 Crown Repair, by report Not Covered $15 $15 Yes

ENDODONTICS

D3110 Pulp Cap - direct (excluding final restoration) $38.00 $38 $38 Yes D3120 Pulp Cap - indirect (excluding final restoration) $38.00 $38 $38 Yes D3220 Therapeutic Pulpotomy (excluding final restoration) $87.00 $87 $87 Yes D3221 Pulpal debridement, primary and permanent teeth $87.00 $87 $87 Yes

D3222 Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development $87.00 $87 $87 Yes

D3230 Pulpal Therapy - Anterior, Primary Tooth Not Covered Not Covered Not Covered Not Covered D3240 Pulpal Therapy - Posterior, Primary Tooth Not Covered Not Covered Not Covered Not Covered

Title Contact Phone # Contact Email

Comments

Complete the grid. ASRS prefers to have the cost for lab work included in the member copay.

CDT Code Description Requested ----------------------------

DHMO COPAYS

Cigna Healthcare Niki Logan…