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Instructions Exhibit 2- Cost Proposal EVT#0010856
Provide a cost quotation of total fees anticipated to complete the project. Bidders shall provide a flat-fee pricing (including travel expenses) for the services on each tab. The flat fee price shall include the vendor being available for up to one calendar year after the acceptance of the final audit report by the Kansas State Employees Health Care Commission (HCC) in order to answer questions about and clarify information about the audit findings to the State Employee Health Plan staff and HCC.
The costs for any services for which you might bill the SEHP in relation to the product being bid, MUST be included on this Cost Proposal.
If there is a service for which you charge that is not listed, include that service in the “Miscellaneous Costs & Optional Services” section. Optional services should be so noted. Any service not listed on your cost proposal is not billable or payable by the SEHP. The SEHP has outlined the core audits requested as well as some additional audits that the SEHP may implement in addition to the core audits during the term of this contract.
Please bid separately on ASO vendors for medical, dental and prescription drug coverage and by each area of review. Please provide pricing options and details in each section. List all assumptions utilized and clearly identify pricing as per audit. If a service on this cost sheet is not offered by your company, mark the cost as “service not available.” An additional hourly rate should be included as part of the bid package in the event additional services may be required.
Medical Vendor Audit Exhibit 2- Cost Proposal EVT# XXXX
| Company Name: |
| Required Medical Plan Audit Services |
| 2.1 Audit of Medical Plan Vendor | Year 1 | Year 2 | Year 3 |
| Cost Per Medical Vendor Audited | | | |
| Services Include: |
| A statistically valid claims sample that will provide a 95% confidence level in the audit findings |
| Confirm that the services were paid according to the Plan documents. |
| Confirm appropriate cost sharing. |
| Confirm appropriate cost sharing were applied: deductibles, copayment, coinsurance, out of pocket maximums, etc. |
| Confirm compliance with contract performance guarantees. |
| 2.2 Targeted Medical Claims Audit | Year 1 | Year 2 | Year 3 |
| Cost Per Medical Vendor Audited | | | |
Services Include:
Specific types of claims that are targeted specifically that were not selected in the random sample type above. (Select 50 claims) Example: Bariatric Claims, High-Cost Claims over $250,000
Additional Requested Audit Services
| 2.3 Audit of Medical Plan Eligibility Records | Year 1 | Year 2 | Year 3 |
| Cost Per Medical Vendor Audited | | | |
Services Include:
Full enrollment audit of all change files for the year Testing of terminated members to confirm there were no paid claims
| 2.4 Recoupment Medical Claims Audit | Year 1 | Year 2 | Year 3 |
| Cost Per Medical Vendor Audited | | | |
Services Include:
Review claim adjustments, reversals, and provider audits for compliance with contract audit requirements for Kansas providers.
Determine if the Plan received appropriate credits for claims refunds.
Dental Vendor Audit Exhibit 2- Cost Proposal EVT# XXXX
| Company Name: |
| Required Dental Plan Audit Services |
| 2.5 Audit of Dental Plan Vendor | Year 1 | Year 2 | Year 3 |
| Cost Per Dental Vendor Audited | | | |
Services Include:
A statistically valid claims sample that will provide a 95% confidence level in the audit findings Confirm that the services were paid according to the Plan documents Confirm appropriate cost sharing was applied: deductibles, copayment, coinsurance, out-of-pocket maximums, etc.
Confirm compliance with contract performance guarantees
Additional Requested Dental Audit Services
| 2.6 Audit of Dental Plan Eligibility Records | Year 1 | Year 2 | Year 3 |
| Cost Per Dental Vendor Audited | | | |
Services Include:
Full enrollment audit of all change files for the year Testing of terminated members to confirm there were no paid claims
| 2.7 Recoupment Dental Claims Audit | Year 1 | Year 2 | Year 3 |
| Cost Per Dental Vendor Audited | | | |
| Services Include: |
| Review claim adjustments, reversals and provider audits for compliance with contract audit requirements for Kansas providers. |
Determine if the Plan received appropriate credit for claims refunds.
PBM Vendor Audit Exhibit 2- Cost Proposal EVT# XXXX
| Company Name: |
| Required Pharmacy Benefit Manager Audit Services |
| 2.8 Pharmacy Claim Audit | Year 1 | Year 2 | Year 3 |
| Cost Per PBM Vendor Audited | | | |
| Services Include: |
| Electronic Audit 100% of pharmacy claims |
| Confirm that the services were paid according to the Plan documents |
| Confirm appropriate cost sharing was applied: deductibles, copayment, coinsurance, out of pocket maximums, etc. |
| Confirm quantity limits applied correctly |
| Confirm prior authorizations applied correctly |
| Confirm proper dispensing fee used |
| Confirm proper NDC level discounts applied correctly |
| Confirm Point-of-Sale rebates applied correctly |
| Confirm discount tier drugs processed correctly |
| Confirm drug exclusions applied correctly |
| Confirm compliance with contract performance guarantees |
| 2.9 PBM Transparency Audit | Year 1 | Year 2 | Year 3 |
| Cost Per PBM Vendor Audited | | | |
| Services Include: |
| The SEHP has a transparent pharmacy arrangement. |
| The audit will validate retail transparency of pass-through pharmacy reimbursements and pricing. |
| The audit includes sampling actual pharmacy payments by contacting retail pharmacies to validate the payments made. This requires contacting a sample of Kansas pharmacies to verify payments. Vendors will need to have experience estimating POS rebates to complete this audit. |
| 2.10 PBM Rebate Audit | Year 1 | Year 2 | Year 3 |
| Cost Per PBM Vendor Audited | | | |
| Services Include: |
| On-site rebate review of manufacturer’s contracts and the application of point-of-sale rebates. |
Ensure that the SEHP has received the total rebate value of the agreement.
The audit may consist of up to twelve (12) pharmaceutical manufacturer contracts or the pharmaceutical manufacturer rebate contracts that account for 70% of the total rebate payments during the selected audit period during an on-site rebate audit.
Additional Required PBM Audit Services
| 2.11 Recoupment PBM Claims Audit | Year 1 | Year 2 | Year 3 |
| Cost Per PBM Vendor Audited | | | |
| Services Include: |
| Retail Pharmacy Recoupment Audit to review adjustments, reversals and review claims audits done by the PBM and compliance with contract audit requirements for Kansas pharmacies. |
| Review claim adjustments and reversals processed to determine if the Plan received appropriate credit for claims amounts refunded. |
| 2.12 Audit of PBM Pricing Across Mail & Retail | Year 1 | Year 2 | Year 3 |
| Cost Per PBM Vendor Audited | | | |
| Services Include: |
| Comparison of PBM’s pricing across channels to evaluate the PBM’s pricing across retail pharmacy and the PBM’s mail and retail settings. |
| 2.13 Audit of PBM Eligibility Records | Year 1 | Year 2 | Year 3 |
| Cost Per PBM Vendor Audited | | | |
| Services Include: |
| Full enrollment audit of all change files for the year |
| Perform a random sample audit on terminated members to confirm that claims were not paid after the SEHP advised the vendor on a change file to term the membership. |
Additional Audits Exhibit 2- Cost Proposal EVT# XXXX
| Company Name: |
| Additional Required Audit Services |
| 2.14 Dependent Eligibility Verfication Audit (DEVA) | Year 1 | Year 2 | Year 3 |
| Annual Audit | | | |
| Services Included: |
| The SEHP has done a full DEVA audit in the past and requires all dependent documents to be submitted to the Plan as dependents are added. |
| The DEVA should be a random sample audit of dependents (Spouses, Children and Grandchildren) done annually to verify that they still meet the plan eligibility requirements to be covered. |
| 2.15 Premium Reconciliation Audit | Year 1 | Year 2 | Year 3 |
| Annual Audit | | | |
| Services Include: |
| Review of member eligibility records and premium collections from state agencies and non state public employers covered under the plan to ensure that the SEHP is being paid for all members covered under the plan. |
Additional Requested Audit Services
| 2.16 Pre or Post Implementation Audit | Year 1 | Year 2 | Year 3 |
| As Needed Basis | | | |
| Services Include: |
| Test vendor setup and or review vendor handling of SEHP benefits for accuracy in claims processing and benefit set up. |
| 2.17 Hour Rate for Audit Services | Year 1 | Year 2 | Year 3 |
| As Needed Basis | | | |
| Services Include: |
| Hourly rate for services if needed by the Plan. |
Misc. Costs & Optional Services Exhibit 2- Cost Proposal EVT# XXXX
| Company Name: |
| Miscellaneous Costs and Optional Services |
| If there are any additional costs for programs, services or audits available from your company that would have additional fees; provide a cost quotation of the recommended ancillary programs those should be reported here and include details of the services and costs. Please add additional boxes as needed. | | | |
| 2.18 Other | Year 1 | Year 2 | Year 3 |
Services Include: