Exhibit 2 Consultant Tasks.doc

Exhibit #2: CONSULTANT TASKS The general purpose of these audits is to (a) assure that membership files are being properly handled in a timely manner, in relation to claims adjudication; (b) that plan contract terms (including performance standards) are being adhered to; (c) that claims have been properly paid and identify dollar amounts associated with claims not processed accurately; (d) that customer service and related claims-support functions are operating at a satisfactory level and (e) to identify fundamental systems associated with claims processing that may need improvement

The tasks for which the Commission seeks assistance under this RFR include:

A. CONTRACT YEAR ONE – FY2016 (and, if the renewal option is exercised, contract year three (FY2018, using FY2017 paid claims)) Claims Dates: FY2015 paid claims

GIC Plans:

Harvard Pilgrim Independence and Primary Choice

Tufts Health Plan Navigator and Spirit

Beacon Health Options* (claims dates may be adjusted to 2/1/15 – 1/31/16 paid claims – or another mutually-agreed upon date range)

Tasks include, but are not necessarily limited to:

A.1.

Claim adjudication review - using sampling methodology (described in your firm’s response to Essay Questions #3a and 3b) - to assess:

· Financial accuracy (amount paid to amount invoiced)

· Payment accuracy, including coding accuracy

· Processing accuracy, including benefit administration (deductible, copays, etc.)

· Claims processing turnaround time

· Referral to Medical Department/Director, when necessary

A.2.

Electronic review of all claims, for the purpose of evaluating/identifying:

· Member eligibility, to assure claimant was a qualified participant on D.O.S.

· Procedures for which the member was ineligible

· Duplicate claims

· Coordination of benefits procedures

A.3.

Split claim review (applicable to Tufts Health Plan and Beacon Health Options)

· Review of claims with behavioral health diagnoses paid by the medical plan vs. the behavioral health plan to determine whether they were paid by the appropriate vendor.

A.4.

Review of Customer Service and claims processing operations, to assess:

· Processing and resolution of member complaints

· Handling of written correspondence for quality of communication and accurate interpretation and representation of benefit/plan design

· Internal procedures for identifying potential areas of claims abuse

· Customer Service response time

· Customer Service telephone abandonment rate

· Customer Service initial training and retraining where a representative requires reinforcement of procedures Claims Dates: FY2015 paid claims for any items that involve a sample of claims, FY2014 and FY2015 paid claims for any items that involve electronic screening

GIC Plan:

CVS/caremark Tasks include, but are not necessarily limited to:

A.5.

Claim adjudication review - using sampling methodology (described in your firm’s response to Essay Questions #3a and 3b) - to assess:

· Financial accuracy (amount paid to amount invoiced)

· Payment accuracy

· Processing accuracy, including benefit administration (deductible, copays, etc.)

· Claims processing turnaround (are there problem areas)

· Dispensing accuracy

A.6.

Electronic review of all claims, for the purpose of evaluating/identifying:

· Member eligibility, to assure claimant was a qualified participant on D.O.S.

· Processing and payment was in line with benefit design/administration

· Prescription pricing was accurate, in accordance with contract A.7.

Operational review to assess performance of:

· PBM mail order facility or specialty drug facility

· PBM customer service center/facility

A.8.

Pricing and rebate administration analysis:

· Determine whether the plan is complying with all pricing/rebate contract terms

· Determine whether the PBM is correctly applying retail and mail order discounts and dispensing fees, where applicable

· Pricing assessment/validation of pricing guarantess/acquisition costs B. CONTRACT YEAR TWO – FY2017 (and, if the renewal option is exercised, contract year three (FY2019, using FY2018 paid claims)) Claims Dates: FY2016 paid claims

GIC Plans:

UniCare State Indemnity Plans (Basic, PLUS, Community Choice, and Optional Medicare Extension (OME))

Fallon Direct Care and Fallon Select Care

Health New England HMO

Neighborhood Health Plan Prime

Tasks include, but are not necessarily limited to:

B.1.

Claim adjudication review - using sampling methodology (described in your firm’s response to Essay Questions #3a and 3b) - to assess:

· Financial accuracy (amount paid to amount invoiced)

· Payment accuracy, including coding accuracy

· Processing accuracy, including benefit administration (deductible, copays, etc.)

· Claims processing turnaround time

· Referral to Medical Department/Director, when necessary

B.2.

Electronic review of all claims, for the purpose of evaluating/identifying:

· Member eligibility, to assure claimant was a qualified participant on D.O.S.

· Procedures for which the member was ineligible

· Duplicate claims

· Coordination of benefits procedures

B.3.

Review of Customer Service and claims processing operations, to assess:

· Processing and resolution of member complaints

· Handling of written correspondence for quality of communication and accurate interpretation and representation of benefit/plan design

· Internal procedures for identifying potential areas of claims abuse

· Customer Service response time

· Customer Service telephone abandonment rate

· Customer Service initial training and retraining where a representative requires reinforcement of procedures C. GENERAL (all years of the audit contract, except as noted) C.1.

Provide the GIC with an assessment of each plan’s performance on the audit against an appropriate benchmark (e.g. your firm’s standards, performance of other plans on recent audits, industry standards, other).

C.2.

Provide the GIC with recommendations based on the claims/operational reviews regarding management of the Plan or the Plan’s vendors.

C.3.

Conduct other assessments as recommended in your proposal if the GIC agrees that they would like to include them in the audit.

C.4.

Prepare corrective action recommendations for each plan based on your audit findings.

C.5.

The Commission requires its auditor to draft (and work with GIC staff) to prepare a written report of your findings on each audit, and for its auditor to present those findings at a Commission Meeting (typically in June). Each report must include an Executive Summary as well as detailed descriptions of the audit methodology, findings, and recommendations, including prioritizing which findings warrant particular attention due to their level of severity and/or potential cost savings for the Commonwealth and/or our members. The auditor must provide both printed and electronic copies of the audit reports.

C.6.

(Audit contract years 3 and 4 only) In the event that the Commission votes to exercise the option to continue the contract in years three and four, the bidder may propose a scaled-back Customer Service and Claims Processing Operations review.

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