GICPND1601_RFR for Claims Audit Services.docx

THE COMMONWEALTH OF MASSACHUSETTS

GROUP INSURANCE COMMISSION

19 STANIFORD STREET

BOSTON, MA 02114

REQUEST FOR RESPONSES

GICPND1601

PROCURING AUDITING SERVICES FOR HEALTH CARE CLAIMS PROCESSING

AND RELATED ACTIVITIES FOR THE GROUP INSURANCE COMMISSION

SEPTEMBER 11, 2015

November 12, 2004 68 Draft # 2 11/12/04

Table of Contents

Required Documentation

A. Notice to Auditors and Other Interested Parties 3

B. RFR – Required Specifications 5

C. COMMBUYS Documentation 12

D. Vendor Procurement Schedule 16

E. Bid Specifications & Submission Process 18

Request for Response

I. Overview of GIC Benefits and Goals 22

II. Essay Questions 24

III. Bidder Qualifications 26

IV. Cost Proposal 27

Appendices and Exhibits

Appendix #1: Instructions for Vendors Responding to Bids

Appendix #2: RFR Submission Checklist

Appendix #3: GIC July 2015 Enrollment Data

Exhibit #1: Sample Cost Proposal Layout

Exhibit #2: Consultant Tasks

Required Documentation

A. Notice to Claims Auditors

NOTICE TO HEALTH CARE CLAIMS AUDITORS

AND OTHER INTERESTED PARTIES

August 21, 2015

This is an announcement only. The Group Insurance Commission (GIC) of the Commonwealth of Massachusetts intends to post a Bid for health care claims auditing services and to require online Quote submission via the Commonwealth’s COMMBUYS system. Bidders are solely responsible to monitor this site for amendments to this announcement and for the complete Bid posting. Bidders may monitor the site through publicly accessible search and browse tools, or through COMMBUYS email notification and record tracking tools by ensuring the commodity codes associated with this record are included in the commodity codes section of their COMMBUYS profile. Bidders may elect to subscribe to COMMBUYS immediately or wait until they have reviewed the complete Bid posting including the RFR and any amendments. Bidders who elect to establish a COMMBUYS account must select the Register link on www.commbuys.com and complete the online subscription process. Bidders for this RFR should include Commodity-EPP codes 80-10-00-00 (Management Advisory Services), 84-11-00-00 (Accounting and Bookkeeping Services), 84-13-16-08 (Medical Claims Review and Management), or 85-10-17-07 (Health systems Evaluation Services) in their COMMBUYS profile.

The GIC seeks a vendor to provide health care claims auditing services for its self-insured and fully-insured health carriers. The GIC expects the successful Bidder to perform audits of the carriers’ claims processing, claims administration management and operations. For the GIC’s pharmacy benefit manager (PBM), the engagement includes an audit of the PBM’s claims processing service, discount analysis and rebate administration. For all carriers, the audit should also examine other management and operational activities performed on the GIC’s behalf by the carriers. The GIC’s incumbent carriers are: UniCare Life and Health Insurance Company, Harvard Pilgrim Health Care, Tufts Health Plan, Fallon Health, Health New England, Neighborhood Health Plan, CVS/Caremark (pharmacy benefit manager) and Beacon Health Options (mental health/substance abuse plan). The audits take place during the winter; findings are reviewed with the staff and presented to the Commission at its June meeting. As part of the audits, the GIC expects a corrective action plan to be prepared for the carrier (as needed) based upon the carrier’s audit results. The successful Bidder will audit the GIC’s carriers over a two-year period (during FY2016 and FY2017). Tentatively, in FY2016 the auditor would audit Beacon Health Options, CVS/Caremark, Harvard Pilgrim Health Care and Tufts Health Plan. The remaining plans would be audited in FY2017. The successful Bidder may also be asked to perform a follow-up audit of each carrier, which would be conducted two years after the initial audit cycle (in FY2018 and FY2019).

Respondents should have substantial experience in auditing health care claims processing and the financial accuracy of large health insurance carriers and pharmacy benefit managers, using the audit process to evaluate claims processing and/or management concerns identified by previous audits or GIC staff, assessing claims processing performance (including, but not limited to, financial accuracy) against industry and contractual standards and in auditing pharmacy rebate administration. Potential vendors are expected to either possess both the medical and pharmacy claims audit expertise in-house or to Bid in partnership with a complementary firm.

Established in 1955, the GIC is a quasi-independent public agency, providing benefits to approximately 435,000 employees, retirees, survivors and dependents of the Commonwealth of Massachusetts, and certain other public and municipal entities. In FY2015, the GIC spent approximately $2.6 billion to provide health care benefits to this population.

The full text of the Request for Response (RFR) may be obtained via the Internet on or about September 9, 2015 using the Commonwealth’s COMMBUYS system. COMMBUYS is located at www.commbuys.com. The file number for this RFR is BD-16-1049-GIC00-07GIC-00000005281. Its title is, “GICPND1601 Procuring Auditing Services for Health Care Claims Processing and Related Activities for the Group Insurance Commission”. Questions regarding the RFR should be directed to Catherine Moore, Budget and Research Director for the GIC, at (617) 727-2310 x7033 or via email at catherine.moore@gic.state.ma.us. The RFR will state the schedule and definitive due date for responses, tentatively set for October 7, 2015. A bidders conference, to be held after the RFR is released, is tentatively set for September 17, 2015.

The GIC reserves the right to reject any or all responses or to accept any proposal or portion thereof, if deemed to be in the best interests of the Commonwealth and its insureds.

Dolores L. Mitchell Executive Director Group Insurance Commission

Procuring Auditing Services for Health Care Claims Processing and Related Activities for the Group Insurance Commission RFR# GICPND1601 / COMMBUYS Bid# BD-16-1049-GIC00-07GIC-00000005281 Released 9/11/2015 21 B. RFR - Required Specifications

In general, most of the required contractual stipulations are referenced in the Standard Contract Form and Instructions and the Commonwealth Terms and Conditions (either version). However, the following RFR provisions must appear in all Commonwealth competitive procurements conducted under 801 CMR 21.00:

The terms of 801 CMR 21.00: Procurement of Commodities and Services (and 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services, if applicable) are incorporated by reference into this RFR. Words used in this RFR shall have the meanings defined in 801 CMR 21.00 (and 808 CMR 1.00, if applicable). Additional definitions may also be identified in this RFR. Other terms not defined elsewhere in this document may be defined in OSD’s Glossary of Terms. Unless otherwise specified in this RFR, all communications, responses, and documentation must be in English, all measurements must be provided in feet, inches, and pounds and all cost proposals or figures in U.S. currency. All responses must be submitted in accordance with the specific terms of this RFR.

Items with the text, "Required for POS Only" specify a requirement for Purchase of Service (POS) Human and Social Services procured under 801 CMR 21.00, Procurement of Commodities or Services, Including Human and Social Services and 808 CMR 1.00, Compliance, Reporting and Auditing for Human and Social Service.

COMMBUYS Market Center. COMMBUYS is the official source of information for this Bid and is publicly accessible at no charge at www.commbuys.com. Information contained in this document and in COMMBUYS, including file attachments, and information contained in the related Bid Questions and Answers (Q&A), are all components of the Bid, as referenced in COMMBUYS and are incorporated into the Bid and any resulting contract.

Bidders are solely responsible for obtaining all information distributed for this Bid via COMMBUYS. Bid Q&A supports Bidder submission of written questions associated with a Bid and publication of official answers.

It is each Bidder’s responsibility to check COMMBUYS for:

· any amendments, addenda or modifications to this Bid, and

· any Bid Q&A records related to this Bid.

The Commonwealth accepts no responsibility and will provide no accommodation to Bidders who submit a Quote based on an out-of-date Bid or on information received from a source other than COMMBUYS.

COMMBUYS Subscription. Bidders may elect to obtain a free COMMBUYS Seller subscription which provides value-added features, including automated email notification associated with postings and modifications to COMMBUYS records. However, in order to respond to a Bid, Bidders must register and maintain an active COMMBUYS Seller subscription account.

All Bidders submitting a Quote (previously referred to as Response) in response to this Bid (previously referred to as Solicitation) agree that, if awarded a contract: (1) they will maintain an active seller account in COMMBUYS; (2) they will, when directed to do so by the procuring entity, activate and maintain a COMMBUYS-enabled catalog using Commonwealth Commodity Codes; (3) they will comply with all requests by the procuring entity to utilize COMMBUYS for the purposes of conducting all aspects of purchasing and invoicing with the Commonwealth, as added functionality for the COMMBUYS system is activated; (4) Bidder understands and acknowledges that all references to the Comm-PASS website or related requirements throughout this RFR, shall be superseded by comparable requirements pertaining to the COMMBUYS website; and (6) in the event the Commonwealth adopts an alternate market center system, successful Bidders will be required to utilize such system, as directed by the procuring entity. Commonwealth Commodity Codes are based on the United Nations Standard Products and Services Code (UNSPSC).

The COMMBUYS system introduces new terminology, which bidders must be familiar with in order to conduct business with the Commonwealth. To view this terminology and to learn more about the COMMBUYS system, please visit the COMMBUYS Resource Center.

Multiple Quotes. Bidders may not submit Multiple Quotes in response to a Bid unless the RFR authorizes them to do so. If a Bidder submits multiple quotes in response to an RFR that does not authorize multiple responses, only the latest dated quote submitted prior to the bid opening date will be evaluated.

Quote Content. Bid specifications for delivery, shipping, billing and payment will prevail over any proposed Bidder terms entered as part of the Quote, unless otherwise specified in the Bid.

Supplier Diversity Program (SDP). Massachusetts Executive Order 524 established a policy to promote the award of state contracts in a manner that develops and strengthens Minority and Women Business Enterprises (M/WBEs) that resulted in the Supplier Diversity Program in Public Contracting. M/WBEs are strongly encouraged to submit responses to this RFR, either as prime vendors, joint venture partners or other type of business partnerships. Similarly, Executive Order 546 established the Service-Disabled Veteran-Owned Business Enterprise (SDVOBE) Program to encourage the participation of businesses owned and controlled by service-disabled veterans in all areas of state procurement and contracting, thereby including them in the SDP. All bidders must follow the requirements set forth in the SDP section of the RFR, which will detail the specific requirements relating to the prime vendor’s inclusion of M/WBEs and/or SDVOBEs. Bidders are required to develop creative initiatives to help foster new business relationships with M/WBEs and/or SDVOBEs within the primary industries affected by this RFR. In order to satisfy the compliance of this section and encourage bidder’s participation of SDP objectives, the Supplier Diversity Program (SDP) Plan for large procurements greater than $150,000 will be evaluated at 10% or more of the total evaluation. Once an SDP commitment, expressed as a percentage of contract revenues, is approved, the agency will then monitor the contractor’s performance, and use actual expenditures with SDO certified M/WBE contractors and the Center for Veterans Enterprise certified SDVOBEs to fulfill their own SDP expenditure benchmarks. M/WBE and SDVOBE participation must be incorporated into and monitored for all types of procurements regardless of size; however, submission of an SDP Plan is mandated only for large procurements over $150,000.

Unless otherwise specified in the RFR, the following SDP forms are required to be submitted by the deadlines noted below in order to meet the mandatory participation requirements of the SDP:

Supplier Diversity Program (SDP) Resources:

· Resources available to assist Prime Bidders in finding potential Minority Business Enterprises (MBE) and Women Business Enterprises (WBE) partners can be found at: www.mass.gov/sdp

· Resources available to assist Prime Bidders in finding potential Service-Disabled Veteran-Owned Business Enterprise (SDVOBE) partners can be found on the Operational Services Division’s SDO webpage at: www.mass.gov/sdo

· The Operational Services Division’s Supplier Diversity Program offers training on the SDP Plan requirements. The dates of upcoming trainings can be found at: http://www.mass.gov/anf/budget-taxes-and-procurement/procurement-info-and-res/osd-events-and-training/osd-training-and-outreach.html In addition, the SDP Webinar can be located on the SDP website at www.mass.gov/SDP

Supplier Diversity Program Subcontracting Policies. In addition to the Subcontracting Policies (See Subcontracting Policies section below and see Section 9, Subcontracting By Contractor, in the Commonwealth Terms and Conditions) that apply to all subcontracted services, agencies may define specific required deliverables for a contractor’s SDP Plan, including, but not limited to, documentation necessary to verify subcontractor commitments and expenditures with Minority or Women-Owned Business Enterprises (M/WBEs) and Service-Disabled Veteran-Owned Business Enterprises (SDVOBE) for the purpose of monitoring and enforcing commitments made in a contractor’s Supplier Diversity Program (SDP) Plan.

Best Value Selection and Negotiation. The Strategic Sourcing Team or SST (formerly referred to as Procurement Management Team or PMT) may select the response(s) which demonstrates the best value overall, including proposed alternatives that will achieve the procurement goals of the department. The SST and a selected bidder, or a contractor, may negotiate a change in any element of contract performance or cost identified in the original RFR or the selected bidder’s or contractor’s response which results in lower costs or a more cost effective or better value than was presented in the selected bidder’s or contractor’s original response.

Bidder Communication. Bidders are prohibited from communicating directly with any employee of the procuring department or any member of the SST regarding this RFR except as specified in this RFR, and no other individual Commonwealth employee or representative is authorized to provide any information or respond to any question or inquiry concerning this RFR. Bidders may contact the contact person for this RFR in the event this RFR is incomplete or the bidder is having trouble obtaining any required attachments electronically through COMMBUYS.

Contract Expansion. If additional funds become available during the contract duration period, the department reserves the right to increase the maximum obligation to some or all contracts executed as a result of this RFR or to execute contracts with contractors not funded in the initial selection process, subject to available funding, satisfactory contract performance and service or commodity need.

Costs. Costs which are not specifically identified in the bidder’s response, and accepted by a department as part of a contract, will not be compensated under any contract awarded pursuant to this RFR. The Commonwealth will not be responsible for any costs or expenses incurred by bidders responding to this RFR.

Electronic Communication/Update of Bidder’s/Contractor’s Contact Information. It is the responsibility of the prospective bidder and awarded contractor to keep current on COMMBUYS the email address of the bidder’s contact person and prospective contract manager, if awarded a contract, and to monitor that email inbox for communications from the SST, including requests for clarification. The SST and the Commonwealth assume no responsibility if a prospective bidder’s/awarded contractor’s designated email address is not current, or if technical problems, including those with the prospective bidder’s/awarded contractor’s computer, network or internet service provider (ISP) cause email communications sent to/from the prospective bidder/awarded contractor and the SST to be lost or rejected by any means including email or spam filtering.

Electronic Funds Transfer (EFT). All bidders responding to this RFR must agree to participate in the Commonwealth Electronic Funds Transfer (EFT) program for receiving payments, unless the bidder can provide compelling proof that it would be unduly burdensome. EFT is a benefit to both contractors and the Commonwealth because it ensures fast, safe and reliable payment directly to contractors and saves both parties the cost of processing checks. Contractors are able to track and verify payments made electronically through the Comptroller’s Vendor Web system. A link to the EFT application can be found on the OSD Forms page (www.mass.gov/osd). Additional information about EFT is available on the VendorWeb site (www.mass.gov/osc).

Successful bidders, upon notification of contract award, will be required to enroll in EFT as a contract requirement by completing and submitting the Authorization for Electronic Funds Payment Form to this department for review, approval and forwarding to the Office of the Comptroller. If the bidder is already enrolled in the program, it may so indicate in its response. Because the Authorization for Electronic Funds Payment Form contains banking information, this form, and all information contained on this form, shall not be considered a public record and shall not be subject to public disclosure through a public records request.

The requirement to use EFT may be waived by the SST on a case-by-case basis if participation in the program would be unduly burdensome on the bidder. If a bidder is claiming that this requirement is a hardship or unduly burdensome, the specific reason must be documented in its response. The SST will consider such requests on a case-by-case basis and communicate the findings with the bidder.

Environmental Response Submission Compliance. In the event that paper submissions are required and in an effort to promote greater use of recycled and environmentally preferable products and minimize waste, all required paper responses that are submitted should comply with the following guidelines:

· all copies should be printed double sided

· all submittals and copies should be printed on recycled paper with a minimum post-consumer content of 30% or on tree-free paper (i.e. paper made from raw materials other than trees, such as kenaf). To document the use of such paper, a photocopy of the ream cover/wrapper should be included with the response

· unless absolutely necessary, all responses and copies should minimize or eliminate use of non-recyclable or non-reusable materials such as plastic report covers, plastic dividers, vinyl sleeves and GBC binding. Three ringed binders, glued materials, paper clips and staples are acceptable

· Bidders should submit materials in a format which allows for easy removal and recycling of paper materials

· Bidders are encouraged to use other products which contain recycled content in their response documents. Such products may include, but are not limited to, folders, binders, paper clips, diskettes, envelopes, boxes, etc. Where appropriate, bidders should note which products in their responses are made with recycled materials

· Unnecessary samples, attachments or documents not specifically asked for should not be submitted.

Executive Order 509, Establishing Nutrition Standards for Food Purchased and Served by State Agencies. Food purchased and served by state agencies must be in compliance with Executive Order 509, issued in January 2009. Under this Executive Order, all contracts resulting from procurements posted after July 1, 2009 that involve the purchase and provision of food must comply with nutrition guidelines established by the Department of Public Health (DPH). The nutrition guidelines are available at the Department’s website: Executive Order # 509 Guidance.

HIPAA: Business Associate Contractual Obligations. Bidders are notified that any department meeting the definition of a Covered Entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will include in the RFR and resulting contract sufficient language establishing the successful bidder’s contractual obligations, if any, that the department will require in order for the department to comply with HIPAA and the privacy and security regulations promulgated thereunder (45 CFR Parts 160, 162, and 164) (the Privacy and Security Rules). For example, if the department determines that the successful bidder is a business associate performing functions or activities involving protected health information, as such terms are used in the Privacy and Security Rules, then the department will include in the RFR and resulting contract a sufficient description of business associate’s contractual obligations regarding the privacy and security of the protected health information, as listed in 45 CFR 164.314 and 164.504 (e), including, but not limited to, the bidder's obligation to: implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the protected health information (in whatever form it is maintained or used, including verbal communications); provide individuals access to their records; and strictly limit use and disclosure of the protected health information for only those purposes approved by the department. Further, the department reserves the right to add any requirement during the course of the contract that it determines it must include in the contract in order for the department to comply with the Privacy and Security Rules. Please see other sections of the RFR for any further HIPAA details, if applicable.

Minimum Quote (Bid Response) Duration. Bidders Quotes made in response to this Bid must remain in effect for at least 90 days from the date of quote submission.

Prompt Payment Discounts (PPD). All bidders responding to this procurement must agree to offer discounts through participation in the Commonwealth Prompt Payment Discount (PPD) initiative for receiving early and/or on-time payments, unless the bidder can provide compelling proof that it would be unduly burdensome. PPD benefits both contractors and the Commonwealth. Contractors benefit by increased, usable cash flow as a result of fast and efficient payments for commodities or services rendered. Participation in the Electronic Funds Transfer initiative further maximizes the benefits with payments directed to designated accounts, thus eliminating the impact of check clearance policies and traditional mail lead time or delays. The Commonwealth benefits because contractors reduce the cost of products and services through the applied discount. Payments that are processed electronically can be tracked and verified through the Comptroller’s Vendor Web system. The PPD form can be found as an attachment for this Bid on COMMBUYS.

Bidders must submit agreeable terms for Prompt Payment Discount using the PPD form within their proposal, unless otherwise specified by the SST. The SST will review, negotiate or reject the offering as deemed in the best interest of the Commonwealth.

The requirement to use PPD offerings may be waived by the SST on a case-by-case basis if participation in the program would be unduly burdensome on the bidder. If a bidder is claiming that this requirement is a hardship or unduly burdensome, the specific reason must be documented in or attached to the PPD form.

Public Records. All responses and information submitted in response to this RFR are subject to the Massachusetts Public Records Law, M.G.L., c. 66, s. 10, and to c. 4, s. 7, ss. 26. Any statements in submitted responses that are inconsistent with these statutes shall be disregarded.

Reasonable Accommodation. Bidders with disabilities or hardships that seek reasonable accommodation, which may include the receipt of RFR information in an alternative format, must communicate such requests in writing to the contact person. Requests for accommodation will be addressed on a case by case basis. A bidder requesting accommodation must submit a written statement which describes the bidder’s disability and the requested accommodation to the contact person for the RFR. The SST reserves the right to reject unreasonable requests.

Restriction on the Use of the Commonwealth Seal. Bidders and contractors are not allowed to display the Commonwealth of Massachusetts Seal in their bid package or subsequent marketing materials if they are awarded a contract because use of the coat of arms and the Great Seal of the Commonwealth for advertising or commercial purposes is prohibited by law.

Subcontracting Policies. Prior approval of the department is required for any subcontracted service of the contract. Contractors are responsible for the satisfactory performance and adequate oversight of its subcontractors. Human and social service subcontractors are also required to meet the same state and federal financial and program reporting requirements and are held to the same reimbursable cost standards as contractors.

C. COMMBUYS Documentation

Accounting and Bookkeeping Services, Management Advisory Services, and/or Health Systems Evaluation Services

1. Description or purpose of procurement:

The GIC seeks a vendor to provide health care claims audits of its eight health insurance carriers.

--- this space is intentionally left blank ---

2. Applicable Procurement Law

Executive Branch Goods and Services

3. Identify acquisition method (choose one of the following):

4. Identify whether single or multiple contractors are required for contract(s):

Check One (“X”):

5. Identify whether single or multiple departments will be able to use:

The Purchasing Department reserves the right to add or remove additional authorized users during the contract term.

6. Expected duration of contract:

Initial Duration

2 years

Total Maximum Contract Duration

4 years

7. Anticipated expenditures, funding or compensation for expected duration:

Estimated Value of Total Procurement: $2,000,000 over four years

· Contract will not have a Maximum Obligation Amount (Rate Contract)

· Contract will not be subject to Quotes by a Pre-Qualified List of Contractors

· Federal Funds will not be Used to Fund Contract(s)

8. Indicate contract performance and business specifications:

See sections IV and V of the RFR.

9. Instructions for submissions of responses:

See section E of the RFR.

10. Deadline for responses (or procurement calendar):

· Indicate deadline date: October 7, 2015

· Indicate deadline time: 12:00 noon ET

· Will a Bidders’ Conference be offered? Yes [ X ] No [ ]

· Bidders’ Conference: September 17, 2015 Will opportunity for written questions be offered? Yes [ X ] No [ ] The GIC encourages bidders to submit questions prior to the Bidders’ conference; the deadline to submit written questions to be answered at the Bidders’ conference is September 15, 2015 at 5:00 PM ET. Questions may also be asked at the Bidders conference and submitted following the Bidders’ conference; the final deadline for all written questions is September 21, 2015 at 5:00 p.m. ET.

All questions should be sent to Catherine Moore at catherine.moore@state.ma.us.

Questions and answers will be posted on COMMBUYS by September 24, 2015.

Please refer to the COMMBUYS website frequently for changes to this schedule.

11. RFR Attachments In addition to complying with the requirements in this text file, the following forms/certifications must be downloaded from the COMMBUYS system and submitted with the proposal in order for the proposal to be considered complete. These forms can be obtained in the Attachment section of this RFR in the file labeled Commonwealth Forms on the COMMBUYS website: http://www.COMMBUYS.com. Respondents are solely responsible for obtaining and completing all required attachments that are identified in this RFR and for checking COMMBUYS for any addenda or modifications that are subsequently made to this RFR or the required attachments.

· Commonwealth Standard Terms and Conditions

· Commonwealth Standard Contract Form

· Business Associate Agreement

· Contractor Authorized Signatory Listing Form

· Verification of Taxpayer Identification Number and Certification (W-9)

· Supplier Diversity Program, Form 1 SDP Plan Commitment

· Authorization for Electronic Funds Payment

· Prompt Payment Discount Form

· Certification – Consultant Conflict of Interest

D. Vendor Procurement Schedule

This schedule is subject to change.

It is the bidder’s responsibility to check COMMBUYS daily for changes in the schedule, clarifications or corrections to the RFR, and responses to questions presented by bidders.

The schedule assumes that final approval of the contract by appropriate state agencies, once awarded by the Commission, could take several weeks. Every effort will be made to expedite the approval process.

To be held at :

Group Insurance Commission 19 Staniford Street, 4th Floor Boston, MA 02114 Positive photo identification required for access

Notes from the Bidders’ Conference will be posted on COMMBUYS as soon as possible afterwards.

Inquiries should be emailed to:

Catherine Moore Budget and Research Director, Group Insurance Commission Email: catherine.moore@state.ma.us

Answers to questions that are submitted in writing will be posted regularly. This date indicates the final anticipated posting of responses to written questions received by the September 21, 2015 written question deadline.

October 7, 2015 by NOON ET

October 7, 2015 by

NOON ET

Note – Proposals must be received in the GIC office on the 4th floor by this deadline. No proposal will be accepted after this date and time.

PROPOSALS DUE - both submitted through COMMBUYS and due to GIC offices To COMMBUYS: Complete proposals must be submitted through the COMMBUYS website by this date and time. Proposals will not be accepted unless both an electronic version is received in COMMBUYS and the hard copies are received at the GIC’s office by the deadline.

To GIC: For instructions on how to submit bids to the GIC, see page 20 of this RFR or Appendix #2: RFR Submission Checklist

Attn: Catherine Moore Budget and Research Director Group Insurance Commission 19 Staniford Street, 4th Floor Boston, MA 02114

E. Bid Specification and Submission Process

General Instructions The proposals received in response to this RFR are subject to review by the Group Insurance Commission. The Commission reserves the right to reject any or all proposals or to accept any proposal or portion thereof, or to request additional information from any or all of the respondents, if deemed in the best interest of the Commonwealth and its program participants.

This RFR requires that respondents provide certain information. All proposals should be based on the requirements, specifications, claim experience and census information provided in this RFR. All information requested must be provided and all questions must be answered before a proposal is deemed to be complete. The Commission may choose not to evaluate an incomplete proposal. Depending on the nature of the omission, the Commission’s Review Committee may decide to (a) continue with the evaluation, (b) suspend consideration of the proposal until the respondent supplies the omitted information, or (c) terminate consideration of the proposal.

Answers to questions may not:

· Exceed the maximum length (where stipulated). The Review Committee will not read, score, or consider parts of responses that exceed the maximums outlined.

· Refer to exhibits located in other areas of the proposal, except where explicitly requested. If a response requires reference to an exhibit, the exhibit must be included with the appropriate written response.

The data requested by this RFR, including the signed Transmittal Letter, the Cost Proposal, and the Minimum Data Set Request, must be provided in the specified formats without modification. Failure to do so may result in disqualification of the proposal. Also, documents may not be labeled confidential. All responses to this RFR are subject to Massachusetts Public Records law, M.G.L., c.66, s.10.

Any and all costs incurred by a respondent in the development of a proposal pursuant to this RFR are the responsibility of the respondent and will not be reimbursed by the Commission.

No commissions, contingency commissions, or any other related direct or indirect placement fees will be paid to any agent or broker. All price and cost estimates submitted should specifically exclude these types of payments.

The Group Insurance Commission of the Commonwealth of Massachusetts is posting this Bid for Auditing Services and requires online quote submission via COMMBUYS. Bidders are solely responsible to monitor this site for amendments to this Bid posting, if any. Bidders may monitor the site through publicly accessible search and browse tools, or through COMMBUYS email notification and record tracking tools by ensuring that the commodity codes associated with this record are included in the commodity codes section of their COMMBUYS profile. Bidders may elect to subscribe to COMMBUYS immediately or wait until they have reviewed the complete Bid posting including the RFR and its amendments, if any. Bidders who elect to establish a COMMBUYS account must select the “Register” link on www.commbuys.com and complete the online subscription process.

Inquiries All inquiries concerning this RFR must be made in writing to the GIC and must be received no later than 5:00 PM ET on September 21, 2015. No questions will be entertained after that date. Answers to questions will be posted on COMMBUYS. Only written inquiries regarding this RFR will be accepted. Questions should be sent to:

Catherine Moore Budget and Research Director, Group Insurance Commission Email: catherine.moore@state.ma.us

Proposals Proposals (in the specified Proposal Format) must be received no later than 12:00 noon ET on October 7, 2015 through the COMMBUYS website as well as at the GIC offices. Proposals will be considered only if both the COMMBUYS electronic response and the GIC copies are received before the deadline.

To COMMBUYS: For instructions on how the submit a bid through the COMMBUYS system, please see Appendix #1: Instructions for Vendors Responding to Bids.

To the GIC: Vendors must submit 3 copies of the unbound proposal which include all the required state forms and certifications listed below. One unbound proposal must contain all original forms with blue ink signatures; the other two can be photocopies of the blue ink set. Each of the 3 transmittal letters must be originals, signed in blue ink. The unbound copies should include all materials associated with the vendor’s bid (both the Technical Proposal and the Cost Proposal).

In addition, vendors must submit both five bound (three-ring binders, binder clips, etc., see page 9 of this RFR) copies of the Technical Proposal and five copies of the Cost Proposal. The Technical Proposal should include the transmittal letter, the responses to the essay questions, the minimum data set request, and the additional requested materials. The Technical Proposal materials must be bound separately from the Cost Proposal materials. Furthermore, bidders must not include any cost information in the Technical Proposal. The required state forms and certifications do not need to be included anywhere in these five bound copies.

Finally, the bidders also must submit a CD containing the proposal and all attachments.

Proposals must be delivered to the GIC’s office on the fourth (4th) floor to be considered received. Please note: If sending this response by courier, be advised that the courier must deliver it to the GIC's office on the fourth floor by the stated date and time, and to no other location. Procurements left in any location other than the GIC's office, including the ground floor lobby front desk or the Hurley Building loading dock or mail room, cannot be guaranteed of on-time delivery. Proposals received past that date and time will not be accepted.

Proposals should be addressed to:

Catherine Moore Budget and Research Director Group Insurance Commission 19 Staniford Street, 4th Floor Boston, MA 02114

Bidder Proposal Submission The below information can also be found in Appendix #2: RFR Submission Checklist. Your bid must have the following specific sections, in the following order. Bidders should utilize a 12-point font size and page margins of 1 inch on white paper with black ink.

· Transmittal Letter and Required Forms/Certifications (Forms/Certifications Available on COMMBUYS)

· A transmittal cover letter must confirm your submission and contain complete contact information (including phone and email) for the person at your organization who has overall responsibility for your proposal and who may be reached for questions or requests for additional information. This letter must not exceed two pages.

· If subcontracting, the subcontractor(s) must also complete a set of required forms and certifications.

· The transmittal letter and all Forms and Certifications must be signed by an individual authorized to bind the firm contractually.

· Originals (delivered to the GIC) must be clearly marked and signed in blue ink.

· Responses to Essay Questions

· Additional Requested Materials

· Please provide the information requested in Section III: Bidder Qualifications (page 26 of this document).

· A copy of an audit report your firm recently provided to a client (note the GIC recommends that you redact any information that would allow someone to identify the client).

· Minimum Data Set Request

· Several weeks will elapse between the time the GIC awards the contract and the time the auditor can begin work. In order to enable the GIC’s health plans to provide data to the auditor in the required timeframe, bidders must provide a detailed data file layout and descriptions of the data they need from the GIC’s plans that are being audited in FY’16, so that the GIC can request those data files in advance of the contract being approved and processed.

· If subcontracting, the subcontractor(s) must also provide its Minimum Data Set Request.

· Cost Proposal

Best Value Selection and Negotiation The GIC will select the response that demonstrates the best value overall, including proposed alternatives, which will achieve the procurement goals of the GIC. The GIC may negotiate a change in any element of an original RFR response that results in lower costs or a more cost-effective or better value than was presented in the original response.

Finalist Interviews and Site Visits Based on the initial review of the proposals, the GIC will select finalist vendors. Interviews are scheduled for the week of October 26, 2015. The purpose of these interviews will be to clarify and substantiate certain aspects of finalists’ proposals, obtain supplemental information, and meet each of the finalists’ proposed team members.

Request for Response

I. Overview of GIC Benefits and Goals The Group Insurance Commission (GIC) is a quasi-independent state agency governed by a seventeen-member body (the Commission) appointed by the Governor. The GIC is located administratively within the Executive Office of Administration and Finance, and is responsible for providing health insurance and other benefits to approximately 435,000 employees, retirees, and their survivors and dependents of the Commonwealth and certain other state and municipal entities. The GIC designs, implements, and manages employee and retiree benefit plans, negotiates plan rates, and continually evaluates the nature, scope, and costs of its programs. Since employee benefits are not part of the state employee collective bargaining process, the GIC designs its benefit program within the parameters set by the Commission and the Legislature. In addition to health insurance, the GIC sponsors life insurance, long-term disability insurance, dental and vision coverage for employees not covered by collective bargaining, a retiree discount vision plan and retiree dental plan, and a pre-tax health care spending account and dependent care assistance program for active employees.

The GIC currently contracts with six insurance carriers to provide a total of 17 different health plan options for its members. Eleven of these health plans are available to employees and non-Medicare retirees; six health plans are offered to Medicare retirees. As of July 1, 2015, for its health insurance benefits for employees and non-Medicare retirees, the GIC fulfills its statutory responsibilities by contracting with UniCare for the provision of three distinct managed indemnity plans and five other carriers for HMO and POS products. Medicare retirees may choose from a managed indemnity plan, administered by UniCare, two Medicare Advantage Plans, administered by Tufts Health Plan and Fallon Health and three HMO-type plans, administered by Harvard Pilgrim Health Care, Health New England and Tufts Health Plan. Prescription drug benefits in the UniCare managed indemnity plans (both non-Medicare and Medicare) are carved out, on a self-insured basis in direct contract with the GIC, to a pharmacy benefit management (PBM) company, CVS/caremark. Beacon Health Options is the carve-out vendor that provides the behavioral health benefits for the aforementioned UniCare plans as well as the two plans offered to employees and non-Medicare retirees by Tufts Health Plan. Appendix #3 provides a list of the GIC's health plans and their July 1, 2015 enrollment figures (contract count).

As part of its management of its vendors, the GIC conducts routine audits of both its self-insured and fully-insured health plans (at this time the plans’ provider payments are predominantly fee-for-service claims). The agency utilizes the services of an external firm specializing in health care claims auditing to perform these audits. The GIC's auditors conduct the plan audits on a rotating cycle (in other words, a plan that is audited in the first and third years of the audit contract will not be audited in years two and four of the contract). However, an exception may be made in the event that an audit uncovers issues sufficiently numerous or an issue that is serious enough that the Commission determines that another audit should be conducted the following year. Copies of past audit reports and presentations will be shared with the auditor the Commission selects as a result of this procurement.

In this audit engagement, the GIC seeks an auditor who has substantial experience in auditing health care claims processing and financial accuracy of both health insurers and pharmacy benefit managers (PBMs), and, in the case of the PBM, in performing discount analyses and evaluating the PBM's rebate administration. The agency seeks an auditor who appreciates that claims processing and related administrative audits are successful when they identify both claims processing problems and identify other organizational issues, and shares our understanding that claims processing systems, management, and operations all play a role in a carrier's ability to successfully administer the GIC's benefits. Potential vendors are expected either to possess both the medical and pharmacy claims audit expertise described above or to partner with a complementary firm in their bid.

II. Essay Questions

This section contains a series of essay questions to be used to further evaluate each vendor. Responses should demonstrate an understanding of the needs of the GIC and the engagement (as described in Exhibit #2 - Consultant Tasks).

Please note the distinct maximum response limits for each question and limit answers accordingly. Restate the question in each response; the questions themselves are not included in the page limit of the responses. All respondents must utilize a black ink 12-point typeface on white paper with 1-inch margins. Any submission exceeding the required page/word length or specifications will be scored only on the portion conforming to those limits and specifications.

Bidders who propose working with a subcontractor on this engagement should answer the all questions below. In question 1, the bidder should address questions 1 (a) and 1 (b) with respect to their own firm. The proposed subcontractor should also, separately, answer question 1 (a), for which the subcontractor has a separate two page limit. For question 2, the bidder should include appropriate subcontractor personnel in their responses to both 2 (a) and 2 (b).

1. Firm Experience and Qualifications:

(a) Describe three recent client engagements with organizations that are similar to the Group Insurance Commission. What did you do in those audits, and how did your findings affect the vendors and/or the clients? (maximum length: two pages)

(b) What do you believe are the key differentiators of your organization and what gives your organization a competitive advantage over other audit firms. What makes your organization unique? (maximum length: one page)

2. Auditor Experience and Qualifications:

(a) Identify each of the key team members on the engagement, what is their role on the team, how their background and experience fits their role on the team, and how do the individuals on the team work together to produce the final result. (maximum length: two pages)

(b) For the Project Manager and the Technical Lead (and, where applicable, the team leader of the engagement at the subcontracting firm), please describe their recent experience on two similar engagements. (maximum length: one page per person)

3. Audit Approach:

(a) Please discuss the consultant tasks outlined in Exhibit #2. How would you approach them (e.g. claims sampling methodology (including targeted sampling), electronic claims screening, rebate analysis, and comparing vendors' performance - to what standards/benchmarks)? If you are partnering with another firm in your bid, how do you propose dividing the audit tasks? (maximum length: two pages)

(b) How does your firm define statistical accuracy in auditing? How do you assure very large clients like the GIC that your audit has, in fact, captured a reasonable representation of how their carriers are paying claims and the adequacy of their claims payment and related processes? (maximum length: one page)

(c) Given the importance of customer service (and other operational areas of the health plan) to assuring member satisfaction with their health plan, the GIC expects its plan audits to include a thorough review of other aspects of health plan operations.