Medical,_Dental_and_Pharmacy_Auditing_(Addendum_#5_Revision).pdf

COUNTY OF ORANGE

COUNTY EXECUTIVE OFFICE - CPO - ON BEHALF OF EMPLOYEE

BENEFITS

REQUEST FOR PROPOSAL (RFP)

FOR

MEDICAL, DENTAL AND PHARMACY AUDITING

RFP NO. RFP-017-2911101-CR

RESPONSES MUST BE SUBMITTED ELECTRONICALLY TO:

https://secure.procurenow.com/portal/ocgov https://secure.procurenow.com/portal/%7bproject.government.code%7d

County of Orange RFP

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County of Orange

County Executive Office - CPO - on behalf of Employee Benefits

Procurement and Contract Services

400 W. Civic Center Dr

Santa Ana, CA

92701

SCHEDULE OF ACTIVITIES

Release of RFP Solicitation September 5, 2025

Question Submission Deadline September 24, 2025, 2:00pm

RFP Submittal Closing October 3, 2025, 2:00pm

Proposal Evaluations to be conducted week of

October 27, 2025

Interviews with the Top Ranked

Firm(s) (if applicable) to be conducted week of

November 3, 2025, 9:00am

Negotiations with Top Ranked Firm(s) to be conducted week of

November 10, 2025

Estimated Approval date of Final

Contract by the Board of Supervisors

(if applicable):

January 13, 2026

PROPOSALS MUST BE RECEIVED ON

OR BEFORE

Friday, October 3, 2025

2:00 pm

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SECTIONS

SECTION 1. INTRODUCTION AND INSTRUCTIONS TO RESPONDENTS

SECTION 2. PROTEST PROCEDURES

SECTION 3. SCOPE OF WORK

SECTION 4. OCLSB AND DVBE PREFERENCE POLICIES CERTIFICATION

REQUIREMENTS

SECTION 5. PROPOSAL SCORING CRITERIA

SECTION 6. PRICING PROPOSAL

SECTION 7. VENDOR RESPONSES

Attachments:

A - Model Contract & Attachments A - D

E - Contract Appendix VI - Dental Plan Document 2024 Signed

F - Contract Appendix I - Sharewell Choice Health Plan Document revised Final 8-20-25

G - Contract Appendix II - Sharewell Retiree Health Plan Document 2025 revised Final 8-20-25

H - Contract Appendix III - Wellwise Choice Health Plan Document 2025 revised Final 8-20-25

I - Contract Appendix IV - Wellwise Non-Medicare Retiree Health Document 2025 revised Final

8-20-25

J - Contract Appendix V - Wellwise Medicare Retiree PPO Plan Document 2025 revised Final 8-

20-25

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SECTION 1. INTRODUCTION AND INSTRUCTIONS TO RESPONDENTS

This Request for Proposal (RFP) is being released for Medical, Dental and Pharmacy Auditing.

This RFP is an opportunity to allow qualified vendors to present proposals that will assist the

County of Orange, CEO/Employee Benefits in selecting a contractor that will best meet the needs of the County for a three (3) year initial contract term with one (1) optional two (2) year renewal term which may require approval by the Board of Supervisors. The County intends that the successful Respondent shall provide Medical, Dental and Pharmacy Auditing proposed in accordance with contract requirements set forth in the solicitation and Model Contract, including

Attachments.

1.1 BACKGROUND INFORMATION

Medical:

The County currently provides five self-insured preferred provider organization (PPO) health plans

(two for employees and three for retirees) with claims administration provided by Blue Shield of

California (Blue Shield). This RFP includes the existing five self-insured PPO health plans. There is also the potential to add new High-Performance Network (HPN) self-insured PPO health plans in the future. If added, the HPN plans will be available to both retirees and employees and will mimic the current plan designs for Sharewell and Wellwise.

For calendar year 2024, Blue Shield processed 172,759 medical claims for approximately 5,432 employees and retirees. Medical expenditures for calendar year 2024 under the County's self-insured PPO health plans totaled approximately $58.6 million.

Eligible employees and retirees of the County of Orange have a choice of health plans. During

2025, employees could choose from two self-insured PPO plans administered by Blue Shield:

Sharewell Choice and Wellwise Choice. Employees could also choose from three HMO plans:

Kaiser, Cigna Choice (Full Network), and Cigna Select (Narrow Network). During 2025, retirees and their dependents with and without Medicare were eligible to enroll in three separate self-insured PPO plans: Sharewell Retiree, Wellwise Retiree Non-Medicare, and Wellwise Retiree

Medicare. In addition, depending on their Medicare eligibility, retirees could choose from other options including Medicare Advantage plans. Only the five self-insured PPO health plans are part of this Contract.

The current five self-insured PPO health plans identified above have varying plan provisions and benefits, Sharewell Choice and Sharewell Retiree closely aligned with each other, and Wellwise

Choice, Wellwise Retiree Non-Medicare and Wellwise Retiree Medicare closely aligned. The five self-insured PPO health plan documents are included as Attachments E, F, G, H and I in the

Attachment Section of this solicitation.

A key plan design difference between the Sharewell and Wellwise health plans is the Sharewell health plans are high deductible health plans (HDHP). Both Sharewell and Wellwise health plans have prescription drug coverage carved out to a pharmacy benefit manager (PBM), OptumRx. The

Wellwise Retiree Medicare PPO pharmacy benefit is an Employer Group Waiver Plan

(EGWP). All Sharewell PPO Plans are non-creditable pharmacy coverage.

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Another key plan design difference is only the Wellwise Non-Medicare Retiree and Wellwise

Medicare Retiree plans offers an annual $50 Non-Smoker Incentive to the subscriber.

Dental:

The County currently provides one self-insured preferred provider organization (PPO) dental plan for eligible employees and their dependents with claims administration provided by Blue Shield of California (Blue Shield) through their subcontractor Dental Benefit Providers. Full-time eligible employees do not pay a premium for their dental plan. Part-time employees and employees on an unpaid leave pay 100% of the premium. The 2025 monthly premiums are $25.85 for employee only, $53.90 for employee plus one, and $82.50 for employee plus two or more.

For calendar year 2024, Blue Shield processed 33,777 dental claims for approximately 6,211 members of the County of Orange Dental Plan. Dental expenditures for calendar year 2024 were

$2.9 million.

Remaining County employees that are not eligible for County dental, do not receive County paid dental benefits, but instead receive dental benefits from their applicable labor organizations.

The County of Orange Dental Plan Document (Plan Document) is included as Attachment J in the

Attachment Section of this solicitation. The Plan Document, effective January 1, 2024, was recently modernized to bring the plan in line with industry standards. The modernized plan increased the annual maximum to $2,000 and added implant and orthodontia coverage with a separate annual maximum.

Pharmacy:

The County currently provides a carve out pharmacy program through OptumRx, Inc. for its self-funded PPO (Preferred Provider Organization) health plans administered through Blue Shield of

California (Blue Shield). The carve out pharmacy program is available to members enrolled in the

County’s five medical plans – Sharewell Choice, Sharewell Retiree, Wellwise Choice, Wellwise

Non-Medicare Retiree, and Wellwise Medicare Retiree. The Wellwise Medicare Retiree PPO pharmacy benefit program is an Employer Group Waiver Plan (EGWP). All Sharewell PPO plans are non-creditable coverage.

For calendar year 2024, Optum processed 110,327 pharmacy claims for approximately 5,432 employees and retirees. Pharmacy expenditures for calendar year 2024 were $25.0 million. Pharmacy rebates from Optum totaled $7.5 million.

Benefits Service Center:

County employees and retirees (Participants) receive benefits information, make all benefit elections, and direct all benefits customer service inquiries to the County of Orange Benefits

Service Center (Benefits Center). These services are provided through Alight Solutions LLC

(Alight). Participants can make their elections on the County of Orange MyOCBenefitsTM website or by calling the Benefits Center toll-free and speaking with a Customer Care Representative. The

Benefits Center is the owner of eligibility on behalf of the County. It sends eligibility files to Blue

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Shield of California for medical and dental enrollment and eligibility. Alight also sends eligibility files directly to Optum for retirees enrolled in the Wellwise Medicare Retiree PPO Plan (Employer

Group Waiver Program (EGWP)). Blue Shield sends eligibility to Optum for all other health plans.

Alight provides electronic eligibility and premium billing files to the Blue Shield and Optum as stated above. Alight receives confirmation of all file transmissions and will work with the County’s vendors in resolving discrepancy reports. It is the responsibility of the vendor to correct their eligibility records to match Alight’s.

Key Laws and Regulations:

The County meets the definition of an applicable large employer (ALE) and therefore is subject to

Internal Revenue Code (IRC) Section 4980H, Affordable Care Act (ACA). The Wellwise Non-

Medicare Retiree, Wellwise Medicare Retiree, and Sharewell Retiree health plans are considered to be retiree only plans and as such, are not subject to all provisions of the ACA.

As a governmental entity, the County’s self-insured PPO health plans are not subject to ERISA

(Employment Retirement Income Security Act). In addition, the County is required to be compliant with federal mental health parity requirements. Under HIPAA privacy requirements, the selected

Contractor will be required by the County to follow all privacy guidelines required under the law and comply with all contractual provisions in the Proposed Contract related to HIPAA.

Eligibility:

The eligibility provisions for County are:

All regular and limited-term employees who are regularly scheduled to work 20 hours or more per week are eligible for health benefits on the first day of the month following 30 days from the date of hire.

All extra help employees who are regularly scheduled to work 30 hours or more per week are eligible for health benefits on the first day of the month following 60 days from the date of hire.

Retirees who meet certain conditions, such as eligible to receive an OCERS pension and separated from an eligible bargaining unit, are eligible for a retiree health plan on the first day of the month following retirement.

Spouses and domestic partners are eligible for coverage.

Dependent children are eligible for coverage to the end of the calendar month in which they turn 26.

Dependent children who are permanently disabled before age 26 are eligible for coverage as a dependent child after age 26.

Additional eligibility provisions may be added to meet the ACA – Employer Shared

Responsibility provisions.

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Stop Loss:

The County implemented Stop Loss coverage for the Wellwise and Sharewell health plans effective January 2024. Stop Loss coverage is provided by Voya, and the individual stop loss deductible is $1.5 million on a 27/12 contract basis.

Contract Intent:

The intent of this Contract is to conduct claims, rebates and operational audits of the County’s self-funded health and dental PPO plans. The County’s goal is to find a single Contractor who has demonstrated a history of successfully providing services for public employers of a size and complexity as the County of Orange. The desired Contractor will provide the County with high quality auditing to fulfill the County’s fiduciary duty to validate health and dental plan administration and performance through audits.

Values and Expectations for Employee Benefit Plans and Programs

The County is committed to providing its valued employees and retirees with comprehensive, high quality, and cost-effective benefit plans and programs that provide optimum value to both the

County and its employees/retirees. The County’s audit of the medical, dental and pharmacy programs contribute to the achievement of these goals by ensuring that claims, rebates, guarantees, operations and eligibility will be administered accurately according to the plans.

1.2 COUNTY HOLIDAYS DURING SOLICITATION PERIOD

During this solicitation period, the County Executive Office - CPO - on behalf of Employee

Benefits will be closed on the following County holidays:

• September 26, 2025, Native American Day

• November 11, 2025, Veterans Day

• November 27, 2025, Thanksgiving Day

• November 28, 2025, Day after Thanksgiving

• December 25, 2025, Christmas Day

1.3 INSTRUCTIONS TO RESPONDENTS AND PROCEDURES FOR SUBMITTAL

A. Proposals are to be uploaded via the County's eProcurement Portal at https://procurement.opengov.com/portal/ocgov. For assistance on uploading proposals via County’s eProcurement Portal, please contact procurement-support@opengov.com or https://help.procurement.opengov.com/en/.

B. Examine the Contract Documents and the site of the proposed work carefully before submitting a Proposal for the work contemplated. Investigate the conditions to be encountered, as to the character, quality, and quantities of work to be performed and materials to be furnished and as to the requirements of all Contract Documents.

https://procurement.opengov.com/portal/ocgov https://procurement.opengov.com/portal/ocgov mailto:procurement-support@opengov.com https://help.procurement.opengov.com/en/

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The County has attempted to provide all information available. It is the responsibility of each Respondent to review, evaluate, and, where necessary, request any clarification prior to submission of a Proposal. If any person contemplating submitting a response to this

Request for Proposals is in doubt as to the true meaning of any part of the solicitation documents attached hereto or finds discrepancies in or omissions from the specifications, they may submit a written request for clarification/interpretation to the County Deputy

Purchasing Agent (DPA) via the County’s eProcurement Portal under the bid page for this solicitation.

If clarification or interpretation of this solicitation is considered necessary by County, an addendum shall be issued, and the information will be posted via the County’s eProcurement Portal. Any interpretation of, or correction to, this solicitation shall be issued by the DPA. It is the responsibility of each Respondent to periodically check the County’s eProcurement Portal to ensure that they have received and reviewed any and all addenda to this solicitation.

The County will not be responsible for any other explanations, corrections to, or interpretations of the documents, including any oral information. If an addendum is issued, proposers must acknowledge the addendum via the County’s eProcurement Portal.

All questions or requests for interpretations must be received within this solicitation by Wednesday, September 24, 2025, before 2:00 pm. The DPA will provide all official communication concerning this solicitation. Any County response relevant to this solicitation other than through or approved by the DPA is unauthorized and will be considered invalid.

C. Proposals must be valid for a period of at least three hundred sixty-five (365) calendar days from the closing date and time of receipt. No Proposal may be withdrawn after the submission date.

D. Each Respondent must submit their proposal electronically via the County’s eProcurement

Portal.

E. All pages must be numbered and identified sequentially by section. Proposals must be tabbed and indexed in accordance with the information requested in the Proposal Response

Requirements Section. It is imperative that all Respondents comply, exactly and completely, with the instructions set forth herein. All responses to this solicitation shall be type written or word-processed (except where otherwise provided or noted), concise, straightforward, and must fully address each requirement and question. Although not as a substitute for a complete written response, additional material, such as technical documents, may be referenced in any response if the material is included in the same section as additional information.

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F. Proposals are not to be marked as confidential or proprietary. The County may refuse to consider any Proposal so marked. All Proposals and supporting documents will be subject to the provisions of the California Public Records Act (California Code

Government Code 7920.000 et seq.) (PRA) and will be disclosed or withheld in accordance therewith. The County shall not be liable in any way for disclosure of any such records.

Additionally, all Proposals shall become the property of the County. The County reserves the right to make use of any information or ideas in the Proposals submitted.

Respondents should not request that certain information be treated as exempt, and statements in the Proposals should not be marked as confidential or proprietary. In the event that any information is marked as confidential or proprietary, as it may be absolutely necessary, Respondents have the sole responsibility of obtaining any applicable injunctive reliefs to prevent the disclosure of such confidential proprietary information in connection with any request made to County pursuant to PRA or a subpoena for disclosure of such information.

G. Each Respondent shall exercise reasonable care and diligence to avoid submitting a

Proposal that could result in a conflict of interest if Respondent were to be selected. This obligation shall apply to the Respondent, the Respondent’s employees, agents, and relatives, sub-contractors, and third parties associated with accomplishing work and services in Proposal. In the event Respondent has done work for the County on this Project in the past or has reason to believe that a conflict of interest may exist for Respondent in regard to this Project, Respondent should consult with its legal counsel prior to responding to this solicitation. Any Respondent who is found to have an actual conflict of interest may have its Proposal rejected on that ground.

Respondent, its employees and/or consultants may be subject to the provisions of the

California Political Reform Act of 1974 (the “Act”), which (1) requires such persons to disclose any financial interest that may be materially affected by services provided under this Contract, (2) prohibits such persons from making, or participating in making, decisions that could reasonably affect such interest; and (3) may require the filing a Statement of

Economic Interest (Form 700).

If subject to the Act, Respondent shall conform to all requirements of the Act. Failure to do so shall constitute a material breach and is grounds for immediate termination of the

Contract by County. Respondent shall indemnify and hold harmless County for any and all claims for damages resulting from Respondent’s violation of this Section.

H. By submitting a Proposal, the Respondent represents that it thoroughly examined the

County’s requirements, is familiar with the services required under this solicitation and is qualified and capable of providing the services to achieve the County’s objectives.

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I. Each Respondent must submit its Proposal in strict accordance with all requirements of this solicitation and compliance must be stated in the Proposal. Deviations, clarifications and/or exceptions must be clearly identified and listed separately as alternative items on additional information section for the County’s consideration as specified in the

Proposal Response Requirements Section, “Statement of Compliance.”

Note: Allow sufficient time to upload all required files. The County’s eProcurement Portal will not allow any uploads after the due date and time specified herein, e.g., if Part 1 and 2 uploaded successfully at 1:58:38 P.M. and Part 3 is in progress of being uploaded at 2:00:01

P.M., Part 3 will not upload successfully.

J. County reserves the right to request proposal revisions and hold discussions and negotiations with any Respondent as necessary to serve the best interests of the County.

Any Proposal may be rejected if it is conditional, incomplete or deviates from specifications in this solicitation. The County reserves the right to waive, at its discretion, any procedural irregularity, immaterial defects or other improprieties which the County deems reasonably correctable or otherwise not warranting rejection of the Proposal. Any waiver will not excuse a proponent from full compliance.

K. Pre-contractual expenses are not to be included in the Cost Proposal, Attachment B, Pricing and Compensation. Pre-contractual expenses are defined as including, but not limited to, expenses incurred by the Respondent in: a) preparing its Proposal in response to this solicitation; b) submitting that Proposal to the County; c) negotiating with the County any matter related to the Respondent’s Proposal; and d) any other expenses incurred by the

Respondent prior to the date of award and execution, if any, of the Contract.

L. Any Proposal may be construed as non-responsive and ineligible for consideration if it does not comply with the requirements of the solicitation. Failure to comply with the technical features and acknowledgment of receipt of addenda are common causes for holding a Proposal nonresponsive.

M. Where two or more Respondents desire to submit a single Proposal in response to this solicitation, they must do so on a prime/subcontractor basis rather than as a joint venture.

The County intends to contract with a single firm that may subcontract with multiple firms

(team) but not with multiple firms doing business as a joint venture.

N. County does not require and neither encourages nor discourages the use of lobbyists or other consultants for the purpose of securing business.

O. The County requires a valid D-U-N-S number prior to Contract Award. If needed, your company may obtain one at no cost at www.dnb.com. If you are unable to provide/obtain a D-U-N-S number, please indicate so in your proposal/bid submission response.

http://www.dnb.com/

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P. The County requires a valid UEI number prior to Contract Award. Your company must obtain one at no cost at www.usfcr.com. If you are unable to provide/obtain a

UEI number, please indicate so in your proposal submission response.

Q. County reserves the right to: a) negotiate the final Contract with any Respondent(s); b) withdraw this solicitation in whole or part at any time without prior notice (the County makes no representations that any Contract will be awarded to any Respondent responding to this solicitation); c) award its total requirements to one Respondent or to apportion those requirements among two or more Respondents; d) reject any Proposal if it is conditional, incomplete or deviates significantly from the services requested in this solicitation; and/or

e) request Best and Final Offer from any Respondent determined to be within the competitive range. Unless requested by the County, late Best and Final Offers will not be accepted by the County for any reason. In addition, negotiations may or may not be conducted with Respondents. Therefore, Proposals submitted shall contain the

Respondent’s most favorable terms and conditions, since the selection and award may be made without discussion with any Respondent.

R. Effective from the issuance date of this solicitation until a Contract is awarded or the solicitation is withdrawn, all individuals or entities responding—including their employees, agents, representatives, proposed partners, subcontractors, members, lobbyists, or attorneys (collectively "Respondents")—are prohibited from engaging in any direct or indirect communication with County personnel involved in the selection process, except with the designated Deputy Purchasing Agent (DPA). Respondents may continue conducting business with the County on matters unrelated to this solicitation and may communicate with County staff, provided the solicitation is not discussed. Any attempt to engage in discussion regarding this solicitation with anyone other than the designated DPA will be presumed to create an unfair competitive advantage and may result in disqualification.

S. After the closing date and time for receipt of proposals, evaluation, and if requested by the

County, interviews will commence. Respondents who submit proposals most responsive to the County’s requirements may be asked to give a presentation of their proposal to

County staff. The County makes no guarantee as to the number of Respondents selected for interviews. Selected Respondents should be prepared to make its presentation within five (5) business days after notification and be prepared to discuss all aspects of its proposal in detail, including technical questions regarding the proposal. Respondents shall not be allowed to alter or amend its proposal through the use of the presentation process.

1.4 EVALUATION PROCESS AND CRITERIA

Proposals deemed to meet all minimum solicitation requirements will be scored based on the established criteria and will be assigned points that measure the responsiveness to each identified http://www.usfcr.com/

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Respondent(s) submitted written materials.

Proposals shall be evaluated by an Evaluation Panel of job knowledge experts on the basis of the responsiveness to the requirements in this RFP. The County may request clarifications, or otherwise verify the contents of the Proposal, including information about the Respondent, Contractors and sub-contractors. The County reserves the right to seek publicly available information about the Respondents.

The scoring is based on evaluation of the Proposal as measured against the Proposal Scoring

Criteria, which includes County of Orange Procurement Preference Policy, in accordance with

Sections 1.8-103 and 4.3-112 of the 2024 County Contract Policy Manual (CPM). A copy of the

2024 CPM can be found at https://cpo.ocgov.com/cpm. Proposals will be evaluated from the most advantageous to the least advantageous to the County.

*Please note: These minimum qualifications must be verified for the Proposal to be deemed responsive. Any Proposal may be construed as non-responsive and ineligible for consideration if it does not comply with the requirements of the solicitation.

Minimum Qualifications/Requirements: Respondent’s Proposal shall meet the following minimum requirements and qualifications to proceed to the evaluation and scoring process:

Respondent must meet the following minimum requirements listed below:

A. Must have the ability to do business in Orange County, California;

B. Complete all required sections of the solicitation, i.e., provide all required information, complete all required Exhibits, and pass all IT security requirements.

C. Have at least five (5) years of experience in providing the services as outlined in the

Scope of Work herein to a major public or private organization.

D. Have at least three (3) years of experience providing the audits outlined in the Scope of

Work for health and dental plans comparable to Blue Shield of California for medical & dental and comparable to OptumRX for pharmacy audits to governmental self-funded

PPO and dental plans.

E. Have at least three (3) years of experience auditing health plans comparable to Blue

Shield of California's medical claim system(s) for self-insured Preferred Provider

Organization (PPO) health plans.

F. Have at least three (3) years of experience auditing health plans comparable to Blue

Shield of California’s subcontractor’s (Dental Benefit Providers) dental claims system(s) for self-insured Preferred Provider Organization (PPO) dental plans.

https://cpo.ocgov.com/cpm

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G. Have at least three (3) years of experience auditing plans comparable to OptumRx’s pharmacy claims and rebates for self-insured Preferred Provider Organization (PPO) health plans, including Employee Group Waiver Plan (EGWP) requirements.

See "Section 5. Proposal Scoring Criteria" section for categories and points.

Written Proposal Scoring: 600 points maximum

*Note: Respondents submitting exceptions to the County Model Contract of this RFP, will receive a score of “0” for that criterion.

Presentation/Interview Scoring: 300 points maximum

Price Proposal: 100 points maximum

1.5 SELECTION/AWARD PROCEDURES

Upon the completion of the evaluation process, the Evaluation Committee will make a recommendation for an award to the County’s DPA. Final award determination shall be subject to reference checks and past performance.

In addition, County reserves the right to verify and validate any information prior to the Contract

Award and during the entire term of the Contract.

The Model Contract contained herein this RFP is the Contract proposed for execution. It may be modified to incorporate negotiated items and other pertinent terms and conditions set forth in this

RFP, including special conditions and requirements and those added by addendum, necessary attachments and/or exhibits, and to reflect Respondent’s Proposal and qualifications. Any additional exceptions to the terms and conditions made by any Respondent after submission of its

Proposal may result in its elimination from further consideration.

Exceptions to the terms and conditions of the proposed Contract or the statements regarding

Respondent’s inability to comply with any of the provisions thereof are to be declared in the response to the RFP in VENDOR RESPONSES - Statement of Compliance.

Negotiations may or may not be conducted with the finalist(s); therefore, the Proposal submitted should contain Respondent(s) most favorable terms and conditions, since the selection and award may be made without further discussion or need for clarification. Any additional exceptions to the terms and conditions made by any Respondent(s) after submission of its proposal may result in elimination from further consideration.

The County will enter into negotiations with the selected Respondent and award a contract upon completion of negotiation of fees and contract terms. The award may require approval by the

County Board of Supervisors.

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If a satisfactory Contract cannot be negotiated in a timely manner, County, in its sole discretion, may terminate negotiations with the selected Respondent and begin negotiations with the next

Respondent.

1.6 TITLE VI SOLICITATION NOTICE

The County of Orange, in accordance with the provisions of the Title VI of the Civil Rights Act of 1964 (78 Stat. 252, 42 USC §§ 2000d to 2000d-4) and the Regulations, hereby notifies all

Respondents that it will affirmatively ensure that any contract entered into pursuant to this advertisement, will be afforded full and fair opportunity to submit proposals in response to this solicitation and will not be discriminated against on the grounds of race, color, or national origin in consideration for an award.

1.7 DEPARTMENT OF THE TREASURY, INTERNAL REVENUE SERVICE FORM

W-9/W-8 REQUIREMENTS

Effective June 3, 2006, all Contractors, entering into a Contract with County, who are not already established in Countywide ERP System as an Auditor-Controller vendor, will be required to submit to County a federal Form W-9, or form W-8 for foreign vendors. County will inform

Contractor, at the time of award, if the Form W-9 or W-8 will be required.

In order to comply with this County requirement, within ten (10) days of notification of selection of award of Contract but prior to official award of Contract, the selected Contractor agrees to furnish to Contract administrator, DPA, or the agency/department deputy purchasing agent the required W-9 or W-8.

1.8 LEVINE ACT REQUIREMENT

Effective January 1, 2023, all contractors entering into a contract with the County, will be required to submit the Campaign Contribution Disclosure Form for any contributions made on or after

January 1, 2023. In order to comply with this requirement, Respondent agrees to furnish the required Campaign Contribution Disclosure Information form as a required submittal with its

Proposal. Failure to include the form as required will render the Proposal nonresponsive.

SECTION 2. PROTEST PROCEDURES

All protests shall be typed under the protestor’s letterhead and submitted in accordance with the provisions stated herein. All protests shall include at a minimum the following information:

A. The name, address, and telephone number of the protestor.

B. The signature of the protestor or the protestor’s representative.

C. The solicitation or contract number.

D. A detailed statement of the legal and/or factual grounds for the protest; and, E. The form of relief requested.

Protest of Solicitation Specifications:

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A. All protests related to solicitation specifications must be submitted to the Deputy

Procurement Agent, Christina Rojas at christina.rojas@ceo.oc.gov, no later than five (5) business days prior to the Closing Date of the solicitation. Protests received after the five

(5) business-day deadline will not be considered by the County.

1. In the event the protest of specifications is denied, and the protestor wishes to continue in the solicitation process, the protestor must still submit a bid/proposal prior to the close of the solicitation in accordance with the solicitation submittal procedures provided in this solicitation.

Protest of Award of Contract:

A. All protests related to the award of a contract, the protest must be submitted no later than five (5) business days after the Notice of Intent to Award is provided by the DPA.

B. Protests relating to a proposed contract award received after the five (5) business day deadline will not be considered by the County.

Protest Process

A. In the event of a timely protest, the County shall not proceed with the solicitation or award of the contract until the DPA issues a decision on the protest.

B. Upon receipt of a timely protest, the DPA will, within ten (10) business days of receipt of the protest, issue a decision in writing which shall state the reasons for the actions taken.

C. The County may, after providing written justification, make the determination that an immediate award of the contract is necessary to protect the substantial interests of the

County. The award of a contract shall in no way compromise the protester’s right to the protest procedures outlined herein.

D. If the protestor disagrees with the decision of the DPA, the protestor may submit a written appeal to the County Procurement Officer requesting an appeal to the

Procurement Appeals Board, in accordance with the process stated below.

Appeal Process

A. If the protestor wishes to appeal the decision of the DPA, the protestor must submit, within three (3) business days from receipt of the DPA’s decision, a written appeal to the Office of the County Procurement Officer.

Written appeals must be sent by mail to the address below with a courtesy copy by email;

County of Orange/County Executive Office

County Procurement Office

400 W. Civic Center Drive, 5th Floor

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Santa Ana, CA 92701

Attn: County Procurement Officer

CPOAppeals@ceo.oc.gov

B. Within fifteen (15) business days, the County Procurement Officer will review all materials in connection with the appeal, assess the merits of the protest and provide a written determination that shall contain his or her decision on whether the appeal shall be forwarded to the Procurement Appeals Board.

C. The decision of the County Procurement Officer on whether to allow the appeal to go forward will be final and there shall be no right to any administrative appeals of this decision.

SECTION 3. SCOPE OF WORK

3.1 GENERAL INFORMATION:

The County of Orange is comprised of 22 Departments and over 18,000 employees located throughout the County. The County’s core businesses are public safety, public works, construction management, public health, environmental protection, regional planning, public assistance, social services, and aviation.

3.2 DEFINITIONS:

A. The Board. The Board of Supervisors for the County of Orange is the legislative and policy making body of the County and is responsible for the review and approval of all service agreements and/or contracts with the County.

B. Employee Benefits Division. A Division of Human Resource Services of the County responsible for the design, implementation and on-going administration of the County’s various employee benefit plans and programs.

C. Human Resource Services (HRS). The County’s HRS is comprised of various divisions and sections that provide a wide array of personnel and employee services to County departments and agencies. The Chief Human Resources Officer reports directly to the

County Executive Officer (CEO).

D. Medical Claims Administrator. Third Party Administrator(s) for the County’s self-insured health plans. The current Medical Claims Administrator is Blue Shield of California since

January 1, 2008.

E. Dental Claims Administrator. Third Party Administrator(s) for the County’s self-insured employee dental plan. The current Dental Claims administrator is Blue Shield of

California (subcontracted to Dental Benefit Providers) since January 1, 2008.

mailto:CPOAppeals@ocgov.com

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F. Pharmacy Benefit Manager (PBM). Third Party Administrator(s) for the County’s self-insured health plan prescription drug programs that is responsible for processing and paying prescription pharmacy claims and passing through rebates. The current Pharmacy

Benefit Manager is Optum Rx, Inc.

G. Pharmacy Rebate. A payment made by a drug manufacturer to a Pharmacy Benefit

Manager (PBM) to help reduce the cost of a drug.

H. Employer Group Waiver Program (EGWP). A pharmacy benefit offered by the County of

Orange that provides Medicare Part D pharmacy benefits to participants.

3.3 SCOPE OF AUDIT SERVICES FOR THE COUNTY OF ORANGE SELF-

INSURED PPO BENEFIT PLANS AND PROGRAMS

The Contractor will provide services in accordance with the following:

1. Medical Claims Audit:

A. The five below self-funded PPO Health Plans are in the Medical Claims Audit scope:

1. Sharewell Choice Health Plan Document (employees)

2. Sharewell Retiree Health Plan Document (retirees)

3. Wellwise Choice Health Plan Document (employees)

4. Wellwise Non-Medicare Retiree Health Plan Document (retirees)

5. Wellwise Medicare Retiree Health Plan Document (retirees)

B. Audit Period: Claims processed in Calendar Year 2025 (Perform audit Year 1 of contract

2026)

Claims processed in Calendar Year 2028 (Perform audit Year 4 of contract 2029)

C. Medical Claims Audit Objectives:

The Contractor shall conduct an audit of the County’s Medical Claims Administrator (Blue Shield of California) which shall meet the following primary audit objectives:

1. Determine the Medical Claims Administrator is administering and reporting medical claims for eligible members in compliance with the County’s Health Plan Documents and Medical Claims Administration contract.

2. Determine the Medical Claims Administrator is adjudicating claims correctly for contractual financial components and appropriate benefits application within contractual timelines.

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3. Determine members are eligible and covered by County of Orange’s health plan at the time a claim was incurred.

4. Determine the Medical Claims Administrator’s performance met contractual performance guarantees and determine how these guarantees can be enhanced in the future to ensure a high level of performance.

5. Determine the Medical Claims Administrator is processing Preferred Provider negotiated rates and utilization review decisions in accordance with program requirements to maximize the cost management savings of these programs.

6. Determine the Medical Claims Administrator is processing out-of-network claims in accordance with County Health Plan Documents and utilizing usual, reasonable, and customary rates.

7. Identify any operational and administrative weaknesses of the Medical Claims

Administrator and develop a plan to work with the Medical Claims Administrator to address those weaknesses and enhance service levels and performance to the County.

D. Medical Claims Audit Requirements:

The Contractor shall:

1. Provide a data request to the County and collect and review information on account structure, benefit design, contract with Medical Claims Administrator, County’s Health

Plan Documents, and other relevant documents.

2. Meet with the County and its Medical Claims Administrator prior to the commencement of the audit to discuss and reach agreement on the specifics of the audit scope and methodology, including operational review areas.

3. Review relevant documents to determine how claims should be processed and paid. These documents include the Claims Administrator’s benefit design documents, written operational procedures, performance reports, etc.

4. Submit a written Project Plan to County Program Manager for review and approval.

The audit approach for medical claims testing to include a) 100% electronic review of claims, b) statistical sample of claims, and c) targeted/judgmental sample of claims.

The written Project Plan shall also include an Operational Review of selected areas of the Medical Claims Administrator’s operational procedures and compliance with its contract with the County.

a. If claims from outside of California will be audited, the Medical Claims

Administrator needs to have all logistics completed 60 days prior to the virtual

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b. Blue Shield allows audit firms to view eligibility, authorizations, and provider contracts that correspond to each claim in the sample.

5. Meet with the County to discuss plan interpretation issues and/or problems prior to the audit testing.

6. Make any needed revisions to the written Project Plan and obtain County Program

Manager’s approval.

7. Obtain Non-Disclosure Agreements (NDA)/confidentiality agreements as needed.

8. Perform 100% Electronic Claims Review: Obtain an electronic file of medical claims processed during the audit period through Contractor’s SharePoint or SFTP site. Conduct an electronic audit of 100% of the medical claim files. Using contractor’s software, re-adjudicate each line of every medical claim paid or denied during the audit period against the County’s Health Plan Document’s benefits. Perform additional data analytics to identify improvement opportunities and potential recoveries such as verifying no duplicate claims were paid, network provider utilization, sanctioned providers, and PPACA preventative services coverage compliance.

9. Perform Tests of Statistical Sample of Claims: Select a random sample of medical claims processed during the audit period (stratified by claim billed amount and date processed) up to 220 claims to provide a statistical confidence level of 95% and +/- 3% margin of error. Perform the following audit procedures to test claims for compliance with the County’s Health Plan documents and Medical Claims Administrator contract:

• Verify eligibility on date of service by comparing with Medical Claims

Administrator records.

• Verify that employee claims and retiree claims are accurately processed under their respective Health Plans based on the date of service.

• Verify claim processing accuracy, claim financial accuracy, and claim turnaround time. Categorize errors into key performance indicators and compare results to optimum industry standards.

• Verify benefits are paid under the proper benefit classification, diagnostic, and procedure codes.

• Verify high dollar individual medical plan payments more than $100,000 met additional approval requirements.

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• Verify appropriate benefit limitations are applied and allowed expenses are properly accumulated and correctly applied to calendar year deductible and out-of-pocket maximums for individuals and families, as applicable. Note:

Electronic accumulator data is sent between the County’s Medical Claims

Administrator (nightly 5 times per week) and Pharmacy Benefit Manager

(nightly 7 times per week).

• Verify payment was made to the proper party.

10. Perform additional tests of the statistical samples to be determined based on processing risks such as:

• Verify prior authorizations were obtained when required by the Medical Plan documents.

• Verify that maximum visit limits were adhered to in approving claims.

• Review out of network ambulatory surgery center claims where the member met the daily maximum.

• Review claims where the member received emergency services from an out-of-network provider.

• Review claims to verify Coordination of Benefits procedures, including

Medicare, and third-party liability provisions are being appropriately applied.

• Review claims to ensure that preventative benefits were claimed and paid appropriately.

11. Perform Tests of Targeted/Judgmental Sample of Claims: From the electronic claim review, judgmentally (i.e. not statistically) select 30 active and 20 retiree medical claims for additional testing to provide insight into the Claims Administrator’s claims administration and operational procedures and ensure compliance with the Health Plan documents and the

Medical Claim Administrator’s contract.

12. Operational Review: Perform agreed upon operational review of selected areas to determine the adequacy of Claims Administrator’s operational procedures and compliance with its contract with the County. If necessary, perform on site operational audits at the

Medical Claims Administrator site. Areas to consider are claim processing system controls and security features, overpayment recovery, subrogation recovery, review of County pended claims to determine if large volume are pending, quality review program, medical appeals processing, complaints processing, and controls over medical claim checks issued by the Medical Claims Administrator.

E. Medical Claims Audit Deliverables:

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The Contractor shall:

1. Following the audit, meet and discuss an action plan with the County Program

Manager.

2. Provide the County and the Claims Administrator with a draft list of errors, discrepancies, and findings. Provide specific recommendations for improvements in performance based upon a comparison to common and best practice industry standards and procedures.

3. Organize the executive summary, audit results, findings, and recommendations into a draft written audit report.

4. Review audit findings with the County Program Manager and Claims Administrator staff.

5. Issue the final written audit report within 90 days of the close of the audit procedures.

6. Obtain and review Medical Claims Administrator’s written plan to address deficiencies and provide feedback to the County.

3.4 DENTAL CLAIMS AUDIT:

A. The one below self-funded dental plan is in the Dental Claims Audit scope:

The County of Orange Dental Plan

B. Audit Period: Claims processed in Calendar Year 2027 (Perform audit Year 3 of contract

2028)

C. Dental Claims Audit Objectives:

The Contractor shall conduct an audit of the County’s Dental Claims Administrator (Blue Shield of California) which shall meet the following primary objectives:

1. Determine the Dental Claims Administrator is administering and reporting dental claims for eligible members in compliance with the County’s Dental Plan Document and Dental Claims Administration contract.

2. Determine the Dental Claims Administrator is adjudicating claims correctly for contractual financial components and appropriate benefits application within contractual timelines.

3. Determine members are eligible and covered by the County of Orange Dental Plan at the time a claim was incurred.

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4. Determine the Dental Claims Administrator’s performance met contractual performance guarantees and determine how these guarantees can be enhanced in the future to ensure a high level of performance.

5.…