part I and part II DHS B-50260.pdf

Sole Source Justification Form

Version 7.01 Page 1 of 6

Bulletin Reference Number 26-444DHS-444OC-B-50260

Requesting Agency/University Department of Human Services

Sole Source Justification Form - Part I Section I - General Information

Department/Bureau/Section: DHS/Office of Clinical Support Services/Bureau of Pharmacy and Clinical Support Services

Need Identified Date: Oct 20, 2025 Supply/Service Need By Date: Jan 18, 2026

Project Title: BPCSS Medicare Part D Reimbursement Claims Processing

Vendor: Public Consulting Group, LLC

Provide a description of the supplies or services required: Vendor to provide Medicare Part D reimbursement claims processing for the Department of Human Services (DHS).

Value: Estimated Value of Initial Term, this Change Order or Amendment: 500,000

Will this Sole Source amend a Professional or Artistic Services contract? Yes No

*Sole Source may not be used for amendments for Professional or Artistic Services if the amendment would increase the value by more than 5% of the initial award or extend the term by more than 60 days.

Type: New Sole Economically Feasible Source

Section II - Proposed Term

One-Time Purchase Term Contract

Estimated Contract Begin Date: Jan 18, 2026

Estimated Contract End Date: Jan 17, 2027

Number of Potential Renewals:

Length of Each Renewal in Months:

Total Value of All Renewals:

If a Term Contract, does the term, including renewals, exceed 12 months? Yes No

Section III - Funding Source Select the type of funding to be used (Check all that apply): State Appropriate Funds Federal Funds Other (Explain):

Section IV - Sole Source Justification

This purchase is economically only available from a single source primarily because it is: (If "Other" explain in one sentence)

Items are Copyrighted or Patented and the Items are Only Available from the Holder

Are there secondary justification(s) for this sole source? Yes No

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Bulletin Reference Number 26-444DHS-444OC-B-50260

Requesting Agency/University Department of Human Services

Section V - Purchase History

Has the Agency or University Purchased these supplies or services in the past? Yes No

Term Term From Term To Value Description Contract Number Type

1 Jul 1, 2017 Jun 30, 2022 4,917,000 BPCSS & Fiscal Services Medicare Part A, B , D and Medicaid Reimbursements 49B1097M40 RFP

2 Jul 1, 2022 Jun 30, 2024 1,966,800 BPCSS & Fiscal Services Medicare Part A, B , D and Medicaid Reimbursements 49B1097M40 Renewal

3 Oct 20, 2025 Jan 17, 2026 350,000 Emergency BPCSS Medicare Part D Reimbursement Claim Processing 4100226074 Emergency

If more than 10, or if other comments, explain:

Section VI - Business Rationale

1. Provide a detailed explanation of the need for the supplies or services:

A vendor is needed to process Medicare Part D prescription drug claims for reimbursement for DHS. Without a vendor for Medicare Part D reimbursement claims, DHS could lose up to $7,000,000 a year. Medicare Part D claims are time sensitive and reimbursement for some claims must be submitted within 90 days. If these claims are not submitted within 90 days, DHS could lose the reimbursement received from the federal government. Currently, DHS does not possess a system to submit claims has no vendor contracted to submit claim reimbursements.

2. Provide a list and describe in detail the specifications required to satisfy the need:

DHS requires a vendor to provide the following:

DHS requires a vendor to provide a system set up to receive raw data of dispensed drugs. Vendor’s system determines which clients are covered by Medicare D benefits and pull the Medicare D plan benefit information into their system. Vendor’s system removes clients’ claims that are covered by Medicare A benefits, removes Medicare B covered drugs, removes medications that are not covered by Medicare D. The vendor's system organizes dispensing data into the required NCPDP format. The vendor utilizes a crosswalk system to determine the National Drug Code and the dollar amount to charge for each prescription claim. The vendor submits claims for reimbursement. The vendor’s system includes web-based claims rejection functionality and an electronic accounts receivable system.

Vendor’s system provides reporting capabilities.

The Vendor shall maintain the system for the duration of the contract period. The Vendor shall ensure a streamlined and compliant billing and collection process that includes an electronic accounts receivable system specific to pharmacy claims.

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Bulletin Reference Number 26-444DHS-444OC-B-50260

Requesting Agency/University Department of Human Services

3. Provide detail explaining the justification selected in Section IV to explain why the requested supplies or services are the only ones available that can satisfy the agency or university requirements?

DHS requires a vendor who possesses a working system that can receive and organize DHS dispensing data into claims for Medicare Part D reimbursement. Without this service from the vendor DHS cannot submit Medicare Part D claims for reimbursement due to the inability of the current dispensing system. Due to an unsuccessful IFB and an RFP that found a vendor that could create a claiming system for a price that far exceeded reimbursements, there are no other vendors that provide the service needed without the time and cost of creating a new system.

The current system used by PCG Consulting Group was created from an RFP done in 2017. There are no "off the shelf " systems that exist for Medicare Part D reimbursement claims processing. PCG has the only customized pre-built system with the capability to do the following:

Receive raw data of dispensed drugs;

Determine which clients are covered by Medicare D benefits;

Pull the Medicare D plan benefit information into their system;

Remove clients’ claims that are covered by Medicare A benefits;

Remove Medicare B covered drugs;

Remove medications that are not covered by Medicare D;

Organize dispensing data into the required National Council for Prescription Drug Programs (NCPDP) format;

Utilizes a crosswalk system to determine the National Drug Code used and the dollar amount to charge for each prescription claim;

Then finally submit the claims for reimbursement.

PCG’s system includes web-based claims rejection functionality and an electronic accounts receivable with reporting capabilities.

4. What are the unique features of the supplies or services that are not available in any other product or by any other vendor? Provide specific quantifiable factors/qualifications:

Public Consulting Group, LLC (PCG) currently has a proprietary system in place that allows processing and submission of Medicare Part D claims for reimbursement in accordance with the Federal government specifications. By utilizing a vendor with a system in place for immediate use, DHS is saving approximately $2.4 million in the creation and start-up of a new system that can receive and organize DHS dispensing data into claims for reimbursement. Since this is a completely customized system for DHS and because of the age of the current DHS medication dispensing system, it would be years before a new system could be created to duplicate what the current system can already do.

An unsuccessful RFP was processed in 2024 with one bidder. Their bid price to system production and development costs was $2.4 million for that portion alone before getting to the reimbursement claims processing.

5. Has the Agency or University considered alternative supplies or services to satisfy their need? Yes No

5a. If no, why weren't alternatives evaluated?

DHS needed these services immediately due to the time sensitive nature of the service and the possible loss of Federal funds. DHS is currently in discussing regarding a future Request for Proposal.

6. Are there resellers or distributors?

Yes No N/A

7. What efforts were made to get the best possible price (i.e. did the agency/university negotiate) and how did you determine the price for this purchase is considered fair and reasonable?

The Vendor has agreed to the same compensation rate they were receiving for this service on a contract with DHS that ended in June 2024. That rate is 5.5% of all successful reimbursement claims.

8. Will this purchase obligate the State to this vendor for future purchases such as maintenance, licensing or continuing need?

Yes No

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Bulletin Reference Number 26-444DHS-444OC-B-50260

Requesting Agency/University Department of Human Services

9. What will be the financial or other impact to the State if this sole source is not approved and a competitive bid is required?

DHS could possibly lose up to $7,000,000 a year in Federal reimbursements if this procurement is not approved.

10. Is there any additional information you would like to add to justify this sole source?

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Bulletin Reference Number 26-444DHS-444OC-B-50260

Requesting Agency/University Department of Human Services

Section VII

Requesting Department Representative

Requesting Department Signature Required

I know and understand the contents of this Sole Source Justification and attest that all statements are true and correct and the fairness and reasonableness of the price was adequately confirmed.

Date Dec 1, 2025

Printed Name Shannon Tribble E-mail Address shannon.tribble@illinois.gov

Phone Number 217-558-0949

State Agency Bureau/Division Head or University Purchasing Director Approval and Signature Required

I know and understand the contents of this Sole Source Justification and attest that all statements are true and correct and the fairness and reasonableness of the price was adequately confirmed. (All prior form fields will lock once this e-signature is completed)

E-mail Address Jean.Sandstrom@illinois.gov

Phone Number 217-557-9298 Date Dec 3, 2025

Printed Name Jean Sandstrom

Agency Bureau/Division Head or University Purchasing Director and Not a Designee

SPO Approval and Signature Required

I have reviewed and understand the contents of this Sole Source Justification and agree with the State Agency or University determination.

I have reviewed and understand the contents of this Sole Source Justification and do not agree with the State Agency or University determination. As a result, the State Agency or University must explore other sourcing methods to satisfy their need.

State Purchasing Officer Signature Phone Number 217-299-5628 Date Dec 3, 2025

Printed Name Allegra Larson E-mail Address allegra.larson@illinois.gov

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Bulletin Reference Number 26-444DHS-444OC-B-50260

Requesting Agency/University Department of Human Services

Sole Source Justification Form - Part II Section I - General Information

Project Title BPCSS Medicare Part D Reimbursement Claims Processing

Vendor Public Consulting Group, LLC

Initial Date of Procurement Bulletin Posting Dec 3, 2025

Was a Sole Source hearing held per 30 ILCS 500/20-25?

Yes - Complete Section II and III below (Section II will only be visible when this option is selected)

No - Section II not required, go to Section III below Section III - CPO Approval and Signature Required

Based on my review, I authorize the Agency/University to proceed in accordance with the published Notice referenced above.

Based upon my review, I authorize the Agency/University to proceed with the following Changes.

Based on my review, the Agency/University is not authorized to proceed with this sole source as presented and my recommendation is that it be cancelled.

Other

CPO Signature CPO Phone 217-622-1857

Printed Name Ellen H. Daley Date Dec 17, 2025

CPO E-mail Ellen.H.Daley@illinois.gov

Version 7.01 Page of Sole Source Justification Form - Part I Section I - General Information Will this Sole Source amend a Professional or Artistic Services contract?

If yes, what was the original contract value?

*Sole Source may not be used for amendments for Professional or Artistic Services if the amendment would increase the value by more than 5% of the initial award or extend the term by more than 60 days.

Section II - Proposed Term If a Term Contract, does the term, including renewals, exceed 12 months?

If yes, provide a detailed justification including any economic benefit received for agreeing to a multi-year term:

Section III - Funding Source Select the type of funding to be used (Check all that apply):

Section IV - Sole Source Justification Are there secondary justification(s) for this sole source?

Section V - Purchase History Has the Agency or University Purchased these supplies or services in the past?

Term Term From Term To Value Description Contract Number Type Section VI - Business Rationale

1. Provide a detailed explanation of the need for the supplies or services:

2. Provide a list and describe in detail the specifications required to satisfy the need:

3. Provide detail explaining the justification selected in Section IV to explain why the requested supplies or services are the only ones available that can satisfy the agency or university requirements?

4. What are the unique features of the supplies or services that are not available in any other product or by any other vendor? Provide specific quantifiable factors/qualifications:

5. Has the Agency or University considered alternative supplies or services to satisfy their need?

5a. If yes, name the alternative vendors whose supplies or services were evaluated:

5b. If yes, what were the alternatives for each vendor and why were they unacceptable? Be specific with regard to features, characteristics, requirements, capabilities and compatibility:

5c. Explain how the market evaluation was conducted?

*This evaluation is to determine available options within a market. If the evaluation is to determine quality or best suited option, this is not the appropriate source selection. Under no circumstances shall the evaluation consist of testing alternative options. These activities must be conducted in a competitive transparent environment (i.e. IFB or RFP).

5a. If no, why weren't alternatives evaluated?

6. Are there resellers or distributors?

7. What efforts were made to get the best possible price (i.e. did the agency/university negotiate) and how did you determine the price for this purchase is considered fair and reasonable?

8. Will this purchase obligate the State to this vendor for future purchases such as maintenance, licensing or continuing need?

8a. If yes, please provide details regarding future obligations and/or needs:

9. What will be the financial or other impact to the State if this sole source is not approved and a competitive bid is required?

10. Is there any additional information you would like to add to justify this sole source?

Section VII Requesting Department Signature Required I know and understand the contents of this Sole Source Justification and attest that all statements are true and correct and the fairness and reasonableness of the price was adequately confirmed.

State Agency Bureau/Division Head or University Purchasing Director Approval and Signature Required I know and understand the contents of this Sole Source Justification and attest that all statements are true and correct and the fairness and reasonableness of the price was adequately confirmed. (All prior form fields will lock once this e-signature is completed) SPO Approval and Signature Required Sole Source Justification Form - Part II Section I - General Information Was a Sole Source hearing held per 30 ILCS 500/20-25?

Section II - Sole Source Hearing Details The State posted to the Illinois Procurement Bulletin a description of the State's need, the justification for the sole source decision, and information regarding the opportunity to submit comments and testify at a public hearing. Notice of the hearing was also posted outside of the hearing room 48 hours prior to the hearing.

The public hearing was conducted for the purpose of receiving testimony regarding the sole source determination. The Hearing Officer recommends the following:

The following relevant documents are attached:

Section III - CPO Approval and Signature Required 9.0.0.2.20101008.1.734229 Ellen.H.Daley@illinois.gov

DHS requires a vendor to provide a system set up to receive raw data of dispensed drugs. Vendor’s system determines which clients are covered by Medicare D benefits and pull the Medicare D plan benefit information into their system. Vendor’s system removes clients’ claims that are covered by Medicare A benefits, removes Medicare B covered drugs, removes medications that are not covered by Medicare D. The vendor's system organizes dispensing data into the required NCPDP format. The vendor utilizes a crosswalk system to determine the National Drug Code and the dollar amount to charge for each prescription claim. The vendor submits claims for reimbursement. The vendor’s system includes web-based claims rejection functionality and an electronic accounts receivable system. Vendor’s system provides reporting capabilities.

The Vendor shall maintain the system for the duration of the contract period. The Vendor shall ensure a streamlined and compliant billing and collection process that includes an electronic accounts receivable system specific to pharmacy claims.

Q3Answer: DHS requires a vendor who possesses a working system that can receive and organize DHS dispensing data into claims for Medicare Part D reimbursement. Without this service from the vendor DHS cannot submit Medicare Part D claims for reimbursement due to the inability of the current dispensing system. Due to an unsuccessful IFB and an RFP that found a vendor that could create a claiming system for a price that far exceeded reimbursements, there are no other vendors that provide the service needed without the time and cost of creating a new system.

The current system used by PCG Consulting Group was created from an RFP done in 2017. There are no "off the shelf " systems that exist for Medicare Part D reimbursement claims processing. PCG has the only customized pre-built system with the capability to do the following:

Receive raw data of dispensed drugs;

Determine which clients are covered by Medicare D benefits;

Pull the Medicare D plan benefit information into their system;

Remove clients’ claims that are covered by Medicare A benefits;

Remove Medicare B covered drugs;

Remove medications that are not covered by Medicare D;

Organize dispensing data into the required National Council for Prescription Drug Programs (NCPDP) format;

Utilizes a crosswalk system to determine the National Drug Code used and the dollar amount to charge for each prescription claim;

Then finally submit the claims for reimbursement.

PCG’s system includes web-based claims rejection functionality and an electronic accounts receivable with reporting capabilities.

Q4Answer: Public Consulting Group, LLC (PCG) currently has a proprietary system in place that allows processing and submission of Medicare Part D claims for reimbursement in accordance with the Federal government specifications. By utilizing a vendor with a system in place for immediate use, DHS is saving approximately $2.4 million in the creation and start-up of a new system that can receive and organize DHS dispensing data into claims for reimbursement. Since this is a completely customized system for DHS and because of the age of the current DHS medication dispensing system, it would be years before a new system could be created to duplicate what the current system can already do.

An unsuccessful RFP was processed in 2024 with one bidder. Their bid price to system production and development costs was $2.4 million for that portion alone before getting to the reimbursement claims processing.