Post Payment Claims Review Services RFP Final~4.docx

State of Illinois Department of Central Management Services Request for Proposal Post Payment Claims Review Services Attachment III Section A. SCOPE OF WORK

A.1. OVERVIEW AND PURPOSE

The Illinois Department of Central Management Services (“CMS”) is requesting proposals for an organization to provide post payment claims review services for members participating in the State Employees Group Insurance Program (SEGIP), Teachers’ Retirement Insurance Program (TRIP), College Insurance Program (CIP), and Local Government Health Plan (LGHP) self-insured benefit programs. The four Programs, which will hereinafter be referred to collectively as the “Programs”, provide members with the following services: medical/behavioral health, prescription, dental, vision, employee assistance plan, life insurance, flexible spending accounts (FSA), and a commuter savings plan (CSP).

CMS is seeking a vendor to conduct post payment claims review and audit services of self-insured medical, prescription, and dental claims to identify anomalies indicating fraud, waste, and abuse within the Program’s claims data. Claims review and audits will be performed on retrospective (up to 60 months) claims and real-time claims.

A.2. DESIRED OUTCOMES OF THIS PROJECT/ENGAGEMENT

The selected vendor will administer the State’s post payment claims review solution to mitigate existing and potential erroneous spending within the programs. The vendor must be able to review and audit 100% of the Agency’s self-insured medical, prescription, and dental claims and work directly with the Agency’s third-party administrators to recover payment errors.

A.3. SCHEDULE & BUDGET

Solicitation and Posting – March 2025 Bid Opening – April 2025 Technical Evaluation – May 2025 Anticipated Award – June 2025 Contract Execution – July 2025 Note: Post payment claims review services are assumed to commence upon contract execution.

State of Illinois Department of Central Management Services Request for Proposal Post Payment Claims Review Services

25-416CMS-BENF4-B-46745

State of Illinois RFP V.25.2.

A.4. UNIQUE CONSIDERATIONS

CMS oversees the administration of group health benefits for four separate and distinct Programs (SEGIP, TRIP, CIP, and LGHP), which collectively cover approximately 450,000 lives. The statutory authority for the Programs is the State Employees Group Insurance Act of 1971, as amended, 5 ILCS 375/1 et seq. (available at https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=120&ChapterID=2 ), hereinafter referred to as the "Act". Each Program has its own plan design and funding source; therefore, each Program must remain mutually exclusive for all reporting packages, financials, reports, claims payments and rates.

The Act defines and establishes base criteria for those eligible to participate in each Program. The current statutory definition, or as amended in the future, will prevail on all questions of eligibility to participate.

A.5. TERM

A.5.1. TERM OF THIS CONTRACT: The contract resulting from this procurement will have an initial term commencing upon the date of execution or July 1, 2025, whichever comes first and ending three (3) years from the date of execution. In no event will the total term of the contract, including the initial term, any renewal terms, and any extensions, exceed ten (10) years. Vendor shall not commence billable work in furtherance of the contract prior to final execution of the contract except when permitted pursuant to 30 ILCS 500/20-80.

A.5.2. RENEWAL: Subject to the maximum total term identified above, the State has the option to renew for the following term(s):

A.5.2.1. The State reserves the right to renew for a total of two (2) years in any one of the following manners:

A.5.2.1.1. One renewal covering the entire renewal allowance;

A.5.2.1.2. Individual one-year renewals up to and including the entire renewal allowance; or A.5.2.1.3. Any combination of full or partial year renewals up to and including the entire renewal allowance

A.5.2.2. Pricing for the renewal term(s), or the formula for determining price: For each contract renewal year, the maximum renewal rates will be calculated as the applicable rate for the immediately preceding contract year times the lesser of (a) 3% or (b) the annual Consumer Price Index Inflation factor. For the purpose of this Contract, the Consumer Price Inflation factor shall be developed from the “Consumer Price Index Urban Wage Earners and Clerical Workers”: All items are as published by the U.S Department of Labor, Bureau of Labor Statistics.

A.5.2.3. Any renewal of the resulting contract is subject to the same terms and conditions that apply to the initial term of the contract unless otherwise provided. The State may renew the contract for any or all of the option periods specified, may exercise any of the renewal options early, and may exercise more than one option at a time based on continuing need and favorable market conditions, when in the best interest of the State. The contract may neither renew automatically nor renew solely at the Vendor’s option.

Section B. CURRENT CONDITIONS

B.1. OVERVIEW & BACKGROUND

As introduced in Section A.4, CMS oversees the administration of group health benefits for the programs. Medical and pharmacy benefits have fully insured HMO benefit options and PPO/OAP/CDHP self-insured options as well as a MAPD option for Medicare eligible retirees. CMS does not have an existing Post Payment Claims Review Service. Offeror must not have any conflicts of interest with any health, pharmacy, or dental insurance providers that would preclude them from providing uncompromised audit results. Additional program information is as follows:

Nationwide Self-insured Medical Plan (SEGIP, TRIP, CIP, and LGHP):

This plan is comprised of medical/behavioral health coverage, and prescription benefit management (PBM) services, with the PBM being carved-out from the medical plan. Each Program currently has a separate and unique plan design. Some current plan designs include salary-based deductible levels (3 salary and deductible bands). The current Carriers for this plan are:

· Aetna provides medical and behavioral health claims processing and associated administrative services such as provider network, call center, 24/7 nurse line, disease management, utilization management and other cost saving services; Aetna also provides BHS claims processing and associated administrative services such as provider network, and Personal Support Program (PSP). Aetna also administers a High Deductible Health Plan for employees. These services are contracted by the State of Illinois directly with Aetna; and

· CVS Health provides PBM services. These services are contracted by the State of Illinois directly with CVS.

· Open Access Plans (OAPs): The OAPs are self-insured and include medical coverage and BHS services under one contract. PBM services are carved-out from the medical plan. The current OAP Carriers are:

· HealthLink;

· Aetna;

· Blue Cross Blue Shield OAP;

· CVS Caremark provides PBM services. These services are contracted by the State directly with CVS.

Dental Plan (SEGIP, CIP, LGHP):

Delta Dental of Illinois is the plan administrator for the dental plan. The dental plan is self-funded. Delta Dental provides claims processing and associated administrative services such as provider network, call center, etc.

Key vendor elements sought in this RFP in addition to PPCR analysis and monitoring are:

· Analytical dashboards/data visualization tools

· The ability to directly data share with CMS’ third-party vendors

· Conduct audit meetings with third-party administrators

· Provide Summary Plan Description analysis to identify benefit loopholes

· The ability to provide additional analytical reporting

B.2. VOLUMES & QUANTITIES

Any figures or utilization numbers provided by the Agency do not guarantee future utilization or needs. The selected Vendor(s) must render the necessary services throughout the Contract period, regardless of whether the utilization is more or less than the estimate initially provided by the Agency. Offerors shall use the data provided to respond to both the Responsiveness Elements and Price components of the RFP. These sections detail the specific requirements and needs determined by the Agency as well as any other specifications. This information should be used by the Offeror to prepare its Offer and will be incorporated as terms in the resulting Contract. Information contained in the proposal submitted by the selected Vendor(s) is subject to acceptance by Agency or negotiation with Agency.

Self-Insured Fiscal Year 2024 (07/01/2023 – 06/30/2024)

· Medical claims: 8,520,938

· Pharmacy claims: 2,331,382

· Dental claims: 1,547,870

Enrollment totals The total enrollment in the Agency’s self-insured plans as of March 2025 is 183,833.

Offerors should note that effective July 1, 2025, the Agency’s contract with Health Alliance, one of its fully insured HMO plan providers will terminate. The contract termination will require members of that plan to select a new plan. The Agency estimates the approximate enrollment in the self-insured plans to be 242,073 on 07/01/2025. The Agency will have an updated enrollment number for the fiscal year 2026 plan year following the Benefits Choice period that ends 06/02/2025.

B.3. AREAS OF CONCERN/CHALLENGES

There are no identified areas of concern.

B.4. STRENGTHS

CMS maintains strong relationships with its third-party administrators. The Agency will work closely with the successful offeror to manage successful relationships between all parties.

Section C. PROPOSAL REQUIREMENTS Only Electronic Submissions through BidBuy of Offers will be Accepted

C.1. REQUIRED DOCUMENTS TO COMPLETE AND SUBMIT

The Offeror shall submit the listed documents in BidBuy under the Attachments tab in the appropriate “Required Attachments” spaces.

· Vendor Disclosure or IPG Active Registered Vendor Disclosure

· Technical response

· Offer to the State of Illinois

· Commitment to Diversity Blank documents may be found on the Chief Procurement Officer for General Service’s website at https://cpo-general.illinois.gov/solicitation-and-contract-templates.html and on the BidBuy posting under “File Attachments:”. Business Enterprise Program/Veterans Small Business Program Utilization Plan may be downloaded from the Commission on Equity and Inclusion’s website at https://cei.illinois.gov/purchasing-entity-resources/compliance.html.

Failure to submit Vendor Disclosure or IPG Active Registered Vendor Disclosure, as applicable, and the Utilization Plan(s), as applicable, with the Offer submitted in BidBuy shall render the Offer non-responsive.

Offerors are required to submit their response to the State’s solicitation through BidBuy. Any information sent to the State outside of BidBuy, for example by US Mail, FedEx, UPS, e-mail, or hand delivery, will neither be accepted nor considered. Offeror submissions will only be considered if they are received through BidBuy and on or before the time and date indicated as the “Bid Opening Date” on the BidBuy posting. Any required attachments must be submitted via BidBuy.

Price entries on the Items tab will be locked automatically upon submission of the quote. Entering cost, pricing or discount information in the Alternate Description may result in disqualification. If the agency requires pricing to be submitted in an attachment, Offeror shall upload pricing under the “Required Documents” section on the Attachments tab and check the box “Does the attachment contain any pricing, cost or discount information?”. Failure to check this box allows your pricing to be viewed when bids are opened and will result in disqualification of your offer. NOTE: Do not check “Does the attachment contain any pricing, cost or discount information” if the attachment does NOT include pricing, cost, or discount information.

Documents shall be submitted in an electronic format that is accessible and readable using Microsoft Office suite software or Adobe Reader. Corrupted files shall not be considered. It is the Offeror’s responsibility to check that files are accessible and legible after uploading.

The Offeror is solely responsible for ensuring timely submission of their electronic solicitation response. Failure to allow adequate time prior to the Bid Opening Date to complete and submit a response to a solicitation, particularly in the event technical support assistance from the State is required, places the Offeror and their offer or response at risk of not being accepted.

The State encourages the Offeror to ensure that their BidBuy account is up-to-date. It is recommended that you access your BidBuy account prior to the solicitation due date and time to make sure that your company’s information is up-to-date and your password is current. Files may be uploaded at any time prior to submission.

File size may impact the uploading and downloading speed and may lead to browser time-outs, resulting in failed upload/download attempts. Please consider this dependency when attaching very large documents.

OFFEROR INSTRUCTIONS TO SUBMIT IN BIDBUY

Create Quote:

Note: any pricing entered in the Unit Cost of the Items Tab will be locked until after Technical Evaluations take place. Do not enter cost, pricing, or any discount information in the Alternate Description field. Entering cost, pricing or discount information in the Alternate Description may result in disqualification.

Note: If taking any exceptions to Standard Terms and Conditions an offeror must submit a redline version of the Standard Terms and Conditions with their proposal.

: “Upload” (next to each required attachment) : “Choose File” Note: If a pricing document is required, mark the box next to the question, “Does this attachment contain any pricing, cost, or discount information?”

Failure to mark this box when attaching a pricing document will result in disqualification.

Check this box ONLY if a separate pricing document is required.

Do NOT check this box for any other required quote attachment such as the Technical Proposal, Vendor Disclosure / IPG Active Registered Vendor Disclosure, or Utilization Plan(s), or Offer.

Offerors may also view the “Request for Proposal (RFP) Vendor Submission Instructions Video found at https://cpo-general.illinois.gov/vendor-resources.html

C.2. DUE DATE AND TIME FOR SUBMISSION OF OFFERS

Each solicitation contains the Offer due date and time, appearing as the “Bid Opening Date:” on the BidBuy posting. Offeror shall submit Offers in BidBuy, and the State shall open Offers electronically in BidBuy on the “Bid Opening Date”. The Offer must remain firm for 180 days from opening.

C.3. CONFLICT BETWEEN INFORMATION IN ELECTRONIC DOCUMENTS AND ON BIDBUY

If the State provides information in electronic documents (i.e., the RFP and other attachments) that is different or in conflict with the information the State provides on BidBuy, then the information in electronic documents is presumed to represent the State’s intent. If the Offeror provides information in electronic documents that is different or in conflict with the information the Offeror provides in BidBuy through their Seller Account, then the information in electronic documents shall represent the Offeror’s intended submission.

C.4. PUBLISHED PROCUREMENT INFORMATION

The State publishes procurement information, including solicitations, awards, and amendments, on the Chief Procurement Officer for General Services’ Illinois Procurement Bulletin, known as the Bulletin or BidBuy (https://www.bidbuy.illinois.gov/bso/). Procurement information may not be available in any other form or location. Offeror is responsible for monitoring BidBuy. The State will not be held responsible if Offeror fails to receive the optional e-mail notice of future amendments to the solicitation.

C.5. INFORMATION CONTACT

The individual listed in the “Info Contact:” field on the BidBuy posting shall be the single point of contact for this solicitation. Unless otherwise directed, Offeror should only communicate with the Information Contact. The State/Agency shall not be held responsible for information provided by or to any other person.

Suspected errors should be immediately reported to the Information Contact. Do not discuss, directly or indirectly, the solicitation or any Offer with any State officer or employee other than the Information Contact.

C.6. OFFEROR QUESTIONS AND AGENCY RESPONSE

All questions, other than questions raised at the Pre-Submission Conference, pertaining to this solicitation must be submitted in writing to the Information Contact no later than April 10, 2025. Questions received and Agency responses may be posted as a Bid Amendment to the original solicitation on BidBuy; only these posted answers to questions shall be binding on the State. Offeror is responsible for monitoring BidBuy and BidBuy email notifications.

C.7. PRE-SUBMISSION CONFERENCE

The Agency may conduct a Mandatory or Non-Mandatory Pre-Submission Conference, listed in the “Pre-Bid Conference:” field of the BidBuy posting. Please refer to BidBuy for this information.

If attendance is mandatory, Offeror (current contractor included) will be disqualified and considered non-responsive if Offeror does not attend, is not on time, leaves early, or fails to sign the attendance sheet. Offeror must allow adequate time to accommodate security screenings at the site.

C.8. SMALL BUSINESS SET-ASIDE

In the Bulletin posting, if “Yes” is shown to the question “Is this a Small Business Set-Aside Procurement?”, then Offeror must be registered by the Illinois Small Business Set-Aside Program at the time Offers are due for the Offer to be evaluated. For requirements on qualifying Offeror’s business in the Small Business Set-Aside Program, please go to the Chief Procurement Office for General Service’s website at https://cpo-general.illinois.gov/sell-2-illinois.html .

C.9. BUSINESS ENTERPRISE FOR MINORITIES, WOMEN, AND PERSONS WITH DISABILITIES ACT PARTICIPATION AND UTILIZATION PLAN

The BidBuy posting indicates whether this solicitation contains a goal to include businesses owned and controlled by minorities, women, and persons with disabilities. If this solicitation contains a goal, then failure to complete and submit a Utilization Plan, including documentation demonstrating good faith efforts when requesting a waiver, shall render the Offer non-responsive. 30 ILCS 575/4(e). All questions regarding the subcontracting goal must be directed to the Information Contact indicated in BidBuy no later than 14 days prior to bid opening date identified in BidBuy. See the Utilization Plan for NIGP codes used to establish this goal.

BEP Goal: 0% Go to https://cei.illinois.gov/vendor-resources/get-bep-certified.html for complete requirements for BEP certification. Go to State of Illinois Commission on Equity and Inclusion at https://supplierdiversitymanagementportal.illinois.gov/home.aspx to search for certified BEP vendors.

C.10. VETERAN SMALL BUSINESS PARTICIPATION AND UTILIZATION PLAN

The BidBuy posting indicates whether this solicitation contains a goal to include businesses owned and controlled by military veterans. If this solicitation contains a goal, then failure to submit a Utilization Plan as instructed later in this solicitation may render the Offer non-responsive. All questions regarding the subcontracting goal must be directed to the Information Contact indicated in BidBuy no later than 14 days prior to bid opening date identified in BidBuy. See the Utilization Plan for NIGP codes used to establish this goal.

VBP Goal: 0% Go to https://cei.illinois.gov/programs0/veterans-business-program.html for complete requirements for Veteran Owned Small Business (VOSB) or Service-Disabled Veteran Owned Small Business (SDVOSB) certification. Go to State of Illinois Commission on Equity and Inclusion at https://supplierdiversitymanagementportal.illinois.gov/home.aspx to search for certified VOSB and SDVOSB vendors.

C.11. SECURITY

Bid/Performance Bond: N/A. If a bond is required, Offeror must submit the Bid Bond with your offer or Performance Bond to the Information Contact within ten (10) days after contract execution. The bond must be from a surety licensed to do business in Illinois. An irrevocable letter of credit is an acceptable substitute. The form of security must be acceptable to the State.

C.12. TERMS AND CONDITIONS

Information and Technology Standard Terms and Conditions. will become a part of any resulting contract. To view the Information and Technology Standard Terms and Conditions., please go to https://cpo-general.illinois.gov/solicitation-and-contract-templates.html.

Section D. EVALUATION PROCEDURES

D.1. EVALUATION PROCESS

The State assesses each Offer for Responsibility (E.10) and Responsiveness. The State considers the information provided and the quality of that information when assessing Offers. If the State finds a failure or deficiency, the State may reject the Offer or reflect the failure or deficiency in the assessment.

There are three scored parts to each proposal – technical, commitment to diversity, and pricing. Each part of the proposal is evaluated and ranked independently of the other parts of the proposal. The results of the evaluation of all three parts shall be used in ranking the proposals.

The State may award to the most responsive and responsible offeror whose offer best meets the specified criteria.

D.2. RESPONSIVENESS

A responsive offeror is one who submits an offer that conforms in all material respects to the Request for Proposal and includes all required forms.

D.2.1. The State will determine whether the Offeror complied with the instructions for submitting offers. Except for late submissions, and other requirements that by law must be part of the submission, the State may require that an Offeror correct deficiencies as a condition of further evaluation.

D.2.2. Subcontractor Disclosure: If the Offer includes any subcontractors, then Offeror shall complete the Subcontractor Disclosure section of the Offer to the State of Illinois.

D.2.3. If completing IPG Active Registered Vendor Disclosure, then responsiveness may include and may not be limited to:

· Active Illinois Procurement Gateway registration # with expiration date

· Certifications timely to this solicitation

· Disclosure of lobbyists for Offeror and parent entity(ies)

· Disclosure of pending and current contracts

D.2.4. If completing Vendor Disclosure, required parts may include and may not be limited to:

D.2.5. The State will determine whether the Offer meets the stated Technical requirements. Minor differences or deviations that have negligible impact on the price or suitability of the supply or service to meet the State’s needs may be accepted or corrections allowed. If no offeror meets a particular Technical requirement, the State may waive that requirement.

D.2.6. When the specification calls for “Brand Name or Equal,” the brand name product is acceptable. Other products will be considered with proof that the other product meets stated specifications and is equivalent to the brand product in terms of quality, performance, and desired characteristics.

D.3. EVALUATION METHODOLOGY

The Technical Requirements are described in Sections F.2. and F.3. The State evaluates the Technical Requirements without consideration of price.

D.3.1. Total Number of Points Available for Technical Requirements is: 600.

D.3.2. Offeror shall complete and return Sections F.1., F.2., F.3. and F.4.

D.3.3. Relative Weight in Point Format

D.4. COMMITMENT TO DIVERSITY ELEMENTS

Sections 20-15 and 35-30 of the Illinois Procurement Code (30 ILCS 500/) require offerors to be evaluated on their commitment to diversity. The points available for Commitment to Diversity are described in Section F.4. and are equivalent to 20% of the Technical Requirements points. The State evaluates Commitment to Diversity without consideration of price.

D.4.1. The total number of points for Commitment to Diversity is 120.

D.4.2. Offeror shall complete and return Section F.4 Commitment to Diversity

D.4.3. Commitment to Diversity Categories: The percentages at the end of each section reflect the weighted distribution of points available identified in D.4.1.

Commitment to Diversity Categories

Category 1 – BEP Compliance - Whether or how well the Offeror meets this solicitation’s goal of contracting or subcontracting with businesses owned by women, minorities, or persons with disabilities. 5%

Category 2 – Subcontracting/Contracting with any WMD businesses (not limited to BEP vendors) - Whether the Offeror assisted businesses owned by women, minorities, or persons with disabilities. 10%

Category 3 – Diversity, Equity and Inclusion (DEI) Spend – Offeror’s percentage of business, education and/or community spend from prior calendar year gross revenue that involves businesses owned by women, minorities and/or persons with disabilities. The assisted businesses are not required to be certified in the Illinois Business Enterprise Program. 20%

Category 4 – DEI Time - Offeror’s hours spent in the prior calendar year on promoting DEI in the workplace, the community, education institutes, or supporting businesses owned by women, minorities, or persons with disabilities. The assisted business is not required to be certified in the Illinois Business Enterprise Program. The success or failure of each event does not impact the points achieved. The event may be voluntary or paid time. 20%

Category 5 – DEI Policies - Entity has provided a written copy of, or link to, their current written workforce diversity, equity, and inclusion policy. Policies must be actionable plans, not overarching concepts around DEI. 10%

Category 6 – Diversity in Staffing - % of individuals on governing board and/ or Senior executives out of all staff who identify as women, minorities or person with disabilities. 10% % of individuals in management /supervisor positions out of all staff who identify as women, minorities or person with disabilities. 13% % of total staff who identify as women, minorities or person with disabilities. 12%

D.5. PRICE

The State opens Price proposals after evaluating all Technical and Commitment to Diversity proposals.

If the State does not consider the price to be fair and reasonable and negotiations fail to meet an acceptable price, the State reserves the right to cancel the award and take appropriate action to meet the needs of the State. The State determines whether the price is fair and reasonable by considering the offer, including the offeror's qualifications, the offeror's reputation, all price proposals submitted, other known prices, the project budget, and other relevant factors.

D.5.1. The total number of points for Price (including all renewals) is 300.

D.5.2. The State will determine Price points using the following formula:

Maximum Price Points X (Lowest Price/Offeror’s Price) = Total Price Points

D.6. MAXIMUM AVAILABLE POINTS

The maximum number of points is 600 (Technical) + 120 (Commitment to Diversity) + 300 (Price) = 1,020 maximum available points.

Section E. ADMINISTRATIVE REQUIREMENTS

E.1. GOVERNING LAW AND FORUM

Illinois law and rules govern this solicitation and any resulting contract. Offeror must bring any action relating to this solicitation or any resulting contract in the appropriate court in Illinois. This document contains statutory references designated with “ILCS”. To view the full text, go to http://www.ilga.gov/legislation/ilcs/ilcs.asp . The Illinois Procurement Code (30 ILCS 500) and the Standard Procurement Rules (44 ILL. ADM. CODE PART 1) are applicable to this solicitation. To view them respectively, go to http://www.ilga.gov/legislation/ilcs/ilcs5.asp?ActID=532&ChapterID=7) and https://www.ilga.gov/commission/jcar/admincode/044/044parts.html

E.2. PUBLIC RECORDS AND REQUESTS FOR CONFIDENTIAL TREATMENT

Offers become the property of the State. All offers will be open to the public under the Illinois Freedom of Information Act (FOIA) (5 ILCS 140) and other applicable laws and rules, unless Offeror requests in its Offer that the State treat certain information as confidential. A request for confidential treatment will not supersede the State’s legal obligations under FOIA. The State will not honor requests to keep entire Offers confidential. Offerors must show the specific grounds in FOIA or other law or rule that support confidential treatment. Regardless, the State will disclose the successful Offeror’s name, the substance of the Offer, and the price.

If Offeror requests confidential treatment, Offeror must submit additional copy/copies (see Instructions for Submission of Offers in Section C.) of the Offer with proposed confidential information redacted. This redacted copy must tell the general nature of the material removed and shall retain as much of the Offer as possible. In a separate attachment, Offeror shall supply a listing of the provisions identified by section number for which it seeks confidential treatment and identify the statutory basis or bases under Illinois law, including a detailed justification for exempting the information from public disclosure.

Offeror will hold harmless and indemnify the State for all costs or damages associated with the State defending Offeror’s request for confidential treatment. Offeror agrees that the State may copy the Offer to facilitate evaluation, or to respond to requests for public records. Offeror warrants that such copying will not violate the rights of any third party.

E.3. MINORITY CONTRACTOR INITIATIVE

The State requires a fee of $15 to cover expenses related to the administration of the Minority Contractor Opportunity Initiative. Any offeror awarded a contract of $1,000 or more under Section 20-10, 20-15, 20-25 or 20-30 of the Illinois Procurement Code (30 ILCS 500) is required to pay a fee of $15. The Comptroller shall deduct the fee from the first check issued to the Vendor under the contract and deposit the fee in the Comptroller’s Administrative Fund. 15 ILCS 405/23.9.

E.4. FEDERAL FUNDS

The resulting contract may be partially or totally funded with Federal funds. Upon notice of intent to award, the percentage of supplies and/or services involved that are Federally funded and the dollar amount of such Federal funds will be disclosed.

E.5. EMPLOYMENT TAX CREDIT

Offerors who hire qualified veterans and certain ex-offenders may be eligible for tax credits. 30 ILCS 500/45-67 and 45-70. Please contact the Illinois Department of Revenue (217-524-4772) for information about tax credits [35 ILCS 5/216, 5/217].

E.6. RESERVATIONS

Offeror must read and understand the solicitation and tailor the Offer and all activities to ensure compliance. The State reserves the right to amend the solicitation, reject any or all offers, award by item/services, group of items/services, or grand total, and waive minor defects. The State may request a clarification, inspect Offeror’s premises, interview staff, request a presentation, or otherwise verify the contents of the Offer, including information about subcontractors and suppliers. The State may request Best & Final Offers when appropriate. The State will make all decisions on compliance, evaluation, and terms and conditions, and shall make decisions in the best interests of the State and in accordance with the Illinois Procurement Code, rules and other applicable State and Federal statutes and regulations. This competitive process may require that Offeror provide additional information and otherwise cooperate with the State. If an offeror does not comply with requests for information and cooperate, the State may reject the offer as non-responsive to the solicitation. Submitting an offer does not entitle Offeror to an award or a contract. Posting a vendor’s name in a Bulletin notice does not entitle the vendor to a contract. The State is not responsible for and will not pay any costs associated with the preparation and submission of any offer.

Awarded Offeror(s) shall not commence and will not be paid for any billable work undertaken prior to the date all parties execute the contract, unless approved in writing in advance by the State Purchasing Officer or the Chief Procurement Officer (or designee).

E.7. AWARD

The State is not obligated to award a contract pursuant to this solicitation. If the State issues an award, the award will be made to the responsive and responsible offeror whose offer best meets the specified criteria unless otherwise permitted by the Illinois Procurement Code and Illinois Administrative Code. However, if the State does not consider the price to be fair and reasonable and negotiations fail to meet an acceptable price, then the State reserves the right to cancel the award and take appropriate action to meet the needs of the State. The State will determine whether the price is fair and reasonable by considering the offer, including the offeror's qualifications, the offeror's reputation, all prices submitted, other known prices, the project budget and other relevant factors. The State will post a notice to the Bulletin identifying the apparent most responsive and responsible offeror.

E.8. INVOICING ADDRESS

The awarded Vendor shall invoice at the completion of the contract unless invoicing is tied in the contract to milestones, deliverables, or other invoicing requirements agreed to in the contract. The Bulletin posting contains the “Bill-to Address:” where invoices should be sent.

Vendor shall not bill for any taxes unless accompanied by proof that the State is subject to the tax. If necessary, Vendor may request the applicable Agency’s Illinois tax exemption number and Federal tax exemption information.

E.9. PROTEST REVIEW OFFICE

Offeror may submit a written protest to the Protest Review Office following the requirements of the Standard Procurement Rules. 44 ILL. ADM. CODE 1.5550. For protests related to specifications, the Protest Review Office must physically receive the protest no later than fourteen (14) days after the solicitation or related addendum was posted to the Bulletin. For protests related to rejection of individual proposals or awards, the protest must be received by close of business no later than fourteen (14) days after the protesting party knows or should have known of the facts giving rise to the protest. The Protest Review Office’s information is as follows:

Chief Procurement Office Attn: Protest Review Office Email: cpogs.pro@illinois.gov

E.10. RESPONSIBILITY

A responsible Offeror is one who has the capability in all respects to perform fully the contract requirements and who has the integrity and reliability that will assure good faith performance. The State determines whether the Offeror is a “responsible” offeror; an offeror with whom the State can or should do business. For example, the State may consider the following:

E.10.1. A “prohibited bidder” includes any person assisting an employee of the State of Illinois by reviewing, drafting, directing, or preparing any invitation for bids, a request for proposal, or request of information, or providing similar assistance unless such assistance was part of a publicly issued opportunity to review drafts of all or part of these documents. For purposes of this section, an employee of the State of Illinois means one who, by the nature of his or her duties, has the authority to participate personally and substantially in the decision to award a State contract. No person or business shall submit specifications to a State agency unless requested to do so by an employee of the State. No person or business that contracts with a State agency to write specifications for a particular procurement need shall submit a bid or proposal or receive a contract for that procurement need.

Nothing herein is intended to prohibit a vendor from bidding or offering to supply developing technology, supplies or services after providing the State with a demonstration of the developing technology, supplies, or services; provided the subject of the demonstration to the State represents industry trends and innovation and is not specifically designed to meet the State's needs. Nothing herein is intended to prohibit a person or business from submitting a bid or offer or entering into a contract if the person or business: (i) initiates a communication with an employee to provide general information about products, services, or industry best practices and, if applicable, that communication is documented in accordance with Section 50-39 of the Illinois Procurement Code or (ii) responds to a communication initiated by an employee of the State for the purposes of providing information to evaluate new products, trends, services, or technologies.

E.10.2. Other factors that the State may use to evaluate to determine responsibility include, but are not limited to: political contributions, certifications, conflict of interest, financial disclosures, taxpayer identification number, past performance in business or industry, references (including those found outside the Offer), compliance with applicable laws, financial responsibility, insurability, effective equal opportunity compliance, payment of prevailing wages if required by law, capacity to produce or sources of supply, and the ability to provide required maintenance service or other matters relating to the offeror’s ability to deliver in the quality and quantity within the time and price as specified in this solicitation.

E.10.3. Awarded offerors must always have financial resources sufficient, in the opinion of the State, to ensure performance of the contract and must provide proof upon request. The State may require a performance bond if, in the opinion of the State, it ensures performance of the contract. The State may terminate the contract, consistent with the termination for cause provision of the contract, if the vendor lacks the financial resources to perform under the contract.

E.10.4. The State may require that an offeror correct any deficiencies as a condition of further evaluation.

E.11. BidBuy Terminology and Guidance: BidBuy is an online e-procurement system. There may be some difference between the procurement terminology used in this solicitation and the terms used in BidBuy. Please learn more about BidBuy by accessing the online resources found here:

https://www2.illinois.gov/cpo/PathwayToProcurement/Pages/Guides-and-Manuals.aspx

Section F. PROPOSAL FORMS Offeror must complete and return:

· The following three (3) tables include: Mandatory Requirements with Evidence (Section F.1), Contract Requirements (Section F.2), and Proposed Technical Solution (Section F.3)

· Commitment to Diversity (Section F.4)

· Offer to the State of Illinois Please read and follow each instruction carefully.

F.1. MANDATORY REQUIREMENTS WITH EVIDENCE

Please check “Met” to each of the mandatory requirements for the proposed solution. An Offeror that does not provide substantiating evidence for each requirement will be disqualified and the rest of the proposal will not be scored.

These Mandatory Requirements shall be included in any contract resulting from this solicitation.

Please provide substantiating evidence in your Proposed Technical Solution. Use the column on the right to indicate the section and page number where your evidence/response to each item may be found. The State will evaluate Offeror’s evidence/response to verify the mandatory requirement is met.

F.2. CONTRACT REQUIREMENTS

Please read each contract requirement carefully in F.2. Please check “Agree” to each of the contract requirements for the proposed solution. An Offeror that does not check “Agree” may be disqualified. These contract requirements shall be included in any contract resulting from this solicitation.

F.2.1. GENERAL REQUIREMENTS

Failure to check “Agree” may result in disqualification

F.2.1.1. Offeror must be able to audit and monitor 100% of self-insured medical, pharmacy, and dental claims. Offeror must be able to audit the following categories, but not limited to: Assistant Surgeon services, Anesthesia payment errors, Coordination of Benefits, Correct coding, Duplicate payments, Eligibility, Global billing, High-Cost Claims, Illogical Procedures, Medically unlikely, Spike Payments, Unbundling, Upcoding.

|_| Agree

F.2.1.3. Offeror shall audit claims in accordance with the Plan Design(s) for each Plan and adhere to Plan Design changes at Agency’s discretion and within timeframes provided by Agency.

F.2.1.4. Offeror agrees to work with Agency and contracted vendors in good faith to resolve post payment claim review service issues related to Offeror’s claim audit findings to arrive at a result that is in the Agency’s best interest.

F.2.1.5. Offeror shall, upon request from Agency, attend in person any and all legislative hearings relating to the services being procured through this solicitation.

F.2.1.6. Offeror shall facilitate and support meetings between the Agency and claims administrators to discuss findings and resolve open questions.

F.2.1.8. The Offeror’s main point of contact will provide responses to CMS within forty-eight (48) hours after receipt of request.

F.2.1.9. The Offeror shall ensure all services provided in the contract are performed in the United States.

F.2.1.10. Offeror shall comply with all requirements of Attachment I Business Associate Agreement and Attachment II Trading Partner Agreement.

F.2.1.11. Offeror shall not engage in nor permit its agents to push adware, software, or marketing not explicitly authorized by the State.

|_| Agree

F.2.1.12. Offeror will restrict the location of information systems that receive, process, store, or transmit State of Illinois Personally Identifiable Information (PII) to areas within the United States.

F.2.1.13. Offeror shall provide an account management team designated from its various divisions to coordinate service for Agency. Members of this team shall have the authority to make decisions, have direct telephone access, and be available to meet and/or work with Agency to discuss issues and resolve problems.

F.2.1.14. Offeror shall provide data files to the third-party administrators to update claims for adjustment.

F.2.1.16. The Offeror will ensure their equipment will not compromise the Agency’s data.

F.2.1.18. Offeror shall only use State data or State-related data for purposes that are set forth in the contract that will result from this RFP. Offeror shall not use State data or State-related data for any other purpose, including, but not limited to, data mining or bids on other government contracts. Offeror and/or its agents shall not resell nor otherwise redistribute information gained from its access to the State’s data. All data shall be returned to the State upon completion of any resulting contract.

F.2.2. REPORTING REQUIREMENTS

Failure to check “Agree” may result in disqualification

F.2.2.1. Monthly reporting: Due fifteen (15) days following the last day of the reporting month, unless otherwise specified.

F.2.2.2. Quarterly reporting: Due forty-five (45) days following the end of the reporting quarter, unless otherwise specified.

F.2.2.2.1. Summary report of identified claims and recovery progress.

F.2.2.2.2. SOC report(s) Bridge Letter(s).

F.2.2.3. Annual reporting: Due forty-five (45) days following the end of the fiscal year, June 30th, unless otherwise specified.

F.2.2.3.1. Fraud Prevention Plan F.2.2.3.2. SOC 1 Type 2, SOC 2 Type 2 or equivalent certifications F.2.2.3.3. Other documents deemed acceptable by the Agency, at implementation and on an annual basis.

F.2.2.4. Agency reserves the right to periodically revise and update reporting requirements, and request ad-hoc reports. Such revisions, updates, and ad hoc reports, must be provided at no cost to the State.

F.2.2.5. Offeror shall immediately notify Agency of any event that may have a material impact on Offeror’s ability to perform the Contract, including but not limited to mergers, acquisitions, etc.

By submitting an offer to this solicitation. The offeror agrees it will meet the contract requirements in Section F.2.

F.3. PROPOSED TECHNICAL SOLUTION – DESIRABLE ELEMENTS

Please explain how your organization meets or will meet each of the desirable elements. Use the column on the right to indicate the section and page number of your proposal where your response to each item may be found.

F.3.1.3. Provide examples of how Offeror’s solution has successfully increased the rate of…