Questionnaire No. 4 - Group Benefit Dental Plan.pdf

City of Miami Questionnaire for RFP No. 2130386

Questionnaire 4 Group Benefit Dental Plan(s)

Completion of this questionnaire is not mandatory, but it is strongly encouraged as failure to do so could negatively impact the overall evaluation score of the

Proposal. Responses will strengthen your technical evaluation and may contribute to your overall proposal score. Please answer in the order presented.

Incomplete responses may affect scoring.

I. General Organization and Experience

1. Provide your company profile, including number of years in business, legal name, and primary service location.

2. List the top three (3) public sector clients by size and describe experience with similar governmental entities.

3. Disclose any mergers, ownership changes, litigation, or regulatory actions in the last seven (7) years.

4. Describe any technological enhancements or innovations recently launched or in development.

II. Plan Design and Coverage

1. Provide benefit design summaries for both Dental Health Maintenance

Organization (“DHMO”) and Preferred Provider Organization (“PPO”) plans.

Indicate any plan design enhancements or flexibility.

2. Indicate whether DHMO allows specialist referrals and how referrals are processed.

3. Provide frequency limits for cleanings, x-rays, and periodontal treatment.

4. Confirm orthodontic benefit design, age limitations, and lifetime max.

5. Indicate the availability of implant and occlusal guard coverage.

6. Does your plan cover the cost of deep cleaning maintenance benefits as a preventative?

7. Provide the transition of care benefits for the dental PPO and dental DHMO plans separately, and address treatment in progress, orthodontia and other treatments

III. Claims and Adjudication

1. What percentage of claims are auto adjudicated?

2. List performance metrics for:

a % of claims paid within fifteen (15) and thirty (30) days b Financial and processing accuracy rates c Average claims turnaround time

3. Describe your image scanning or Electronic Data Interchange (“EDI”) capabilities.

4. Confirm the ability to process claims from out-of-network providers.

IV. Reporting and Data Access

1. List all standard ad hoc reports available (e.g., utilization, savings, network access, grievance summary).

2. Indicate frequency, delivery method, ands ample report availability.

3. Confirm if custom reporting is available at no charge.

V. Eligibility and Administration

1. Confirm real-time eligibility updates and accepted data formats (EDI, manual, online).

2. Describe the member ID card process, branding options, and turnaround times.

3. Indicate preferred member ID structure (SSN, alt ID, etc.).

4. Outline procedures for retroactive eligibility corrections.

VI. Implementation and Account Management

1. Describe in detail the implementation timeline, assuming a January 1st effective date and include the assigned tasks for all parties.

2. Identify the dedicated account management team and bios, and contact information.

3. Describe procedures for handling enrollment updates, billing inquiries, and escalated service issues.

VII. Networks and Access

1. Provide a Geo-Access report using 2 and 5-mile urban / 10-mile rural standards.

a. General Dentist

b. Dental Specialist

2. Attach a list of providers by county, identifying DHMO and PPO.

3. Confirm average provider tenure and turnover rates.

4. Explain how terminated providers are replaced and how members are notified.

5. Describe any provider outreach, credentialing standards, and compliance audits.

6. Please provide the average provider discounts of Usual, Customary, and

Reasonable (“UCR”) for General Dentists and Dental Specialists.

7. What procedures are in place to prevent a member from being overbilled or balance billed by a participating Provider or Specialist?

8. Does the Proposer anticipate any significant changes to the network in the next two (2) years?

VIII. Member Services

1. Confirm the following in a checklist format:

• US-based call center

• Dedicated service line for the City of Miami

• After-hours service or voicemail return protocol

• Multilingual support

2. Provide customer service hours and call center performance metrics (e.g., Average

Speed of Answer, First Contact Resolution).

3. List mobile App and Web Portal capabilities.

IX. Continuous Omnibus Budget Reconciliation Act (“COBRA”) Administration and Compliance

1. Confirm the ability to administer COBRA for dental benefits

2. Provide a summary of COBRA services, file formats accepted, and any fees.

3. Describe how you ensure compliance with Health Insurance Portability and

Accountability Act (“HIPAA”) and Americans with Disabilities Act (“ADA”) requirements.

4. Is the Proposer willing to administer COBRA for other insurance carriers if needed?

X. Pricing and Discounts

1. Provide fee schedules for PPO reimbursements (UCR percentile, MAC).

2. Submit DHMO capitation rates and premium equivalents.

3. Confirm which services are included in the proposed fees (ID cards, reports, portals).

4. Attach a sample of provider reimbursement methodology for common procedures.

XI. Performance Guarantees

1. Provide any performance guarantees you offer (claims accuracy, turnaround, network access, satisfaction).

2. Include applicable penalties or credits if guarantees are not met.