S000000375 Official Solicitation Price Sheet.xlsx

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Attached to
Third Party Administrator
Solicitation number
S000000375
Issued by
Arkansas

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This is a Third Party Administrator price sheet from the Arkansas Employee Benefits Division for solicitation S000000375, detailing required pricing structures for health insurance and medical management services. The file contains detailed pricing tables and instructions for bidders to submit costs for providing TPA services across multiple scenarios - as either a sole administrator (100% enrollment) or as part of a multi-administrator arrangement (ranging from 10-90% enrollment) over a seven-year contract term. The services requested include health insurance administration, claims processing, network management, reporting, accounting services, and medical management services including case management, utilization review, disease management, and wellness programs.

The pricing structure requires bidders to provide per-member-per-month (PMPM) fees for various service categories, with separate tables for mandatory components (health insurance and medical management) and optional services like Employee Assistance Program (EAP). Bidders must also submit provider network discount data using Uniform Discount Data Submission (UDS) format and complete claims repricing exercises using actual 2023 claims data. The pricing sheets include mechanisms for calculating total seven-year costs based on varying membership levels, with implementation credits to be identified separately. Optional services pricing is collected but not used for low-cost determination in awarding points.

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Other files

File Type Posted
Attachment C Three-Digit Zip Code Analysis.xlsx XLSX spreadsheet
S000000375 Third Party Administrator~3.pdf PDF
Attachment G Performance Standard Examples.pdf PDF
S000000375 TPA Questions and Answers Final.pdf PDF
Attachment B Business Associate Agreement.docx DOCX document
Attachment F Introduction to EAP.pdf PDF
S000000375 Contract and Grant Disclosure.pdf PDF
Attachment A Non-Disclosure Agreement.docx DOCX document
Attachment C Three-Digit Zip Code Analysis REVISED.xlsx XLSX spreadsheet
Attachment A Non-Disclosure Agreement REV.docx DOCX document
S000000375 Services Contract SRV-1 Sample.pdf PDF
S000000375 Technical Proposal Packet.docx DOCX document
Attachment D Nurse Line Utilization.pdf PDF
Attachment E EAP Utilization Report 2024.pdf PDF
S000000375 Official Solicitation Price Sheet REVISED.xlsx XLSX spreadsheet
S000000375 Third Party Administrator REVISION TWO.pdf PDF
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Instructions Official Solicitation Price Sheet S000000375 Third Party Administrator Transformation and Shared Services Employee Benefits Division

Instructions
Tab #1 Major Components
Section 1: Health Insurance
Table A: Used for low-cost determination
1. The Contractor shall identify the total seven (7) year cost for the TPA Health Insurance Services.
2. The cost must include all costs associated with the activities and tasks that meet the requirements of the RFP for Health Insurance Services and all additional activities and tasks identified in the Prospective Contractor’s proposal.
3. The Contractor shall enter the Per Member per Month fee in the blue-shaded cells using the service breakdown provided in Table A.
4. Each service item must be individually priced and must not be blended with other services or pricing.
5. The Prospective Contractor shall enter a "0" or leave blank any cell for services that are provided at no cost.
6. The table will automatically calculate the costs from the blue-shaded cells into the yellow-shaded cells.
7. For the section titled “Items Not Specified on This Price Sheet but Necessary to Fulfill the Requirements of the Program,” services and costs must be filled in to reflect complete pricing of the required services. Lines may be added to this section as necessary.
8. The table will automatically calculate the subtotals to an estimated seven (7) year cost for Health Insurance Services.
Table B: Implementation Credit - Used for low-cost determination
1. The Contractor shall identify any Implementation Credit that may offset the overall services costs.
Section 2: Medical Management
Table C: Used for low-cost determination
1. The Contractor shall identify the total seven (7) year cost for the TPA Medical Management Services.
2. The cost must include all costs associated with the activities and tasks that meet the requirements of the RFP for Medical Management Services and all additional activities and tasks identified in the Prospective Contractor’s proposal.
3. The Contractor shall enter the Per Member per Month fee in the blue-shaded cells using the reporting breakdown provided in Table C.
4. Each service item must be individually priced and must not be blended with other services or pricing.
5. The Prospective Contractor shall enter a "0" or leave blank any cell for services that are provided at no cost.
7. For the section titled “Items Not Specified on This Price Sheet but Necessary to Fulfill the Requirements of the Program,” services and costs must be filled in to reflect complete pricing of the required services. Lines may be added to this section as necessary.
8. The table will automatically calculate the subtotals to an estimated seven (7) year cost for Administrative Services.
Section 3: Grand Total
1. The table will automatically calculate the seven (7) year estimated cost for Health Insurance and Medical Management based on the subtotals in Tables A, B, and C.
Tab #2 EAP (Mandatory Optional)
Table D:
1. Will not be used for low-cost determination in awarding cost points.
2. The Contractor shall enter costs in the yellow-shaded cells.
3. The table will automatically calculate the seven (7) year estimated cost in the green-shaded cells.
Table E:
1. Will not be used for low-cost determination in awarding cost points.
2. All EAP-related services which are proposed or offered in a Prospective Contractor’s proposal, but which are not required in the RFP, must be listed in this table and must have a price entered for each service.
3. Lines may be added to this table as necessary.
Tab #3 Provider Discounts
Table F:
1. Prospective Contractors shall submit medical provider network discount data using the Uniform Discount Data Submission (UDS) dataset for full-year 2022 actual discounts and projected discounts to 2023.
2. Prospective Contractors shall submit discount data by three (3) digit zip code for the locations where the Arkansas members reside. The three (3) digit zip codes and related member residents are provided in the first two columns of Table J.
3. Prospective Contractors shall use the standard UDS specifications and shall develop discounts by three (3) digit zip code weighted based on the Arkansas employee census.
Tab #4 Claims Repricing
1. Prospective Contractors shall submit claim repricing data as described in Tab #5 Claims Repricing and in the instructions below.
2. To obtain a copy of the claims data files, the Prospective Contractor shall initiate a request via email to julie.robnolt@arkansas.gov.
a. Prospective Contractors shall complete a non-disclosure agreement (NDA) (Attachment A: Non-Disclosure Agreement) and shall submit as directed prior to receiving claims data files.
b. Information and instructions for accessing the claims data files will be provided within one (1) business day of receiving the signed NDA.
3. The claim data files provide actual claims incurred during 2023 for the Arkansas membership. There are twelve (12) spreadsheets in total, with one spreadsheet per month during 2023.
4. Tab #5 Claims Repricing provides the data layout and repricing instructions.
5. Prospective Contractors shall provide repricing as instructed in Tab #5 Claims Repricing for the entire data set (all twelve (12) files. Failure to provide pricing for the entire data file will result in rejection of the Prospective Contractor’s proposal.
6. The Prospective Contractor shall provide their network repricing for each claim on the data file. Repricing must be submitted on twelve (12) spreadsheets with the format exactly as shown in Tab #5 Claims Repricing, with each claim pricing as a single horizontal row on the spreadsheets.
7. Pricing must include the amount for that specific provider in the given location on the given date. Also, in-network or out-of-network status must be provided.
8. Repricing files must be called “Repricing_YYY_xxxxxx,” where “YYY” reflects the month (e.g., “Jan”) and “xxxxxx” reflects your organization’s name.
9. The Prospective Contractor shall respond to the five (5) questions shown in the table in Tab #5 Claims Repricing.
Tab #5 Optional Services
Section 1: Health Insurance
Table G:
1. Will not be used for low-cost determination in awarding cost points.
2. The Contractor may enter costs for the yellow-shaded cells.
Table H:
1. Will not be used for low-cost determination in awarding cost points.
2. The Contractor may enter costs for the yellow-shaded cells.
Table I:
1. Will not be used for low-cost determination in awarding cost points.
2. All Health Insurance-related services which are proposed or offered in a Prospective Contractor’s proposal, but which are not required in the RFP, should be listed in this table and should have a price entered for each service.
3. Lines may be added to this table as necessary.

Section 2: Medical Management

Table J:
1. Will not be used for low-cost determination in awarding cost points.
2. All Medical Management-related services which are proposed or offered in a Prospective Contractor’s proposal, but which are not required in the RFP, should be listed in this table and should have a price entered for each service.
3. Lines may be added to this table as necessary.

Tab #1 Major Components

Price Sheet: Official Solicitation Price Sheet for Cost Score
S000000375 Third Party Administrator
Section 1: Health Insurance
THIS SECTION IS FOR AWARDS OF 100% OF TOTAL ENROLLMENT (SOLE ADMINISTRATOR SITUATION)THIS SECTION IS FOR AWARDS OF LESS THAN 100% OF TOTAL ENROLLMENT (MULTI-ADMINISTRATOR SITUATION)
TABLE A - Used for low cost determinationFill in responses in columns G through K
Per Member Per Month (PMPM) Fee
if Sole AdministratorX Estimated 144,000 Number of Members (100%)x 84 months = 7-Year Estimated CostPer Member Per Month (PMPM) Fee
if 130,000 Members (90%)Per Member Per Month (PMPM) Fee
if 108,000 Members (75%)Per Member Per Month (PMPM) Fee
if 72,000 Members (50%)Per Member Per Month (PMPM) Fee
if 36,000 Members (25%)Per Member Per Month (PMPM) Fee

if 14,000 Members (10%)

GENERAL ADMINISTRATIVE SERVICES$0.00$0$0$0.00$0.00$0.00$0.00$0.00
Member Customer Service
Provider Customer Service
Maintaining Eligibility Consistent with EBD Standards (based on EBD continuing responsibility for eligibility)
Member EOB Production
Member EOB Mailing
Generate Member ID Cards
In-State Account Manager
Customer Satisfaction Surveys
Member Communications (letters, brochures, newsletters, etc.)
Website
CLAIMS ADMINISTRATION$0.00$0$0$0.00$0.00$0.00$0.00$0.00
Claim Adjudication
Imaging of Paper Claims
RA/Payments Made to Providers Per EBD's Schedule
Coverage Policy Administration
Subrogation
Coordination of Benefits
Pre-Service Claims Review/Appeals
Post-Service Claims Review/Appeals
Section 1: Health Insurance
THIS SECTION IS FOR AWARDS OF 100% OF TOTAL ENROLLMENT (SOLE ADMINISTRATOR SITUATION)THIS SECTION IS FOR AWARDS OF LESS THAN 100% OF TOTAL ENROLLMENT (MULTI-ADMINISTRATOR SITUATION)
TABLE A Continued - Used for low cost determinationFill in responses in columns G through K
Per Member Per Month (PMPM) Fee
if Sole AdministratorX Estimated 144,000 Number of Members (100%)x 84 months = 7-Year Estimated CostPer Member Per Month (PMPM) Fee
if 130,000 Members (90%)Per Member Per Month (PMPM) Fee
if 108,000 Members (75%)Per Member Per Month (PMPM) Fee
if 72,000 Members (50%)Per Member Per Month (PMPM) Fee
if 36,000 Members (25%)Per Member Per Month (PMPM) Fee

if 14,000 Members (10%)

NETWORK ADMINISTRATION$0.00$0$0$0.00$0.00$0.00$0.00$0.00
Managing Provider Contracts
Timely Notification Prior to Any Contractual or Network Change
Credentialing of Providers
Provider Satisfactions Surveys
Provider Transparency
Value Based Physician Programs
ACCESS FEES$0.00$0$0$0.00$0.00$0.00$0.00$0.00
TMJ Network
Custom Networks
BHSA Network
Transplant Network
Lab Network
Radiology Network
Chiropractic Network
Alternative Care Network
REPORTING$0.00$0$0$0.00$0.00$0.00$0.00$0.00
Required Reports
Ad Hoc Reporting Tools Access
HEDIS Data Collection
Section 1: Health Insurance
THIS SECTION IS FOR AWARDS OF 100% OF TOTAL ENROLLMENT (SOLE ADMINISTRATOR SITUATION)THIS SECTION IS FOR AWARDS OF LESS THAN 100% OF TOTAL ENROLLMENT (MULTI-ADMINISTRATOR SITUATION)
TABLE A Continued - Used for low cost determinationFill in responses in columns G through K
Per Member Per Month (PMPM) Fee
if Sole AdministratorX Estimated 144,000 Number of Members (100%)x 84 months = 7-Year Estimated CostPer Member Per Month (PMPM) Fee
if 130,000 Members (90%)Per Member Per Month (PMPM) Fee
if 108,000 Members (75%)Per Member Per Month (PMPM) Fee
if 72,000 Members (50%)Per Member Per Month (PMPM) Fee
if 36,000 Members (25%)Per Member Per Month (PMPM) Fee

if 14,000 Members (10%)

ACCOUNTING$0.00$0$0$0.00$0.00$0.00$0.00$0.00
Billing
Billing Reconciliation
Indirect Costs
OTHER COSTS/FEES$0.00$0$0$0.00$0.00$0.00$0.00$0.00
Repricing Services
Provider negotiation for large claims (Out-of-Network)
Claims Data Interface (other than the ongoing claims data feed to EBD)
ITEMS NOT SPECIFIED ON THIS PRICE SHEET BUT NECESSARY TO FULFILL THE REQUIREMENTS OF THE PROGRAM
$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
ESTIMATED MONTHY COST FOR SERVICES$0.00$0$0.00$0.00$0.00$0.00$0.00
TOTAL 7-YEAR ESTIMATED COST$0$0$0$0$0$0

Table B - Used for low cost determination One-Time Amount if Sole Administrator One-Time Amount if 130,000 Members (90%) One-Time Amount if 108,000 Members (75%) One-Time Amount if 72,000 Members (50%) One-Time Amount if 36,000 Members (25%) One-Time Amount if 14,000 Members (10%)

Implementation Credit

Price Sheet: Official Bid Price Sheet for Cost Score
S000000375 Third Party Administrator
Section 2: Medical Management
THIS SECTION IS FOR AWARDS OF 100% OF TOTAL ENROLLMENT (SOLE ADMINISTRATOR SITUATION)THIS SECTION IS FOR AWARDS OF LESS THAN 100% OF TOTAL ENROLLMENT (MULTI-ADMINISTRATOR SITUATION)
Please note that medical management services do not apply to post-65 retirees (Medicare-eligible). PMPM Fees should still be quoted based on total members.
Table C - Used for low cost determinationFill in responses in columns G through K
Per Member Per Month (PMPM) Fee
if Sole Administratorx Estimated 144,000 Number of Members (100%)x 84 months = 7-Year Estimated CostPer Member Per Month (PMPM) Fee
if 130,000 Members (90%)Per Member Per Month (PMPM) Fee
if 108,000 Members (75%)Per Member Per Month (PMPM) Fee
if 72,000 Members (50%)Per Member Per Month (PMPM) Fee
if 36,000 Members (25%)Per Member Per Month (PMPM) Fee

if 14,000 Members (10%)

Medical Management Reporting$0.00$0$0$0.00$0.00$0.00$0.00$0.00
Case Management
Utilization Review/Management
Disease Management
Maternity Management
Wellness Services
Member Appeals
Nurse Line
Medical Management Reporting
Predictive Modeling
Risk Stratification
Health Education Programs
Medical Director Review
Pre-notification Program for Out-of-State Admissions
Prior Authorization for High-Tech Imaging
Transplant Case Management
ITEMS NOT SPECIFIED ABOVE BUT NECESSARY FOR FULFILLING THE REQUIREMENTS OF THE PROGRAM
$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
ESTIMATED MONTHY COST FOR SERVICES$0.00$0$0$0$0$0$0
TOTAL 7-YEAR ESTIMATED COST$0$0$0$0$0$0

Section 3: Grand Total

7-Year Estimated Cost Payable Monthly7-Year Estimated Cost Payable Monthly
Section 1, Table A: Health Insurance Services$0.00$0.00$0$0.00$0.00$0.00$0.00$0.00
Section 2, Table C: Medical Management$0.00$0.00$0$0.00$0.00$0.00$0.00$0.00

GRAND TOTAL 7-Year Estimated Cost (Health Insurance and Medical Management Only, less any Implementation Credit) $0 $0 $0 $0 $0 $0

Tab #2 EAP (MANDATORY OPTIONAL)

Price Sheet: Optional Bid Price SheetPAGE 1 of 1
S000000375 Third Party Administrator
Section 4: Employee Assistance Program
THIS SECTION IS FOR AWARDS OF 100% OF TOTAL ENROLLMENT (SOLE ADMINISTRATOR SITUATION)THIS SECTION IS FOR AWARDS OF LESS THAN 100% OF TOTAL ENROLLMENT (MULTI-ADMINISTRATOR SITUATION)
Please note that EAP services are only available to active employees / members. PMPM Fees should still be quoted based on total members.
Table D - NOT used for low cost determinationPer Member Per Month Fee (PMPM)
if Sole Administratorx 144,000 Estimated Average Membersx 84 months = 7-Year Estimated CostPer Member Per Month (PMPM) Fee
if 130,000 Members (90%)Per Member Per Month (PMPM) Fee
if 108,000 Members (75%)Per Member Per Month (PMPM) Fee
if 72,000 Members (50%)Per Member Per Month (PMPM) Fee
if 36,000 Members (25%)Per Member Per Month (PMPM) Fee

if 14,000 Members (10%)

Fee for All Employee Assistance Services$0$0
TOTAL 7-YEAR ESTIMATED COST$0$0$0$0$0$0
Table E - Not used for low cost determination
Related Services Available But Not Required in the RFPPricing Details

($/PMPM, $/PEPM, $/Hour, X% of X, 1-time fee, etc.)

Tab #3 Provider Discounts

S000000375 Third Party Administrator
Provider Discount Results Format
Submitted by:
Indicate Senior Actuary Sign Off (Y or N)
Date Submitted:Table F: Data provided below should be current UDS data based on your Book of Business and weighted by the AR employee home zip codes
Actual Full-Year 2022 WeightsActual Full-Year 2022 Provider Discount %sProjected 2023 Provider Discount %s
In-NetworkIn-NetworkIn-NetworkOONOONIn-NetworkIn-NetworkIn-NetworkOONOONIn-NetworkIn-NetworkIn-NetworkOONOON
Location NameEE CountInpatientOutpatientProfessionalContractedNon-ContractedInpatientOutpatientProfessionalContractedNon-ContractedInpatientOutpatientProfessionalContractedNon-Contracted
0132
0151
0161
0241
0321
0602
0681
1091
1201
1331
1431
1471
1511
1561
1701
1901
2001
2171
2212
2221
2361
2441
2611
2723
2731
2752
2771
2801
2821
2832
2843
2871
2901
2921
2941
2951
2961
2971
2981
3006
3015
3023
3032
3051
3062
3091
3101
3131
3151
3206
3218
3221
3233
3246
3254
3272
3295
3331
3341
3352
3361
3373
3382
3391
3411
3424
3442
3472
3501
3521
3551
3612
3631
36511
3662
3682
37011
3713
3722
3762
3772
3783
3791
38037
381125
3821
3839
3841
3853
38674
387111
3886
3894
3904
3913
3921
3941
3952
3963
3971
3981
4001
4031
4051
4111
4201
4211
4221
4231
4271
4301
4321
4431
4501
4511
4601
4632
4692
4741
4771
4811
4821
4851
4901
4941
4971
5001
5051
5062
5071
5201
5321
5351
5512
5631
5641
5811
5881
5983
5991
6001
6052
6061
6121
6271
6282
6291
6312
6335
6361
6374
63855
63926
6401
6412
6471
64856
6522
6543
6551
65683
65794
6587
6591
6606
6622
6671
6701
7012
7043
7052
7062
7071
7083
71031
7119
71249
7166,058
7172,862
7183,187
7194,868
72014,236
72110,825
7227,356
7233,865
7246,612
7253,482
7263,603
72710,904
7283,672
7296,063
73012
7315
7351
74017
7417
74344
74419
7451
74715
7481
749283
75018
7516
7525
7532
7546
755330
7567
7574
7581
7592
7608
7611
7627
7641
7651
7662
7702
7738
7743
7753
7781
7792
7802
7814
7823
7855
7862
7874
7951
7971
7991
8011
8022
8041
8054
8101
8111
8131
8201
8341
8381
8402
8411
8461
8511
8533
8563
8576
8631
8712
8752
8902
8912
8951
9001
9111
9221
9351
9451
9601
9751
9771
9811
9822
9851
9863
9901
9951
9961
9991

Tab #4 Claims Repricing

Claim Repricing File Layout Pricing Submission Format
benefit_plansystemplan_sourcefile_dateclaim_numberclaim_lineadj_indinterim_billpatient_idpatient_genderpreauth_numberfirst_datelast_dateicd_flagprin_icd_9_diag_codeother_icd_9_diag_code_1other_icd_9_diag_code_2prin_icd_10_diag_codeother_icd_10_diag_code_1other_icd_10_diag_code_2proc_code__hcpcs_codeproc_code_mod_1proc_code_mod_2place_of_servicerevenue_codedrgbilled_unitschargesIn-Network/Out-of-Network (I, O, or X)Allowed Amount ($.cc)anesthesia_claiminstitutional_or_professionalProvider EIN/TAXIDProvider NPI NumberMember Home Zip
The un-shaded columns indicate the columns in the claims data provided.
The shaded columns show the information that must be provided by the Prospective Contractor for each claim, as follows:
Prospective Contractor response to In-Network/Out-of-Network must either indicate "I" for In-Network, "O" for Out-of-Network, or "X" for Cannot Identify Provider
Prospective Contractor response to Allowed Amount must be in dollars.cents format
Information/Pricing for each claim submitted by the Prospective Contractor must be formatted as above with one horizontal row for each claim on the spreadsheet, and the record order must be the same as the data file provided. Column width may be expanded as data necessitates.
Responses will be used to estimate discount percentage, which will be used to estimate 2025 claims cost. 2025 claims cost will be estimated as follows: Estimated 2025 Claims Cost = Projected 2025 Charges x (1 - Estimated Discount %) x Estimated Actuarial Value
Claim Re-Pricing Submission Questions - Prospective Contractors Must Respond
All questions relate to how responders define and establish their "Allowed Amount(s)"
Questions are supplementary to Attachment D and are not scored
For each question, respond with an "X" in either the Yes or No column, and enter any comments as needed
YesNoComments
1. Are Allowed Amounts specific to Provider?
2. Are Allowed Amounts specific to 3-digit zip code?
3. Are Allowed Amounts specific to procedure code?
4. Are Allowed Amounts specific to revenue code?
5. Are Allowed Amounts driven by UDS data by zip code and service type?

Tab #5 Optional Services Section 1: Health Insurance

TABLE G - Not used for low cost determinationPer Member Per Month (PMPM) Fee
Access Fees for Other Networks
Administration of Enrollment Process / Benefit Enrollment Portal (should EBD decide to transfer responsibility to Contractor)
COBRA Management
TABLE H - Not used for low cost determinationHourly Rate
Customized Reports
External Review
Please List Any Related Services Available But Not Required in the RFP - Not used for low cost determination
TABLE I - Not used for low cost determinationPer Member Per Month (PMPM) Fee
if Sole AdministratorX Estimated 144,000 Number of Members (100%)x 84 months = 7-Year Estimated CostPer Member Per Month (PMPM) Fee
if 130,000 Members (90%)Per Member Per Month (PMPM) Fee
if 108,000 Members (75%)Per Member Per Month (PMPM) Fee
if 72,000 Members (50%)Per Member Per Month (PMPM) Fee
if 36,000 Members (25%)Per Member Per Month (PMPM) Fee

if 14,000 Members (10%)

$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
$0$0
Section 2: Medical Management
Table J - Not used for low cost determination
Related Services Available But Not Required in the RFPPricing Details

($/PMPM, $/PEPM, $/Hour, X% of X, 1-time fee, etc.)

File details come from the government source that posted it. Updated .