S000000375 Official Solicitation Price Sheet REVISED.xlsx

XLSX spreadsheet 78 KB Posted Jan 10, 2025

Attached to: Third Party Administrator
Solicitation number: S000000375
Issued by: Arkansas

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Written by GovTribe AI · Feb 3, 2025

This is a pricing sheet template from the Arkansas Department of Transformation and Shared Services for solicitation S000000375 seeking Third Party Administrator (TPA) services for health insurance and medical management programs. The template outlines the pricing structure for administering services to approximately 144,000 members, with pricing scenarios for varying membership levels (90%, 75%, 50%, 25%, and 10% of total enrollment). The contract term is structured as an initial three-year period with four one-year renewal options, for a maximum potential term of seven years.

The pricing sheet requires vendors to provide Per Member Per Month (PMPM) fees across multiple service categories including general administrative services, claims administration, network administration, access fees, reporting, accounting, and medical management services. Vendors must submit pricing for both sole administrator and multi-administrator scenarios, with rates held firm for the first three years and potential adjustments allowed in subsequent years subject to state approval. The template includes separate tabs for mandatory optional Employee Assistance Program (EAP) services, provider discount data submissions, claims repricing requirements, and additional optional services. Vendors must also indicate any implementation credits that would offset overall service costs.

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Other files

File	Type	Posted
Attachment C Three-Digit Zip Code Analysis.xlsx	XLSX spreadsheet	Jan 10, 2025
S000000375 Third Party Administrator~3.pdf	PDF	Jan 10, 2025
Attachment G Performance Standard Examples.pdf	PDF	Jan 10, 2025
S000000375 TPA Questions and Answers Final.pdf	PDF	Jan 10, 2025
Attachment A Non-Disclosure Agreement REV.docx	DOCX document	Jan 10, 2025
S000000375 Services Contract SRV-1 Sample.pdf	PDF	Jan 10, 2025
S000000375 Technical Proposal Packet.docx	DOCX document	Jan 10, 2025
Attachment D Nurse Line Utilization.pdf	PDF	Jan 10, 2025
Attachment E EAP Utilization Report 2024.pdf	PDF	Jan 10, 2025
S000000375 Third Party Administrator REVISION TWO.pdf	PDF	Jan 10, 2025
Attachment B Business Associate Agreement.docx	DOCX document	Jan 10, 2025
S000000375 Official Solicitation Price Sheet.xlsx	XLSX spreadsheet	Jan 10, 2025
Attachment F Introduction to EAP.pdf	PDF	Jan 10, 2025
S000000375 Contract and Grant Disclosure.pdf	PDF	Jan 10, 2025
Attachment A Non-Disclosure Agreement.docx	DOCX document	Jan 10, 2025
Attachment C Three-Digit Zip Code Analysis REVISED.xlsx	XLSX spreadsheet	Jan 10, 2025

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Instructions Official Solicitation Price Sheet S000000375 Third Party Administrator Transformation and Shared Services Employee Benefits Division

REVISED

CHANGES TO THE PRICE SHEET ARE DISPLAYED IN RED FONT

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. Prices must be firm offers for the first three (3) years and annual adjustments thereaffter may be negotiated at the time of contract renewal. A request for a price increase must include supporting documentation demonstrating that the increase in contract price is based on an increased cost to the Contractor and that the proposed pricing is still competitive in the marketplace. The State has the right to approve or deny any request for a price adjustment.

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. Prices must be firm offers for the first three (3) years and annual adjustments thereaffter may be negotiated at the time of contract renewal. A request for a price increase must include supporting documentation demonstrating that the increase in contract price is based on an increased cost to the Contractor and that the proposed pricing is still competitive in the marketplace. The State has the right to approve or deny any request for a price adjustment.

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.

6. 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.

7. 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. Prices must be firm offers for the first three (3) years and annual adjustments thereaffter may be negotiated at the time of contract renewal. A request for a price increase must include supporting documentation demonstrating that the increase in contract price is based on an increased cost to the Contractor and that the proposed pricing is still competitive in the marketplace. The State has the right to approve or deny any request for a price adjustment.

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) - Fill in responses in columns K through AI

TABLE A - Used for low cost determination

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Per Member Per Month (PMPM) Fee if Sole Administrator

X Estimated 144,000 Number of Members (100%)

x 12 months = 7-Year Estimated Cost

Per 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	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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) - Fill in responses in columns K through AI

TABLE A Continued - Used for low cost determination

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Per Member Per Month (PMPM) Fee if Sole Administrator

X Estimated 144,000 Number of Members (100%)

x 12 months = 7-Year Estimated Cost

Per 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	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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) - Fill in responses in columns K through AI

TABLE A Continued - Used for low cost determination

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Per Member Per Month (PMPM) Fee if Sole Administrator

X Estimated 144,000 Number of Members (100%)

x 12 months = 7-Year Estimated Cost

Per 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	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Billing
Billing Reconciliation
Indirect Costs
OTHER COSTS/FEES	$0.00	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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)
ADDITIONAL ITEMS	ITEMS NOT SPECIFIED ON THIS PRICE SHEET BUT NECESSARY TO FULFILL THE REQUIREMENTS OF THE PROGRAM							ITEMS NOT SPECIFIED ON THIS PRICE SHEET BUT NECESSARY TO FULFILL THE REQUIREMENTS OF THE PROGRAM										ITEMS NOT SPECIFIED ON THIS PRICE SHEET BUT NECESSARY TO FULFILL THE REQUIREMENTS OF THE PROGRAM										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	$0.00	$0.00	$0.00	$0.00	$0		$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
TOTAL 7-YEAR ESTIMATED COST							$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$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) - Fill in responses in columns K through AI

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 determination

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Per Member Per Month (PMPM) Fee if Sole Administrator

x Estimated 144,000 Number of Members (100%)

x 12 months = 7-Year Estimated Cost

Per 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	$0.00	$0.00	$0.00	$0.00	$0	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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
Additional Items	ITEMS NOT SPECIFIED ON THIS PRICE SHEET BUT NECESSARY TO FULFILL THE REQUIREMENTS OF THE PROGRAM							ITEMS NOT SPECIFIED ON THIS PRICE SHEET BUT NECESSARY TO FULFILL THE REQUIREMENTS OF THE PROGRAM										ITEMS NOT SPECIFIED ON THIS PRICE SHEET BUT NECESSARY TO FULFILL THE REQUIREMENTS OF THE PROGRAM										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
ESTIMATED MONTHY COST FOR SERVICES	$0.00	$0.00	$0.00	$0.00	$0.00	$0		$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
TOTAL 7-YEAR ESTIMATED COST							$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0

Section 3: Grand Total
7-Year Estimated Cost Payable Monthly
	Per Member Per Month (PMPM) Fee if Sole Administrator	Per 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%)

	Years 1-3	Year 4	Year 5	Year 6	Year 7			Years 1-3	Year 4	Year 5	Year 6	Year 7	Years 1-3	Year 4	Year 5	Year 6	Year 7	Years 1-3	Year 4	Year 5	Year 6	Year 7	Years 1-3	Year 4	Year 5	Year 6	Year 7	Years 1-3	Year 4	Year 5	Year 6	Year 7
Section 1, Table A: Health Insurance Services	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Section 2, Table C: Medical Management	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00	$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 GRAND TOTAL 7-Year Estimated Cost - 130,000 members $0 GRAND TOTAL 7-Year Estimated Cost - 108,000 members $0 GRAND TOTAL 7-Year Estimated Cost - 72,000 members $0 GRAND TOTAL 7-Year Estimated Cost - 36,000 members $0 GRAND TOTAL 7-Year Estimated Cost - 14,000 members $0

Tab #2 EAP (MANDATORY OPTIONAL)

Price Sheet: Optional Bid Price Sheet

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.

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Years 1-3

Year 4

Year 5

Year 6

Year 7

Table D - NOT used for low cost determination

Per Member Per Month Fee (PMPM)

if Sole Administrator

x 144,000 Estimated Average Members

x 12 months = 7-Year Estimated Cost

Per 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
				$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0	$0
	TOTAL 7-YEAR ESTIMATED COST		$0	TOTAL 7-Year Estimated Cost - 130,000 members				$0	TOTAL 7-Year Estimated Cost - 108,000 members				$0	TOTAL 7-Year Estimated Cost - 72,000 members				$0	TOTAL 7-Year Estimated Cost - 36,000 members				$0	TOTAL 7-Year Estimated Cost - 14,000 members				$0

Table E - Not used for low cost determination
Related Services Available But Not Required in the RFP	Pricing 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 Weights					Actual Full-Year 2022 Provider Discount %s					Projected 2023 Provider Discount %s
		In-Network	In-Network	In-Network	OON	OON	In-Network	In-Network	In-Network	OON	OON	In-Network	In-Network	In-Network	OON	OON
Location Name	EE Count	Inpatient	Outpatient	Professional	Contracted	Non-Contracted	Inpatient	Outpatient	Professional	Contracted	Non-Contracted	Inpatient	Outpatient	Professional	Contracted	Non-Contracted
013	2
015	1
016	1
024	1
032	1
060	2
068	1
109	1
120	1
133	1
143	1
147	1
151	1
156	1
170	1
190	1
200	1
217	1
221	2
222	1
236	1
244	1
261	1
272	3
273	1
275	2
277	1
280	1
282	1
283	2
284	3
287	1
290	1
292	1
294	1
295	1
296	1
297	1
298	1
300	6
301	5
302	3
303	2
305	1
306	2
309	1
310	1
313	1
315	1
320	6
321	8
322	1
323	3
324	6
325	4
327	2
329	5
333	1
334	1
335	2
336	1
337	3
338	2
339	1
341	1
342	4
344	2
347	2
350	1
352	1
355	1
361	2
363	1
365	11
366	2
368	2
370	11
371	3
372	2
376	2
377	2
378	3
379	1
380	37
381	125
382	1
383	9
384	1
385	3
386	74
387	111
388	6
389	4
390	4
391	3
392	1
394	1
395	2
396	3
397	1
398	1
400	1
403	1
405	1
411	1
420	1
421	1
422	1
423	1
427	1
430	1
432	1
443	1
450	1
451	1
460	1
463	2
469	2
474	1
477	1
481	1
482	1
485	1
490	1
494	1
497	1
500	1
505	1
506	2
507	1
520	1
532	1
535	1
551	2
563	1
564	1
581	1
588	1
598	3
599	1
600	1
605	2
606	1
612	1
627	1
628	2
629	1
631	2
633	5
636	1
637	4
638	55
639	26
640	1
641	2
647	1
648	56
652	2
654	3
655	1
656	83
657	94
658	7
659	1
660	6
662	2
667	1
670	1
701	2
704	3
705	2
706	2
707	1
708	3
710	31
711	9
712	49
716	6,058
717	2,862
718	3,187
719	4,868
720	14,236
721	10,825
722	7,356
723	3,865
724	6,612
725	3,482
726	3,603
727	10,904
728	3,672
729	6,063
730	12
731	5
735	1
740	17
741	7
743	44
744	19
745	1
747	15
748	1
749	283
750	18
751	6
752	5
753	2
754	6
755	330
756	7
757	4
758	1
759	2
760	8
761	1
762	7
764	1
765	1
766	2
770	2
773	8
774	3
775	3
778	1
779	2
780	2
781	4
782	3
785	5
786	2
787	4
795	1
797	1
799	1
801	1
802	2
804	1
805	4
810	1
811	1
813	1
820	1
834	1
838	1
840	2
841	1
846	1
851	1
853	3
856	3
857	6
863	1
871	2
875	2
890	2
891	2
895	1
900	1
911	1
922	1
935	1
945	1
960	1
975	1
977	1
981	1
982	2
985	1
986	3
990	1
995	1
996	1
999	1

Tab #4 Claims Repricing

Claim Repricing File Layout Pricing Submission Format

benefit_plan

system

plan_source

file_date

claim_number

claim_line

adj_ind

interim_bill

patient_id

patient_gender

preauth_number

first_date

last_date

icd_flag

prin_icd_9_diag_code

other_icd_9_diag_code_1

other_icd_9_diag_code_2

prin_icd_10_diag_code

other_icd_10_diag_code_1

other_icd_10_diag_code_2

proc_code__hcpcs_code

proc_code_mod_1

proc_code_mod_2

place_of_service

revenue_code

drg

billed_units

charges

In-Network/Out-of-Network (I, O, or X)

Allowed Amount ($.cc)

anesthesia_claim

institutional_or_professional

Provider EIN/TAXID

Provider NPI Number

Member 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
	Yes	No	Comments
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 determination	Per 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 determination	Hourly 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 determination	Per Member Per Month (PMPM) Fee
if Sole Administrator	X Estimated 144,000 Number of Members (100%)	x 84 months = 7-Year Estimated Cost		Per 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 RFP	Pricing Details

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

File details come from the government source that posted it. Updated Feb 3, 2025.