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Instructions Official Solicitation Price Sheet S000000413 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 Prospective Contractor shall identify and 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. |
| 2. The Prospective Contractor shall enter the Per Member per Month fee in the blue-shaded cells using the service breakdown provided in Table A. |
| 3. Each service item must be individually priced and must not be blended with other services or pricing. |
| 4. The Prospective Contractor shall enter a "0" or leave blank any cell for services that are provided at no cost. |
| 5. The table will automatically calculate the costs from the blue-shaded cells into the yellow-shaded cells. |
| 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 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 Prospective Contractor shall identify and 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. |
| 2. The Contractor shall enter the Per Member per Month fee in the blue-shaded cells using the reporting breakdown provided in Table C. |
| 3. Each service item must be individually priced and must not be blended with other services or pricing. |
| 4. The Prospective Contractor shall enter a "0" or leave blank any cell for services that are provided at no cost. |
| 5. 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. |
| 6. 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 fee cost for Health Insurance and Medical Management less any implementation credit based on the subtotals in Tables A, B, and C. |
| 2. The table will use the seven (7) year estimated allowed claim cost from Tab #4 Claims Repricing. |
| 3. The table will sum the seven (7) year estimated fees cost and estimated allowed claim cost to get the Total Estimated Cost used of low-cost determination. |
| Tab #2 Employee Assistance Program |
| Table D: |
| 1. Will not be used for low-cost determination in awarding cost points. |
| 2. The Prospective Contractor shall identify and include all costs associated with the activities and tasks that meet the requirements of the RFP for Employee Assistance Program. |
| 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 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 in aggregate as indicated for the locations where the State of Arkansas members reside. |
| 3. Prospective Contractors shall use the standard UDS specifications and shall develop discounts in aggregate as indicated weighted based on the Arkansas employee home zip code provided in the Non-Medicare tab of the census data spreadsheet (See Section 1.7 of the RFP for details to obtain the census data and claims repricing files). |
| 4. Additionally, Prospective Contractors shall fill in the information requested in the Blue cells. |
| Tab #4 Claims Repricing |
Section 1: Claims Repricing Summary
| Table G: |
| 1. Prospective Contractors shall submit claim repricing SUMMARY data as described in the instructions below (See Section 1.7 of the RFP for details to obtain the census data and claims repricing files). |
| 2. The claim data files provide actual claims charges incurred during 2023 for the State of Arkansas membership. There are twelve (12) spreadsheets in total, with one spreadsheet per month during 2023. |
| 3. Prospective Contractors shall provide repricing in Tab #4 Claims Repricing for the entire data set (claims from all twelve (12) files combined). Responses must be provided in aggregate and summarized as indicated below. |
| 4. Prospective Contractor shall fill in Table G for the repricing results IN AGGREGATE for the twelve (12) claim data files COMBINED. Use the Charge from the claim files and apply current (March/April 2025) contracted provider discounts to determine Discount % (percentage). |
| 5. Prospective Contractors shall fill in the Blue cells (Total Charges and Discount Percentages) which will allow the Yellow cells to automatically populate. |
| 6. Prospective Contractors shall input Total Charges in the four (4) categories shown (In-Network Providers, Out-of-Network Contracted Providers, Out-of-Network Non-Contracted Providers, and Cannot Identify Providers) and the Discount Percentage in the three (3) categories shown (In-Network Providers, Out-of-Network Contracted Providers, and Out-of-Network Non-Contracted Providers). |
| 7. Total One-Year Cost (item 6.) under Total Charges column should equal $1,479,924,536.98 (total of 12 months of charges from claim files). |
| 8. Figure in Green cell will be used in Tab #1 for Low-Cost Determination. |
| 9. Scoring with respect to claim repricing will be determined as follows: |
| 10. Determine seven (7) year Allowed Claims as 7 times the One-Year Allowed Cost from Tab #4. See cell D14 in Tab #4. This value is reflected in cell I136 in Tab #1. |
Section 2: Questions Concerning Repricing
| Table H: |
| 1. Prospective Contractors shall respond to the seven (7) questions shown in the Table H in Tab #4 Claims Repricing Section 2 (these questions are not scored). |
| 2. Prospective Contractors shall respond to these questions related to how responders define and establish their "Allowed Amount(s)" |
| 3. The Prospective Contractor shall respond to each question one through six (1 - 6), respond with an "X" in either the "Yes" or "No" column, and enter any comments as needed. |
| 4. The Prospective Contractor should respond to question seven (7) with a name. |
| Tab #5 Optional Services |
| Section 1: Health Insurance |
| Table I: |
| 1. Will not be used for low-cost determination in awarding cost points. |
| 2. The Prospective Contractor may enter costs for the yellow-shaded cells. |
| Table J: |
| 1. Will not be used for low-cost determination in awarding cost points. |
| 2. The Prospective Contractor may enter costs for the yellow-shaded cells. |
| Table K: |
| 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 L: |
| 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
| Official Solicitation Price Sheet |
| S000000413 Third Party Administrator |
| Section 1: Health Insurance |
| TABLE A - Used for low cost determination | | | | | | | |
| Years 1-3 | Year 4 | Year 5 | Year 6 | Year 7 | | |
| Per Member Per Month (PMPM) Fee | | | | | X Estimated 144,000 Number of Members (100%) | x 12 months = 7-Year Estimated Cost |
| GENERAL ADMINISTRATIVE SERVICES | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0 | $0 |
| 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 |
| 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
| TABLE A Continued - Used for low cost determination | | | | | | | |
| Years 1-3 | Year 4 | Year 5 | Year 6 | Year 7 | | |
| Per Member Per Month (PMPM) Fee | | | | | X Estimated 144,000 Number of Members (100%) | x 12 months = 7-Year Estimated Cost |
| NETWORK ADMINISTRATION | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0 | $0 |
| 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 |
| 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 |
| Required Reports | | | | | | | |
| Ad Hoc Reporting Tools Access | | | | | | | |
| HEDIS Data Collection | | | | | | | |
Section 1: Health Insurance
| TABLE A Continued - Used for low cost determination | | | | | | | |
| Years 1-3 | Year 4 | Year 5 | Year 6 | Year 7 | | |
| Per Member Per Month (PMPM) Fee | | | | | X Estimated 144,000 Number of Members (100%) | x 12 months = 7-Year Estimated Cost |
| ACCOUNTING | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0 | $0 |
| Billing | | | | | | | |
| Billing Reconciliation | | | | | | | |
| Indirect Costs | | | | | | | |
| OTHER COSTS/FEES | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0 | $0 |
| 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 | | | | | | |
| | | | | | $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 | |
| TOTAL 7-YEAR ESTIMATED COST | | | | | | | $0 |
Table B - Used for low cost determination One-Time Amount
Implementation Credit
| Official Solicitation Price Sheet |
| S000000413 Third Party Administrator |
| Section 2: Medical Management |
| 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 | | |
| Per Member Per Month (PMPM) Fee | | | | | x Estimated 144,000 Number of Members (100%) | x 12 months = 7-Year Estimated Cost |
| Medical Management Reporting | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0 | $0 |
| 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 | | | | | | |
| | | | | | $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 | |
| TOTAL 7-YEAR ESTIMATED COST | | | | | | | $0 |
| Section 3: Grand Total | |
| 7-Year Estimated Cost Payable Monthly | |
| Per Member Per Month (PMPM) Fee |
| Years 1-3 | Year 4 | Year 5 | Year 6 | Year 7 | | |
| Section 1, Table A: Health Insurance Services Fees | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0 |
| Section 2, Table C: Medical Management Fees | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0 |
TOTAL 7-Year Estimated Fee Cost (Health Insurance Fees (Table A) plus Medical Management Fees (Table D), less any Implementation Credit (Table B) $0
TOTAL 7-Year Estimated Allowed Claims Cost (from Tab #4 Claims Repricing) ERROR:#DIV/0!
GRAND TOTAL 7-Year Estimated Fee Cost Plus Allowed Claim Cost ERROR:#DIV/0!
Tab #2 Employee Assistance Prog
| Official Solicitation Price Sheet |
| S000000413 Third Party Administrator |
| Section 4: Employee Assistance Program |
| | 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 |
| 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 | |
Fee for All Employee Assistance Services $0 $0
TOTAL 7-YEAR ESTIMATED COST $0
| Table E - Not used for low cost determination | |
| Related Services Available But Not Required in the RFP | Pricing Details |
($/PMPM, $/PEPM, $/Hour, X% of X, 1-time fee, etc.)
Tab #3 Provider Discounts
| Official Solicitation Price Sheet |
| S000000413 Third Party Administrator |
| TABLE F - Used for low cost determination |
| 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 |
| Aggregate Results * | 75,718 | | | | | | | | | | | | | | | |
| | Sum of weights above should be 100% | | | | | | | | | | | | | | |
* Aggregate Results should be weighted based on employee home zip code as provided in the employee census data
Tab #4 Claims Repricing
| Official Solicitation Price Sheet |
| S000000413 Third Party Administrator |
| Section 1: Claims Repricing Summary |
| TABLE G - Used for low cost determination | | | |
| Total Charges | Total Allowed | Discount Percentage |
| 1. In-Network Providers | | $0 | |
| 2. Out-of-Network Contracted Providers | | $0 | |
| 3. Out-of-Network Non-Contracted Providers | | $0 | |
| 4. Total Identified Providers | $0 | $0 | ERROR:#DIV/0! |
| 5. Cannot Identify Providers | | not applicable | not applicable |
| 6. Total One-Year Cost | $1,479,924,536.98 | ERROR:#DIV/0! | |
| 7. Total Seven-Year Allowed Cost | | ERROR:#DIV/0! | |
Section 2: Questions Related to Claims Repricing Summary (NOT Included in Pricing Score)
| TABLE H - Not used for low cost determination | | | |
| 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? | | | |
| 6. Was the repricing data above signed off on by an actuary? | | | |
| Name |
| 7. If answer to question 6. is Yes, enter Actuary name | |
Tab #5 Optional Services
| Official Soliciation Price Sheet |
| S000000413 Third Party Administrator |
Section 1: Health Insurance
| TABLE I - 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 J - 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 K - Not used for low cost determination | Per Member Per Month (PMPM) Fee | X Estimated 144,000 Number of Members (100%) | x 84 months = 7-Year Estimated Cost |
| $0 | $0 |
| $0 | $0 |
| $0 | $0 |
| $0 | $0 |
| $0 | $0 |
| $0 | $0 |
| $0 | $0 |
| $0 | $0 |
Section 2: Medical Management
| Table L - Not used for low cost determination | |
| Related Services Available But Not Required in the RFP | Pricing Details |
($/PMPM, $/PEPM, $/Hour, X% of X, 1-time fee, etc.)