S000000413 TPA Questions and Answers.pdf

QUESTION NUMBER QUESTION SUBJECT QUESTION TEXT ANSWER TEXT

1.3.I "High Dollar Claim" requirement

Our claims administration platform has a number of edits and programs built-in that check numerous aspects of all claims filed for validity and appropriateness including member eligibility, place of service, diagnosis and treatment codes, medical policy, benefit coverage, date of service and many other edits built into the adjudication process. These processes are designed to identify claims that may require additional information or corrected information. If the Contractor conforms with the definition of high and small dollar claims and the stated requirement that medical records must be ordered and reviewed to ensure medical appropriateness, this will create a number of issues for the Plan managers, including member abrasion, potential penalties and interest, claim payment delays, and other potential compliance issues. Additionally, there would be significant costs associated with resourcing this level of record requests and review. Please confirm this is the intention of the bid requirement and how/if bidders should proceed in responding to this requirement that is currently not a part of the administration of this group's benefits.

The outcomes described in this question (member abrasion, potential penalties and interest, claim payment delays, potential compliance issues, significant costs) are not the intention of the bid requirement. The intention of the bid requirement is for the Prospective Contractor to periodically report to EBD the number of claims above a dollar threshold and periodically provide participant-level information concerning such claims. Please reference in the RFP Sections 2.14.O.2 and 2.27.M which describe the requirements for reporting.

1.3.Y "Small Dollar

Claim" requirement

Our claims administration platform has a number of edits and programs built-in that check numerous aspects of all claims filed for validity and appropriateness including member eligibility, place of service, diagnosis and treatment codes, medical policy, benefit coverage, date of service and many other edits built into the adjudication process. These processes are designed to identify claims that may require additional information or corrected information. If the Contractor conforms with the definition of high and small dollar claims and the stated requirement that medical records must be ordered and reviewed to ensure medical appropriateness, this will create a number of issues for the Plan managers, including member abrasion, potential penalties and interest, claim payment delays, and other potential compliance issues. Additionally, there would be significant costs associated with resourcing this level of record requests and review. Please confirm this is the intention of the bid requirement and how/if bidders should proceed in responding to this requirement that is currently not a part of the administration of this group's benefits.

The outcomes described in this question (member abrasion, potential penalties and interest, claim payment delays, potential compliance issues, significant costs) are not the intention of the bid requirement. The intention of the bid requirement is for the Prospective Contractor to periodically report to EBD the number of claims above a dollar threshold and periodically provide participant-level information concerning such claims. Please reference in the RFP Sections 2.14.O.2 and 2.27.M which describe the requirements for reporting.

2.7.L The Contractor shall provide subrogation/recovery services.

We understand subrogation services are an important part of plan management and we utilize third-party expertise to provide our clients with optimum recoupment results when subrogation recovery opportunities arise.

However, we do not charge a flat monthly fee on a PMPM basis simply for making this service available- we only charge our groups when a recovery is actually made. We do not charge for subrogation activities that do not result in a recovery. As such, the most economical practice for our customers is to pay a percentage of the savings associated with a recovery, when and if that is made. We will disclose this percentage in the pricing worksheet as part of our bid submission.

The Official Solicitation Price Sheet is not set up to allow for percentages. All costs must be presented as requested on the Official Solicitation Price Sheet .

2.7.X External payment integrity requirement

Upon review of any future vendor selected for payment integrity review services, as a contractor, we will collaborate with the Plan to coordinate vendor services and understand the resources required to support this work. If the resources required to support this vendor activity are beyond the operational resources we have built-in to accommodate this work, we will communicate this to the Plan in an effort to get any vendor in this space to augment their processes to achieve the required result or provide the Plan with an estimate of additional costs that may be required for a period of time to support this work.

As indicated in Section 2.7.X of the RFP, potentially working with external vendors for payment integrity is a requirement. Per the Official Solicitation Price Sheet , "The Prospective Contractor shall identify and include all costs associated with the activities and tasks that meet the requirements of the

RFP and all additional activities and tasks identified in the Prospective Contractor's proposal."

Official Solicitation Price

Sheet Tab 4

Please confirm our understanding that our response should NOT include submission of the detailed repricing claims allowance file. We are happy to submit this file for your reference in case it might be required when reviewing the aggregate summary; if so, please provide us with appropriate submission directions.

Confirmed.

Official Solicitation Price

Sheet Tab 4

Please confirm the bid requirement is that only an aggregated summary be provided based on pricing in place for provider contracts as of March/April 2025 utilizing ONLY the 2023 billed charges actually on the claim.

Confirmed.

Official Solicitation Price

Sheet Tab 4

Please confirm your recognition that utilizing 2023 billed charges with 2025 allowances (i.e. pricing) will result in incorrect discount percentages. This will occur because charge masters are generally adjusted annually so 2023 billed charges will likely be lower than 2025 billed charges, resulting in this proposed methodology creating misstated (i.e., incorrect) discount percentages. How do you plan to adjust 2023 billed charges to align with 2025 allowances to correct this misstatement? Please note, we can add comments regarding the discounts we are currently observing. Please clarify.

No adjustments will be made. The discount percentages are not determined by OSP/EBD, but rather, the Prospective Contractors are instructed to enter the Discount Percentage by category (In-

Network Providers; Out-of-Network Contracted Providers; and Out-of-Network Non-Contracted

Providers) that represents the percentage discount currently in effect (based on the Provider and service category). This discount result will be compared to the UDS actual 2022 discounts and projected 2023 discounts. Further, the Annual Allowed Charges will be calculated in the response spreadsheet applying the total discount to the billed charges. The Annual Allowed Charges will be multiplied by seven (7) (to represent the potential seven (7) years of this contract award) for the purposes of combining with the quoted administrative fees and determining the low-cost bidder in Tab

#1 Major Components.

8 Data Retention

Would vendors be permitted to retain one copy of State's data, after termination of the agreement, in accordance with applicable law (for example, AR law requires hospitals to retain medical records for 10 years after the last discharge which may require a carrier/administrator to also retain records for a similar period of time to address any issues related to a claim paid) as well as its own record retention policy?

Yes, so long as it conforms with state and federal law and regulations. And our data rentention policy.

Successful contractor will be required to provide a copy of data rentention methods and policy.

S000000413 Third Party Administrator Questions and Answers

9 Claims Files-Network

In review of your claims files released and to truly ensure limited provider disruption to your members (as referenced in 2.2.F), is it possible to get some additional field data as listed below to help ensure the highest results? If not on all providers, if we could at least get this additional data for the behavioral provider / claims.

Data elements:

1. Provider TIN

2. Provider NPI

3. Provider full name

4. Provider Address, City, State, Zip

5. Provider specialty

6. Par/Non-Par Indicator - shows whether provider is or isn't participating in the current carrier's network

1. Provider TIN - Both TIN and NPI were provided for every row

2. Provider NPI - Both TIN and NPI were provided for every row

3. Provider full name - Where available, name, and address were provided, but not all

4. Provider Address, City, State, Zip - Where available, name, and address were provided, but not all

5. Provider Specialty - Additional provider data may be provided by EBD as needed during the discussions phase

6. Par/Non-Par Indicator - This would give the Prospective Contractor the other plan network providers, so cannot be provided.

10 Interview D.1.b. There is reference to identify 1 person to attend the interview. Is it confined to 1 person or would there be allowance for 2?

The State will allow up to to two (2) people to participate in the interview phase.

11 Interview Please confirm the Predetermined questions for the meeting will be provided in advance of the physical meeting date.

Yes, confirmed.

12 EAP

The RFP states that we need to match the current EAP features that you have today. Does the State of

Arkansas have a listinig of the full complement of financial and legal features with your current provider or another resource? We are not seeing anything within the RFP documentation that allow us to get those details. If there is a listing of these services, it would be most helpful for us to have it.

Please see new Attachment H: Colonial Life LawAssure. Also please reference Attachment E: EAP

Utilization Report 2024, and Attachment F: Introduction to EAP for more details.