SMCO-TPA-RFP-APP-D-QandA-022825.xlsx
XLSX spreadsheet 366 KB Posted
- Solicitation number
- SCG03242025
- Issued by
- Teller County, Colorado
About this file
This document is a Request for Proposal (RFP) #SCG03242025 issued by Summit County Government in Colorado for Third-Party Medical Plan Administration and Solutions. The RFP seeks qualified contractors to provide comprehensive medical plan administration services, including self-funded medical plan administration, claims re-pricing, claims payment, direct contracting, network development, PPO network access, health care management, member advocacy, telemedicine, and integrated cost-saving solutions. The proposal was released on March 24, 2025, with questions due by April 11, 2025, at 3:00 PM Mountain Time, and final proposals due by May 9, 2025, at 3:00 PM Mountain Time. Bidders are required to submit questions and proposals through BidNet Direct.
The RFP includes detailed requirements for potential contractors, covering areas such as claims administration, data management, network integration, compliance with Consolidated Appropriations Act (CAA) and Transparency in Coverage rules, healthcare management, member services, and performance guarantees. The county expects vendors to provide a comprehensive solution with specific performance metrics, including 97% call answer rates, 90% clean claims processed within 20 business days, 99% claims accuracy, and system availability of 99%. The proposal requests transparent pricing information, including all revenue streams, fees, and compensation arrangements, to be presented on a per employee per month (PEPM) basis. The current plan includes a Consumer-Driven Health Plan (CDHP) with a Health Reimbursement Arrangement (HRA) and potential future plan options such as an HSA-eligible PPO.
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Cover
Request for Proposal (RFP)
RFP#: SCG03242025
Medical Plan Administration
Medical Claims Administration;
Direct Contracting Network Development and Maintenance;
PPO Network Access, Health Care Management, including:
- Prior Authorization (PA);
- Utilization Review (UR);
- Large Case Management (LCM); and
- Disease Management (DM).
Member Advocacy/Concierge Telehealth/Teledoc and Integrated Cost Savings Solutions.
Proposal Release Date: March 24, 2025 Questions Due Date: April 11, 2025; 3:00 PM MT Proposal Due Date: May 9, 2025; 3:00 PM MT Submit Questions via BidNet Direct.
https://www.bidnetdirect.com/ Sect 1-General Info
| Third Party Administrator | |||||
| Section 1 - General Info | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| General Information | |||||
| Company Name | |||||
| Years in Business | |||||
| Ownership Identification: Please describe your organization’s ownership structure, including whether it is owned by a private equity firm or part of a larger national insurance carrier. Provide details on how this ownership structure impacts your ability to make decisions that are solely in the best interest of your clients. Please include your EIN. | |||||
| Ownership Limitations: Are there any limitations or constraints imposed by your ownership structure that could influence your approach to selecting optimal products/services for the client, benefits administration, claims processing, or client service? If so, please provide specific examples. | |||||
| Future Ownership Plans: Does your owner have any plans or intentions for a sale, merger, or change in ownership of your organization within the next five years? If yes, how would such a change impact your clients? | |||||
| Growth & Business Capacity: Is your organization positioned to support growth? What is your current business capacity? | |||||
| Financial Reports and Rating: Please furnish a copy of the annual audited financial report for the company's most recent fiscal year. | |||||
| Locations of claim offices and customer service centers quoted for this client | |||||
| Are any services serviced out of off-shore locations? If yes, please indicate where and what services. | |||||
| Confirm you can administer services in all 50 states. Please indicate if clients must be domiciled in certain states. | |||||
| How many clients of similar size (450-1,000 enrolled employees) do you administer medical benefits for? Please break down count for just medical administration. |
| If selected as a finalist, please be prepared to supply 3 - 5 references of client in the public sector space of a similar size as the County. | |
| Account Support Team | |
| How would you assign an account manager to a new client of this size? Would you need to hire or does your current team have capacity? | |
| Please confirm if your organization will have assigned dedicated service members for a group this size. For example, please clarify what the service model would be with regards to: |
- Dedicated account manager/executive,
- Claims payment specialist,
- Customer/Member support,
- Escalated issues.
| What are the hours of operation for the assigned account team? Please include time zone. |
| What is the average years of employee benefits experience by Account Managers on the team? |
| Please provide the tenure and book of business for the proposed account manager. |
| Who would be responsible for implementation activities? Does the account manager run the implementation or would there be a separate implementation manager? |
| Benefits Administration (Y/N/Contracted) - Confirm if you offer and if included in your proposal: | |
| Medical (PPO/HDHP/CDHP), including multiple consumer designs | |
| Dental | |
| Vision | |
| FSA | |
| HSA | |
| LSA | |
| HRA | |
| STD | |
| LTD |
&G &"Arial,Regular"&10 200 South Wacker Drive, Chicago, IL 60606
&"-,Bold"&G Page &P of &N https://www.bidnetdirect.com/ Sect 2 - Claims Admin
| Third Party Administrator | |||||
| Section 2 - Claims Administration and Repricing | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Medical Claims Administration | |||||
| Claims Processing and Payments | |||||
| Provide an overview of your medical claims process. What makes your model unique? | |||||
| Are claims processing functions done in-house or outsourced? If direct contracts are used, does this change where claims are processed? | |||||
| If in-house what technology and software do you use for claims administration process? | |||||
| What percentage of claims were received electronically during the past 12 months? | |||||
| What percentage of electronic claims were processed and paid electronically without manual intervention? | |||||
| What is your current clean claims processing goal? | |||||
| Does this turnaround time under a direct contract network arrangement? | |||||
| Are claims handled by a specific dedicated client team? | |||||
| Supplier agrees to respond to any and all Medicare Secondary Payer Demand letters on a timely basis and to assume responsibilities for any fees, fines, assessments, interest, or taxes levied by the federal government for failure to do so. | |||||
| Confirm and acknowledge compliance with all appropriate Medicare laws and rules related to the correct processing order of claims. All costs associated to Medicare compliance must be disclosed in the cost section of your proposal. | |||||
| Will you agree to be a named fiduciary on behalf of the plan? If so, is there a cost associated with this? Please include any additional cost in the cost section of your proposal. | |||||
| Service agreements and contract must include a runoff claim period of 12 months following termination of any contract resulting from this RFP. Any additional fees for processing these runoff claims must be provided with your response in the cost section of your proposal. | |||||
| Stop Loss Administration | |||||
| Who are your approved (preferred) /currently engaged stop loss carriers? | |||||
| Are there additional fees for using non-preferred stop loss carriers? If yes, please clearly outline in your cost proposal. | |||||
| Is your stop loss reporting automated? | |||||
| Is your stop loss reporting integrated with carve-out Rx? | |||||
| How often are spec reports sent? What is the trigger? Can you report at 50% of spec? | |||||
| Do you provide trigger diagnosis reporting? How often? | |||||
| Are stop loss reimbursements reflected in your utilization reporting? If so, how are they reflected? Please provide highlighted sample. | |||||
| How are reimbursements handled for your clients? Direct to the client, or via your office? | |||||
| Claims Re-pricing | |||||
| What specific services will you provide as part of the claims repricing process? | |||||
| How do you handle claims denials and appeals? | |||||
| What is your process for identifying and correcting coding errors? | |||||
| Can you provide a detailed workflow of your claims repricing process? | |||||
| What technology and software do you use for claims repricing? | |||||
| How do you ensure compliance with relevant regulations and industry standards? | |||||
| What reporting capabilities do you offer to track and analyze repriced claims? | |||||
| How do you integrate with existing systems and workflows? | |||||
| What is your experience with medical claims repricing? | |||||
| Can you provide references from previous clients who have used your services for claims repricing? |
https://www.bidnetdirect.com/ Sect 3 -Banking and Billing
| Third Party Administrator | |||||
| Section 3 - Banking and Billing | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Financial | |||||
| Billing Method | |||||
| The County prefers to self-bill for TPA fees. Payment would be remitted for the prior month’s services within thirty (30) days of month end. | |||||
| For claims payments, the County will be invoiced weekly for claims processed and paid by the TPA. The County Treasurer only allows for ACH pushes. Claims submittals received by Tuesday of each week will be funded each Thursday. Claims submittals received after Tuesday, will be funded the following week. | |||||
| It is expected the supplier will continue to follow these guidelines. | |||||
| Banking | |||||
| Following the billing guidelines and banking procedures described above, it is expected that the selected supplies will eliminate or mitigate any upfront deposit or reserve requirements. Will you agree to this arrangement? | |||||
| Is the supplier able to make direct payments to both participant/contracted network providers and members with manual claims submissions? | |||||
| Please describe your recovery process for overpayments. | |||||
| Can you manage the client's account reconciliation? | |||||
| Can you hold / manage client's health benefits checking account if requested? |
https://www.bidnetdirect.com/ Sect 4 - Data Management
| Third Party Administrator | |||||
| Section 4 - Data Management | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Data Management | |||||
| HR Administration | |||||
| Describe your web-based administrative capabilities. | |||||
| Can authorized County personnel access claims details and information, including individual EOB online to assist their employees? | |||||
| It there an associated cost to setting up online access? | |||||
| Enrollment Data Transfer | |||||
| Do you work with BenTek? Do you have prebuilt integration in place? | |||||
| Do you provide consolidated eligibility for medical and ancillary programs (e.g., file includes all employees not just those enrolled in medical to a wellness vendor)? Please describe your timing and output files for transmission of eligibility data, both new client and ongoing. | |||||
| Employer requires TPA to provide eligibility and claim files to third party partners. These partners include companies such as, PBM, telehealth, price transparency vendors, and other various health management organizations, etc. | |||||
| Do you provide consolidated billing for ancillary programs? Does this include line by line application of cost by employee? Please describe your payment procedures to ancillary partners. | |||||
| Plan Members Portal | |||||
| Please describe any online tools available for plan members, including claims lookup, EOBs, etc. | |||||
| Please confirm compliance with machine readable files, publicly accessible provider directory, and cost estimator tools. Please confirm if additional fees are required for these services. | |||||
| Experience and Claims Reporting | |||||
| What reporting capabilities do you offer to track and analyze claims? | |||||
| Can you provide data to a data warehouse? What would be estimated fees to integrate with a third party data warehouse? | |||||
| How often can you push claims files to a third party data warehouse? | |||||
| Do you have any restrictions on data sharing from your network partners? | |||||
| Is your online/mobile app a real time connection to your administration system? | |||||
| All reports should be available electronically online in an in an excel format. | |||||
| Is the County's claims data available online through a system that will allow the user the ability to drill down into the details, and change the view from a paid basis to an incurred basis, all at no additional charge to the County or their authorized representatives? | |||||
| Supplier agrees to provide, at a minimum, to the County and any authorized third party claims reports on a monthly basis that include: |
- Dollars by type of claim paid (Medical, Rx, Dental, etc.)
- Details on large claims (over $25,000); and
- Number of covered employees, spouses, and dependents each month by group number or plan design.
On a quarterly basis:
- Claims Lag Triangle
| Data Management and Retention | |
| Does the service provider have a comprehensive and understandable cybersecurity program? | |
| What are the elements of the service provider’s cybersecurity program? | |
| How will the plan’s data be maintained and protected? | |
| Will the data be encrypted at rest, in transit, and on devices, and is the encryption automated rather than manual? | |
| Will the service provider assume liability for breaches? | |
| What are the protocols for detecting and responding to a data breach? | |
| How often are security audits conducted, and can we review the results? | |
| What measures are in place to ensure that subcontractors also follow stringent security protocols? | |
| How is participant data monitored for suspicious activity, and what steps are taken if suspicious activity is detected? | |
| What is the communication plan for notifying plan sponsors and participants in the event of a breach? | |
| Will the service provider assume liability for breaches? | |
| What are the protocols for detecting and responding to a data breach? | |
| How often are security audits conducted, and can we review the results? | |
| What measures are in place to ensure that subcontractors also follow stringent security protocols? | |
| How is participant data monitored for suspicious activity, and what steps are taken if suspicious activity is detected? | |
| What is the communication plan for notifying plan sponsors and participants in the event of a breach? | |
| Please provide copies of the following: | |
| Please provide the following reports: | |
| SOC 2 Type 2 report. If the SOC2-2 report is over a year old, please provide a bridge letter. | |
| HITRUST certification & corresponding assessment summary where the assessment was completed by third-party auditor. | |
| Consensus Assessment Initiative Questionnaire (CAIQ) or Cloud Controls Matrix (CCM), if available | |
| If your organization does not hold two or more of the above items, are you working towards obtaining, if not please explain. |
https://www.bidnetdirect.com/ Sect 5 - Network & Integration
| Third Party Administrator | |||||
| Section 5 - Network and Vendor Integration | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Network and Vendor Integration | |||||
| Network Associations and Third-Party Integration | |||||
| Please list your PPO network partners and any other provider relationships you have established in the communities where County employees are located. | |||||
| Can you administer custom/employer direct networks? (e.g., custom physician network in a specific geographic area, carve out networks for fertility, bariatric surgery, etc.) | |||||
| On average how long does it take to build a custom network? In the County's scenario approximately 120-140 contracts. | |||||
| If acting as the TPA, will you permit layering of custom networks with your PPO network partners? For example, client specific local network of doctors/facilities, musculoskeletal network, wrapped with a national network (assuming approval is received from the network). | |||||
| If acting as the TPA, will you allow the direct contract network to receive all of the claims for repricing as an alternative you sending claims directly to the the different PPO networks that the client selects as their wrap-around network? | |||||
| Have you worked with any point of service or bundled service partners? Explain how you integrated their payment data into the system for stop loss filing and utilization reporting. | |||||
| Per the CAA requirements, are you integrated with any third-party cost/quality provider finder? Can this be integrated with your networks to meet the CAA requirements? | |||||
| Can you build plans that offer reduced deductibles/incentives for using a high-quality provider? OR can you administer a plan that has a tiered benefit plan, such as tier 1 best benefits/best discounts, etc. - each would be subject to a separate deductible and out-of-pocket and needs to be able to accommodate separate accumulators? | |||||
| Do you support Reference Based Reimbursement/Pricing programs? Are your member services representatives fluent in this design to help navigate members and providers through the model? | |||||
| Can you administer a custom incentive networks that are based on outcomes (e.g., musculoskeletal, maternity, etc.). | |||||
| Do you allow for certain J-Codes to be processed through a carve-out PBM? | |||||
| Using the employee census, provide a geo access report for you PPO network and/or PPO network affiliate. Please include 2 providers within a 25 mile radius. | |||||
| Please confirm how you contain member service disruption, while building a custom network? | |||||
| Vendor Integration | |||||
| What custom solution or options are included in your standard network fees? | |||||
| Can you integrate (systems, claims and reporting) with the following type of vendor carve outs: prescription drug, stop loss, specialty drug carve-out, diabetes, maternity, organ transplant, onsite employer-owned clinic, bariatric surgery, cancer, etc. | |||||
| Can you administer a customized program for select services that include bundled payment, outside UM partner integration and a food/travel benefit? | |||||
| Can you provide claims data to a third party price transparency program that the County selects? | |||||
| Can you support real-time data sharing to and from the carve-out Rx vendor? | |||||
| Do you have any limitations or fees associated with these carve-out solutions? The expectation is that you would integrate these carve-out from a claims and reporting basis. | |||||
| Is there a limit to the number of vendor integrations included in standard fees? If yes, please outline. | |||||
| Are there any restrictions to vendor carve outs (e.g., areas that you cannot carve-out to a third party vendor such as utilization management)? | |||||
| Strategies and Approach | |||||
| What strategies do you recommend for optimizing provider access while balancing cost control, employee choice, and ease of administration? | |||||
| How would you structure a provider network solution to simplify the employee experience while maintaining or improving access to high-quality care? | |||||
| What steps can be taken to reduce administrative complexity for both the plan sponsor and employees while ensuring a competitive provider network and cost savings? | |||||
| How do you recommend structuring Reference Based Pricing to ensure a smooth member experience, provider acceptance, and optimal cost savings? | |||||
| What is your approach to pricing transparency for network access and Reference Based Pricing services? Please detail how your fee structure ensures predictability for the plan sponsor and avoids incentives that may drive up costs over time. |
https://www.bidnetdirect.com/ Sect - 6 NSA and CAA
| Third Party Administrator | ||||
| Section 6 - Transparency in Coverage | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | |||
| Rule | Requirement of the Rule | Response | ||
| (note if additional fee applies) | Additional Notes | Document Reference | ||
| Transparency in Coverage Rules | ||||
| External Disclosure | ||||
| Requires carriers and group health plans to post 3 machine readable files: |
(1) all in-network rates for covered items and services;
(2) out-of-network allowed amounts and billed charges for covered items and services;
(3) all in-network negotiated rates and historical prices for prescription drugs. Information must be updated monthly and made publicly available on an insurer’s or plan’s website free of charge, without having to log-in or otherwise submit identifying information.
July 1, 2022 currently enforce for items (1) & (2). Item (3) prescription drug component delayed pending further rulemaking.
| How do you plan to help the County meet this requirement? | |
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |
| Will you charge additional fees to help meet this requirement? If so, how much? | |
| Internal Price Comparison Tool (note that the CAA contained a similar requirement that is considered duplicative so will be encompassed by Final Rule requirements). | |
| Requires carriers and group health plans to make price comparison information available to participants. Which allows users to search based on specific criteria through an internet based real-time self-service tool and to provide paper copies upon request and free of charge. Content that must be disclosed upon request: |
(1) estimated cost share liability;
(2) accumulated amounts;
(3) in-network rates;
(4) out-of-network allowed amounts;
(5) items and services content list for a bundled payment;
(6) notice of any prerequisites to coverage; and
(7) disclosure notice.
| Compliance began for plan years beginning on or after January 1, 2024. | |||
| How do you plan to help the County meet this requirement? | |||
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |||
| Will you charge additional fees to help meet this requirement? If so, how much? | |||
| Rule | Requirement of the Rule | Response | |
| (note if additional fee applies) | Additional Notes | Document Reference | |
| Consolidated Appropriations Act of 2021 | |||
| Plan Identification Cards | |||
| Requires carriers and group health plans to include in clear writing, on any physical or electronic plan or ID card issued to participants, any applicable deductibles, any applicable out-of-pocket maximum limitations, and a telephone number and website address for individuals to seek consumer assistance. |
| For plan years beginning on or after January 1, 2022. | |
| How do/will you plan to help employers meet this requirement? | |
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |
| Will you charge additional fees to help meet this requirement? If so, how much? | |
| Advanced Explanation of Benefits | |
| Requires carriers and group health plans, upon receiving a good faith estimate” regarding an item or service, to send a participant, (through mail or electronic means, as requested by the participant, beneficiary, or enrollee) an Advanced Explanation of Benefits notification in clear and understandable language containing the content required by the CAA. Must be provided within 1 business day of request or 3 business days if a service is scheduled at least 10 business days out. |
| Delayed pending further rulemaking. | |
| If or when enacted how do you plan to help employers meet this requirement? | |
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |
| Will you charge additional fees to help meet this requirement? If so, how much? | |
| Prohibition on Gag Clauses on Price and |
Quality Data
| Prohibits carriers and group health plans from entering into a agreement with a provider, network or association of providers, TPA, or other service provider offering access to a network of providers that would directly or indirectly restrict the plan or issuer from providing provider-specific cost or quality of care information, electronic access to de-identified claims and encounter information for enrollees in a plan, or sharing of the above information/data with business associates in accordance with HIPAA standards. Requires annual compliance attestation to DOL. | |
| Became effective December 27, 2020 with the first attestation due December 31, 2023. Subsequent attestation due annually by December 31. | |
| How do/will you plan to help employers meet this requirement? | |
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |
| Will you charge additional fees to help meet this requirement? If so, how much? | |
| Protecting Patients and Improving the Accuracy of Provider Directory Information. | |
| Requires insurers and group health plans to publish on a public website a provider directory that is updated at least every 90 days and the database must also be updated within two (2) business days of receiving new or revised information from a provider. |
Requires a respond to participant inquiries within one business day.
Insurers and group health plans must also provide information about the federal and applicable state law prohibitions and rules on balance billing, as well as contact information for appropriate state and federal agencies to report any issues.
If an individual receives an item or service by a nonparticipating provider or at a nonparticipating facility, and was provided inaccurate information via the provider directory, the plan must cover the service at the in-network rate.
Printed directories must be dated and refer to the website for more current information.
All versions of the directory must include:
Names, addresses, specialty, telephone numbers, and digital contact information of individual health care providers; and
Names, addresses, telephone numbers, and digital contact information of each medical group, clinic, or health care facility contracted to participate in any of the networks of the group health plan or health insurance coverage involved
| Plan years beginning on or after January 1, 2022. Plans and issuers are expected to implement these provisions using a good faith, reasonable interpretation of the statute. | |
| How do/will you plan to help employers meet this requirement? | |
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |
| Will you charge additional fees to help meet this requirement? If so, how much? | |
| Continuity of Care | |
| Requires insurers and group health plans to provide notice of the right to continuing care and to provide such care to continuing care patients (as defined by the CAA) when treatment is disrupted as a result of contractual changes that impact participant access to or payment for certain providers and facilities. |
On request, the plan must permit continued care under the same terms and conditions as would have applied had the changes to the plan’s network not occurred through the earlier of 90 days beginning on the date the required notice was provided or until the individual is no longer a continuing care patient.
| Plan years beginning on or after January 1, 2022. Plans and issuers are expected to implement these provisions using a good faith, reasonable interpretation of the statute. | |
| How do/will you plan to help employers meet this requirement? | |
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |
| Will you charge additional fees to help meet this requirement? If so, how much? | |
| Pharmacy and Healthcare Cost Reporting | |
| Requires insurers and group health plans to submit detailed data on their plans prescription drug benefits and healthcare spending. It is expected that carriers and TPAs will report of behalf of the group health plans, but with an understanding that the group may need to submit limited additional data directly to CMS. | |
| Effective December 27, 2021 with first reporting due December 27, 2002 for 2021 and 2022 plan years then annually thereafter by June 1. | |
| How do/will you plan to help employers meet this requirement? | |
| How will you help the County meet this requirement in regards to a direct contracted network arrangement? | |
| Will you charge additional fees to help meet this requirement? If so, how much? |
https://www.bidnetdirect.com/ Sect 7 - Health Care Manag
| Third Party Administrator | |||||
| Section 7 - Health Care Management | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Health Care Management | |||||
| Please identify all products for which you are providing a quote: |
- Pre-certification/Prior Authorization
- Utilization review
- Disease management
- other care management, such are maternity.
| Please describe your pre-authorization and case management programs. Are they in-house or outsourced? | |
| What is the average turnaround time of a standard prior authorization. | |
| Please describe your triggers for case management. | |
| Do you have medical directors on staff? | |
| Do you have behavioral health resources involved in medical management? Describe how you use these resources. | |
| Please describe how you train and incorporate information on specific disease state point solution partners. | |
| Are you integrated with any third-party cost/quality provider finder? Can this be integrated with your networks to show in-network status of the provider? | |
| Can you build plans that offer reduced deductibles/incentives for using a high quality provider? | |
| Do you support Reference Based Reimbursement/Pricing programs? Are your member services representatives fluent in this design to help navigate members and providers through the model? | |
| Can your team direct to tier 1 or best discount providers? Assuming appropriate provider look up is provided. | |
| Does your prior authorization team only approve for medical necessity based on if the service is covered? Please explain your process. | |
| Will quarterly reports be provided to the County illustrating the cost of each programs and the savings generated? | |
| Strategies and Approach | |
| How does your care management approach integrate with local hospital systems to improve care coordination, patient outcomes, and cost efficiency? | |
| How do your population health and care management programs leverage hospital system partnerships to proactively manage high-risk members and reduce avoidable hospital utilization? | |
| Do you have other care management recommendations the County should consider? |
https://www.bidnetdirect.com/ Sect 8 - Member Services
| Third Party Administrator | |||||
| Section 8 - Member Experience | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Member Services | |||||
| Member Experience | |||||
| Does your team operate in pods by client, or do all staff work on all clients? | |||||
| Do you assign each customer a specific toll-free phone number? | |||||
| How would you staff a customer of this size? | |||||
| What are the service hours of the customer service staff? Please include time zone. | |||||
| Do you offer electronic customer service support? Email? Chat? Text? App/Web based communication? Please describe. | |||||
| How does your customer service team educate and guide members toward high-value, in-network providers and cost-effective care options? | |||||
| Do your customer service representatives provide episodic resolution? For example, a member undergoing significant treatment has many bills with potential errors - will your team assist member in organizing and handling billing errors with providers office? | |||||
| Do your customer service representatives have the ability to adjust claims or are they routed to another department? | |||||
| Do you offer any form of consolidated medical billing for members, or medical bill finance options? If so, please describe the service and any associated costs. | |||||
| Do you have the ability to allow single sign on to your member website/app via another member site? (i.e., a member website built by the client or Alliant, single sign on entry to your site). | |||||
| Are you able to integrate with a third-party concierge service on behalf of a member. Do you charge additional fees for this type of integration/coordination of member services? | |||||
| What processes do you have in place to ensure a smooth experience for members using Reference Based Pricing, including provider outreach and balance billing prevention? | |||||
| How do you measure member satisfaction? | |||||
| Member Advocacy | |||||
| Does your organization provide patient support tools, such as find a doctor, schedule appointments, obtain a second opinion, research treatment options? | |||||
| Does your organization provide patient financial tools, such as resolve insurance claims, correct provider billing mistakes, Medicare issues, provider negotiations for non-insurance covered services. | |||||
| If a member receives a balance bill, what steps does your customer service team take to resolve the issue, and how do you protect the member from financial liability? | |||||
| Recommendations or Differentiators | |||||
| Do you have any other recommendations on supporting the member experience? | |||||
| Are there any other differentiators that you'd like the County to be aware of? |
https://www.bidnetdirect.com/ Sect 9 - Compliance & Comm
| Third Party Administrator | |||||
| Section 9 - Compliance & Communication | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Compliance and Communications | |||||
| Compliance | |||||
| Do you monitor and provide ongoing compliance updates to your clients? | |||||
| Do you provide your clients with compliance advice when implementing and developing programs? It is understood that clients will rely on their legal Counsel for all final decisions. | |||||
| Do you draft SPD's & SBC's as well as make recommendations for updates on an ongoing basis? | |||||
| Are SPDs/SBCs drafted in-house or by an outside vendor? | |||||
| Do you have fees for SPD/SBC and amendment drafting? | |||||
| Please provide a complete outline of your appeals process, including steps, committees and timeline (clinical and non-clinical appeals). | |||||
| Please confirm how your organization supports the following compliance requirements, Gag Clause, RxDC reporting, and other Transparency in Coverage regulations. | |||||
| Supplier agrees to respond to any and all Medicare Secondary Payer Demand letters on a timely basis and to assume responsibilities for any fees, fines, assessments, interest, or taxes levied by the federal government for failure to do so. | |||||
| Confirm and acknowledge compliance with all appropriate Medicare laws and rules related to the correct processing order of claims. All costs associated to Medicare compliance must be disclosed in the cost section of your proposal. | |||||
| Will your organization assist with NQTL testing or make recommendation to help ensure compliance? | |||||
| Communications | |||||
| Provide sample employee communications included in your fees. Does this include communication of plan changes each year? | |||||
| What level of customization is provided at no additional charge? |
https://www.bidnetdirect.com/ Sect 10 -Performance Guarantees
| Third Party Administrator | |||||
| Section 10 - Performance Guarantees | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | Additional Notes | Document Reference | |||
| Performance Guarantees | |||||
| The County has established a minimum set of performance guarantees and expects the Bidder to meet or exceed these standards. Please confirm your willingness to accept these performance standards and the associate fees and penalties. For clarification, all associated fees and penalties will be payable to The Summit County Benefit Plan ("The Plan"), as maintained by Summit County Government, Colorado. If you are not able to perform at the outlined level, please suggest alternative measurement of success. | |||||
| Member Services | |||||
| Bidder agrees to answer member calls with 30 seconds; with a monthly targeted answer rate of 97%. Failure to maintain the 97% answer rate will result in a $1,000 penalty each month the metric falls below 97%. | |||||
| Claims Adjudication | |||||
| Bidder agrees to adhere to the agreed-upon discounts and pricing arrangements outlined in any resulting contract. Failure to adhere to these will result in Bidder being responsible and liable for reimbursement to The Plan all dollars spent that exceed the agreement plus an additional 10% penalty of all excess dollars spent by The Plan. | |||||
| Bidder agree to a clean claim turnaround metric of 90% paid within 20 business days. Failure to maintain the outlined clean claim turnaround time, measured monthly, will result in in a penalty of $2,500 for each month this metric falls below 90% paid within 20 business days payable to The Plan. | |||||
| Bidder agrees to maintain a claims accuracy rate of at least 99% as measured by a random sample of at least 300 claims processed per quarter. Failure to maintain at least a 99% accuracy rate will result in the Bidder paying The Plan a penalty of $2,500 per percentage point or any fraction thereof that exceeds the allowable 1% error rate. | |||||
| Bidder’s system must be available at least 99% of time, based on a monthly review. Failure to meet this availability will be subject to a financial penalty of 10% of the administrative fees for each month that the standard is not met, subject to minimum penalty of $1,000 payable to The Plan, regardless of administrative fees or charges (even $0.00 admin arrangements). For purposes of this performance guarantee, downtime is any time a point-of-sale (POS) submitted claim by a provider is transmitted to the Bidder and cannot be electronically adjudicated by the system for any reason other than a scheduled maintenance downtime for which the County has received prior notice (notice is required at least 72 hours in advance of all scheduled downtimes that occur outside of the agreed upon scheduled maintenance). | |||||
| Problem Resolution | |||||
| Bidder will have available personnel to accurately respond to and assist the County administration within 1 business day (24 hours) of the County reaching out to Bidder either telephonically or via e-mail. (hours between 5:00pm Friday evening through 8:00am Monday morning, Mountain Time, are not included, nor are Federally recognized holidays). Failure to maintain this availability will result in a financial penalty of $1,000 per occurrence, payable to The Plan. | |||||
| Bidder agrees to resolve any problems or concerns voiced by the County within 24 hours. If resolution cannot be achieved in 24 hours, Bidder agrees to provide regular status updates, including an estimated timeline for resolution. Regular status updates will be provided by e-mail each Friday until the problem has been fully resolved. Failure to maintain this ongoing problem resolution communication will result in a $1,000 penalty for each occurrence, payable to The Plan. | |||||
| Reporting | |||||
| Bidder agrees that standard monthly reporting will be delivered and/or electronically available by the 15th of the following month. Delayed delivery/availability will result in a $1,000 penalty per occurrence, payable to The Plan. | |||||
| Client Satisfaction | |||||
| Bidder agrees to submit a quarterly client satisfaction survey. Failure to maintain a client satisfaction score of 8.5 or higher (based on a scale of 1 - 10) will result in quarterly financial penalty of 5% of the quarterly administrative fee for each 0.5 increment that falls below 8.5, subject to a minimum penalty of $2,000, payable to The Plan. |
https://www.bidnetdirect.com/ Sect 11 - Implementation
| Third Party Administrator | |||||
| Section 11 - Implementation | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT | ||||
| Response | |||||
| (note if additional fee applies) | Additional Notes | Document Reference | |||
| Implementation | |||||
| Provide a sample implementation timeline and information request. | |||||
| Please describe you implementations team and related duties. | |||||
| Describe your plan review process for benefit implementation. | |||||
| Describe and provide samples of your identification card welcome kit. | |||||
| Provide an overview of your transition of care program/protocol/outreach. |
https://www.bidnetdirect.com/ Sect 12 - Pricing & Fees
| Third Party Administrator | |
| Section 12 - Pricing and Fees | Submit all question via BidNet Direct by April 11, 3:00 p.m. MST/MDT |
| Medical Claims Administration Fees | ||||
| Please provide a detailed breakdown of all revenue streams associated with your administration of the health plan, including, but not limited to: | ||||
| Any compensation received from PBM arrangements, including rebates, spread pricing, or administrative fees. | ||||
| Any commissions, overrides, or revenue-sharing from stop-loss placement. | ||||
| Any fees, markups, or retained savings tied to provider network discounts, claims repricing, or Reference Based Pricing savings | ||||
| Cost should be presented as a Per Employee Per Month (PEPM) or clearly state fee type (e.g. annual, one-time, per case, etc.) | ||||
| Add rows as needed, to the bottom of the existing list. | ||||
| Stand-Alone | Discount Bundled | Included in core fee or additional cost? | Notes | |
| Setup Fees | ||||
| Implementation |
| Programs & Services |
| Medical Administration Fee |
| Access Fee - Direct Contracted Provider Network |
| Access Fee - Provider Network |
| Access Fee - any other specialty |
| Appeals - 1st/2nd level |
| Appeals - Independent Review Organization (IRO) |
| Any fee associated with an accountable care type arrangement |
| Stop Loss Interface / Coordination - Non-preferred vendor |
| Stop Loss Interface / Coordination - Preferred vendor |
| Claims Audit by Client or Third Party |
| Acting as Claims Fiduciary |
| Claims Run In |
| Claims Run Out, full 12 months, fee MUST be disclosed |
| Coordination of Benefits |
| Deductible / Out-of-Pocket Integration (Medical & Rx) - In-house |
| Deductible / Out-of-Pocket Integration (Medical & Rx) - Carveout PBM |
| ID Cards - Customized |
| ID Cards - Standard (CAA Compliant) |
| Medicare Part D - Letters |
| Member Website - Standard |
| EDI - Enrollment Feeds |
| Claims and Enrollment - Standard Reporting |
| Claims and Enrollment - Ad-hoc Reporting |
| Claims and Enrollment - Feeds to third party for eligibility and/or data analytics |
| EOB File feed to third party for HSA/FSA administration |
| Summary Plan Documents (SPD) |
| SPD Amendments |
| Preparation of SMM |
| Summary of Benefits and Coverage (SBC) |
| Transparency Tool (cost tool estimators TiC compliant) |
| Health Care Management |
| 24/7 Nurse Line |
| Admission & Concurrent Review |
| Care Management |
| Disease Management |
| Asthma |
| Diabetes |
| Congestive Heart Failure (CHF) |
| Coronary Artery Disease (CAD) |
| Chronic Obstructive Pulmonary Disorder (COPD) |
| Hypertension |
| Cholesterol |
| Smoking Cessation |
| Pain Management |
| Large Case Management |
| Post Admission & Discharge Planning |
| Utilization Review |
| Health Care Solutions/Integrations (Third Party or In-house) |
| Maternity Program |
| Infusion Care Solutions |
| Specialty Drug Carve-outs |
| Dialysis Programs/Preferred Networks |
| Centers of Excellence/Medical Tourism |
| Digital/Virtual Physical Therapies |
| Infertility / Family Planning |
| Diabetes Management (Devices, Coaching, Nutrition, etc.) |
| Weight Management (Medications, Nutrition, Coaching, etc.) |
| Cost Containment Services |
| Fraud, Waste and Abuse Review |
| Secondary Network Administration |
| Large Bill Review - Hospital/ Vendor Recoveries |
| Subrogation/ Other Party Liabilities |
| Post-payment Claims Review Audit |
| Optional Programs |
| EAP Program |
| Telehealth Services |
| Member Advocacy/Concierge |
| Health & Wellness Program |
| Biometric Screenings |
| On-site Flu-Shoot Clinics |
| Health Coach |
| Health Risk Assessments |
| Other Items of Importance |
| Is there a limit of vendor integrations included in your fees? Are there extra fees for vendor integrations? |
| Please provide any caveats that impact your pricing. |
https://www.bidnetdirect.com/ Sect 13 - Claims reprice
| Third Party Administrator |
| Section 13 - Re-pricing and Provider Disruption |
| Claims Re-pricing |
| Appendix E, includes billed charges for incurred claims. The County requests that the contractor re-price these claims and provide their ALLOWED AMOUNT based on the same facilities, providers, and dates of service as shown in the file. Include a MS Excel copy of the re-priced claims as a separate attachment. |
| Using the re-priced allowed amounts, show the “in-network” total, “out-of-network total” and the combined total in the following categories. If quoting more than one network option provide the same detail for each network: |
| A. Hospital Inpatient; |
| B. Outpatient Facilities; |
| C. Professional Charges; |
| D. Other; and |
| E. TOTAL |
| Response must include the number of claims actually used for the study, the billed amount processed in the study, and the Allowed Amount calculated as requested. |
| The bidder agrees to use the same discount/payment arrangement that will be provided to the County if selected as the claims payer. |
| The bidder shall also provide the top 10 providers based on dollar amount billed in a list and confirm if they are participating providers in the network being offered by the supplier. |
| Using the paid claims data, please provide a standard provider disruption report for your proposed network(s). |
| Using the paid claims data, please provide a top hospitals disruption report for your proposed network(s). |
Current Plans
| Below reflects and exerpt form the current SPD. It has been blinded to maintain confidentiality | |
| Plans: | |
| Medical Plan | |
| Prescription Drugs administered via carve-out carrier, MedTrak | |
| Medical Clinic - Administered by the client | |
| Dental - Administered by DeltaDental | |
| Vision - Administered by VSP | |
| EAP - Administered by Magellan | |
| Current Medical Networks: | |
| Cigna PPO/Choice Fund | |
| Blue Cross/Blue Shield for some regions | |
| Cobra - Administered by TPA (included in this quote) | |
| NEED TO ADD FSA FROM OTHER SPD | |
| The assests of the Plan are not held in a trust, and are not funded by a trust. | |
| HRA Plan Design: | |
| The currnet 2019, medical plan is a CDHP with an HRA. HRA amounts are awarded based on enrollment tier as well as participation in the wellness program. Moving into 2020, it is likely that there will be more than one plan offered, and potentially and HSA eligible PPO. | |
| HRA is pro-rated for mid-year new entrants to the Plan. If the subscriber elects to cease participation, all HRA dollars are forfeited. Partciipatns are allowed to file claims against their HRA for 90 days from the date their coverage ended. If a subscriber chagnes their states to a Covered Depended, the Subscriber will not recieve any new HRA allocations but may continue to have access to thee balance of their prior HRA, provided tha tthe individual remains continually Covered by the Plan and they provide the proper notification to the employer of their change in status. | |
| The HRA may only be used for Qualified Medical Expenses for the Subscriber and their Covered Dependents. | |
| Not all IRS Qualified Medical Expenses are Covered expenses under the Plan. Only Covered expenses are applied towards the Deductible and Cost Share. Expenses not Covered can be deducted from the HRA, but are not eligible to be applied towards the Deductible or Annual Maximum. | |
| If Subscribers do not use the full amount of their HRA in a Plan Year, the remaining amount will be rolled over and used the next Plan Year. | |
| HRA Opt Out Auto-Pay | |
| The Plan has enabled an auto-pay feature that automatically pays Participant deductible and cost-share portions to the Provider for Covered Services from the Subscriber's HRA account. This feature can be shut off if the Subscriber completes the HRA opt out form located on the Employer portal. If auto-pay is shut off, the Participant is required to submit eligible expenses for reimbursement. The Subscriber can opt back into Auto-Pay at any time by completing the form located on the Employer's portal. | |
| HRA Opt Out Plan Allocation | |
| Benefits provided by an HRA constitutes minimum essential coverage and may preclude an individual from receiving tax credits or subsidies if enrolling in a public Healthcare Marketplace. Employees may choose to opt out of receiving the HRA allocation each year and, upon termination of employment, may permanently opt out of and waive future reimbursements from the HRA. To opt out of the HRA allocation, please contact the Service Center to complete the appropriate documentation. By opting out, you will be opting out of the following: 1. Annual HRA funding, 2. HRA funding through the wellness program | |
| Rx Couponing: | |
| If a participant chooses to use a coupon or simlar cost-reduction program available for the payment of certain presrcrtpion medicaltions (such as through a pharmacy or pharmaceyutical company), the amount o fthe coupon (or similar offering) which is not actually paid by the Participant is not counted toward a Participant's Deductible, Cost Share or Annual MAximum resonsibilities. | |
| Eligibility | |
| All employees working a standard 20 hours per week or more. | |
| In addition, all employees classified as "Senior Advisors" who meet the following requirements at the time of enrollment are eligible: | |
| 1. Must be approved for a Special Employment Agreement | |
| 2. Must perform 60 hours per quarter of work activities, or if the employee holds the title of Founder Emeritus, the employee must perform 20 hours or more of work activities per quarter; and | |
| 3. Must have a minimum of 3 years of continuous service with the employer or a Predecessor Employer, and be 50 years of age or older. | |
| Dependent Eligibility | |
| Eligible dependents are: | |
| 1. A Spouse, unless separated by a judicial decree of legal separation. For purposes of this Plan, a Spouse means a husband or wife as defined or recognized under state law for the purposes of marriage in the state where the marriage was celebrated and common law marriage as recognized in the state where the employee resides. | |
| 2. A Child means either of the following: | |
| a. A child that meets the definition of a "��qualifying child" under Code Section 152, as modified by Code Section 105(b). Notwithstanding the foregoing, Child includes the Employee's biological child, stepchild, adopted child, or foster child who has not yet attained age 26. | |
| b. A child for whom the Employee is the court appointed legal guardian. | |
| If the Child is permanently and totally disabled, he or she may be Covered under the Plan regardless of his or her age. The Employee must provide substantiation from the individual's physician of the individual's permanent and total disability. Such substantiation must be provided within 31 days of the individual's enrollment or disability, whichever is later. | |
| 3. A "��Domestic Partner" For benefits eligibility, Domestic Partners are persons who have a registered domestic partnership in any State or local municipality. Domestic Partners are subject to the same enrollment rules as other Dependents. | |
| Once Covered, Domestic Partners (and their enrolled Dependents) receive equivalent benefits as Spouses (and their enrolled Dependents), including continuation of coverage through COBRA and/or individual conversion. | |
| 4. The children of a Covered Domestic Partner. Children of a Covered Domestic Partner are also eligible to be Covered under the same Plan and terms as the Domestic Partner so long as the child has not yet attained age 26. | |
| 5. A child named as an alternate recipient under a state domestic relations order, or who is the subject of a court or administrative order seeking to enforce a law relating to medical child support, which order is determined by the Plan Administrator to be a "qualified medical child support order" (as defined in Section 609 of ERISA). |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .