Claims Audit Services

The Texas Education Agency is requesting proposals for claims audit services for the Teachers Retirement System (TRS) under solicitation TRS000646, with proposals due July 17, 2026. The contract spans an initial three-year term from the effective date through August 31, 2029, with two optional two-year renewals available at TRS's discretion, potentially extending through August 31, 2033.

The scope encompasses comprehensive audit services for TRS-Care and TRS-ActiveCare self-funded plan options, including medical claim audits, prescription drug claim audits, pharmacy rebate audits, and clinical validation review services. The contractor must perform 100% claims analysis combined with targeted testing of high-risk claims identified by TRS, provide pre-payment and post-payment clinical validation reviews, retrieve and review medical records, manage appeals, and deliver customer service to providers. The audit schedule includes six cycles with final reports due on specified dates; liquidated damages apply for late delivery. The contractor must collaborate closely with TRS Internal Audit on methodology, fieldwork, and reporting.

The not-to-exceed contract amount is not specified in the draft documentation; it will be inserted prior to execution. TRS does not guarantee a minimum contract amount. Bidders must submit detailed cost proposals including labor rates, overhead allocations, and expenses using the provided Price Form. The contract may include set-asides for historically underutilized businesses (HUBs) or small businesses as determined by Texas procurement regulations.

The contractor must comply with HIPAA Business Associate Agreement requirements, maintain cyber liability insurance of at least $10 million in aggregate, encrypt data in transit and at rest, store and process all TRS data within the continental United States, and destroy or return data within 90 days of contract termination. Additional requirements include E-Verify employment verification, criminal background checks, debarment certification, and compliance with Texas boycott and discrimination prohibitions. Award will be based on price, qualifications, experience, and overall value to the state.