Post Payment Claims Review Services

The Illinois Department of Central Management Services (CMS) is soliciting proposals for post payment claims review services for four state health insurance programs: State Employees Group Insurance Program (SEGIP), Teachers' Retirement Insurance Program (TRIP), College Insurance Program (CIP), and Local Government Health Plan (LGHP). The comprehensive project requires a vendor to conduct retrospective and real-time claims audits for medical, prescription, and dental claims, with the goal of identifying fraud, waste, and abuse. The current enrollment of 183,833 members is expected to increase to 242,073 by July 1, 2025, with annual claim volumes including 8,520,938 medical claims, 2,331,382 pharmacy claims, and 1,547,870 dental claims. The evaluation process will be structured with three components: technical proposal (600 points), commitment to diversity (120 points), and pricing (300 points), totaling 1,020 possible points. Key deliverables include comprehensive data analysis, reporting capabilities, case management, compliance monitoring, and robust security features. The proposal is due by April 29, 2025, with an anticipated contract award in June 2025 and contract execution in July 2025 for an initial three-year term, with options to renew for up to two additional years.

There are no specific small business set-asides or veteran business program goals for this procurement. Current claim administrators include Aetna for medical and behavioral health services, CVS Health for pharmacy benefits, Delta Dental for dental services, and various Open Access Plan carriers. The state has implemented a unique Commitment to Diversity (C2D) evaluation process that allows vendors to earn additional points by demonstrating commitment to diversity, equity, and inclusion (DEI) across five criteria: Business Enterprise Program goal compliance, subcontracting with Women, Minorities, and Persons with Disabilities (WMD) businesses, DEI spending from gross revenue, hours promoting DEI in workplace and community, and organizational staffing diversity. Vendors are not required to be BEP-registered to participate, but must provide comprehensive documentation to receive points. Pricing will be firm, with renewal rates calculated using the lesser of 3% or the annual Consumer Price Index Inflation factor. While specific budget ranges are not explicitly stated, the extensive claim volumes and multi-year contract structure suggest a significant potential contract value for the selected vendor.