RFP-270-20250414MCA, Medical Claims Audit-Operation Services

The North Carolina State Health Plan for Teachers and State Employees is soliciting proposals for comprehensive medical claims audit services through RFP-270-20250414MCA. The procurement seeks qualified vendors to conduct three types of medical claims audits: Standard, Focused, and Additional Medical Claims Audits for their approximately 578,000 self-funded members. The contract will have an initial term of forty months, spanning from September 2, 2025 to December 31, 2028, with services commencing January 1, 2026, and options for two additional one-year renewal terms through December 31, 2030. Vendors must perform quarterly Standard Audits of 250 stratified claims and Focused Audits of 750 targeted claims, with key objectives including measuring claims accuracy, ensuring proper claims processing, and identifying potential errors or improper payments. The evaluation criteria will follow a 50/50 split between technical and cost proposals, requiring vendors to demonstrate expertise in auditing self-funded health plans, provide comprehensive security and HIPAA compliance documentation, and conduct detailed claims reviews. The proposal is due by May 16, 2025, with vendors expected to validate prior authorizations, allowed charges, provider network status, coordination of benefits, and payment accuracy.

The RFP does not explicitly mention specific set-aside designations or restrictions for disadvantaged enterprises. The current third-party administrator is Aetna Life Insurance Company, with Healthcare Horizons serving as the incumbent medical claims audit vendor. Vendors must be prepared to integrate with existing claims processing infrastructure and provide fixed fee pricing for both Standard and Focused Audit services across the initial contract term and potential renewal periods. Performance guarantees are included, with potential fee reductions for failure to meet specified audit delivery timelines and quality standards. While a specific budget range is not disclosed, the comprehensive nature of the audit services and the sizeable membership of 578,000 suggests a significant potential contract value. Interested vendors will need to demonstrate robust capabilities in claims auditing, technological integration, and compliance with healthcare data protection standards to be competitive in this procurement opportunity.