SD State Employee Health Plan Medical Claims Audit
Closed State & local contract opportunity Posted
- Solicitation number
- 26RFP19878
- State
- South Dakota
- Responses due
Opportunity facts
- Jurisdiction
- NIGP code
Opportunity details come from postingboard.esmsolutions.com. Updated .
About this opportunity
The South Dakota Bureau of Human Resources & Administration is requesting proposals for medical claims audit services for the State Employee Health Plan, with proposals due October 24, 2026 and an anticipated award decision by December 7, 2026.
The scope covers performance review audits of medical claims processing by Wellmark Blue Cross Blue Shield across three twelve-month audit periods (Fiscal Years 2028, 2029, and 2030). Work includes electronic screening of 100% of paid medical claims, statistical sampling of 200 claims per period, diagnosis-related group hospital claims review of 50 inpatient claims per period, and out-of-network claims review of 20 claims per period. The auditor must assess claims processing accuracy, payment accuracy, financial accuracy, turnaround time, and recovery potential in accordance with Generally Accepted Government Auditing Standards (GAGAS) and industry-standard methodologies. The plan covers approximately 12,150 State employees and COBRA participants with approximately 26,800 total participants including dependents. Fiscal Year 2026 claims totaled approximately $160 million in health plan costs, of which approximately $108 million was for medical claims. Annual paid claims volume is approximately 314,300 medical claims and 282,700 pharmacy claims.
The contract term is three years with the State retaining an option to renew for up to two additional one-year extensions. Total contract amount will be negotiated. Proposals must include detailed cost breakdowns identifying all direct and indirect expenses, including subject matter expert fees, professional services, conference call time, and travel expenses. The selected vendor must maintain professional liability insurance with minimum limits of $1 million, comply with HIPAA guidelines and Business Associate Agreement requirements, maintain cyber liability insurance with limits to be specified, encrypt data at AES256 level, undergo annual risk assessments, and agree to fingerprint-based background investigations for staff accessing protected health information. The auditor must execute a Non-Disclosure Agreement with Wellmark. Questions are due before the proposal deadline and should be emailed to Peggy.Canter@state.sd.us with subject line "RFP#26RFP19878." Proposals must be submitted electronically with attachments limited to 20MB.
Opportunity text
2 versions
Update #2 · Latest ·
Wellmark Blue Cross Blue Shield of South Dakota ("Wellmark") has been administering the State's self-funded medical and pharmacy plans since July 1, 2021. Approximately 12,150 State employees and COBRA participants enrolled in four (4) State of South Dakota State Employee Health Plans ("SDSEHP") which includes 2 low-deductible Preferred Provider Organization ("PPO") plans and 2 high-deductible plans which offer a Health Savings Account ("HSA"). The total number of plan participants including spouses and dependent children is approximately 26,800. As of May 1, 2026, 65.00% of plan members were enrolled in the high-deductible health plans and 35.00% were enrolled in the low-deductible plans. Annual paid claims volume is approximately 314,300 medical claims and 282,700 pharmacy claims. For Fiscal Year 2026 (ended on June 30, 2026), the SDSEHP paid a total of approximately $160 million in total health plan costs (medical claims, prescription drug claims, and administrative fees), of which approximately $108 million was for medical claims alone.
The Bureau of Human Resources & Administration ("BHRA") is soliciting proposals from vendors who can conduct a performance review of medical claims processing performed by Wellmark. The auditor selected through this RFP process will be required to execute a Non-Disclosure Agreement "(NDA") with Wellmark.
All written questions should be sent to: Peggy.Canter@state.sd.us, only emailed questions will be accepted.
Each offeror may submit questions via email concerning this RFP to obtain clarification of requirements. No questions will be accepted after the date and time indicated in the above schedule of activities. Email questions to the email address listed above with the subject line "RFP#26RFP19878". The questions and their answers will be sent to all offerors that submitted Letters of Intent, submitted questions, or requested the questions and answers via email before the proposal submittal date and will be sent by the date and time indicated in the above calendar of events. Offeror may not rely on any other statements, either of a written or oral nature, that alter any specification or other term or condition of this RFP that have not originated from the SD RFP Project Contact. Offerors will be notified in the same manner as indicated above regarding any modifications to this RFP. Offerors and their agents may not contact any state employee other than the buyer of record regarding any of these matters during the solicitation and evaluation process. Inappropriate contacts are grounds for suspension and exclusion from specific procurements.
As a courtesy, the State is providing the BHRA Business Associates Agreement for vendor review. The agreement has been added as an attachment to the RFP document.
Update #1 ·
Wellmark Blue Cross Blue Shield of South Dakota ("Wellmark") has been administering the State's self-funded medical and pharmacy plans since July 1, 2021. Approximately 12,150 State employees and COBRA participants enrolled in four (4) State of South Dakota State Employee Health Plans ("SDSEHP") which includes 2 low-deductible Preferred Provider Organization ("PPO") plans and 2 high-deductible plans which offer a Health Savings Account ("HSA"). The total number of plan participants including spouses and dependent children is approximately 26,800. As of May 1, 2026, 65.00% of plan members were enrolled in the high-deductible health plans and 35.00% were enrolled in the low-deductible plans. Annual paid claims volume is approximately 314,300 medical claims and 282,700 pharmacy claims. For Fiscal Year 2026 (ended on June 30, 2026), the SDSEHP paid a total of approximately $160 million in total health plan costs (medical claims, prescription drug claims, and administrative fees), of which approximately $108 million was for medical claims alone.
The Bureau of Human Resources & Administration ("BHRA") is soliciting proposals from vendors who can conduct a performance review of medical claims processing performed by Wellmark. The auditor selected through this RFP process will be required to execute a Non-Disclosure Agreement "(NDA") with Wellmark.
All written questions should be sent to: Peggy.Canter@state.sd.us, only emailed questions will be accepted.
Each offeror may submit questions via email concerning this RFP to obtain clarification of requirements. No questions will be accepted after the date and time indicated in the above schedule of activities. Email questions to the email address listed above with the subject line "RFP#26RFP19878". The questions and their answers will be sent to all offerors that submitted Letters of Intent, submitted questions, or requested the questions and answers via email before the proposal submittal date and will be sent by the date and time indicated in the above calendar of events. Offeror may not rely on any other statements, either of a written or oral nature, that alter any specification or other term or condition of this RFP that have not originated from the SD RFP Project Contact. Offerors will be notified in the same manner as indicated above regarding any modifications to this RFP. Offerors and their agents may not contact any state employee other than the buyer of record regarding any of these matters during the solicitation and evaluation process. Inappropriate contacts are grounds for suspension and exclusion from specific procurements.
Files
| File | Type | Posted |
|---|---|---|
| - BHRA Business Associates Agreement.docx | DOCX document | |
| Response to Offeror Questions document.docx | DOCX document | |
| RFP Document.pdf |
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