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MB-3603 - USA (Texas) - Medical and Pharmacy Claims Audit Services - Deadline November 21,2019

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-3603

Government Authority located in Texas; USA based organization looking for expert vendor for medical and pharmacy claims audit services.

[A] Budget: Looking for Proposal

[B] Scope of Service:

Vendor needs to provide medical and pharmacy claims audit services.
- Medical and Pharmacy Claims Audit Vendor shall not take any action to recover any amounts from employees of NEISD unless authorized to do so by the agency. Medical and Pharmacy Claims Audit Vendor will inform NEISD of any recoverable amounts from agency employees. It is at the agency
sole discretion to pursue recovery against employees.
- Medical and Pharmacy Claims Audit Vendor will contact Administrator to review audit process and data needs.
- Medical and Pharmacy Claims Audit Vendor will electronically compare 100% of District enrollment
records versus 100% of paid claims within the most recent 24 months period.
- Medical and Pharmacy Claims Audit Vendor will review all pertinent plan design documents.
- Medical and Pharmacy Claims Audit Vendor will electronically audit 100% of the Medical and Pharmacy Claims paid by Administrator within the most recent 24 months period.
- Medical and Pharmacy Claims Audit Vendor will then review the potential errors and provide an electronic copy of the entire patient histories for each error.
- Medical and Pharmacy Claims Audit Vendor will then judgmentally select a “validation sample” of Medical and Pharmacy Claims that will provide the necessary information to support other issues within each error category of the electronic audit.
- Medical and Pharmacy Claims Audit Vendor will then perform an on-site audit of those judgmentally selected claims at Administrator’s claims payment locations. Each on-site audited claim will be logged onto a worksheet detailing the reason for which Medical and Pharmacy Claims Audit Vendor considers the claim to be paid in error.
- Administrator will be provided copies of all worksheets in order for them to reply to Medical and Pharmacy Claims Audit Vendor’s findings. Administrator will then return their responses back to Medical and Pharmacy Claims Audit Vendor within a reasonable amount of time and will be published verbatim in the Final Report.
- Medical and Pharmacy Claims Audit Vendor will prepare and deliver the Final Report using detailed spreadsheets, narrative findings, and recommendations based on the electronic analysis, on-site audit reviews, and Administrator’ responses.
- Medical and Pharmacy Claims Audit Vendor will communicate with the Districts’ Internal Audit Division on an on-going basis, and at least monthly, to discuss concerns, findings, etc.

[C] Eligibility:

- Onshore (USA Only);

[D] Work Performance:

Performance of the work will be Offsite. Vendor needs to carry work in their office location

Expiry Date : Thursday, 21 November, 2019

Category : Medical Billing and Coding, Auditing, Finance and Accounting

Country : USA

State : Texas

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