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MB-3638 - USA (Texas) - Claims Audit Services - Deadline January 3,2020

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-3638

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

[A] Budget: Looking for Proposal

[B] Scope of Service:

(1) Vendor needs to provide claims audit services to conduct medical claim, prescription drug claim, and pharmacy rebate audit work,
- An HSA-qualifying high deductible health plan (HDHP) with an integrated carved-out pharmacy benefit,
- An exclusive provider organization plan with Accountable Care Organizations in limited geographic areas with an integrated carved out pharmacy benefit,
- The TRS-Care Alternative plan, which covers Medicare-eligible retirees who face hardship or delay in obtaining Medicare or who are only enrolled in Medicare Part A and have not obtained or maintained Medicare Part B,
- seeks a qualified vendor to conduct medical claim, prescription drug claim, and pharmacy rebate audit services for the TRS-ActiveCare and TRS-Care populations,
- The fully-insured Medicare Advantage plan options and HMOs are outside the scope of the audit,
- Determine whether claims payments are accurate, allowable, adjudicated, and paid in accordance with contractual arrangements. This includes out-of-network and emergency claims,
- Review the HPA’s operations, controls, and procedures that influence or impact the administration of TRS’ health claims through a comprehensive procedural questionnaire, interviews with key management personnel, and site visits as necessary. examples of operational areas may include: hospital audits, claim processing, subrogation and other third-party recoveries, customer services, eligibility and enrolment processing, special investigation unit recoveries and protocols, disaster recovery planning and business continuity,
- Each pharmacy claims audit requires a Comprehensive 100%-of-Claims Audit, the Pharmacy Audit will also include a Comprehensive 100%-of-Claims Audit on the minimum prescription discount guarantees,
- Claim Accuracy:
- Determine whether claims payments are accurate, allowable, adjudicated, meet minimum network guaranteed, and paid in accordance with contractual arrangements.
(2) A non-mandatory pre-proposal conference will be held on December 10, 2019.
(3) All the questions must be submitted no later than December 12, 2019.

[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 : Friday, 3 January, 2020

Pre-proposal Conference Date : Tuesday, 10 December, 2019

Question Answer Deadline : Thursday, 12 December, 2019

Category : Medical Billing and Coding

Country : USA

State : Texas

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