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MB-4257 - USA (Ohio) - Employee Benefits Auditor and Market Check Services - Deadline June 10,2020

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-4257

Government Authority located in Ohio; USA based organization looking for expert vendor for employee benefits auditor and market check services.

[A] Budget: Looking for proposal

[B] Scope of Service:

Vendor needs to provide auditing/consultant firms to audit claims for medical, pharmacy, dental, and short-term disability programs. In addition, the City is also seeking pharmacy rebate audits and market check services.
- Tests should include, but not be limited to verifying accurate plan design, provider contract terms, exclusions, and limitations such as maximum visits, prior authorization, and investigations of other party liability. The Offeror may recommend additional areas as appropriate.
- Specific to the pharmacy benefit manager (PBM) claims audit the City is looking for a review of (but not limited to): Dispensing fees, Discounts, Brand, Generic, Specialty, Pricing Assessments, Average Wholesale Price, Pricing Accuracy, Aggregate Discount Accuracy, The offeror may recommend additional areas as appropriate.
- Medical Audits. During the term of the Agreement, and at any time within twelve (12) months following its termination, a mutually agreeable entity may conduct an annual medical claims audit of United’s performance under the Agreement once each calendar year. Prior to the commencement of this audit, United must receive a signed, mutually agreeable confidentiality agreement. As part of the annual medical claims audit, United will also support either a small targeted audit of appeals, member calls, or clinical transactions (not to exceed 100 transactions).
- Pharmacy Audits. During the term of the Agreement, and at any time within six (6) months following its termination, a mutually agreeable entity (“Auditor”) may conduct an annual pharmacy claims audit of United’s performance under the Agreement once each calendar year. Prior to the commencement of this audit, United must receive a signed, mutually agreeable confidentiality agreement.
- Market Check. On an annual basis, Customer or its designee may provide United a written firm proposal for pharmacy benefit management services offered by a pharmacy benefit management service provider to Customer which takes into account, the aggregate plan design, clinical and trend programs, pharmacy network, specialty pharmacy and mail pharmacy utilization, demographics and other relevant factors for comparable companies (“Customer Current Market Price”). United shall have a reasonable opportunity to evaluate the Customer’s Current Market Price. If the Customer or its designee conclude that the Customer’s Current Market Price would yield an annual one percent (1%) or more savings of Net Plan Costs (with Net Plan Costs defined as the sum of the cost of Covered Drugs, dispensing fees, and claims administrative fees, less Rebates received by Sponsor) under the Agreement, and United is unable or unwilling to offer new terms and conditions that would result in the savings offered by the competing offer, as determined by the Customer or its designee, then Customer may terminate the Agreement upon ninety (90) days’ prior written notice to United.
- For more information describe in documents.

[C] Eligibility:

- Onshore (USA Organization Only);

[D] Work Performance:

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

Expiry Date : Wednesday, 10 June, 2020

Category : Medical Billing and Coding

Country : USA

State : Ohio

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