Medical Dental and Pharmacy Auditing Services

The Vendor is required to provide for medical, dental and pharmacy auditing.
- Medical Claims Audit:
•    Determine the medical claims administrator is administering and reporting medical claims for eligible members in compliance with the county’s health plan documents and medical claims administration contract.
•    Determine the medical claims administrator is adjudicating claims correctly for contractual financial components and appropriate benefits application within contractual timelines.
•    Determine members are eligible and covered by county of orange’s health plan at the time a claim was incurred.
•    Determine the medical claims administrator’s performance met contractual performance guarantees and determine how these guarantees can be enhanced in the future to ensure a high level of performance.
•    Determine the medical claims administrator is processing preferred provider negotiated rates and utilization review decisions in accordance with program requirements to maximize the cost management savings of these programs. 
•    Determine the medical claims administrator is processing out-of-network claims in accordance with county health plan documents and utilizing usual, reasonable, and customary rates.
•    Identify any operational and administrative weaknesses of the medical claims administrator and develop a plan to work with the medical claims administrator to address those weaknesses and enhance service levels and performance to the county. 
•    Provide a data request to the county and collect and review information on account structure, benefit design, contract with medical claims administrator, county’s health plan documents, and other relevant documents.
•    Meet with the county and its medical claims administrator prior to the commencement of the audit to discuss and reach agreement on the specifics of the audit scope and methodology, including operational review areas. 
•    Review relevant documents to determine how claims should be processed and paid. These documents include the claims administrator’s benefit design documents, written operational procedures, performance reports, etc.
- Dental Claims Audit:
•    Determine the dental claims administrator is administering and reporting dental claims for eligible members in compliance with the county’s dental plan document and dental claims administration contract.
•    Determine the dental claims administrator is adjudicating claims correctly for contractual financial components and appropriate benefits application within contractual timelines.
•    Determine members are eligible and covered by the county dental plan at the time a claim was incurred.
•    Determine the dental claims administrator’s performance met contractual performance guarantees and determine how these guarantees can be enhanced in the future to ensure a high level of performance. 
•    Determine the dental claims administrator is processing preferred provider negotiated rates and utilization review decisions in accordance with program requirements to maximize the cost management savings of these programs.
•    Determine the dental claims administrator is processing out-of-network claims in accordance with the dental plan document and utilizing usual, reasonable, and customary rates.
•    Identify any operational and administrative weaknesses of the dental claims administrator and develop a plan to work with the dental claims administrator to address those weaknesses and enhance service levels and performance to the county 
•    Provide a data request to the county and collect and review information on account structure, benefit design, contract with dental claims administrator, county’s dental plan document, and other relevant documents.
•    Meet with the county and its dental claims administrator prior to the commencement of the audit to discuss and reach agreement on the specifics of the audit scope and methodology, including operational review areas.
•    Review relevant documents to determine how claims should be processed and paid. These documents include the dental claims administrator’s benefit design documents, written operational procedures, performance reports, etc.
- Pharmacy Benefit Claims & Rebates Audit
•    Determine the pharmacy benefit manager is administering and reporting pharmacy claims (commercial, non-EGWP) for eligible members in compliance with the county’s health plan documents and the pharmacy benefit manager contract.
•    Determine the pharmacy benefit manager is adjudicating claims correctly for contractual financial components and appropriate benefits application within contractual timelines.
•    Determine that members are eligible and covered by the county’s health plan at the time a claim was incurred.
•    Determine the pharmacy benefit manager’s compliance with the discount and dispensing fee terms of the pharmacy benefit manager contract.
•    Determine the pharmacy benefit manager’s performance met contractual performance guarantees and determine how these guarantees can be enhanced in the future to ensure a high level of performance.
•    Identify any operational and administrative weaknesses of the pharmacy benefit manager and develop a plan to work with the pharmacy benefit manager to address those weaknesses and enhance service levels and performance to the county.
•    Provide a data request to the county and collect and review information on account structure, benefit design, contract with pharmacy benefit manager, county’s health plan documents, and other relevant documents.
•    Provide a request to the pharmacy benefit manager to access rebate agreements between pharmaceutical manufacturers and the pharmacy benefit manager and sign agreement /confidentiality agreement.
•    Meet with the county and its pharmacy benefit manager prior to the commencement of the audit to discuss and reach agreement on the specifics of the audit scope and methodology, including operational review areas.
•    Verify allowed medical and pharmacy expenses are properly accumulated and correctly applied to calendar year deductibles and out of pocket maximums for individuals and families, as applicable.
•    Validate agreed upon performance guarantees from county’s contract with pharmacy benefit manager. Categorize errors into key performance indicators and compare results to optimum industry standards.

- Contract Period/Term: 3 years
- Questions/Inquires Deadline: September 24, 2025