Pharmaceutical Claims Audit Services

The Vendor is required to provide pharmaceutical claims audit services.
- The objectives of the work include:
• Support the government to find any inadequacies with submitted claims for payment.
• Support state pharma care to understand rationale for billed claims.
- The work will include:
• Information gathering:
1. Identify key elements required for a submitted claim to be appropriately submitted.
2. Gather and review existing, claim submissions to determine if accurately submitted.
3. Collaborate with subject matter experts to determine if specific claims are accurate.
4. Communicate types of claims and value incorrectly submitted to state pharmacare for collections from the pharmacy, if applicable.
• Design a presentation of the audit findings to communicate the results to leadership.
1. Train state pharmacare leadership on data interpretation.
2. Determine format to present findings to the impacted pharmacy.
3. Prepare a presentation summarizing key findings to impacted pharmacy.
• Identify opportunities and recommended approach for scaling audits to reach more potential partners should agency desire.
• Final presentation of findings:
1. Prepare a final presentation summarizing key findings to agency leadership.
- Create multiple audit-specific tools, such as information packages, tailored summaries, toolkits, etc., that are easy to use and accessible to show the value of the audit.
- Conduct, finalize and certify accuracy of the audit conducted for pharmacy claims and service at one pharmacy.
- Coordinate meetings with the department leadership every one to two weeks, including a launch meeting, monthly meeting, and close-out meeting; and 
- In association with the check-in meetings, provide a written status update outlining progress, next steps, and decisions.
- Estimate any other project expenses that may be incurred, once the proposed personnel are onsite at the primary work location.
- Questions/Inquires Deadline: July 17, 2025