Evidence Based Medicine Services

The Vendor is required to provide evidence-based medicine services through claims data analysis for the state health plan and the agency health plan.
- Responsible for the administration and management of the state’s employee insurance programs and retirement systems.
- Entities that participate in the employee insurance programs (all state agencies, public school districts, public higher education institutions, as well as participating charter schools and those eligible optional employers who have chosen to participate) must offer to all their eligible employees the entire package of available state insurance benefits and allow individual employees to refuse all or any part of the state insurance benefits package.
- Employees may also participate in dental plus, the state vision plan, optional and dependent life insurance, supplemental long term disability, but they pay the full premium for these benefits.
- Active employees may also participate in agency cafeteria plan, called MoneyPlus which includes flexible spending accounts and Health Savings Accounts.
- Administer, manage, and provide all equipment, personnel, and services necessary to deliver evidence-based medicine services through claims data analysis for the self-funded State Health Plan and the agency Health Plan.
- Clinical protocols shall be derived from evidence-based medicine or nationally accepted practice guidelines.
- Clinical protocols shall be derived in a manner that can be presented and defended to health care providers as promoting cost effective and quality care.
- Support changes in health care provider and patient behavior that enhance health and safety outcomes of participants.
- Calculate the “Guaranteed Return on Investment” of interventions utilizing the Contractor’s proposed methodology for calculating return on investment.
- Identify the high-risk chronic disease population and recommend interventions to health care providers that result in reduction of the rate of participant’s hospitalizations, enhanced participant’s safety, and better quality of care.
- Eligibility
•    Person identifier
•    Date of birth
•    Gender
•    Relationship to the insured
•    Subscriber type
•    ZIP code
•    Enrolled plan
•    Effective date of coverage
•    Ending date of coverage
- Medical claims
•    Person identifier
•    Date of service
•    Discharge date (if applicable)
•    Discharge status (if applicable)
•    Paid date
•    Provider identifier (NPI)
•    Provider name
•    Procedure code(s) (professional claims)
•    Procedure modifier(s) (professional claims)
•    UB04 revenue code (institutional claims)
•    DRG code (institutional claims)
•    Place of service
•    Type of service
•    ICD 10 diagnosis code(s)
•    Units of service
•    Submitted charges
•    Covered charges
•    Plan payments
- Pharmacy claims
•    Person identifier
•    Dispense date
•    Pharmacy ID
•    Pharmacy type
•    Prescriber ID (NPI)
•    Metric quantity
•    Days of therapy
•    NDC code
•    Drug type
•    Covered charge (ingredient cost plus dispensing fee)
•    Plan payments
- Dental claims
•    Person identifier
•    Date of service
•    Paid date
•    Provider identifier (NPI)
•    Provider name
•    Dental procedure code(s)
•    Dental procedure code modifier(s)
•    Place of service
•    ICD10 diagnosis code(s)
•    Units of service
•    Submitted charges
•    Covered charges
•    Plan payments
- Vision claims
•    Person identifier
•    Date of service
•    Paid date
•    Provider identifier (NPI)
•    Provider name
•    CPT code(s)
•    CPT code modifier(s)
•    Type of service
•    ICD 10 diagnosis code(s)
•    Units of service
•    Submitted charges
•    Covered charges
•    Plan payments.

- Contract Period/Term: 3 years
- Pre-Proposal Conference Date: November 19, 2025
- Questions/Inquires Deadline: November 14, 2025