Medical Benefit Claims Monitoring Services

The Vendor is required to provide for monitoring all medical benefit claims for every individual enrolled in the public employee health insurance program, commonly referred to as the plan.
- Vendor eligibility:
•    Shall be capable of performing the analysis of medical benefit claims to validate accuracy of the claims and identify errors in near real time as further. 
•    Shall not be an entity that performs annual retroactive audits of pharmacy or medical benefit claims for agency. 
•    For as long as the contract awarded pursuant to this RFP is in effect, shall not be affiliated by a common parent company or holding company, share any common members of the board of directors, or share managers in common with: 
o    Any insurer that agency may contract with pursuant to 18a.225;
o    Anthem or any other third-party administrator that agency may contract with in the future pursuant to 18a.2254; 
o    Caremark or any other pharmacy benefit manager that agency may contract with in the future; and 
o    Any other pharmacy benefit manager contracted by an insurer pursuant to 18a.225 or a third-party administrator contracted pursuant to 18a.225. 
•    Shall not be an entity that performs drug utilization reviews, clinical reviews or intervention, or otherwise adjudicates or re-adjudicates any medical claim or coverage amount as determined by anthem or any other agency contracted entity. 
•    Shall not be an entity that exercises any authority over the provision of health care benefits for Medicare eligible retirees.
- Vendor responsibilities:
•    An analysis of one hundred percent (100%) of medical invoices or claims submitted for payment to the agency by anthem or any TPA with which personnel cabinet may contract in the future while the contract awarded pursuant to this TPA is in effect. 
•    The vendor shall not utilize statistical sampling methods in lieu of analyzing all pertinent medical invoices and claims; 
•    Identification and correction of errors in medical benefit claims in order to avoid or reduce erroneous overpayments by agency through the agency contracted entities, including a check for any duplicate claim reporting (such as duplicate claims resulting from pre-payment, or claims incorrectly applied to an agency member due to faulty identification); 
•    Identification of underpayments made by the agency contracted entities; 
•    Identification of inappropriate or erroneous fees imposed by a agency contracted entity; 
•    Submission of a quarterly report to the personnel cabinet and the legislative research commission, which shall include the following:
o    A summary of the analysis conducted;
o    A statement of the errors identified pursuant to the vendor’s responsibilities outlined herein; 
o    A statement of the resolutions of the errors identified pursuant to the vendor’s responsibilities outlined herein; and 
o    Savings realized by agency as a result of the vendor’s analysis, validation, and resolutions of the errors.
- Personnel cabinet responsibilities:
•    Shall grant full access to the contract awarded to anthem or any future medical third-party administrator with which the personnel cabinet may contract while this contract is in effect, including all pertinent reference documents; 
•    Shall grant full access to any other contract that defines an insurer’s or TPA’s obligations and responsibilities as it relates to processing agency medical benefit claims, including any contract between an insurer contracted pursuant to 18a.225 or a third-party administrator contracted pursuant to 18a.2254; 
•    Shall grant full access to invoices and unaltered claims files associated with agency medical benefits; and 
•    In the event of a disagreement between the vendor and an agency contract entity regarding an identified discrepancy, intervene to the extent necessary and at the option of the personnel cabinet to resolve the disagreement.