The vendor is required to provide for delegated risk bearing organization (RBO) limited medical risk (LMR) review services on behalf of agency.
- Core responsibilities
• Conduct a thorough evaluation of each delegated RBO’s MLR report for calendar year 2024.
• Identify and investigate outliers in reported medical cost per member per month (PMPM).
• Validate the classification of medical and non-medical expenses in MLR calculations.
• Ensure reported service expenses align with encounters and payment records.
• Confirm that revenues reported by RBOs match payments received from upstream entities.
• Review allocation methodologies for RBOs operating multiple lines of business.
• Assess the reasonableness of incurred but not reported (IBNR) calculations.
• Test and verify the accuracy of MLR percentage calculations.
• Identify remittance obligations for RBOs with MLRs below 85%, calculating amounts due to agency.
• Service locations
• Evaluations will be conducted on-premises at agency, delegated RBO locations, or virtually as required.
- Key activities and milestones
a. Engagement phase
• Initial meetings with agency and delegated RBOs to align expectations.
• Review of historical financial data and previous reporting methodologies.
• Development of an evaluation framework in alignment with department regulations.
b. Evaluation phase
• Comprehensive assessment of financial reporting elements in the MLR filings.
• Cross-verification of reported expenses and revenue data.
• Identification of discrepancies or compliance risks.
c. Reporting and recommendations
• Draft detailed evaluation reports summarizing findings.
• Submit a final MLR evaluation report no later than November 30, 2025.
• Provide recommendations for process improvements and compliance alignment.
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: May 19, 2025