The vendor is required to provide medical claims audit services must include medical claims audits for the purpose of measuring financial, payment, and processing accuracy.
- Provided services to at least one public or private self-funded client with more than 250,000 covered lives.
- Standard audits are performed on a statistically valid random claims sample which will be used to measure claims accuracy for performance guarantees on a quarterly basis.
- Financial accuracy: total dollar amount of claims processed accurately divided by the total dollar amount processed in the audit sample; the total dollar amount processed accurately is calculated by subtracting the absolute values of the dollars processed in error from the total dollars processed; underpayments and overpayments are not offset by one another.
- Payment accuracy: the number of claims with the correct benefit dollars paid divided by the total number of claims paid in the audit sample.
- Processing accuracy: the number of claims processed with no procedural errors divided by the total number of claims processed in the audit sample.
- Perform portions of the audit, including reviewing provider contracts, at the TPA’S site to access provider contracts or in a virtual environment as required by the TPA to access provider contracts.
- Participate in screen sharing with TPA for appropriate claims processing documentation or other clarifying documents, when necessary.
- Provide an audit that will be a comprehensive and objective review of the claims processed by the plan’s TPA to determine if claims were adjudicated appropriately according to provider contracts, plan benefits and policies, and federal and state requirements; this also includes the following:
• Ensuring the appropriate prior authorizations are in place;
• Validating the reasonableness of allowed charges;
• Validating the provider’s network status;
• Validating that the appropriate coordination of benefits (COB) was made, including commercial and medicare COB;
• Confirming payments were made to the appropriate party (assignment of benefits);
• Ensuring there are no hidden fees or other charges included in the claim that the plan did not agree to pay.
- Identify, and include in the audit report, out-of-sample claim errors to the plan on a quarterly basis based on the claim categories selected in the 250-claim sample.
- Apply industry standards, such as those associated with cost containment and recovery procedures, when evaluating the accuracy of the claim’s adjudication.
- Determine that refunds were properly applied and credited to claims.
- Identify the root cause for any errors noted and provide recommended corrective actions for the TPA.
- Monitor the collections process of overpaid claims that have been identified and placed into recovery by the TPA, to a point of completion that is satisfactory to both the vendor and the agency.
- Contract Period/Term: 2 years
- Questions/Inquires Deadline: April 18, 2025