Benefits Medical Claims Audit 5693 Services

The Vendor is required to provide benefit plan administration performance and included the following components:
• A medical claim audit
• An operations review
• An appeals audit
• A customer service audit.
- Requirements
• This review assesses systems and administrative capabilities.
• Administrator capabilities should be measured against industry standards and best practices.
• The general topics of the review include the following:
o Eligibility determination and data file maintenance including update procedures for additions, terminations, cobra, and age limits
o Workflow procedures from claim receipt to disbursement
o Claim payment platforms and the proper coding of plans in the systems
o Member service capabilities and workflow
o Staffing of claim and customer service teams, training, and supervisory responsibilities
o Quality assurance programs including fraud control and random claim audits
o Performance monitoring and reporting
o Utilization management protocols
• This component is to evaluate cps's claims operations to:
o Determine the vendor's effectiveness in providing a high level of service to cps employees
o Uncover administrative issues that can lead to service problems
o Compare the vendor’s processes and procedures to industry standards and best practices
o Identify opportunities.