SOURCES SOUGHT
R -- Medical Claims Audit of Third Party Administrators
- Notice Date
- 7/31/2007
- Notice Type
- Sources Sought
- NAICS
- 561439
— Other Business Service Centers (including Copy Shops)
- Contracting Office
- Department of Energy, BWXT Pantex (DOE Contractor), Pantex, PO Box 30020, Amarillo, TX, 79120, UNITED STATES
- ZIP Code
- 00000
- Solicitation Number
- JC
- Response Due
- 8/8/2007
- Archive Date
- 8/8/2007
- Small Business Set-Aside
- Total Small Business
- Description
- ALL QUESTIONS WHETHER TECHNICAL OR CONTRACTUAL, MUST BE SENT ELECTRONICALLY TO JUDITH CONLEY, JCONLEY@PANTEX.COM IF YOU WILL BE RESPONDING TO THIS SOLICITATION, YOU MUST SUBMIT AN EMAIL TO JCONLEY@PANTEX.COM ACKNOWLEDGING YOUR PARTICIPATION IN THIS SOLICITATION. IF ANY QUESTIONS SHOLD ARISE, YOU WILL BE NOTIFIED ELECTRONICALLY. FOR PARTIES INTERESTED IN PROPOSING ON THE MEDICAL CLAIMS AUDIT OF THIRD PARTY ADMINISTRATORS PROJECT, PLEASE RESPOND VIA E-MAIL. INCLUDE THE FOLLOWING IN YOUR E-MAIL BY AUGUST 8, 2007: 1. NAME, ADDRESS, PONT OF CONTACT 2. E-MAIL ADDRESS 3. PHONE NUMBER 4. TWO PAGE OR LESS OF SUPPLIERS EXPERIENCE AND CAPABILITIES Statement of Work For Medical Claims Audit of Third Party Administrators July 30, 2007 Prepared By: BWXT Pantex P. O. Box 30020 Pantex Plant Amarillo, Texas 79120-0020 Operated for the U. S. Department of Energy / National Nuclear Security Administration under U. S. Government Contract DE-AC04-00AL66620 1 SCOPE 1.1 Background BWXT Pantex LLC (BWXT Pantex) is the Prime Contractor of the Department of Energy's (DOE) Pantex Plant located near Amarillo, Texas. The Pantex Plant is America's only nuclear weapons assembly and disassembly facility. The Benefits Department of BWXT Pantex administers a number of health plans, some of which are fully-insured plans and some that are self-insured plans. The activities associated with administration of these plans are directed by BWXT Pantex Management, the applicable Collective Bargaining Agreements, and the Department of Energy (DOE). It is the Benefits Department?s responsibility to facilitate an independent claims audit of the Third Party Administrators (TPAs) in order to provide greater assurance that the administrators are achieving the agreed-upon performance guarantees and that the payment of claim transactions reflects the appropriate rates, discounts, and benefit determination accuracy. This audit will focus on the self-insured medical plan and the self-insured prescription drug plan. 1.2 Objective BWXT Pantex Benefits Department needs professional audit services to determine if payments made on our self-insured medical plans are appropriately distributed according to plan design and terms of the administrative agreement. Third Party Administrators that will be included under the scope of this audit include: TPA Health Plan Aetna Medical Insurance ? Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO) Caremark Prescription Drug Plan ? Mail-order and Retail 1.3 Contract Duration This agreement covers the period from award through 120 calendar days. 1.4 Points of Contact: The points of contact for BWXT Pantex are: Cathy Prosser Phone: 806-477-3772 Benefits, Bldg 16-12B Fax: 806-477-3762 BWXT Pantex Email: cprosser@pantex.com PO Box 30020 FM 2373 and HWY 60 Amarillo, TX 79120-0020 Kelly McDonald Phone: 806-477-6747 Benefits, Bldg 16-12B Fax: 806-477-7654 BWXT Pantex Email: kmcdonal@pantex.com PO Box 30020 FM 2373 and HWY 60 Amarillo, TX 79120-0020 2 APPLICABLE DOCUMENTS Documents needed to perform the audit include: Administrative Services Agreement with Aetna Prescription Benefit Services Participating Group Agreement with Caremark Aetna Open Access Select EPO Plan Description Aetna Standard Open Choice PPO Plan Description Caremark Client Plan Design Document Claims Detail Reports (to be obtained from Aetna and Caremark) 3 REQUIREMENTS 3.1 Signed Agreements 3.1.1 A signed CARF three-way agreement will be required between the contractor, BWXT Pantex and Aetna and between the contractor, BWXT Pantex and Caremark. 3.2 Meetings 3.2.1 A post-award meeting will be held between the Benefits Manager, HR Benefits Specialist(s) and the Contractor?s project manager and lead auditor within seven (7) calendar days of the subcontract award at a mutually agreeable time and date. The meeting will be held at BWXT Pantex, Amarillo, TX. 3.2.2 A wrap-up meeting will be held between the Benefits Manager, HR Benefits Specialist(s) and the contractor to discuss the written report sometime during the last two weeks of the contract duration. The meeting will be held at BWXT Pantex, Amarillo, TX at a mutually agreeable time and date. 3.3 Activities 3.3.1 Teleconference(s) between BWXT Pantex, the contractor and the TPAs to address any outstanding questions 3.3.2 Onsite visits to both Caremark, San Antonio, TX and Aetna, Fort Worth, TX will be required. 3.3.3 Review a sufficient stratified random sample of TPA claims to ensure that claims are adjudicated in accordance with plan design and eligibility; ensuring the following: ? The appropriate procedure and diagnosis codes are used; ? Network providers are identified and the applicable negotiated fees are correctly applied; ? Plan exclusions and limitations are applied; ? Stop loss/excess insurance are correctly recovered; ? Deductibles and out-of-pocket maximums are appropriately tracked; ? Proper coordination with other sources of insurance occurs; ? Charged amounts are reasonable and suspect providers are identified; ? Questionable and inpatient hospital charges are reviewed for billing errors; ? Charges are entered correctly and payments are properly coded as to service type; ? Claim overpayments are promptly identified and refunded to the Plan sponsor; ? The accuracy of the administrator?s self reported performance results; and ? The payment of any rebates. The engagement should identify financial recovery opportunities and provide written reports and recommendations to BWXT Pantex. The list of activities stated above is not an all-inclusive list. 3.3.4 Review TPA claims to ensure that performance guarantees are being met. The performance guarantees for the medical plans administered by Aetna include overall account management, turnaround time, financial accuracy, payment incidence accuracy, total claim accuracy and telephone service factor. The performance guarantees for the prescription drug plan administered by Caremark include annual client survey, first call resolution, mail turnaround time (clean), mail turnaround time (non-clean), rebate accuracy, report distribution (ad hoc reporting), report distribution (benchmark reporting), report distribution (performance guarantee report card), and written inquiry. 4 GOVERNMENT-FURNISHED PROPERTY None 5 GOVERNMENT-FURNISHED FACILITIES None 6 DELIVERABLE DATA 6.1 The contractor shall provide a monthly status report on all ongoing and completed processes. The report should identify the status of individual milestones and any outstanding issues or concerns. The monthly status report shall be submitted by the 15th of the following month to the BWXT Pantex POC and the BWXT Contract Administrator: BWXT Pantex Attn: Judith A Conley, C.P.M. Contract Administration, Mail Drop 6-12F P.O. Box 30020 FM 2373 and HWY 60 Amarillo, TX 79120-0020 6.1.2 The Contractor will provide BWXT Pantex a draft of the proposed audit report and recommendations 90 calendar days after contract award 6.1.3 BWXT Pantex will respond with comments to the Contractor within 14 calendar days of receipt of the draft report. 6.1.4 The contractor shall provide an Executive Summary of the audit process, the findings, and proposed recommendations that have incorporated all comment resolution to the BWXT Pantex within 120 calendar days after contract award. The Contractor shall make a final presentation to the Benefits Manager at a wrap-up meeting at a mutually agreeable time and date immediately following the audit submission. 6.1.5 All report deliverables will be made in electronic form plus one hard copy document to the BWXT Pantex POC. BWXT Pantex Attn: Cathy Prosser Benefits, Bldg 16-12B PO Box 30020 FM 2373 and HWY 60 Amarillo, TX 79120-0020 Attn: Judith A Conley, C.P.M. Contract Administration, Mail Drop 6-12F P.O. Box 30020 FM 2373 and HWY 60 Amarillo, TX 79120-0020 ALL QUESTIONS WHETHER TECHNICAL OR CONTRACTUAL, MUST BE SENT ELECTRONICALLY TO JUDITH CONLEY, JCONLEY@PANTEX.COM IF YOU WILL BE RESPONDING TO THIS SOLICITATION, YOU MUST SUBMIT AN EMAIL TO JCONLEY@PANTEX.COM ACKNOWLEDGING YOUR PARTICIPATION IN THIS SOLICITATION. IF ANY QUESTIONS SHOLD ARISE, YOU WILL BE NOTIFIED ELECTRONICALLY. FOR PARTIES INTERESTED IN PROPOSING ON THE MEDICAL CLAIMS AUDIT OF THIRD PARTY ADMINISTRATORS PROJECT, PLEASE RESPOND VIA E-MAIL. INCLUDE THE FOLLOWING IN YOUR E-MAIL BY AUGUST 8, 2007: 1. NAME, ADDRESS, PONT OF CONTACT 2. E-MAIL ADDRESS 3. PHONE NUMBER 4. TWO PAGE OR LESS OF SUPPLIERS EXPERIENCE AND CAPABILITIES
- Place of Performance
- Address: P. O. BOX 30020, AMARILLO, TX
- Zip Code: 79120
- Country: UNITED STATES
- Zip Code: 79120
- Record
- SN01357198-W 20070802/070731220525 (fbodaily.com)
- Source
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