Posted Date : September 19,2018
Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID : MB-2561
Government Authority located in Mississippi; USA based organization looking for expert vendor for pharmacy claims and performance audit services.
[A] Budget: Looking for Proposals
[B] Scope of Service:
(1) Vendor needs to provide pharmacy claims and performance audit services to comprehensive and objective claims and performance audit of the Plan’s pharmacy benefit manager includes
a. Pharmacy Claims Payment and Pricing - Electronic re-adjudicating of 100% of all claims to include determining if the appropriate benefit plan design, application of deductible, co-payments, AWP pricing and discounts, MAC pricing, and generic substitution were used in adjudicating the claims
b. Pharmacy Network Agreements Audit
c. Rebate Audit - An analysis of rebates to determine the level of rebate due the Plan. The rebate audit is subject to include, but is not limited to, the following:
i. Audit of drug manufacturer contracts for base/formulary, market share, and any other applicable rebates which may be applied to the Plan’s branded drug utilization
ii. Comparison of the amounts invoiced to the drug manufacturer by the pharmacy benefit manager to identify discrepancies
iii. Comparison of the actual total rebates per claim compared to the rebate guarantee
d. Cost containment procedures
e. Operational Review - A detailed operational audit of the pharmacy benefit manager shall include, but is not limited to, the following:
i. Claims payment system
ii. Pharmacy Audit Process
iii. Exception processing
iv. Paper claim receipt and tracking
v. Evaluation of the security of records and data
vi. Security and override procedures relating to approval of claims and access to records
vii. Internal audit
viii. Compliance with HIPAA/HITECH Act to verify the Plan’s vendors are HIPAA compliant during the annual claims and performance audits.
ix. Evaluation of customer service, including communication of the Plan’s benefits and audit of performance guarantees related to call answering response time and abandonment rate
f. Fraud, Waste and Abuse Review.
(2) An Intent to Propose/Questions due on October 5, 2018.
(3) A contract period will be for four years.
[C] Eligibility:
- Onshore (USA Only);
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office location.
Budget :
Deadline to Submit Proposals: October 23,2018
Cost to Download This RFP/RFQ/RFI/Solicitation/Tender/Bid Document : 5 US$
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Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID : MB-2561
Government Authority located in Mississippi; USA based organization looking for expert vendor for pharmacy claims and performance audit services.
[A] Budget: Looking for Proposals
[B] Scope of Service:
(1) Vendor needs to provide pharmacy claims and performance audit services to comprehensive and objective claims and performance audit of the Plan’s pharmacy benefit manager includes
a. Pharmacy Claims Payment and Pricing - Electronic re-adjudicating of 100% of all claims to include determining if the appropriate benefit plan design, application of deductible, co-payments, AWP pricing and discounts, MAC pricing, and generic substitution were used in adjudicating the claims
b. Pharmacy Network Agreements Audit
c. Rebate Audit - An analysis of rebates to determine the level of rebate due the Plan. The rebate audit is subject to include, but is not limited to, the following:
i. Audit of drug manufacturer contracts for base/formulary, market share, and any other applicable rebates which may be applied to the Plan’s branded drug utilization
ii. Comparison of the amounts invoiced to the drug manufacturer by the pharmacy benefit manager to identify discrepancies
iii. Comparison of the actual total rebates per claim compared to the rebate guarantee
d. Cost containment procedures
e. Operational Review - A detailed operational audit of the pharmacy benefit manager shall include, but is not limited to, the following:
i. Claims payment system
ii. Pharmacy Audit Process
iii. Exception processing
iv. Paper claim receipt and tracking
v. Evaluation of the security of records and data
vi. Security and override procedures relating to approval of claims and access to records
vii. Internal audit
viii. Compliance with HIPAA/HITECH Act to verify the Plan’s vendors are HIPAA compliant during the annual claims and performance audits.
ix. Evaluation of customer service, including communication of the Plan’s benefits and audit of performance guarantees related to call answering response time and abandonment rate
f. Fraud, Waste and Abuse Review.
(2) An Intent to Propose/Questions due on October 5, 2018.
(3) A contract period will be for four years.
[C] Eligibility:
- Onshore (USA Only);
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office location.
Budget :
Deadline to Submit Proposals: October 23,2018
Cost to Download This RFP/RFQ/RFI/Solicitation/Tender/Bid Document : 5 US$