Employee Benefits Administration & Consulting RFP: 07-17-17

Advertisement Notice For

EMPLOYEE BENEFITS ADMINISTRATION AND CONSULTING REQUEST FOR

PROPOSAL

The TEJAS BEHAVIORAL HEALTH MANAGEMENT ASSOCIATION (herein, “Tejas”) is a non-

profit association, formed to increase the efficiency of care delivery, improve the access to private Payors,

and expand the service potential for Community Behavioral Health Centers and other Community-Based

Organizations throughout Texas. This Association was formed through a collaboration among three

Community Centers in Texas with demonstrated leadership and innovation in the behavioral health arena

for over 50 years.

Tejas was formed pursuant to the Texas Interlocal Cooperation Act. The Community Center Members

cooperate in discharging administrative and governmental functions, including those related to employees

benefits. Community Centers, individually, are recognized as units of government of the state of Texas,

and are subject to rights and obligations of governmental entities/political subdivisions. Community

Centers in Texas may participate in the services procured under this RFP in order to discharge their

governmental functions.

Tejas is seeking proposals for the provision of both Self-funded Medical and Prescription Drug

Administration services and Employee Managed Health Benefits Consulting Services for Community

Centers in Texas that are seeking to arrange for and manage employee benefits. Potential participants

must request the services which could be performed at Center locations across Texas. There is no

guarantee that such services will be requested or accessed.

The initial contract period shall commence approximately 30 days after the contract award and continue

through August 31, 2020 with an option to renew for two additional one year periods based on

satisfactory performance.

Copies of the RFP Document may be obtained via internet at www.tejashma.org written request or faxed

request for mailed copy or picked up at 893 N. IH 35, Ste 130, Round Rock, Texas 78664.

Questions regarding the RFP Part 1 or Part 2 should be directed to Hollie Chenault at Tejas, 512-279-

9372 and hollie.chenault@tejashma.org and responses posted at http://tejashma.org/rfp.

Please submit sealed: one (1) original (clearly marked) and two (2) copies of your proposal OR one

electronic version by e-mail or by USB or CD-ROM to:

Tejas Health Management

ATTN: Hollie Chenault/Employee Benefits RFP 07-17-17

893 N. IH 35, Ste 130

Round Rock, Texas 78664

INTERESTED PARTIES MUST RESPOND TO THE RFP BY 3:00P.M., AUGUST 9, 2017, IN

ACCORDANCE WITH THE INSTRUCTIONS WITHIN THE RFP DOCUMENT.

Tejas appreciates your time and effort in preparing this proposal. All proposals must be received

at the specified location before opening date and time. The official time shall be determined by the

time/date stamp when received at location. Faxed responses shall not be accepted. Proposals

received after above date and time shall be returned unopened.

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TEJAS BEHAVIORAL HEALTH MANAGEMENT ASSOCIATION

EMPLOYEE BENEFITS ADMINISTRATION AND CONSULTING REQUEST FOR

PROPOSAL

The TEJAS BEHAVIORAL HEALTH MANAGEMENT ASSOCIATION (herein, “Tejas”)

is a non-profit association, formed to increase the efficiency of care delivery, improve the access

to private Payors, and expand the service potential for Community Behavioral Health Centers

and other Community-Based Organizations throughout Texas. This Association was formed

through a collaboration among three Community Centers in Texas with demonstrated leadership

and innovation in the health arena for over 50 years.

Tejas was formed pursuant to the Texas Interlocal Cooperation Act. The Community Center

Members cooperate in discharging administrative and governmental functions, including those

related to employees benefits. Community Centers, individually, are recognized as units of

government of the state of Texas, and are subject to rights and obligations of governmental

entities/political subdivisions. Community Centers in Texas may participate in the services

procured under this RFP in order to discharge their governmental functions.

Tejas is seeking proposals for the provision of both Self-funded Medical and Prescription Drug

Administration services and Employee Managed Health Benefits Consulting Services for

Community Centers in Texas that are seeking to arrange for and manage employee benefits.

Potential participants must request the services which could be performed at Center locations

across Texas. There is no guarantee that such services will be requested or accessed.

The initial contract period shall commence approximately 30 days after the contract award and

continue through August 31, 2020 with an option to renew for two additional one year periods

based on satisfactory performance.

Copies of the RFP Document may be obtained via internet at www.tejashma.org written

request or faxed request for mailed copy or picked up at 893 N. IH 35, Ste 130, Round Rock,

Texas 78664.

Questions regarding the RFP Part 1 or Part 2 should be directed to Hollie Chenault at Tejas,

512-279-9372 and hollie.chenault@tejashma.org and responses posted at http://tejashma.org/rfp.

Please submit sealed: one (1) original (clearly marked) and two (2) copies of your proposal OR

one electronic version by e-mail or by USB or CD-ROM to:

Tejas Health Management

ATTN: Hollie Chenault/Employee Benefits RFP

893 N. IH 35, Ste 130

Round Rock, Texas 78664

INTERESTED PARTIES MUST RESPOND TO THE RFP BY 3:00P.M., August 9, 2017

ACCORDANCE WITH THE INSTRUCTIONS WITHIN THE RFP DOCUMENT.

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Mark Envelope: “RFP for Employee Benefits Administration & Consulting”

Tejas appreciates your time and effort in preparing this proposal. All proposals must be

received at the specified location before opening date and time. The official time shall be

determined by the time/date stamp when received at location. Faxed responses shall not be

accepted. Proposals received after above date and time shall be returned unopened.

Any questions regarding the RFP should be directed in writing to Hollie Chenault; 893 N. IH 35,

Ste 130, Round Rock, Texas 78664 or at hollie.chenault@tejashma.org no later than July 24,

2017 COB. Responses shall be responded to no later than 24 hours following receipt and will be

posted at http://tejashma.org/rfp. It is the sole responsibility of respondents to review that site

for responses.

As stated in Section B, this is a two part RFP; Part 1 is for services regarding

Self-Funded Medical & Prescription Drug Administration; and Part 2 is for

services regarding Managed Health Benefits Consultant Services.

Proposals may be submitted for Part 1, Part 2, or both Part 1 and Part 2. If

submitting proposals for both Part 1 and Part 2, please submit as two

separate packets.

Timeline: RFP Posting – July 17, 2017; RFP Questions July 17 through July

24 2017; RFP Submission Deadline August 9, 2017; RFP Scoring to be

completed by August 16, 2017; Announcement and contract negotiation to

follow scoring.

TABLE OF SECTIONS

SECTION A: INSTRUCTIONS AND CONDITIONS – pages 3 to 7

SECTION B: DESCRIPTION AND SCOPE OF SERVICES Part 1 – pages 8 to 44

SECTION B: DESCRIPTION AND SCOPE OF SERVICES Part 2 – pages 45 to 46

SECTION C: EVALUATION AND SELECTION CRITERIA AND PROCESS –

pages 47 to 48

SECTION D: SUBMISSION OF PROPOSAL – page 49

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SECTION A

INSTRUCTIONS AND CONDITIONS

1. LATE PROPOSALS: Proposals received at the specified location or electronically after

submission deadline shall be returned unopened and shall be considered void and unacceptable.

The official time shall be determined by the time/date stamp when received by the front desk

receptionist at Tejas’ specified location or by the date and time of the electronic communication.

Tejas is not responsible for lateness of mail, carrier, etc.

2. FUNDING: This contract shall be between Tejas and successful respondent(s); however

access and use of the services shall be funded by Community Centers who choose to utilize the

services offered. There is no guarantee that any Center will access the services. Community

Centers provide services in every county in Texas.

3. ETHICS: Respondents shall not offer or accept any gifts or anything of value nor enter

into any business arrangement with any employee, official or agent of Tejas.

4. IT IS UNDERSTOOD that Tejas reserves the right to accept or reject any and/or all

proposals for any or all services covered in this solicitation and to waive informalities or defects

in proposals or to accept such proposals as it shall deem to be in the best interest of Tejas.

5. MODIFICATIONS: Tejas reserves the right to modify the general description and

scope of services, by issuing written addenda of any such modifications.

6. ADDENDA: Any interpretations, corrections or changes to the Request for Proposal

(RFP) and specifications shall be made by written addenda. Sole issuing authority of addenda

shall be vested in the Director of Business Operations. Addenda shall be mailed to all who are

known to have received a copy of the Request for Proposal. All such addenda become, upon

issuance, an inseparable part of the specifications which must be met for the offer to be

considered. All responding Respondents shall acknowledge receipt of all addenda.

7. ALTERING PROPOSALS: Any corrections, deletions, or additions to offers may be

made prior to closing date and time of the solicitation. No oral, telephone, telegraphic, fax, E-

mail, or other electronically transmitted corrections, deletions, or additions shall be accepted.

The Respondent shall submit substitute pages in the appropriate number of copies with a letter

documenting the changes and the specific pages for substitution. The signatures on the form and

letter must be original and of equal authority as the signatures on the offer.

8. WITHDRAWAL OF PROPOSALS: A proposal shall not be withdrawn or canceled by

the Respondent unless the Respondent submits a letter prior to the closing date. The signature on

the withdrawal letter must be original and must be of equal authority as the signature of the offer.

9. PROPOSALS SHALL BE received and publicly acknowledged at the location, date and

time stated within this document. Respondents, their representatives and interested persons may

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be present. The proposal shall be received and acknowledged only so as to avoid disclosure of

the contents to competing Respondents and kept confidential during negotiations.

However, all proposals shall be open for public inspection after the contract is awarded and

written notification is sent to both successful and unsuccessful Respondents, except for trade

secrets and confidential information contained in the proposal and identified by the Respondents

as such. Such information may still be subject to disclosure under the Public Information Act

based on the Texas Attorney General opinions and on steps taken by the Respondent to protect

the information outside the scope of the RFP process.

10. SALES TAX: Tejas is by statute exempt from the State Sales Tax and Federal Excise

Tax; therefore, the proposal shall not include taxes. Individual Community Centers are as well

exempt from state tax.

11. PROPOSALS MUST COMPLY with all federal, state, county and local laws. All

services must be in compliance with federal, state, county and local rules, codes, regulations,

laws, and executive orders.

12. RESPONDENTS SHALL PROVIDE with this proposal response, all documentation

required by this RFP. Failure to provide this information may result in rejection of proposal.

There is no expressed or implied obligation for Tejas to reimburse responding firms for any

expenses incurred in preparing proposals in response to this Request for Proposals and Tejas will

not reimburse responding firms for these expenses, nor will Tejas pay any subsequent costs

associated with the provision of any additional information or presentation, or to procure a

contract for these services.

1. Title page. Title page should include the RFP Title and subject. The Respondent’s name,

the name, address, and telephone number of a contact person; and the date of the proposal

transmitted.

2. Submission Letter. A letter of understanding by the person or officer of the Respondent

entity that is authorized to enter into a contractual agreement on behalf of Respondent

indicating acceptance and commitment to the work to be done as well as a succinct

statement as to why the Respondent believes itself is the best qualified. (If proposal is

submitted electronically, Letter must be in PDF format and signed.)

3. Detail Proposal. Response to Proposal Guidelines as specified in this document.

4. References. Submit as specified in Section A.16 of this document.

5. Respondent’s contact. Include the name of the designated individual(s), along with

respective telephone numbers, who will be responsible for answering technical and

contractual questions with respect to the Proposal

13. EXCEPTIONS/SUBSTITUTIONS: All proposals meeting the intent of this Request

for Proposal shall be considered for award. Respondents taking exception to the specifications,

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terms and conditions or offering substitutions, shall state these exceptions in the section provided

or by attachment as part of the proposal. The absence of such a list shall indicate that the

Respondent has not taken exceptions and Tejas shall hold the resultant Contractor responsible to

perform in strict accordance with the specifications, terms, and conditions of the contract. Tejas

reserves the right to accept any and/or none of the exception(s) /substitution(s) as deemed to be

in the best interest of Tejas.

14. MINORITY OWNED BUSINESSES: Historically Underutilized Business and/or

Minority business enterprises will be afforded full opportunity to submit proposals in response to

this invitation and will not be discriminated against on the grounds of race color, creed, sex, or

national origin in consideration for an award.

15. SILENCE OF SPECIFICATIONS: The apparent silence of these specifications as to

any detail or to the apparent omission from it of a detailed description concerning any point,

shall be regarded as meaning that only best practices of quality services and facilities will

prevail. All interpretations of these specifications shall be made on the basis of this statement.

16. REFERENCES: Tejas requests Respondent to supply, with this RFP, a list of at least

three (3) references where similar services have been provided by their organization. Include

name, contact name, address, telephone number and description of services provided for each

reference.

17. INSURANCE: Successful contractor must provide proof of minimum insurance

coverage prior to start of contract and annually thereafter of liability insurance (including general

liability, and workers compensation coverage) as follows:

SCHEDULE: Professional Liability $1,000,000

General Liability $1,000,000/3,000,000

Worker’s Compensation In accordance with Texas Statutory

Requirements

A Certificate of Insurance naming as an additional insured TEJAS BEHAVIORAL HEALTH

MANAGEMENT ASSOCIATION shall be provided prior to start of work.

18. MINIMUM STANDARDS FOR RESPONSIBLE PROSPECTIVE

RESPONDENTS: A prospective Respondent must affirmatively demonstrate Respondent's

responsibility. A prospective Respondent must meet the following minimum requirements:

1. have adequate financial resources, or the ability to obtain such resources as required;

2. be able to comply with the required or proposed performance schedule;

3. have a satisfactory record of performance;

4. have a satisfactory record of integrity and ethics; and

5. be otherwise qualified and eligible to receive an award

Tejas may request representation and other information sufficient to determine Respondent's

ability to meet these minimum standards listed above and any other required documentation.

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19. LIMITATIONS: Any Respondent currently held in abeyance from or barred from the

award of a Federal or State contract may not contract with Tejas.

20 CONSIDERATION: For an offer to be considered, the Respondent must meet Tejas’s

requirements, demonstrate the ability to perform successfully and responsibly under the terms of

the prospective contract, and submit the completed offer according to the time frames,

procedures, and forms stipulated by Tejas.

21. CONTRACT: In the event Respondent and Tejas are satisfied with the proposal

submission and its conditions in its entirety and no modification or negotiations are warranted,

the submitted proposal shall serve as a legal and binding agreement. In the event modification is

necessary, a sample contract containing the major provisions of Respondent’s anticipated

agreement subject to refinement and negotiation can be obtained upon request to Director of

Business Operations; hollie.chenault@tejashma.org

22. TERMINATION OF CONTRACT: Tejas reserves the right to terminate any resulting

contract with thirty (90) days written notice. In the event that Tejas or Potential Participants

cease operation fail to receive state funding then Termination may be immediate.

23. CONFLICT OF INTEREST: No public official shall have interest in this contract, in

accordance with Texas Local Government Code Chapter 171.

24. SUCCESSFUL RESPONDENT SHALL defend, indemnify and save harmless Tejas

and Community Center participants or its designee and its officers, directors and employees from

any and all suits, claims, actions, losses, damages, liability and expenses, including attorney’s

fees arising from any negligent or willful act, error, omission or misrepresentation of Contractor

or his employees, agents (including subagents) or servants. The provisions of the subparagraph

shall continue and be ongoing in any contract resulting from this RFP.

25. NOTICE: Any notice provided by this proposal (or required by Law) to be given to the

successful Respondent by Tejas shall be deemed to have been given and received on the day

delivery by Registered or Certified Mail with sufficient postage affixed thereto, addressed to the

successful Respondent at the address so provided; provided this shall not prevent the giving of

actual notice in any other manner.

26. CONTRACT MONITOR: Under this contract Tejas shall appoint a contract monitor

with designated responsibility to ensure compliance with contract requirements. The contract

monitor will serve as liaison between Tejas and the successful Respondent.

27. ASSIGNMENT: The successful Respondent shall not sell, assign, transfer or convey

any contract resulting from this RFP, in whole or in part, without the prior written consent of

Tejas.

28. ORDER OF PRECEDENCE: Any inconsistency in this solicitation or contract shall

be resolved by giving precedence in the following order.

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A. Request for Proposal Instructions and Conditions

B. Proposal Guidelines, if any.

C. Other documents, exhibits and attachments

29. SUBMISSION OF PROPOSAL: Submit the proposal describing your organization and

services in detail following the sequence as outlined, and requirements of the Solicitation of

Offers and Request for Proposal Instructions and Conditions.

Please submit sealed: one (1) original (clearly marked) and two (2) copies of your proposal OR

one electronic version by e-mail or by USB or CD-ROM to:

Tejas Health Management

ATTN: Hollie Chenault/Employee Benefits RFP

893 N. IH 35, Ste 130

Round Rock, Texas 78664

If submitting the proposal electronically, please submit the Letter of Assurance and the

Assurance document from Section D in PDF and signed.

There is no expressed or implied obligation for Tejas to reimburse Respondents for any expense

incurred in preparing Proposal in response to this request, and Tejas will not reimburse anyone

for those expenses. Tejas will consider Proposals from all responsible Respondents.

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SECTION B

DESCRIPTION AND SCOPE OF SERVICES

Self-Funded Medical & Prescription Drug Administration (Part 1)

Managed Health Benefits Consultant Services (Part 2)

Proposals may be submitted for Part 1, Part 2, or both Part 1 and Part 2. If submitting proposals

for both Part 1 and Part 2, please submit as two separate packets.

Instructions for Self-Funded (Part 1)

PROPOSAL GUIDELINES

Each Respondent must answer each of the following items completely. You may attach

additional materials as necessary to provide support information and details. Failure to disclose

or provide complete and accurate responses, or to utilize format described below, may be

considered a basis for eliminating the proposal from further consideration. Each Respondent

must use the proposal response format as follows: State the question or item exactly as appears;

then provide your detailed response.

I. Proven ability to provide high quality services.

a. Describe your operation:

i. Identify Ownership

ii. Organization Structure (attach organization chart)

iii. Indicate years of experience providing the requested type of service.

iv. Identify any award or special recognition from regulatory, licensing bodies or

professional associations.

b. Describe background and experience of the entity or individual as a provider of Self-

funded Medical & Pharmacy Administration and/or Employee Benefits Consultation

services or substantially similar services showing ability to provide these services.

c. Provide three references who are familiar with your background in providing Self-

funded Medical & Pharmacy Administration and/or Employee Benefits Consultation

services (provide name, title, address, telephone).

d. Provide detailed information on all contracts which have been terminated in Self-

funded Medical & Pharmacy Administration and/or Employee Benefits Consultation

services or in a substantially similar service in the past 5 years.

II. Cost Proposal

a. Describe your proposal fee structure.

III. Questionnaire and Forms

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Please complete, sign and return the following forms and questionnaires. Only complete those sections you are proposing. Failure to do so could result in disqualification. Should you have any questions, please do not hesitate to contact the person designated in the RFP.

FORMS/QUESTIONNAIRE CHECKLIST

Anticipated Proposal Specifications ☐

MEDICAL

Medical Administrative Questionnaire ☐

Patient Advocacy ☐

Audit Language Questionnaire ☐

Claim Processing Capabilities ☐

Disease Management Questionnaire ☐

Utilization Management Questionnaire ☐

Network Evaluation Questionnaire ☐

Performance Acknowledgement ☐

PHARMACY: Retail/Mail Order Prescription Drug Questionnaire ☐

STOP LOSS: Stop Loss Questionnaire ☐

Anticipated Participant Proposal Specifications

MEDICAL/RX/ADMINISTRATION 1. Please include Click here to enter text.% commission in your proposal

2. Plan design: Click here to enter text.

3. Please quote administration fees in these two scenarios: 1) assume client uses your PBM, and 2)

assume client uses an outside PBM. If additional fees will be charge for sharing and/or integrating data with an outside PBM, please include those fees in your quote.

4. Your administration fee should include the cost of detailed claim reports requested by Tejas throughout the plan year – Monthly Management, Financial, Utilization & Performance Reports.

5. Carrier Reporting Requirements: (Note - All of these reports must be available upon request)

a. Monthly Premium vs. Claims (on a paid and incurred basis) b. Monthly Enrollment broken down by plan c. Paid & Pended claims broken down by inpatient/outpatient/Rx d. Discount Analysis e. Monthly LCR > $50,000 f. Network Analysis (In vs. Out) g. Rx Utilization (patient ID, date filled, NDC-11, quantity, days’ supply, AWP, ingredient

cost, dispensing fee, tax, allowed cost, plain paid amt, member copay, member deductible, admin fee, submitted U&C, cost basis (MAC, AWP, U&C, etc.), brand/generic, mail/retail, formulary tier, maintenance indicator, specialty indicator, submitted compound indicator, submitted DAW indicator, prior authorization indicator, NCPDP#/NABP#)

6. In addition to the above reporting requirements, your cost must include a full data dump

requested by Tejas throughout the year.

7. Please provide description of your capacity for delivering Geo Access reports to include

the State of Texas and areas of surrounding states that may service border regions.

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8. Please Click here to enter text. COBRA administration

9. Include HSA administration, if applicable

10. Your standard Wellness Program must include: a. Health Assessment b. Online Wellness Program c. Personal Healthcare Record d. Preventive Care e. Disease Management (with reporting capability) f. Health Maternity Program

11. The selected administrator must agree to add their proposal response as an Addendum to the

Administrative Service Agreement between the selected administrator and the client and agree to be bound contractually to all the requirements outlined in the Request for Proposal.

12. You must agree to release the renewal proposal within 120 days of expiration

I acknowledge I have read the statements above ☐

STOP LOSS

1. Please include Click here to enter text. % commission in your proposal

2. Contract basis: Click here to enter text.

3. ISL options: Click here to enter text.

4. Pharmacy is included in the Aggregate

5. Corridor: Click here to enter text.

6. Max Aggregate Annual Payment: Click here to enter text.

7. Include Spec & Agg Advance Funding option. If there is a cost associated with it, please break it

out in your proposal.

8. You must waive any “actively-at-work” provisions

9. You must waive any late entrant penalties

10. Run-in should not be limited

11. Please include 12 months of run-out coverage in your rates

12. You must agree to no new lasers at renewal

13. You must agree to release the renewal proposal within 120 days of expiration

I acknowledge I have read the statements above ☐

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Medical Administrative Questionnaire

1. From what city will claims be administered? Click here to enter text.

2. Do you provide in-state and/or national 800 telephone service? What, if any, are the additional charges for this service? What hours is the service available? Can you offer a dedicated 800 number for the client? Click here to enter text.

3. Describe your company's performance standards with respect to: a. Employee inquiries (both written and telephonic);

Click here to enter text. b. Claims turnaround;

Click here to enter text. c. Claims accuracy - both financial and procedural

Click here to enter text. d. Claims process with time frames for review

Click here to enter text. 4. Is your firm willing to incorporate guaranteed turnaround time, COB recovery and quality performance

standards in its contract with the client? Click here to enter text.

5. Describe your company’s quality assurance and/or internal audit procedures and programs. Are you willing to provide the client with quarterly audit reports on its claims? You will be required to allow an annual audit done by an external auditor; do you have any provisions surrounding audits that would in any way limit the client’s ability to fully audit their claims? Click here to enter text.

6. Describe in detail your claims hardware and software systems, and in particular, your claims editing capabilities (code review). Specifically, address how it checks for procedural discrepancies based on diagnosis, diagnostic “creep”, and procedural unbundling. What percent of claims are detected by these edits? What percent of dollars claimed? How do you treat claims detected as a result of these edits? Do you charge extra for this? Click here to enter text.

7. What percentage of claims are currently auto-adjudicated by your system? Do you expect this percentage to increase or decrease over time? Click here to enter text.

8. What are normal business hours for participant questions or precertification? Click here to enter text.

9. Please describe the nature of the contract you would propose, indicating: a. The length of time of the contract;

Click here to enter text. b. The length of time your fees are guaranteed beyond the required three years

Click here to enter text. c. Termination notices required

Click here to enter text. 10. Please describe the implementation process in detail. Provide a sample timeline assuming award is made

August 15th and effective January 1st. Click here to enter text.

11. How do you propose to collect claims data from the prior carrier to accommodate a smooth transition? Click here to enter text.

12. How would you determine “Days per 1000” by plan? Please explain in detail. Click here to enter text.

13. Are you able to administer on-line, electronic transfer, and tape-to-tape eligibility transfers? How does this impact your cost proposal? Click here to enter text.

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14. Do you have the capability for the client to have access to your claims and eligibility system through an on-line system? Any cost for such a system should be included in your PEPM costs. Click here to enter text.

15. Does your system incorporate scanning capability and if so, is it incorporated into claims adjudication automatically? Click here to enter text.

16. Do you have physician and patient profiling/reporting capabilities? If so, please describe the standard reports available and ad hoc capability. Provide sample reports. Click here to enter text.

17. How would your organization determine usual, reasonable and customary charges for medical, surgical and anesthesia procedures? Answer this question in specific detail for both PPO and indemnity claims including what data source you utilize (e.g. HIAA, etc.) and how often it is updated. Click here to enter text.

18. If claims exceed the individual attachment point, how often are updated claim reports sent to the stop-loss carrier? Do you provide both clinical evaluations as well as claim costs with your standard updates to carriers for stop-loss claims? What carriers do you currently work with? Are there any carriers or MGU’s that you have difficulty working with? Click here to enter text.

19. Please submit a sample of your proposed claim and Explanation of Benefits forms. Would you be willing to customize the information contained in these forms? Would there be an additional cost? Click here to enter text.

20. Please provide a list of all data elements which will be captured off of the claim forms and stored in your claims adjudication system. Do you capture DRG classifications? What information is coded off of a hospital U.B. 92? All revenue codes? How many levels of diagnosis codes are captured? Click here to enter text.

21. Please state what records (including the participant and data processing documents) would; in fact, belong to the client upon contract termination. Click here to enter text.

22. In the event of contract termination, when would records which are property of the client be released to the party or organization designated by the client? Describe your termination notice requirement. Click here to enter text.

23. It is required that all reporting requirements be included in your per capita administrative fee. Do you agree with this provision? Please provide copies of your standard reports for review by the client. Click here to enter text.

24. Are you willing to guarantee ASO fees beyond the initial term? If so, what are your proposed service renewal guarantees or terms? Click here to enter text.

25. Does your system, or can you, administer a program that identifies and coordinates deductibles/claims on a family basis for dual working spouses? Click here to enter text.

26. Please describe any insurance you carry for Fiduciary Liability and Errors and Omissions Insurance. Amount? Carrier? Click here to enter text.

27. Do you pay the printing of checks; EOI’s, and claim forms? Do you process checks and/or EOB’s in house or is this function outsourced? Click here to enter text.

28. Can you handle electronic transfer of prescription drug claims? Click here to enter text.

29. Please attach samples of standard reports or any special cost containment reports available. If there is a charge, please state. Click here to enter text.

30. What process do you have to ensure that claims are not paid after a termination of coverage, or if paid, recovery of payments? Click here to enter text.

31. Does the Administrator employ a full-time M.D. as a medical advisor? If not on a full-time basis, when are the advisors available?

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Click here to enter text. 32. Will you work with the client to design a tailor made claim form?

Click here to enter text. 33. Is your system capable of tracking NPI?

Click here to enter text. 34. Can your system track referrals made by the primary care physician? Is this information date sensitive to

the change? Click here to enter text.

35. Can your system track and provide information by physician (PCP) as to all patients treated, any/all hospital admissions, any emergency treatment, laboratory and any/all physicians referred by PCP? Click here to enter text.

36. Can you guarantee the client that you will enter all ICD-9 and CPT codes to the agreed upon number of digits? The client will insist upon complete and accurate coding entry. Click here to enter text.

37. Can your system track and process itemized hospital charges by code? Click here to enter text.

38. Will there be a guaranteed dedicated contact to assist with the client’s Health Benefits? Refusal to adhere to this provision may directly result in your company not being awarded this contract. Click here to enter text.

39. Please identify any fees or penalties that will be assessed should the client choose to terminate any or all products provided by the vendor within the first 12 months of the agreement, or prior to the agreement end date. Your response should include all related penalties or fees regardless of whether or not they have been previously stated in this RFP response. Click here to enter text.

40. Does your claims system have the following capabilities?

a. Able to process in-network, out-of-network, and out-of-area claims

Yes ☐ No ☐

b. Is there a fee to reprice out-of-network provider claims

Yes ☐ No ☐

c. Integrated access to provider-specific data including contractual and financial arrangements

Yes ☐ No ☐

d. Able to maintain historical eligibility information

Yes ☐ No ☐

e. Able to separate eligibility dates for employees and each covered dependent

Yes ☐ No ☐

f. Flexibility to process benefits at difference coinsurance and out-of-pocket levels for in-network, out-of-network, and out-of-area plans

Yes ☐ No ☐

g. Able to process hospital and all other medical plan related claims including prescription drugs and capture hospital revenue codes

Yes ☐ No ☐

h. Ability to identify authorized referrals and admissions by network status.

Yes ☐ No ☐

i. Able to apply stringent utilization and price controls for out-of-network usage

Yes ☐ No ☐

j. Able to automatically match claims with utilization management information both in-network and out-of-network

Yes ☐ No ☐

k. Common database for edits, pricing, production of EOI's and reporting

Yes ☐ No ☐

l. Able to customize EOI messages

Yes ☐ No ☐

m. Able to report account specific per capita utilization and savings statistics by network site

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Yes ☐ No ☐

n. Able to show the actual and negotiated charge on the EOI

Yes ☐ No ☐

o. Able to show the applicable procedure code

Yes ☐ No ☐

p. Able to show the percentage of payment

Yes ☐ No ☐

q. Able to show the amount of deductible satisfied

Yes ☐ No ☐

r. Automatic rollover of FSA claims

Yes ☐ No ☐

s. Able to accept or reject rollover FSA claims on an individual employee basis

Yes ☐ No ☐

t. Able to integrate telemedicine encounter claims

Yes ☐ No ☐

41. Is your organization also willing to agree to the following performance standards? The percentage at risk will be negotiated at a later date.

Yes No

a. Claim Processing Accuracy (95%) ☐ ☐

b. Claim Turnaround (90% - 30 days) ☐ ☐

c. Financial Payment Accuracy (99.5%) ☐ ☐

d. Financial Coding Accuracy (97%) ☐ ☐

e. Implementation score greater than 90% ☐ ☐

f. Employee Satisfaction score greater than 90% ☐ ☐

42. Do you share OON provider negotiated discounts with the Plan?

Yes ☐ No ☐

43. Is there a fee for accommodating the transfer of carrier data feeds for eligibility, deductible and out-of-pocket accumulator data, or any other data exchanges that may be necessary, between your system and those of the employers other benefit vendors?

Yes ☐ No ☐

44. Is there a charge to participants who work or reside outside of Texas who access a network provider outside of Texas? -

Yes ☐ No ☐

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Patient Advocacy Questionnaire

1. Please provide a brief overview of your company. Include information on the length of time your company has been in business, number of clients, facilities and ownership. Click here to enter text.

2. What is the average daily call volume your company handles? Click here to enter text.

3. What are your standard service metrics for wait time, abandoned calls, service levels and blockage? Click here to enter text.

4. How many facilities do you have and where are they located? How many workstations does each facility have? Click here to enter text.

5. Please describe your ACD and telecommunications structure including number of T1 circuits. Click here to enter text.

6. Please describe your minimum computer hardware and software for each agent workstation. What is the typical start-up time for a new program? Click here to enter text.

7. What hours is your computer center staffed? How many people do you have in your IT department? Click here to enter text.

8. What security measures do you have in place to protect client data? Click here to enter text.

9. What are your ACD reporting capabilities? What report delivery options do you offer? Click here to enter text.

10. Can you provide customized reports? Is there a customer portal? Click here to enter text.

11. Describe the type and frequency of reporting that you will provide, Click here to enter text.

12. Please provide samples of your standard reports. Click here to enter text.

13. What is the start-up process for a new account? Please describe your forecasting process. Which staffing and/or scheduling tools do you use? Please provide information on your key management. How are account managers selected for each program? Click here to enter text.

14. How many client programs does each account manager oversee? Click here to enter text.

15. What is your hiring criteria and process for new agents? How do you train your agents, initially and on-going? What type of agent motivation and retention programs are currently in place? Click here to enter text.

16. What is your overall annual agent turnover rate? Click here to enter text.

17. What quality assurance programs do you have in place? Describe your monitoring capabilities. Do you provide remote monitoring capabilities to your clients? What is your quality assurance staff to agent ratio? Click here to enter text.

18. How often are your agents monitored? Please provide a copy of your standard monitoring form. Click here to enter text.

19. How does your company illustrate a return on the client’s investment? Click here to enter text.

20. Describe how your program assists members in addressing provider balance billing for ineligible items such as excesses of reasonable and customary. Click here to enter text.

21. Please provide a list of the scope of services that your company provides. Click here to enter text.

22. What tools & resources do you provide or are available the client to distribute to the employees?

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Click here to enter text. 23. Please provide all costs associated with your services. Include price per minute. Please denote initial

charges and on-going costs. Click here to enter text.

24. What start-up fees do you charge? Click here to enter text.

Audit Language Questionnaire

Please answer “Agree” or “Disagree” only:

1. Client retains access to 100% of all claims data including all data fields necessary to perform a 100% analysis of claims paid by the plan for the applicable period, including but not limited to all claims payment fields, provider name, provider billing address, and all provider contact information including phone number. Click here to enter text.

2. The client may audit the two prior plan years Click here to enter text.

3. The Administrative Service Agreement will include the following language, “Incurred Claims for the prior two plan years, and all claims paid through the current plan year”. Click here to enter text.

4. Remove any restrictions that could limit client’s access to service including: a. Selection of 3rd party vendors to perform review or recovery

Click here to enter text. b. Limitations on 3rd party contract terms (i.e. “no contingency arrangements”)

Click here to enter text. 5. Any improper payments by the plan as determined by the client or administrator may be

recovered by the administrator, the client or a third party chosen by the client at the client’s sole discretion. NOTE TO THE INCUMBENT: This should be effective retroactively to include the most-recent contract and plan year(s). Click here to enter text.

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Claim Processing Capabilities Please answer “Automated” or “Manual” only Processes:

1. Claims inventory - Click here to enter text.

2. Eligibility of employees - Click here to enter text.

3. Eligibility of dependent - Click here to enter text.

4. Track dual addresses (i.e. QMCSO) - Click here to enter text.

5. Usual, customary, reasonable - Click here to enter text.

6. Benefit plan excluded charges - Click here to enter text.

7. Pre-existing conditions - Click here to enter text.

8. Adjudication - Click here to enter text.

9. Coordination of benefits - Click here to enter text.

10. Check issuance - Click here to enter text.

11. Subrogation - Click here to enter text.

12. Explanation of benefits issuance - Click here to enter text.

13. UR authorized in-patient days - Click here to enter text.

14. Medical necessity - Click here to enter text.

15. Deductible - Click here to enter text.

16. Out-of-pocket benefit maximums - Click here to enter text.

17. Co-insurance - Click here to enter text.

18. Duplicate charges - Click here to enter text.

19. Second opinion program - Click here to enter text.

20. Co-pays - Click here to enter text.

21. Preferred provider/Nonpar - Click here to enter text.

22. Unbundling of charges - Click here to enter text.

23. Physician referrals - Click here to enter text.

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Disease Management Questionnaire

GENERAL QUESTIONS

1. Please provide a brief description of your organization, including history, business philosophy, and target market. Click here to enter text.

2. Describe any unique qualifications that distinguish your company within the disease management industry. Click here to enter text.

3. How do you protect individual participant data? How are you addressing HIPAA-specific data privacy requirements? Are you up to date with HIPAA compliance with EDI and privacy requirements? Date first operational: Click here to enter text.

4. Describe your service area. Click here to enter text.

ACCOUNT MANAGEMENT/IMPLEMENTATION

1. Who are the individuals that would provide account management services to the client? What are their qualifications? Click here to enter text.

2. Provide a detailed description of the implementation process, including how you will work with the client, its plans and other programs. Click here to enter text.

3. How often will you meet in person with the client during implementation, including promotion and education of client beneficiaries regarding the availability of your program? Click here to enter text.

4. Once the program is implemented, how often will you meet with the CLIENT to provide feedback, updates and reports? Click here to enter text.

5. Describe your process to communicate the disease management program to employees. Click here to enter text.

6. Can communications materials be customized? If yes, identify what can be customized and if there would be any additional fees for customization. Click here to enter text.

7. Are multi-lingual materials available? Click here to enter text.

8. Please provide copies of all implementation AND communication materials. Click here to enter text.

9. List the diseases covered in your disease management programs and specify whether they are currently available or in development. Click here to enter text.

10. Do you use clinical practice guidelines? If yes, specify which guidelines are used and how they are applied. Click here to enter text.

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11. Describe the types of interventions and methods of delivery used for the disease management programs you offer. Click here to enter text.

12. Explain how Disease Management interventions are targeted to individual participants’ needs and motivation to change. Click here to enter text.

13. Do you use a readiness to change behavioral model in the delivery of your services? If so, describe. Click here to enter text.

14. How do you track and monitor patients over time? Click here to enter text.

15. Describe how you handle co-morbid conditions and provide a list of the co-morbid conditions you address. Click here to enter text.

16. Do you have an educational component to your program and educational materials? Click here to enter text.

17. What is the literacy level of your written materials? Click here to enter text.

18. What methods do you use to identify candidates for the disease management programs and the frequency of each method? Click here to enter text.

19. Describe your information technology infrastructure. Click here to enter text.

20. Describe the desktop system that is used in your Disease Management operations? Click here to enter text.

21. Do you use any data mining software in your Disease Management? Click here to enter text.

22. Describe system security and back-up procedures. Click here to enter text.

23. Describe the process of Claims Data and Eligibility transfer from the Medical plan TPA. Click here to enter text.

24. How much data do you need initially? Click here to enter text.

25. What is the frequency of subsequent feeds? Click here to enter text.

26. Please provide the file feed format and any necessary specifications. Click here to enter text.

ENROLLMENT 1. How does your organization encourage participation in Disease Management programs?

Click here to enter text.

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2. What is your program enrollment rate?

Click here to enter text. 3. Do participants graduate from the program? If so, what is the graduation criteria?

Click here to enter text. 4. How often are outbound calls made to participants?

Click here to enter text. 5. Describe the makeup, qualifications, and experience of the Disease Management staff?

Click here to enter text. 6. List the components that make up your staff training and indicate whether each component

occurs during orientation or is ongoing.

Click here to enter text. 7. Provide the hours of operation.

Click here to enter text. 8. Do you offer a 24-hour nurse line service?

Click here to enter text. 9. Describe in detail how your organization will implement the current plan and what services your

organization can provide to assist the client in managing the Diabetic Plan.

Click here to enter text. 10. Describe how your organization collaborates with an employer’s other health care initiatives to

deliver integrated disease/condition management services.

Click here to enter text. 11. How do you identify the participants’ physician and how are they incorporated within the care of

participant?

Click here to enter text. 12. How do you handle physicians that are non-compliant with the necessary protocol for the

patient’s disease state?

Click here to enter text. 13. Describe all care management services available through your organization to large employers.

Which services, if any are outsourced to third parties?

Click here to enter text. 14. Describe how your organization retrieves & reviews paid claim data when analyzing a prospective

client’s needs.

Click here to enter text. 15. Are reporting tools available to clients electronically?

Click here to enter text. 16. Do you utilize any statistical methodology for early disease detection (e.g. predictive modeling)?

Click here to enter text. 17. Indicate which measures you use to determine program impact and cost savings.

Click here to enter text. 18. Please provide a sample of standard client reports.

Click here to enter text. 19. What data elements are captured and tracked in your Disease Management programs and which

ones can you report back to the client?

Click here to enter text. 20. Describe the types of client reports available. How often are reports provided?

Click here to enter text. 21. Will you provide comparative data from your book of business?

Click here to enter text. 22. Please provide copies of standard client reports.

Click here to enter text. 23. Are you capable and will you provide customized client reports?

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Click here to enter text. 24. What services are included in your fees? Describe all potential extra fees in providing services.

Click here to enter text. 25. List all Disease Management programs and services you propose to provide to the client and

indicate your proposed fees.

Click here to enter text.

Utilization Management Questionnaire

1. Name of Firm, Headquarters Address and Phone Number: Click here to enter text.

2. Executive contact, name and title: Click here to enter text.

3. How many locations does your firm have working within its Utilization Review Program? Click here to enter text.

4. Include primary contact, number of professionals by category (M.D., R.N., etc.) number of para-professionals and size of support staff. Identify the location which would provide review services. Click here to enter text.

5. How long has your firm been providing Utilization Review services? Click here to enter text.

6. What is the present number of employees working in Utilization Review? Click here to enter text.

7. Approximately how many groups and covered persons does your firm presently serve? Click here to enter text.

8. What were these totals 12 months ago? Click here to enter text.

9. Can the above services be purchased separately? Click here to enter text.

10. Does your firm provide consulting advice or other services in regard to Wellness Programs? Click here to enter text.

11. Does your firm have any geographic restrictions regarding where it may provide services? Click here to enter text.

12. Please provide the most recent annual report for your firm. (Submit with your proposal.) Click here to enter text.

13. Are your UR services provided by your company, a subsidiary or a vendor? Click here to enter text.

14. Are all hospitalizations, regardless of diagnosis, included in Utilization Review? Click here to enter text.

15. How is each party kept informed? (Patient, Physician, Employer) Click here to enter text.

16. How are certifications obtained by phone and by mail? Click here to enter text.

17. What specific information is submitted in the initial request for certification? (Include sample form) Click here to enter text.

18. Are length of stay guidelines provided with initial admission approval? Click here to enter text.

19. To what extent are nurses and/or physicians involved, step-by-step in the certification procedures? At what point is a physician called to review the nurse in the evaluation? Click here to enter text.

20. Are concurrent review and discharge planning normally included with your firm’s pre-admission certification review? Click here to enter text.

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21. Are length of stay extensions typically administered within this part of the program? Click here to enter text.

22. What procedures does your firm believe belong with concurrent review and discharge planning? Click here to enter text.

23. Is this procedure handled by your firm or delegated? Click here to enter text.

24. If delegated, do you contract with various Peer Review Organizations? Click here to enter text.

25. How are contracts made by your administrators with attending physicians to be certain estimated discharge dates are met? Click here to enter text.

26. Does your firm regard Retrospective Review and Hospital Bill Audit as one or separate services? Click here to enter text.

27. What is your procedure regarding retrospective review? Click here to enter text.

28. What is your procedure regarding hospital audits? Click here to enter text.

29. Does your firm provide a medical case management program? Click here to enter text.

30. Indicate how your program states its objectives in view of typical goals of: a. Identifying alternate care

Click here to enter text. b. Recommending accelerated care

Click here to enter text. c. Reduction of medical complications

Click here to enter text. 31. Has your firm identified a list of illnesses and injuries it considers best for MCM? If so, please list:

Click here to enter text. 32. If your firm were selected to administer the Utilization Review Program, do you believe your firm

would be in a position to also administer the MCM program more efficiently than the primary claim administrator? Explain. Click here to enter text.

33. Indicate what levels of Disease Management your firm currently provides by disease state. Click here to enter text.

34. Number of local full-time equivalent Medical Directors on staff? Click here to enter text.

35. Number of local full-time equivalent Nurses on staff? Click here to enter text.

36. Average number of year's clinical experience and utilization review experience. Click here to enter text.

37. Do you have on-line access to claim payment function? Click here to enter text.

38. Do you handle both in-network and out-of-network claims? Click here to enter text.

39. How are cases identified for potential case management? Describe specialized handling of catastrophic illnesses. Click here to enter text.

40. What guidelines do you use for in-patient pre-admission certification and concurrent review? To what extent is concurrent review performed on-site at the hospital? Click here to enter text.

41. How do you measure patient satisfaction? Click here to enter text.

42. Are you accredited by NCQA or any other accrediting organization? Please provide name of organizations and accreditation dates. Click here to enter text.

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43. Based upon your firm’s experience, what do you believe is typically a satisfactory lead time (stated in days) to implement a Utilization Review Program? Click here to enter text.

44. Will your firm be willing to provide a representative to attend meetings to explain your Utilization Review Program? Click here to enter text.

45. Please provide us with examples of your recent communication work Click here to enter text.

46. Does your firm issue ID cards or stickers to be used on existing ID cards? Click here to enter text.

47. Does your firm supply postage-paid envelopes for mail-in requests? Click here to enter text.

48. How many hours per day and days per week are your firm’s phone lines open? Click here to enter text.

49. Do you provide a toll-free number for use by covered members, providers, and the client? Click here to enter text.

Network Evaluation Questionnaire

1. Where do you provide the following tertiary care? What types of contracts do you have with these facilities (none, case to case, or blanket)? a. Premature infants:

Click here to enter text. b. Cardiovascular care:

Click here to enter text. c. Burns:

Click here to enter text. d. Organ transplants:

Click here to enter text. e. Severe trauma:

Click here to enter text. f. Other tertiary:

Click here to enter text. 2. Are hospital reimbursements at the lesser of billed charges or contracted price?

Click here to enter text. 3. How many Primary Care Physicians and Specialist Physicians are participating in your Network in

the 4 counties surrounding the client? Click here to enter text.

4. Are you able to track out-of-network charges? If yes, what percentage of the physician charges reimbursed within medical plans you sponsor/administer are paid to participating physicians? Click here to enter text.

5. Describe your reimbursement arrangement (e.g., McGraw-Hill M.D.R. - HIAA, R&C, etc.) and provide the CPT code allowable chart. Click here to enter text.

6. Are there any fees associated with the repricing of claims for out-of-network providers? If so, please explain. Click here to enter text.

7. Are participating primary care physicians required to accept new patients? Click here to enter text.

8. Do primary care physicians have “gatekeeper” responsibilities within your system? Click here to enter text.

9. If not, how are specialty utilization and out-of-network referral costs controlled? Click here to enter text.

10. Are PCP referrals required to access specialist care? Click here to enter text.

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11. What information/assistance for referrals does the Network provide PCPs? Click here to enter text.

12. Do physicians have risk-sharing arrangements (e.g., risk pools, withholds)? If yes, please describe. Click here to enter text.

13. Describe your physician selection and termination criteria. Describe your credentialing requirements for physicians. Are these requirements made prior to or after acceptance into the network? Who performs the credentials review and how often are physicians re-credentialed? This may be provided elsewhere on proposal. Click here to enter text.

14. How many physicians have been added and dropped out of the network over the last three years? Describe and quantify reasons. Click here to enter text.

15. Provide a GeoAccess Map of Network Physicians and Hospitals in the counties immediately surrounding the client for an exact zip code match. Click here to enter text.

16. Clearly outline your proposed PPO Discount Performance Guarantee to include any claims which may be excluded and all caveats to above mentioned guarantee. Click here to enter text.

17. Describe your quality assurance program and provide a copy of any guidelines utilized. Click here to enter text.

18. What data and education do you provide to providers? Do you have a provider “report cards” system (e.g., specialist referral rate, in-patient statistics) member feedback, comparisons to standards and peers? If so, describe. Click here to enter text.

19. Does a technology assessment process exist? Click here to enter text.

20. How are medical necessity guidelines developed and modified? Click here to enter text.

21. How are guidelines communicated to network providers? Click here to enter text.

22. Does network perform clinical outcome studies? If so, describe: Click here to enter text.

23. Is a portion of physician compensation directly based on individual quality results? Click here to enter text.

24. What percentage of your statewide network is owned by you and what percentage is leased? Click here to enter text.

25. If you are utilizing a lease network, please list the areas of the state by client that you access via the lease network. Click here to enter text.

26. Describe work flow. Does the network re-price claims prior to submission to payer? Is this data captured? (Please provide reports.) Click here to enter text.

27. What data is available and in what format? Click here to enter text.

28. What census data, membership demographics is available? Click here to enter text.

29. What frequency of service data is maintained and how often are reports run and reviewed? Click here to enter text.

30. What charge data is captured and how often are reports run summarizing the results? Click here to enter text.

31. What provider data is captured and how often are reports run summarizing the results? Click here to enter text.

32. How is hospital reimbursement calculated and who does it? The network or a third party? Is payment accuracy verified? If so, how? Click here to enter text.

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33. How is physician reimbursement calculated and who does it? The network or a third party? Is payment accuracy verified? If so, how? Click here to enter text.

34. Is payment accuracy verified and if so, how? Click here to enter text.

35. Does network credential all participating providers and facilities? If not, which are? Click here to enter text.

36. What hospital credentialing and re-credentialing criteria are required? Click here to enter text.

37. How often are facilities re-credentialed? Click here to enter text.

38. What percent of physicians are credentialed? What documentation is kept in network files? Click here to enter text.

39. Is the credentialing function delegated to a third party (e.g., IPA or hospital)? If so, to whom? Click here to enter text.

40. Is each physician credentialed before being accepted into network? Click here to enter text.

41. What percent of your participating physicians are board certified PCP and Specialists? Click here to enter text.

42. Do you contract with any entities such as prescription drug organizations, mental, nervous and chemical dependency companies, etc. which perform their functions at discounted and/or capitated rates? Click here to enter text.

43. Please describe these arrangements, the associated reimbursement contract, the utilization reporting capabilities and the generic substitution rate (for prescription drug arrangements). Click here to enter text.

44. What is your fee for accessing the network? What services are included in the fee?

Click here to enter text. 45. What other services are available, and at what cost?

Click here to enter text. 46. Please include copies of the following:

a. Financial statement or annual report Click here to enter text.

b. Current organizational chart Click here to enter text.

c. Background and profile of your management personnel Click here to enter text.

d. Sample hospital contract and reimbursement arrangement Click here to enter text.

e. Sample physician contract and reimbursement arrangement Click here to enter text.

f. Copies of standard data report (especially reports that demonstrate medical management capabilities and/or savings achieved) Click here to enter text.

g. Client area provider directory Click here to enter text.

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Performance Acknowledgement Please answer “Agree” or “Disagree” only. If you disagree, please explain:

CLAIMS SETTLEMENT

1. ASO - A client account will be established and you will be given authority to draw benefit checks from this account. The client would like to operate a zero balance account for this plan. Please indicate if this is a problem for your organization.

Click here to enter text. 2. It will be your responsibility to maintain computer eligibility. The client would like

an adequate "direct" claim status system for review of claim processing as well. You will be responsible for training on the claim status system.

Click here to enter text. 3. You will be responsible for the complete calculation of the benefits payable,

including investigation, follow-up coordination of benefits, preparation and sending of Form 1099 to providers, and the drawing and mailing of checks. Other than PPO providers, checks are to be mailed directly to the employee unless he/she specifies on the claim form that payment should be sent directly to the medical/dental providers.

Click here to enter text. 4. The TPA will be fully responsible for preparation and dissemination of any

information to be sent to the I.R.S. If penalties are assessed because of incorrect or late filings by the TPA, the TPA will be responsible for any such assessments and will hold the client harmless.

Click here to enter text. 5. If the client or an employee of the client has a question concerning the settlement

or status of a claim, it is your responsibility to provide a satisfactory and timely answer to the question.

Click here to enter text. 6. In settling the claim, you will be required to perform up to the following minimum

standards: a. All claims received in your office(s) in proper, complete order will be

calculated and paid within 30 working days; Click here to enter text.

b. All benefit checks must reach the employee or provider within 30 days after submission of a claim, unless more information or C.O.B. is involved; Click here to enter text.

c. No claim shall go un-worked for more than 21 days. The status of a pending or C.O.B. claim must be updated on the system within this time; Click here to enter text.

d. No claim can be over 60 days old for any reason; Click here to enter text.

e. The clerical error ratio on claims must be less than two percent and dollar ratio of one percent;

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Click here to enter text.

f. Meet all federal guidelines on claims turnaround and processing standards; Click here to enter text.

g. Meet all electronic standards for transmission of electronic claims; Click here to enter text.

h. Be completely compliant with all HIPAA requirements for claims administrators; and Click here to enter text.

i. Medical must meet PPACA standards/requirements Click here to enter text.

7. TPA will be responsible for re-pricing of all claims for PPO discounts. Click here to enter text.

8. A 1-800 number shall be provided to the employees for customer service from 6 a.m. to 10 p.m. Central Standard time. Please include a toll free nurse line as well. Click here to enter text.

9. Administrative service personnel shall be available for on-site consultations with client personnel as necessary. Click here to enter text.

10. All records, member files and miscellaneous data necessary to administer the plan shall be the property of the client. The selected administrator will be asked to transfer records to the client in an electronic format of their choice. Click here to enter text.

11. The administrator shall not charge against the plan experience any claim payment not authorized under the health policy (except those specifically authorized in writing by the client). In the event of such an error, the administrator shall be responsible for all collections and/or plan reimbursement expenses. Click here to enter text.

12. The administrator shall indemnify, hold, and save the client, the consultant and their agents, officers and employees harmless from liability of any nature or kind, including costs, expenses, and attorney's fees, for harm suffered by an entity or person as a result of the negligent, reckless, or willful acts of omissions by the carrier, its officers, agents or employees. Click here to enter text.

13. The proposals/proposers must quote a price for all services. The client does not wish to pay additional/separate fees under the contract for the following items, whether or not they are customized: a. ad hoc reports requested on as needed basis

Click here to enter text.

b. enrollment materials Click here to enter text.

c. claim forms Click here to enter text.

d. identification cards Click here to enter text.

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e. plan booklets Click here to enter text.

f. PPO savings reports Click here to enter text.

g. provider reports monthly, quarterly and annual Click here to enter text.

h. reasonable and customary information Click here to enter text.

i. dedicated service professional to assist the client with electronic claims status system Click here to enter text.

14. The client may conduct an annual written randomly selected employee satisfaction survey. The TPA must meet an employee satisfaction level of 90% as determined by the client. Click here to enter text.

15. Annual renewal prices will not exceed the percentage increase specified in the proposal. All proposals/proposers must sign and agree to this stipulation in order to be considered. Click here to enter text.

16. All proposals/proposers must sign and agree to the standard contract language regarding indemnification, ownership of records and databases, term of agreement, and no arbitration clause in order to be considered. Click here to enter text.

17. Besides on-line claims adjudication services, the Administrator must maintain a detailed eligibility file that includes date of birth, social security number, premium detail and address information for the employee and/or dependent(s). The Administrator should be able to calculate premium listings by line of coverage and disburse reinsurance payments for the clients. Claim checks must be run on a client directed schedule. The Administrator must be able to administer all of the benefits offered by the client accurately and timely. The Administrator must be capable of designing and assisting in booklet preparation, plan documents, custom claim forms, ID Cards, and worksheets. Failure to fulfill these provisions on a consistent basis may result in termination of this contract for default. Click here to enter text.

18. All proposals must include a flat administration fee. All proposals must exclude any alternative revenue streams generated via the claims wire. This includes but is not limited to arrangements like shared savings, NAP, or blue card fees. Click here to enter text.

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STATISTICS

1. The client has not designed nor developed an informational system. Therefore, the major portion of your statistical responsibilities will be to provide the client with monthly appropriate claims information they deem necessary for their operations. Click here to enter text.

2. The other type of statistical reporting you must provide for the medical benefits is a monthly total of the paid claims by plan. This monthly total must be provided by the 15th of the following month. Click here to enter text.

3. Daily, weekly and monthly check registers must be available. Click here to enter text.

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Retail/Mail Order Prescription Drug Questionnaire

1. Who owns your organization? If applicable, please describe the organizational relationship between your organization and its parent company. Click here to enter text.

2. When did your organization begin administering the following? POS retail programs, mail service programs, integrated POS retail/mail service pharmacy programs. Click here to enter text.

3. Is the Quantity Level limits plans flexible or does the client have to abide by proposers set programs? Click here to enter text.

4. Please provide a location for each of the following as they relate to the client’s account: Home Office, Regional Office, Claims Processing, Mail Order Services, and Customer Service. Click here to enter text.

5. Please list all employees that will be assigned to the client’s account including their titles, roles and responsibilities and information regarding advanced customer service systems and programs, personal ownership and commitment by customer service staff to provide prompt and accurate information to members. Click here to enter text.

6. Is your organization authorized to do business in the state of Texas? What other states are you authorized to do business in? Click here to enter text.

7. Do the fees provided include any level of commissions, overrides or bonuses? Click here to enter text.

8. Does your organization agree that all records, member files, and miscellaneous data used in administration of this plan shall remain the property of the client? Click here to enter text.

9. For those third party administrators with integrated pharmacy services, who is your pharmacy benefit manager? Click here to enter text.

10. Please describe methodology for ingredient costing and whether zero balance costing is applied. Click here to enter text.

11. Please describe your mail-order system. Click here to enter text.

12. Please describe available programs/options to control high costs associated with compound drugs and specialty drugs. Click here to enter text.

13. Please describe your patient compliance program. What interventions do you perform? What evidence do you have of the program's success? Click here to enter text.

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14. Please provide your ability to interface with other carriers for the delivery of claims data that supports plan design (deductibles, maximum out of pocket). Click here to enter text.

15. Please describe your formulary process -- how drugs are selected, by whom, how often it is updated, etc. Click here to enter text.

16. Please describe your ability to manage a customized formulary (one of our design). Click here to enter text.

17. Please describe how you communicate the formulary and any midyear changes to the formulary to physicians, pharmacists and our employees. Click here to enter text.

18. Please describe your rebate process -- how do you track utilization, how and when you submit utilization to manufacturers, how and when you distribute rebate monies. Click here to enter text.

19. What pharmacy rebate guarantees are you providing? Click here to enter text.

20. All retail and Retail-90 claims must be priced using “lowest of logic," which means that claims will price at the lowest of the discounted ingredient price plus dispensing fee, the MAC plus dispensing fee, or the pharmacy’s U&C amount (including the pharmacy's sale price, if any). Pharmacies/Offerors will not be allowed to use “zero balance logic” or charge a "minimum copayment amount." Please explain if the above does not meet your criteria. Click here to enter text.

21. When a formulary change occurs, will respondent send a target communication to affected individuals 60 days prior to the change taking effect? If so, please provide a copy of the communication. Click here to enter text.

22. Please confirm a pre-implementation audit would include pharmacy as well as medical. Click here to enter text.

23. Please list all national and local retail pharmacies available to members. Click here to enter text.

24. Please provide statistics on employee resolutions as well as statistics for each service line when an employee calls into the help line. Click here to enter text.

25. What is the staffing model for serving the Plan Sponsor? Click here to enter text.

26. Will staff be dedicated to the Plan Sponsor for no additional cost? Click here to enter text.

27. Please provide claim adjudication statistics for the proposed claim office. Your Standard and 2016 Results for the following: a. Financial accuracy (percent of dollars paid correctly)

Click here to enter text. b. Overall accuracy (average payment incidence accuracy)

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Click here to enter text. c. Percentage of clean claims completed in 15 calendar days

Click here to enter text. d. Percentage of clean claims completed in 30 calendar days

Click here to enter text. 28. Please provide sample of performance guarantees and administrative fee

adjustments for failure to meet implementation and ongoing service requirements. Click here to enter text.

29. Please provide vendor fiduciary levels and any fees associated with each level. Click here to enter text.

30. Please indicate the amount of Implementation Credit you will provide, which will be funds that the client may use to offset "Implementation expenses." At no point will the client be required to pay for used or unused portions of the credit offered by your organization. Click here to enter text.

31. What is respondent’s preferred billing method? Are there any alternatives? Click here to enter text.

32. Will respondent mail out SBCs to employees for no additional cost to the client? Click here to enter text.

33. Please describe technologies which assure claims payment accuracy and timely turnaround; electronic eligibility interface; flexible technology to respond promptly and efficiently to rapid plan design changes, interactive voice response for members when accessing services, and/or web applications. Click here to enter text.

34. Please provide a description of your fraud control programs. Specifically describe your internal fraud control procedures for prevention of the following:

a. Processor or other internal fraud Click here to enter text.

b. Provider fraud Click here to enter text.

c. Enrollee fraud Click here to enter text.

d. Method of reporting fraud control activities and results back to clients Click here to enter text.

e. Where are offices located that will handle fraud; provide staffing for these offices and an organization chart. Click here to enter text.

35. Describe your standard appeals procedures for disputed claims. Click here to enter text.

36. Do you provide services for Independent Review for external review claims? Click here to enter text.

37. Describe your standard subrogation process. Click here to enter text.

38. Please provide sample reporting to include but not limited to: a. Census by demographic profiles

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Click here to enter text.

b. Recoveries for coordination of benefits, subrogation, claims processing errors, etc. Click here to enter text.

c. Large case claimants by plan Click here to enter text.

d. Report of participant activity by plan for preventive screenings, physical exams, ect. Click here to enter text.

39. Ability for the client to access "drill-down" reporting on specified utilization concerns of the client Click here to enter text.

40. Ability to report on appeals status and turn-around performance, etc. Click here to enter text.

41. Sample explanation of benefits forms, coordination of benefits requests, requests for third party accident forms, and other notices that would be provided to members. Can the above reports be pulled off the respondent’s portal? If so, how often? Click here to enter text.

42. Will respondent provide a monthly large case review with the clinical consultant for no additional cost? Click here to enter text.

43. Please provide a formulary disruption report. Click here to enter text.

44. Will respondent provide and mail creditable coverage notices for no additional cost to the client? Click here to enter text.

45. Please provide a list and summary of additional value added services not mentioned above with a price schedule. Click here to enter text.

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Stop Loss Questionnaire

GENERAL INFORMATION

1. What year was your organization established? Click here to enter text.

2. Has your company done business under other names? If yes, please provide historical background information. Identify any interests your organization may have with associated vendors (claims administrators, brokerage firms, managed care firms, etc.). Click here to enter text.

3. Have you ever been suspended from writing this line of coverage? Click here to enter text.

4. Is your organization licensed to do business in all 50 states and U.S. territories? If not, list the states/territories in which you are not currently licensed. Click here to enter text.

5. What percentage of the risk does your company assume? If less than 100%, please identify additional reinsurer(s) and the respective percentage of assumed liability. Click here to enter text.

6. In what month do your reinsurance treaties renew? Click here to enter text.

7. How many excess loss clients do you currently have? Click here to enter text.

8. How much annualized premium do these clients represent? Click here to enter text.

9. Please provide your current A.M. Best Rating and Financial Size Category. Click here to enter text.

10. Please describe your disclosure process for pre-sale and at renewal (if different). Click here to enter text.

11. Please provide a copy of your reinsurance contract and any amendments. a. When was the enclosed contract adopted?

Click here to enter text.

b. Please provide a copy of your disclosure statements. Click here to enter text.

In most cases, we require that your organization work directly with Tejas rather than our

client’s claims administrator (TPAs, BCBS plans, carriers, etc.) on such things as Renewals,

Specific & Aggregate contract concerns, Plan Document/SPD adoption / approval and Plan

amendments.

Click here to enter text.

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PROPOSAL

1. What is the minimum group size for which your company will issue a proposal? Click here to enter text.

2. What industries (if any) does your company consider to be “preferred”? Please list. Click here to enter text.

3. What industries (if any) does your company consider to be “ineligible”? Please list. Click here to enter text.

4. For public entities, do you have any restrictions on percentages of certain types of employees, such as police and fire employees? Click here to enter text.

5. Is your organization able to work with any claims administrator (TPAs, BCBS plans, carriers, etc?) If no, provide a listing of all U.S. based claims administrators with whom your organization will do business. Please also indicate those that may have a “preferred” status and describe the advantage to the client in doing business with these claims administrators. Click here to enter text.

6. Is your organization’s excess loss contract guaranteed renewable? If no, describe your determination and notification methods. Click here to enter text.

7. Does your second year contract automatically renew as a paid contract? Click here to enter text.

8. Is your organization capable and willing to contact the claims administrator (TPAs, BCBS plans, carriers, etc.) or Case Management firm directly to obtain additional information related to large claimants? Click here to enter text.

9. When do you consider claims experience to be fully credible? Click here to enter text.

10. Coverage is based on a no-loss / no-gain full transfer of coverage basis. If you disagree, please explain. Click here to enter text.

11. Tejas desires firm rates at least 90 days prior to sale. Click here to enter text.

12. Tejas considers coverage to be “bound” when the new carrier is in receipt of the binder check or first month’s premium payment and executed application. Do you agree with this statement? Click here to enter text.

13. Once firm rates are presented and coverage is bound, under which circumstances, if any, would your organization modify rates / factors mid-year? Click here to enter text.

14. Are you able to propose a terminal liability option for a group that may, at some point in the future, choose to convert to a fully-insured arrangement? Click here to enter text.

a. What is the cost to include this option? Click here to enter text.

b. Is this option available at initial policy issue and also at renewal?

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Click here to enter text.

15. Does your organization offer “preferred” pricing based upon the client’s network(s)? Click here to enter text.

16. If yes, provide a listing of the networks your organization has rated; identify the status level for each and the associated percentage of savings discount. Click here to enter text.

17. What is your range of commissions offered? Click here to enter text.

18. Do you require that the prospective client purchase additional lines of coverage in order to bind stop loss coverage with your organization? If yes, outline your requirements. Click here to enter text.

19. Do you require that the prospective client purchase additional lines of coverage in order to bind stop loss coverage with your organization? If yes, outline your requirements. Click here to enter text.

20. Do you limited the percentage of covered lives that are COBRA and / or retirees? If yes, please provide details. Click here to enter text.

SPECIFIC

21. What is the minimum individual specific deductible your company offers? Click here to enter text.

22. What percentage discount / credit is applied to your “first year” (i.e., 12/12) specific pricing? Click here to enter text.

23. How long are your specific rates guaranteed? Click here to enter text.

24. Are you willing to guarantee these rates for a period longer than twelve months? If yes, will this impact rates? If yes, how so? Click here to enter text.

25. Please describe the specific incurred/paid contract periods (i.e., 12/12, 12/15, etc.) that you offer. Click here to enter text.

26. Is there a run-in limit on specific stop loss? If yes, what is the percentage or formula? Click here to enter text.

27. What is the maximum individual lifetime maximum amount your contract recognizes as eligible (i.e., $2 million, $5 million, unlimited)? Click here to enter text.

28. Do you have more than one option available? Click here to enter text.

29. Confirm that your specific coverage(s) can include the following benefits: a. Medical

Click here to enter text.

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b. Prescription Drug Click here to enter text.

c. Vision Click here to enter text.

d. Dental Click here to enter text.

e. Short Term Disability Click here to enter text.

30. Do you laser individuals at policy inception? Click here to enter text.

31. Do you laser individuals at renewal? If yes, indicate whether this applies only to those lasered under the initial contract terms, or if potentially large claimants are reviewed annually. Click here to enter text.

32. If you do not laser, will you laser upon request and offer a lower premium? Click here to enter text.

33. If you do laser, will you offer a premium increase instead of the laser? Click here to enter text.

34. Does your organization offer the specific deductible on a standard, aggregating and / or family basis? Click here to enter text.

35. What is your organization’s average turnaround time, in days, for specific claims submitted for reimbursement? Click here to enter text.

36. With respect to specific claims submitted for reimbursement, please describe any limitations (i.e., minimum dollar amounts). Click here to enter text.

37. Is the maximum benefit for specific excess loss the plan’s lifetime maximum amount less the specific deductible? Click here to enter text.

38. Do you offer advance funding or quick pay options for specific claims? If so, please provide details including any additional cost. Click here to enter text.

39. When do you require notification of a specific claim? Click here to enter text.

AGGREGATE

40. What percentage discount / credit is applied to your “first year” (i.e., 12/12) aggregate pricing? Click here to enter text.

41. How long is your aggregate premium guaranteed? Click here to enter text.

42. Are you willing to guarantee these rates for a period longer than twelve months? If so, how would this impact rates? Click here to enter text.

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43. Please describe the aggregate incurred / paid contract periods (i.e., 12/12, 12/15, etc.) that you offer. Click here to enter text.

44. Confirm that your aggregate coverage can include the following benefits: a. Medical

Click here to enter text.

b. Prescription Drug Click here to enter text.

c. Vision Click here to enter text.

d. Dental Click here to enter text.

e. Short Term Disability Click here to enter text.

45. At what percentage of expected claims can the aggregate corridor be set? Can you quote more than one option? Click here to enter text.

46. Do you retain the right to modify your aggregate factors based on experience subsequent to the proposal? Click here to enter text.

47. Does your aggregate contract impose an annual maximum claim liability? If yes, identify the amount. Click here to enter text.

48. Are there any other options available? Please explain. Click here to enter text.

49. Please describe the specific incurred / paid contract period (i.e., 12/12, 12/15, etc.) that you offer. Click here to enter text.

50. What percentage, if any, of annual paid claims applies to initial run-in limitations on your aggregate contract? Click here to enter text.

51. Will your organization waive run-in limitations? If yes, at what cost / percentage? Click here to enter text.

52. What is your minimum attachment point percentage or formula for first year cases? Does this differ for renewals? Click here to enter text.

53. If there is an aggregate claim, is an audit part of your standard process? Click here to enter text.

54. What is your organization’s average turnaround time, in days, for aggregate claims submitted for reimbursement? Click here to enter text.

55. With respect to aggregate claims submitted for reimbursement, please describe any limitations (i.e., minimum dollar amounts). Click here to enter text.

56. Do you offer advance funding or quick pay options for aggregate claims before end of plan year? If so, please provide details, including any additional cost.

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Click here to enter text. 57. How often do you require aggregate claim reporting information?

Click here to enter text. 58. What information do you require to process an aggregate stop loss claim?

Click here to enter text.

RENEWAL

59. Discuss your renewal philosophy. Be specific as it relates to known ongoing large claims, high deductibles, lasering, rating up, exclusion, etc. Click here to enter text.

60. Has a renewal ever been denied solely due to claim experience? Click here to enter text.

61. Many of our clients require preliminary renewal information from their vendors 120 days in advance of their actual renewal. Is your organization able to comply with this request? If no, explain. Click here to enter text.

62. What information do you require from the client, their claims administrator and / or Tejas to issue a renewal? Be specific regarding all claim experience and disclosure requirements. Click here to enter text.

63. We require renewal rates and factors to be finalized no later than thirty days prior to the date of renewal. If disagree, explain. Click here to enter text.

64. What contract features are subject to adjustment from preliminary to final renewal?

Yes No

a. Specific Rate(s) ☐ ☐

b. Aggregate Factor ☐ ☐

c. Aggregate Rate(s) ☐ ☐

CLAIM REIMBURSEMENT

65. Under health care reform, non-grandfathered plans must include an external review option. A claim filed in a timely manner (consistent with the requirement of the stop-loss policy) and denied by the claim administrator is subject to appeal. A claim properly incurred and adjudicated (denied) in one coverage period and subsequently appealed by the participant, including an external review, could easily extend beyond that coverage period. How does your organization address claims that were denied in one coverage period and paid in another coverage period? Click here to enter text.

66. What are your proof of claim and timely filing requirements for claim reimbursement requests? Click here to enter text.

67. What is your company’s timing requirements with respect to notification and claim filing? Click here to enter text.

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68. Who has final claim decision-making authority with respect to specific and aggregate claims? Click here to enter text.

69. When do you consider a claim paid? Please be specific. Click here to enter text.

70. Who defines what the reasonable and customary amounts are? Click here to enter text.

71. Explain your organization’s underwriting guidelines for incorporating plan changes. Click here to enter text.

72. Must plan changes be approved in writing prior to implementation and / or renewal? Click here to enter text.

73. Do you designate a Large Case Management firm with whom the claims administrator (or Pre-cert vendor) must coordinate potentially catastrophic cases? Click here to enter text.

74. Are there any conditions or circumstances (i.e., diagnosis, procedure, medical services, etc.) that require pre-approval by your case managers? If yes, please list. Click here to enter text.

75. Is there a Transplant Center of Excellence provision in your contract? Click here to enter text.

76. If so, is this a voluntary or mandatory program? Explain the consequences of non-compliance. Click here to enter text.

77. If voluntary, do you offer any discounts for including it in the plan? Click here to enter text.

78. Are case management fees reimbursable to the client? Click here to enter text.

79. Are case management fees included in an individual’s lifetime maximum benefit calculation? Click here to enter text.

80. Will you allow “non-covered” alternative care, if approved by your case managers? Click here to enter text.

81. Are there any charges and/or fees that standardly do not apply to specific or aggregate coverage? Click here to enter text.

82. Provide a listing of all specific conditions or diagnosis your organization considers to be “catastrophic”. Click here to enter text.

83. If the client is a health care facility or provider (i.e., hospital, physician group), are charges performed at their facility reimbursed at a lesser amount than other charges? Click here to enter text.

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84. Does your contract recognize all eligible employees, spouses, domestic partners, dependents, FMLA, retirees (if applicable), and COBRA beneficiaries as defined by the employer’s Plan Document / SPD? Click here to enter text.

85. Other than the employer’s Plan Document / SPD, does the contract allow for guidelines found in the employer’s Employee Handbook (i.e., leave of absence policy)? Click here to enter text.

86. Is there ever a situation in which you would deny a claim that was a covered benefit in an employer’s Plan Document / SPD you had previously approved? Click here to enter text.

87. Please detail the process involved in obtaining coverage for out-of-contract services. Click here to enter text.

88. If PPO access fees are payable as a percentage of savings, are the charges in excess of the specific deductible reimbursed? Click here to enter text.

89. Your contract must waive “Actively at work” provisions, based upon HIPAA guidelines. Click here to enter text.

90. If a client acquires a new company during the contract year, are you willing to waive the actively at work, dependent non-confinement and pre-existing condition limitation provisions for the newly acquired employees, their dependents, spouses, domestic partners, FMLA, retirees (if applicable), and COBRA beneficiaries? Click here to enter text.

91. Tejas desires that the employer’s Plan Document / SPD be the controlling document for all claim determinations. If your contract does not rely on the employer’s Plan Document / SPD for stop loss claim determination, please explain your organization’s position regarding coverage for the listed provisions: a. Work-related exclusions (worker’s compensation vs. any gainful employment)

Click here to enter text.

b. Pre-existing Conditions Click here to enter text.

c. Non-medically necessary charges Click here to enter text.

d. Experimental and investigational procedures, drugs or treatment Click here to enter text.

e. Biologically-based mental disorders Click here to enter text.

f. "Non-biologically-based mental/nervous, alcohol and substance abuse" Click here to enter text.

g. Administrative, investigative and legal services, including compensatory & punitive damages Click here to enter text.

h. Charges recoverable by a third-party (subrogation and/or Medicare)

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Click here to enter text.

i. Expenses that are incurred as a result of war Click here to enter text.

j. Expenses that are incurred as a result of an act of terrorism on domestic and foreign soil Click here to enter text.

k. Expenses incurred while committing assault / felony Click here to enter text.

l. Charges related to attempted suicide Click here to enter text.

m. Charges related to self-inflicted injuries Click here to enter text.

n. Charges related to hazardous pursuits Click here to enter text.

o. Please include any other significant provisions you feel need addressed along with your organization’s position regarding those provisions. Click here to enter text.

p. If you do not mirror the employer’s plan document, then please summarize your stop loss contract exclusions / limitations not listed above and how it might affect what the employer has in their plan document. Click here to enter text.

92. If you do not agree to mirror the employer’s plan document, then will you agree to review the employer’s plan document, if provided, as part of your pre-sale activities, and point out any potential gaps between your stop loss policy and the employer’s plan document, and if possible, offer solutions? Click here to enter text.

93. Identify whether your excess loss contract has any limits related to the following provisions. If there are limitations, please provide detail by provision: a. Late Entrants

Click here to enter text.

b. Annual Open Enrollment Click here to enter text.

c. Section 125-qualified change in status events Click here to enter text.

d. Domestic Partner coverage Click here to enter text.

e. Transplants (describe any requirements and limitations) Click here to enter text.

f. Biologically-based mental disorders Click here to enter text.

g. Non-biologically based mental/nervous and/or substance abuse Click here to enter text.

h. Alternative therapies (e.g. acupuncture, homeopathic, naturopathic) Click here to enter text.

i. Attempted suicide (whether sane or insane) Click here to enter text.

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j. Acts of war Click here to enter text.

k. Acts of terrorism on domestic and foreign soil Click here to enter text.

l. Commission of a felony Click here to enter text.

m. If you do not mirror the employer’s plan document, then please summarize your stop loss limits not listed above and how it might affect what the employer has in their plan document. Click here to enter text.

94. What is your definition of a paid claim? Click here to enter text.

95. If you purchase reinsurance protection, does the reinsurer need to review all claims before they are paid, or are your decisions binding on the reinsurance? Click here to enter text.

96. If a claim is delayed beyond the end of the contract period, do you grant a waiver of the time limits for payments if the circumstances are reported to you prior to the end of the period? If not, how are such situations handled? Click here to enter text.

97. Do you require that large claim management services be used? Under what circumstances? Do you pay for such services? Click here to enter text.

98. Do you accept the reasonable and customary determinations made by the TPA, or do you have a database you use? Click here to enter text.

99. What is the maximum time allowed for submission after the termination date of valid claims that were paid within the contract period? Click here to enter text.

100. Please provide the definition of experimental procedures and note how this provision is interpreted for a claim approved for payment under the medical plan. Click here to enter text.

101. Does the insurer assist in claim determination before reimbursement is requested? Click here to enter text.

ADDITIONAL QUESTIONS

102. How do you comply with the guidance regarding participation in clinical trials? Click here to enter text.

103. Does your contract allow you to limit or exclude coverage for an individual who becomes disabled or begins receiving treatment after you are awarded the contract but prior to the contract effective date? Click here to enter text.

104. If the policy is issued through an MGU, describe what happens when the reinsurer changes on a date other than the client's Plan anniversary. Click here to enter text.

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105. Please disclose all commissions, fees, MGU charges, overrides or other forms of compensation. Click here to enter text.

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Instructions for Consultant (Part 2) Proposals shall be divided into tabbed, marked sections and include any required forms/disclosures elsewhere identified in this RFP. For clarity, please keep the format of your proposal aligned with RFP specifications as closely as possible. When preparing your response, please repeat each question before providing your answer. Your response shall also include a title page, table of contents, an overview of the firm with historical background, and length of time in existence. The Response section is organized as follows:

a. Questionnaire b. Your Organization

a. Questionnaire

1. What is the average size of the client for your book of business?

2. What services do you provide self-funded and fully-funded health plan clients?

3. Describe your company’s services to assist the Center with health insurance benefits benchmarking and competitive analysis?

4. Describe services that make your firm unique from other benefits consultants?

5. Does your company employ a medical director or resource?

6. Describe your company’s actuarial and compliance/legal resources.

7. Explain how your company stays abreast of emerging trends and regulations?

8. Describe your company’s ability to provide analytics on claims data.

9. List your due diligence steps you normally conduct before recommending an employee

benefit vendor.

10. Provide an example of a recommended program to a client provided by your company and the results of the recommendation.

11. Include sample materials: (a) three compliance notices (b) sampling of reports you provide

to clients.

12. Describe how your firm can help the Center’s bid process to achieve the best pricing.

b. Your Organization

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1. What is the full name of your organization and the address and telephone number for the location of your principal executive (home) offices?

2. Identify by name and title the top executive who would have overall responsibility for

Center account.

3. Submit a copy of your most recent Annual Report or financial statement.

4. Provide the name, phone number, fax number and email address for the authorized negotiator for your proposal.

5. Provide an organizational chart and resumes of all professional staff members will be

assigned to the account.

6. Provide biographical and contact information for the account manager.

7. Provide current references for four (4) current clients including size.

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SECTION C

EVALUATION AND SELECTION CRITERIA AND PROCESS

Any award made based upon this Request for Proposal will be based upon Best Value to Tejas

and potential Community Center Particpants, which is the optimum combination of economy and

quality resulting from fair, efficient, and practical procurement decision-making and which

consider the following relevant factors:

1. the delivery terms;

2. the quality and reliability of the respondent's services;

3. the extent to which the services meet Tejas's needs;

4. indicators of probable respondent performance under the contract, such as the respondent's

past performance, the respondent's financial resources and ability to perform, and the

respondent's experience and responsibility;

5. the impact on the ability of Tejas to comply with laws and rules relating to historically

underutilized businesses or relating to the procurement of services from persons with

disabilities;

6. the total long term cost to Tejas and Particpants of contracting for the respondent's services;

7. the cost of any staff training associated with the contract;

8. the contract price;

9. the ability of the respondent to perform the contract and to provide the required services

within the contract term, without delay or interference;

10. the respondent's history of compliance with the laws relating to its business operations and

the affected service(s) and whether it is currently in compliance;

11. whether the respondent's financial resources are sufficient to perform the contract and to

provide the service(s);

12. whether necessary or desirable support and ancillary services are available to the respondent;

13. the character, responsibility, integrity, reputation, and experience of the respondent;

14. the quality of the facilities and equipment available to or proposed by the respondent;

15. the ability of the respondent to provide continuity of services;

16. the ability of the respondent to meet all applicable written policies, principles, regulations,

and standards of care; and

17. any other factor relevant to determining the best value for Tejas in the context of a particular

contract.

The evaluation process is as follows:

1. All proposals received by the established deadline will be evaluated and ranked by Tejas’s

RFP Evaluation Committee according to the factors above.

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2. Respondents meeting the requirements and criteria may be invited to interview with Tejas to

further clarify the evaluations of proposals, if deemed necessary by the committee.

3. Additional information, such as copies of the Respondent’s Organizational Policies,

Procedures and Quality Assurance documents, may be requested during contract

negotiations.

4. Visits may be conducted to potential service contractors.

5. Based on resulting ranking of the proposals one or more Respondents may be asked to

participate in negotiation with Tejas.

6. APPEALS and/or PROTEST. Any Respondent’s wishing to protest or appeal the selection

process must do so within 7 days of the proposal award. Protest or appeals must clearly state

with specificity the grounds upon which the award selection is being challenged. Send via

certified mail to:

TEJAS BEHAVIORAL HEALTH MANAGEMENT ASSOCIATION

ATTN: Hollie Chenault/Employee Benefits RFP

893 N. IH 35, Ste 130

Round Rock, Texas 78664

7. Proposals submitted become the property of Tejas and will not be returned to the

Respondent’s.

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SECTION D

SUBMISSION OF PROPOSAL

ASSURANCES

The undersigned does make the following assurances that:

1. That the Respondent is not currently held in abeyance or barred from the award of a federal or state

contract.

2. That the Respondent is not currently delinquent in its payments of any franchise tax or state tax owed to

the state of Texas, pursuant to Texas Business Corporation Act, Texas Civil Statutes, Article 2.45.

3. No attempt will be made by the Respondent to induce any person or firm to submit or not to submit a

response, unless so described in the RFP response document.

4. The Respondent does not discriminate in its services or employment practices on the basis or race, color,

religion, sex, national origin, disability, veteran status, or age.

5. That no employee of Tejas, DSHS or DADS, and no member of Tejas’s Board of Trustees will directly or

indirectly receive any pecuniary interest from an award of the proposed contract. If the Respondent is

unable to make the affirmation, then the Respondent must disclose any knowledge of such interests.

6. Respondent accepts Tejas’s right to cancel the RFP at any time prior to contract award.

7. The RFP response submitted by the Respondent has been arrived at independently without consultation,

communication, or agreement for the purpose of restricting competition.

8. No claim will be made for payment to cover costs incurred in the preparation of the submission of the

application or any other associated costs.

9. The individual signing this document and any subsequent contract (if necessary) is authorized to legally

bind the Respondent.

10. That Respondent will comply with the rules and standards adopted under Section 534.052 of the Texas

Health and Safety Code, the DSHS Community Standards of Community Mental Health, Tejas, and

Community Service Programs, and applicable local, state, and federal laws, rules and regulations,

including the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.

11. No member of the Respondent’s staff or governing authority has participated in the development of

specific criteria for award of the contract, nor will participate in the selection of the proposal to be

awarded the contract.

The Organization or Individual named below offers and agrees to furnish all labor, materials, and services

offered within the designated time frame for the amount to be agreed upon and upon conclusion of a

successful contract.

Name of Respondent Firm or Individual: _______________________________________________

Type of Legal Entity: __________________________________________________________________

Address: ___________________________ Phone No.: _________________________

__________________________ FAX No.: _________________________

Auth. Signature: ________________________________ Date: _________________

Printed Name: ________________________________Title: __________________________________