Sample Offer Counter Letter Insurance Claim - Excel by slk11942

VIEWS: 553 PAGES: 47

More Info
									A. ADMINISTRATIVE SERVICES
1.0 Administrative and Account Management Services
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No               A/D/N     Explanation
1. The Proposer shall assign dedicated 100% to the
County of El Paso: one fulltime on site account manager
within Proposer's organization who has accountability and
authority for the quality of service and compliance to the
County of El Paso contract. When possible, The Proposer
shall provide the County of El Paso a minimum of sixty
(60) days advance notice of any changes to your Account
Management team.

2. The County of El Paso reserves the right to request
replacements on the Account Management team and/or
implementation team, if dissatisfied with the performance
of existing team plan member(s) . Your organization shall
comply with the County of El Paso request and shall make
every reasonable effort to provide a qualified replacement,
subject to the County of El Paso approval, within 30 days
of the County of El Paso's written request.

3. Implementation of new programs or benefit changes
must be supported year round as required by the County of
El Paso.
4. The Proposer shall provide the County of El Paso staff
access to a secure online tool that contains health
benefit/policy information, plan administration components
including eligibility information, prior authorizations,
provider locator, patient claim history, subject to Health
Insurance Portability and Accountability Act of 1996
(HIPAA) standards and other legal limitations.

5. The Proposer shall provide training and ongoing
support services to the County of El Paso staff.
6. The Proposer shall provide for the County of El Paso
approval an initial plan design benefit coding document for
Proposer's internal quality control process to ensure
accurate and ongoing administration of the County of El
Paso health benefit programs. Additionally, The Proposer
shall maintain a documented quality control and pre-
implementation document and provide it to the County of
El Paso for review and approval prior to implementation of
any benefit or program change. the County of El Paso
reserves the right to audit the Proposer onsite for accuracy
of the entry of initial plan design benefit coding, as well as
test for the accuracy of claims payment prior to the
effective date.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     1
7. The Proposer shall be required to provide, upon the
County of El Paso's request and at Proposer's own
expense, an agreed upon number of staff and materials as
determined jointly by Proposer and the County of El Paso
for at least 20 open enrollment benefit fairs, health fairs,
and member outreach programs throughout the calendar
year. Benefit fairs are typically held between September
1st and October 31st. Health fairs and member outreach
programs are held at various times throughout the year.

8. The Proposer shall collaborate and consult with the
County of El Paso to proactively identify opportunities and
implement changes for improving quality of services, cost-
effectiveness, and operational efficiency under the Plans.

9. The Proposer shall conduct quarterly business reviews
of network adequacy, service levels, Plan performance
and strategic trend analysis with the County of El Paso
staff within 60 days after the end of each quarter. The
Proposer shall proactively focus on methods to manage
costs and interpret trends in the Plans and in the market
place. The Proposer shall provide comparable book-of-
business results for metrics jointly selected by the County
of El Paso and Proposer.

10. The Proposer shall provide administrative services not
specifically addressed in the Agreement upon written
request by a duly authorized representative of the County
of El Paso and prior mutual agreement between the the
County of El Paso and Proposer.

2.0 Eligibility
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                 A/D/N   Explanation
1. The Proposer must be fully HIPAA compliant, including
processes involving eligibility file maintenance and
including encryption of data.
2. The Proposer shall provide a dedicated team for the
County of El Paso to manage eligibility maintenance
process.
3. The Proposer shall receive and update HIPAA
compliant eligibility data from the County of El Paso. All
paper enrollment forms will be imaged and retained by the
Proposer. Proposer will assign a unique identifier, but must
also capture and cross reference the 9-digit SSN in
Proposer’s eligibility system.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     2
4. The Proposer shall send compliant eligibility data via
electronic transmission for update purposes to Pharmacy
Administrator or other identified vendors who support the
County of El Paso's various benefit offerings. The
Proposer shall receive a discrepancy report from the
vendor which identifies discrepancies resulting from receipt
of eligibility and enrollment data by the vendor from
Proposer. Proposer, in collaboration with vendor, shall
resolve such discrepancies identified in the report and
resubmit corrected records on a subsequent eligibility
transmission within 48 hours.

5. A monthly full eligibility file shall be run, transmitted and
reconciled between Proposer and the Pharmacy
Administrator or other identified vendor. The County of El
Paso shall consider a variance of no greater than one
percent of enrolled Plan member(s) for each Plan as
acceptable. In the event the variance is greater than one
percent, Proposer and the Pharmacy Administrator or
other identified vendor shall resolve the discrepancy within
thirty (30) days, and also will notify the County of El Paso
of all discrepancies.
6. The Proposer shall provide electronic access to the
Proposer’s eligibility/enrollment database to the County of
El Paso.
7. The Proposer shall develop and maintain an
eligibility/enrollment database for the various plans offered
by the County of El Paso. The Proposer shall develop and
maintain enrollment for plan member(s) by group as
identified by the County of El Paso Plan group file
structure, which may require tracking by department. The
Proposer’s eligibility/enrollment database shall have the
capacity to develop, maintain and produce enrollments for
plan member(s) by: family size, age, product line, zip
code, presence of secondary coverage, and Medicare
eligibility group.
8. The County of El Paso shall authorize Pharmacy
Administrator to provide on-line inquiry access to Proposer
for the purpose of accessing the Pharmacy Administrator’s
mainframe system. The purpose of the on-line access
shall be to assist Proposer with enrollment and eligibility
processing, utilization management, and claims process
functions for the County of El Paso Self-Funded Health
Plans.
9. Based on the eligibility files Proposer receives, the
Proposer shall:
     a. Add coverage for plan member(s) who have joined
     the plan within 48 hours of receipt of eligibility data.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     3
    b. Update member information (e.g., address
    changes) within 24 hours of receipt of eligibility data.

     c. Terminate plan member(s) within 24 hours of
     receipt of eligibility data and confirm that no claims
     have been paid during interim period.
     d. Notify appropriate party of eligibility file issues within
     24 hours of receipt of eligibility data.
10. The Proposer must be responsible for transmitting
eligibility information received from the County of El Paso
to all affiliated vendors with which the Proposer has
subcontracted any portion of the administration of the Plan.
Eligibility files will be updated in the Proposer’s system and
transmitted to third party vendors within one business day
of receiving an eligibility file from the County of El Paso.

11. The Proposer understands that a member is entitled
to continuation of coverage under the terms and conditions
set forth in the federal Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) and under the terms
and conditions set forth in Texas law governing
continuation coverage upon expiration of COBRA rights.

12. The Proposer shall provide COBRA administration
including but not limited to set-up and maintenance of
COBRA enrollments and associated premium billing and
collection. When applicable, Proposer shall provide
COBRA enrollees with notices that Federal law requires for
non-COBRA plan member(s) .
13. The Proposer shall provide Plan member(s) with
Certifications of Creditable Coverage as required of group
health plans pursuant to HIPAA, any amendments thereto,
and its implementing regulations, and CMS guidelines-
MMA of 2003.
14. The Proposer shall provide immediate online real-time
manual eligibility updates for urgent requests by the
County of El Paso staff.
15. The Proposer shall obtain from the Pharmacy
Administrator relevant information needed, as determined
by the County of El Paso, to create an integrated ID card.

16. No minimum participation standards are to be
imposed upon the County of El Paso. Proposer may not
change its administrative fees if there is a change in
enrollment, or Plan member to subscriber ratio.

3. Identification Cards
All Services Below Will Be Included in the Base Administrative Fee

A = Agree      D = Agree With Deviations             N = No          A/D/N   Explanation




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                          4
1. The Proposer shall produce and mail plan member
identification cards with the County of El Paso logo and
Pharmacy Administrator logo.
    a. The Proposer shall send identification cards for total
    population distribution within ten (10) business days of
    receipt of eligibility file from the County of El Paso.

    b. The Proposer shall send identification cards for new
    enrollments, in addition to requests for duplicate
    identification cards, to Plan member(s) within three (3)
    business days of receipt of eligibility file from the
    County of El Paso.
2. The Proposer shall issue identification cards for the
Subscriber and each individual family member. The ID
card(s) shall display the Subscriber’s member number and
the name of the Subscriber or family member to whom the
card is issued. The Proposer shall provide the capability
for plan member(s) to print a temporary identification card
from the Proposer’s web site.
3. The Proposer shall coordinate and ensure access to
medical services for Plan member(s) who have not
received identification cards but are eligible for services
under the Plans.
4. The Proposer shall print the unique alpha numeric
health care ID number on plan member ID cards. The
Social Security Number (SSN) shall be maintained as an
essential part of the eligibility record layout, but shall not be
printed on ID cards nor displayed on the member web site.


4. Member Services (Customer and Client Support)
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No              A/D/N      Explanation
1. The Proposer shall provide a dedicated team to include
customer service staff and supervisors with:
   a. Minimum two years of experience with your
   organization required for supervisors
   b. Minimum one year of experience with your
   organization required for customer service
   representatives
   c. Formal training and ongoing quality monitoring
   required for customer service representatives in
   accordance with the County of El Paso’ performance
   guarantees outlined in the RFP Questionnaire
   Financial Section
   d. Automated tracking of workload by customer
   service representative; and




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     5
     e. Customer service staffing adequate to consistently
     achieve or exceed performance standards. At a
     minimum one dedicated customer service
     representative per 2,500 members.
2. The Proposer shall be fully compliant with HIPAA
requirements and provide the County of El Paso with
samples of its tracking and incident reporting tools.
3. The Proposer shall provide a tracking system for the
County of El Paso specific member/provider telephone,
written and email inquiries and shall provide monthly
reports for, at a minimum: call volume, first call resolution
rates, average wait time, abandonment rates, and
response time to resolve written/email member inquiries
and call categories/types.
4. The Proposer shall provide special telephone services
for member consultations, TDD number for hearing
impaired Plan member(s) , ATT language line, and a
dedicated customer service toll free phone number for all
plan members.
5. The Proposer shall provide to Plan member(s) the
ability to communicate customer service issues and/or
inquiries through telephone. Telephone service
representatives shall be available from 7:30 a.m. to 6:00
p.m. MST Monday through Friday for customer service and
7:30 to 6:00 p.m. MST Monday through Friday for
utilization management, except Medical Administrator
holidays.
6. The Proposer shall perform an annual County of El
Paso-specific member service satisfaction survey with a
mutually agreed upon survey tool and methodology. The
Proposer will share aggregate results of the survey with
the County of El Paso and will develop an action plan for
improving upon results.
7. The Proposer shall implement and maintain a co-
branded web site by September 1, 2008, to include the
following:
     a. The Proposer shall provide year-to-date cumulative
     benefit statements separately for each individual plan
     member, and access to online accounts shall be
     maintained at an individual level. Please attach a
     sample benefit statement.
     b. The Proposer shall provide the ability for Plan
     member(s) and providers to view Claims status on-line
     with a secure PIN number.
     c. The Proposer shall provide the ability for Plan
     member(s) to request duplicate ID cards.
     d. The Proposer shall have the ability to respond via
     email to address customer service issues directly with
     plan member(s) and network providers.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     6
   e. The Proposer shall provide online eligibility and
   coverage information for network providers.
   f. The Proposer shall provide the ability and support
   for plan member(s) to receive Plan information by e-
   mail.
   g. The Proposer shall provide information for plan
   member(s) to assess credentials of providers in the
   network (e.g. Board certification status, Specialty,
   Years practiced, Medical school attended)

   h. The Proposer shall provide consumer education
   tools and literature for plan member(s) to understand
   health costs and research condition information


5. Member and Employer Communications
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No               A/D/N     Explanation
1. The Proposer shall prepare, print and mail the
summary benefit booklets for all self-funded health plans.
The Proposer shall maintain such documents on the
Proposer/the County of El Paso co-branded web site. The
booklet text shall be prepared by Proposer and reviewed
by the County of El Paso, who has final authority on the
plan design and content of the booklets. The Proposer
shall provide input by their customer service, medical
management, account management staff and legal
department relative to the content of the booklets, and
requirements of state and federal laws. The booklets
shall meet the following specifications during the term of
this Agreement:
    a. Cover shall be heavy quality gloss paper printed in
    four colors;
    b. Size shall be 8 ½ inches by 11 inches, bound in the
    center.
2. The Proposer shall assist the County of El Paso in the
preparation of any Summary Annual Reports and/or
Summaries of Material Modifications when required by
plan changes.
3. The Proposer shall be responsible for providing and
possibly mailing enrollment packets to all new Subscribers
as identified by the County of El Paso. The enrollment
package shall consist of the following:
    a. Welcome letter
    b. Applicable benefit summary and network provider
    brochure
    c. Proposer claims forms
    d. and other materials as deemed appropriate by the
    County of El Paso



              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     7
4. The Proposer shall be responsible for preparing and
printing the marketing plan comparison brochure which is
used in health fairs and by the County of El Paso
marketing staff.
5. The Proposer shall be responsible for preparing and
printing an educational brochure that provides information
on health plan changes or improvements occurring in the
upcoming year as well as prevention, wellness and
disease management programs. The brochure will be
included in the annual package.
6. The Proposer shall send up to 4 additional mailings per
year, as requested by the County of El Paso, and the
Proposer will be responsible for all mailing and postage
costs.

6. Medical Claims Processing
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                 A/D/N   Explanation
1. Proposer shall process medical claims incurred for
services provided on or after January1, 2009. Claims
received up to 15 months from the date of service shall be
processed for payment by the Proposer. Claims shall be
processed in accordance with the terms of the applicable
Plan Document in effect on the date the service was
provided, and in accordance with the Proposer’s standard
medical policies. Proposer is responsible for administration
of all run-out claims, for twelve months upon contract
termination.
2. On an minimum annual basis, the Proposer shall solicit
coordination of benefits information from plan member(s) .
The Proposer shall administer coordination of benefits in
accordance with the benefit booklets.

3. The Proposer shall receive and process Claims for
payment making determinations to pay or deny Claims in
accordance with Plan Document Booklets if sufficient proof
is provided to Proposer that Claims submission was within
the fifteen month submission period.

4. The Proposer shall review appeals of Claims (even
from the period of time prior to the takeover date) and
make determinations as specified in the sections of the
applicable Plan Documents. The Proposer shall review
requests for reconsideration of Claims to ensure the Plan
member’s full and fair consideration of complaints
submitted to the Claims Department.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     8
5. The Proposer shall utilize an automated claims
processing system for uniform claims processing so that
benefit and administrative guidelines are consistently
applied to all Plan member(s) . The automated claims
processing system shall include the following at a
minimum in Proposer’s database:
   a. Detailed benefit codes
   b. Appropriate edits and audits, including high dollar
   review thresholds
   c. On-line access to network provider and pricing files,
   and
   d. Integration with all other units/teams including but
   not limited to staff supporting eligibility, medical review,
   other party liability, and pre-service authorization.

6. The Proposer will mail Explanation of Benefits (EOB's)
for all In-network and out-of-network services, unless an
agreed upon system of electronic EOB's is agreed to.

7. All information system modifications necessitated by
changes in plan benefits shall be in place by the effective
date of the changes
8. Proposer agrees to use diligence to identify, investigate,
track and recover third-party liability liens. In evaluating
and processing third party liability recoveries, the Proposer
shall respect Plan member(s) ’ legal rights concerning
such recoveries as well as any additional policies
communicated by the County of El Paso. The Proposer
shall submit monthly reports to the County of El Paso
listing all cases identified as subject to third party liens, the
amount of claims paid, the current status of collection
efforts and a report of all amounts collected and waived.
the County of El Paso shall advise Proposer of those
cases, which, in the County of El Paso’s determination,
shall warrant recovery. The Proposer shall advise the
County of El Paso of any outside vendor involved in third
party recovery and the basis of payment to the vendor

9. The Proposer shall provide a dedicated team of claims
processors and supervisors to perform claims adjudication
services for this Agreement. The dedicated team will be
comprised of staff with the following qualifications:

    a. Minimum two years of experience with your
    organization required for supervisors.
    b. Minimum one year of experience with your
    organization required for claim processors.
    c. The Proposer shall have and maintain a formal
    training program for claims processors with standards
    for performance clearly communicated and enforced.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     9
     d. The Proposer shall monitor claims processors for
     quality on an ongoing basis in accordance with the
     County of El Paso performance guarantees.
10. The Proposer shall credit the County of El Paso for the
total amount of overpayments for claims on the date
identified, not the date recovered, on a monthly basis by an
adjustment to the Administrative Service Fee. Proposer
may recoup said overpayments of $50 or more from
providers and plan member(s) . The overpayment
collection process used by Proposer is subject to the
County of El Paso approval. The Proposer shall provide
monthly reports of all overpayments identified to the
County of El Paso.
11. Proposer agrees to audit inpatient hospital charges
billed by Preferred and Non-Preferred Provider hospitals
for determination of billing errors, and shall recover any
overpayment made on account of such billing errors,
subject to the following:
     a. The Proposer shall screen monthly paid claims
     reports to identify hospital claims for audit. Claims
     screening includes an evaluation of the hospital billing.
     Inpatient hospital claims which are greater than
     $10,000 in billed charges and have been paid at a
     percentage of billed charges, and outpatient hospital
     claim billings which are greater than $3,000 in billed
     charges in which payment of more than $1,000 has
     been made, shall be evaluated for audit.

   b. The audit shall verify that the County of El Paso has
   paid only for covered services which were actually
   rendered to the patient, documented by physician
   order, accurately billed, consistent with the prevailing
   hospital contracts, and reasonably related to the
   patient’s condition.
   c. The total amount of recoveries shall be credited to
   the County of El Paso by an adjustment to the
   Administrative Service Fees.
   d. Proposer (or your subcontractor) shall provide the
   County of El Paso with monthly reports summarizing
   audit activities on behalf of the County of El Paso.




7. Systems and Data Reporting Management
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                     A/D/N   Explanation




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                      10
1. The Proposer shall have knowledgeable personnel
available to provide collaborative analytical assistance and
advice, and to provide ongoing training in the use of the
reports and analyze claims data in the management of the
Plans.
2. The Proposer shall provide Plan member claims data
upon the request of the County of El Paso to the Pharmacy
Benefit Manager, and any additional third party Proposer
designated to receive such data by the County of El Paso,
at the frequency requested by the County of El Paso for
use in such programs as disease management and
coverage management programs as well as data
warehousing in accordance with all applicable federal and
state laws and regulations relating to the confidentiality and
protection of member and provider information, including
the Privacy Rule.

3. The Proposer shall provide written progress reports to
the County of El Paso to monitor the following:
    a. whether Proposer is performing to specified
    performance standards and guarantees.
    b. problem identification and resolution encountered in
    the administration of this Agreement and the operation
    of the Plans.
    c. provide action plans for improvement when metrics
    are below goals.
4. The Proposer shall provide the following information
and reports to the County of El Paso on a quarterly basis
(provide samples):
        a. A report listing the network–wide cost per day
        average for your contracted hospitals ranked by
        in–patient admissions, out–patient visits, in–patient
        dollars paid, out–patient dollars paid, and total
        dollars paid. (The “Hospital Costs Report”)

5. The Proposer shall provide the following comparative
information:
    a. The County of El Paso Total Plan member
    admissions and Proposer's total comparable preferred
    provider business member admissions and
    comparable preferred provider business member
    admissions for each hospital;
    b. Total inpatient payments by the County of El Paso
    for each hospital and total inpatient payments by
    Proposer's comparable preferred provider business
    and by Proposer's comparable preferred provider
    business in aggregate for the County of El Paso;




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     11
   c. Average length of stay for Plan member(s), for
   Proposer insured comparable preferred provider
   business and for Proposer comparable preferred
   provider business for each hospital;
   d. Average cost per day for inpatient services for Plan
   member(s) for each hospital and average cost per
   day for inpatient services for Proposer's comparable
   preferred provider business and for Proposer's
   comparable preferred provider business in aggregate
   for the County of El Paso;
   e. Total Plan member out patient visits, total
   Proposer's comparable preferred provider business
   member out patient visits and total Proposer's
   comparable preferred provider business member out
   patient visits for each hospital;
   f. Total out patient payments by the County of El Paso
   for each hospital and total out patient payments by
   Proposer's comparable preferred provider business
   and total out patient payments by Proposer's
   comparable preferred provider business in aggregate
   for the County of El Paso;
   g. Average cost per out patient visit for Plan
   member(s) for each hospital and average cost per out
   patient visit for Proposer's comparable preferred
   provider business and average cost per out patient visit
   for Proposer comparable preferred provider business
   in aggregate for the County of El Paso; and,

   h. The Proposer shall also provide total inpatient
   hospital payments and total outpatient hospital
   payments in aggregate for the County of El Paso, as
   well as total inpatient hospital payments and total
   outpatient hospital payments by Proposer's
   comparable preferred provider business and by
   Proposer comparable preferred provider business in
   aggregate for the County of El Paso .

    i. Proposer shall provide an annual report of Hospital
    inpatient infection rates, which lists and compares
    infections rates amongst all network hospitals. At the
    County of El Paso discretion, said reports will be
    posted on a co-branded web site.
6. The Proposer shall reconcile the County of El Paso
payments with the County of El Paso eligibility records.
The Proposer will compare the payment reports to the
County of El Paso eligibility records and create a
discrepancy report that will be provided to the County of El
Paso electronically.
7. The Proposer shall provide their policies, procedures,
and controls to ensure integrity of financial data.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     12
8. Third Party Recovery
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                   A/D/N   Explanation
1. All claims above $1,000 with the potential of third-party
liability shall be pursued for possible subrogation and
reports will be provided to the County of El Paso quarterly
comparing the County of El Paso specific recoveries to
Proposer's entire insured and self-insured book of
business. The Proposer will work with the County of El
Paso Attorney in managing recoveries.

9. Claims Appeals
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                A/D/N      Explanation
1. The Proposer shall review requests for reconsideration
of claims and make determinations as specified in the
applicable Plan Documents.
2. The Proposer shall implement and maintain a medical
claim appeals process as described in the County of El
Paso Self Funded Plan Document. These booklets are
modified and amended as needed in accordance with the
County of El Paso policies and procedures. The Proposer
agrees to handle initial claim determinations for first and
second level appeals, including physician requested urgent
appeals in accordance with the County of El Paso policies
and procedures and DOL regulations.

3. The Proposer shall share medical necessity criteria and
any other medical/clinical guidelines with the County of El
Paso that apply to final administrative determinations.



10. Medicare
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                   A/D/N   Explanation
1. The Contractor shall provide claims administration
services for Medicare Secondary Claims incurred on or
after January 1, 2009 through the end of this Agreement
and shall approve or deny claims in accordance with the
Benefit Booklet.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     13
2. The Contractor shall notify the County of El Paso when
a Plan member and/or family member may become
eligible, enrolls and/or cancels enrollment in the Federal
Medicare programs Part A, Part B and/or Part D. The
Contractor shall refer plan member(s) to the County of El
Paso to discuss the consequences of enrolling in or
canceling Federal Medicare coverage in Part A, Part B
and/or Part D.
3. The Contractor shall provide The County of El Paso
members with Notice of Creditable Coverage letters (in
accordance with CMS guidelines) upon enrollment in the
County of El Paso Medicare Primaryplan, annually, and in
the event the member's coverage changes.

11. Medicare Part D
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                  A/D/N   Explanation
1. Do you have the capability to be able to support the
County of El Paso decision to receive the federal drug
subsidy in 2009 (and beyond as requested by the County
of El Paso) by providing the following services to ensure
compliance with the Centers for Medicare and Medicaid
Services (CMS) requirements, including but not limited to:

   a. Track and submit claims data eligible for the
   subsidy to CMS for all employer groups under the
   County of El Paso, and its contracting agencies
   b. Calculate, or provide information necessary for the
   County of El Paso to calculate, subsidy amounts for
   individual contracting agencies and schools

   c. Perform annual reconciliation to adjust for actual
   rebates, discounts and price concessions
   d. Provide creditable coverage notification to Medicare-
   eligible retirees
   e. Store claims, utilization management and eligibility
   data for the period required by CMS
   f. Develop at least two reports which measure
   recoveries from the subsidy calculations? One report
   will show the dollars recovered from CMS allocated to
   the various County of El Paso purchasing
   organizations? Another report will show the number of
   claimants by size of annual claims

   g. Estimate the value of CMS reimbursements related
   to the subsidy during the County of El Paso’ rate
   renewal process each year
   h. Provide claims data necessary to support audit
   processes



              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     14
    i. Coordinate with the County of El Paso's previous
    vendor as needed to support annual reconciliation for
    2009
    j. File required application to CMS if necessary in 2009
    and beyond
2. Do you have the capability to provide all analysis and
data necessary for the County of El Paso to evaluate other
Medicare Part D options for 2009 and beyond?

3. For Medicare Part D options, do you have the capability
to:
    a. Act as Third Party Administrator of a self-funded
    PDP
    b. Support The County of El Paso application process
    to become a PDP
    c. Offer a The County of El Paso-specific, fully-
    insured, plan-administered PDP
4. Offer a fully insured Medicare Advantage Plan
comparable to the current Buy Up option.

12. Stop Loss Insurance Support
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                   A/D/N   Explanation
1. The Contractor shall provide necessary claim reports
and additional claim specific detail to the County of El
Paso's selected Stop Loss Insuror and will also oversee
the notice of claim process, as well as the filing of Stop
Loss claims with the County of El Paso's selected Stop
Loss Insuror. Claim recoveries will be deposited into the
County of El Paso's designated bank account with proper
documentation provided to the County Auditor.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, TPA Administrative Services
COUNTY OF EL PASO                                                                     15
B. MEDICAL MANAGEMENT
All Services Below Will Be Included in the Medical Management Fee



A = Agree; D = Agree With Deviations; N = No             A/D/N      Explanation
1. The Proposer shall make available to the County of El
Paso qualified licensed medical, pharmaceutical, nursing
and utilization review personnel to assess policy,
participate in medical necessity discussions, etc., as
requested by the County of El Paso. The Proposer shall
provide an evidence-based definition of medical
necessity and any criteria by which it will apply these
definitions in its reviews.

2. The Proposer shall provide a medical services
management program which assures delivery of high
quality, cost effective health care for Plan member(s) .
The Proposer shall provide medical services
management by utilizing health care resources to
achieve optimum member outcome in the most cost-
effective manner (e.g.encourage patient use of urgent
care instead of E.R. when appropriate).
3. The Proposer shall maintain compliance with the
Utilization Review Accreditation Commission (URAC)
national standards.
4. For medical management support to the County of El
Paso Proposer shall provide a full time, dedicated
medical services liaison, who shall be a health care
professional or licensed registered nurse, to interact with
the County of El Paso staff.
5. The Proposer shall provide a medical services liaison
that shall be available to the County of El Paso as
needed to assist with issues including but not limited to
member health care issues, complaint resolution and
assistance with medical appeals, and to Plan member(s)
seeking additional medical services or benefits.

6. The liaison will respond to the County of El Paso
within 24 hours and any follow-up will be completed
within 5 business days.
7. The Proposer shall provide a medical services liaison
that shall communicate to the County of El Paso staff
information affecting the Plans, including but not limited
to changes in Proposer policies and procedures within 30
days of the change. The liaison will respond to the
County of El Paso within 24 hours and any follow-up will
be completed within 5 business days.




COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management     16
8. The Proposer shall ensure that key medical personnel
have clear accountability and authority to assure contract
compliance in the medical services management
functions and the delivery of overall quality service to the
County of El Paso and the County of El Paso trustees,
staff, and Plan member(s) .

9. The Proposer shall ensure that key medical personnel
shall be responsible for integrating all medical services
and reports for the County of El Paso and to assist the
County of El Paso in project management and resolution
of operational problems.
10. The Proposer shall ensure that key medical and
behavioral health personnel shall participate in the
development of the Benefit Booklets annually, utilizing
knowledge of the Plan benefit design and an overall
understanding of your administration and operation. The
Proposer shall identify these key personnel in response
to the RFP.
11. The Proposer shall make available within two
business days of a request from the County of El Paso,
medical directors with responsibilities for: utilization
management program, case management, disease
management, demand management, transplant
program, behavioral health program, medical policy and
technology assessment, and quality improvement
program.
12. The Proposer shall assure that utilization
management services shall be conducted by
experienced licensed registered nurses or licensed
medical professionals and provide dedicated utilization
management and case management staff for the Plans
that report to the medical services liaison.

13. The Proposer shall ensure that case management
shall be staffed with experienced licensed registered
nurses preferably certified in case management. The
Proposer shall ensure an adequate ratio of case
managers to member cases in order to effectively and
efficiently manage cases in accordance with established
policies and procedures. Case managers will be available
to the County of El Paso plan member(s) Monday-
Sunday, 7:30 a.m. to 5:30 p.m. MST.

14. The Proposer shall provide utilization management
services from 7:30 a.m. to 5:30 p.m. MST, on weekdays,
except for holidays recognized by the County of El Paso.




COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management   17
15. The Proposer shall require that behavioral health
program case managers be experienced professional:
registered nurses, medical doctors, licensed clinical
social workers, psychiatrists, psychologists, and/or
marriage, family and child counselors, all with experience
in behavioral health.
16. The Proposer shall ensure that behavioral health
program case managers work with Plan member(s) ,
providers, and the County of El Paso to coordinate all
services deemed necessary for behavioral health care
and shall report quality measures demonstrating this on a
quarterly and annual basis. These measures shall
include, but not be limited to, utilization measures and
HEDIS antidepressant medication management
measures, follow up after hospitalization, and initiate and
engage alcohol and drug abuse treatment.

17. The Proposer shall have specially trained customer
service staff that are licensed professionals, to make
appropriate mental health and substance abuse referrals.

18. The Proposer shall provide a Physician Advisor staff
comprised of various medical, surgical and behavioral
health specialists who are licensed to practice in Texas
with appropriate board certification, training, experience
and expertise commensurate with utilization
management or case management. Texas-based
Physician Advisors shall be available to defend utilization
and case management decisions by Proposer when the
County of El Paso makes such a request (at no
additional expense to the County of El Paso).

19. The Proposer shall have a standardized, written and
ongoing formal training program administered and
facilitated by a dedicated training manager for all Medical
Management staff dedicated to the Plans. A copy will be
supplied to the County of El Paso if requested.

20. The Proposer shall have written policies and
procedures for each area of the Medical Management
program, which clearly describe the policy and
procedures to be followed by staff and state the date
when the policy or procedure was revised. A copy will be
supplied to the County of El Paso.




COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management   18
21. The Proposer shall have a mechanism for
monitoring and measuring the consistency of the
application by Proposer staff of the Proposer’s written
policies and procedures as they apply to operation and
administration of the medical services management
program. The Proposer shall submit to the County of El
Paso for review, a minimum of 15 days prior to
implementation, revisions to your policy and procedures,
that affect medical management provided to Plan
member.
22. The Proposer shall ensure that all areas of the
Proposer’s medical management program are integrated
internally, and that all medical management program
staff have system access to Plan member information
regardless of the management program that is serving
the member.
23. The Proposer shall integrate all activities under the
medical management program for Plan member(s) to
ensure that decisions made by different departments are
not in conflict, and that decisions support efficient
utilization of health care resources and achieve optimum
member outcomes in the most cost-effective manner.

24. The Proposer shall provide a utilization management
program designed to objectively monitor and evaluate the
efficiency, appropriateness and quality of all aspects of
care delivery systems. The utilization management
program shall efficiently utilize available health care
benefit resources and support activities which continually
improve the provision of quality medical services to Plan
member(s) . The Proposer shall demonstrate efficiency
of the utilization management program by reporting
agreed upon objective quality measures on a quarterly
basis.

25. The Proposer shall not delegate its authority to
determine medical necessity to any other entity unless
agreed to by the County of El Paso.
26. The Proposer shall ensure that appropriate, optimal
healthcare services are delivered in the most appropriate
and cost effective setting by monitoring and evaluating
the services rendered to Plan member(s) , and the
Proposer shall report quarterly to the County of El Paso
the Proposer’s evaluation.
27. The Proposer shall identify Plan member(s) with
complex and exceptional needs due to chronic or
catastrophic illness or injury and provide proactive and
intensive case management to optimize the most
effective available benefit coverage and resources. The
selection criteria shall be approved by the County of El
Paso.



COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management   19
28. The Proposer shall develop a communication plan to
facilitate communication and develop partnerships
between Plan member(s) , providers, and the County of
El Paso and support preventive health care behaviors.
The Proposer’s communication plan shall be approved
by the County of El Paso.
29. The Proposer shall support preventive health care
behavioral plans and shall report quarterly to the County
of El Paso the Proposer’s performance status.
30. The Proposer shall facilitate the appeals process for
the utilization management decisions as specified in
URAC guidelines and agreed to by the County of El Paso.

31. The Proposer shall conduct an annual evaluation of
the utilization management and case management
program to ensure that the process used continues to be
current, appropriate, and effective. A written copy of the
annual evaluation shall be provided to the County of El
Paso.
32. The Proposer shall provide quarterly reports on
utilization, case management and appeals as specified
by the County of El Paso.
33. The Proposer shall perform targeted pre-service
review, to determine medical necessity of elective
services and focus on utilization management processes
where maximum impact and increased cost savings that
will benefit the County of El Paso’s population. The
Proposer shall provide a list of recommended elective
services subject to pre-service review.

34. The Proposer shall apply the utilization management
program to all hospitalizations, both inpatient and
outpatient, including emergencies.
35. The Proposer shall conduct a utilization/medical
review to determine the appropriateness and or medical
necessity of disputed claims which do not fall within the
typical guidelines of your standard utilization
management program. The Proposer shall fully
cooperate with the County of El Paso, at no cost to the
County of El Paso, in the County of El Paso’s defense of
an action arising out of matters related to the disputed
claim.
36. The Proposer’s utilization management program
shall include:
    a. Prospective or pre-service review, which
    determines the medical necessity of scheduled, non-
    emergency hospital admissions and selected
    outpatient medical services as defined and covered
    in the benefit booklets.




COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management   20
   b. Concurrent review, which determines the medical
   necessity of services as they are being rendered,
   such as a determination of the need for continued
   inpatient care for hospitalized Plan member(s) .

   c. Retrospective review, which is performed to
   review services after they have been provided if (i)
   Proposer was not notified and therefore was unable
   to perform a pre-service or concurrent review, or (ii)
   services continued longer than originally certified
   without notification of the extension.

37. The Proposer shall provide that 70% of Reviews are
conducted prior to service to minimize retrospective
reviews.
38. The Proposer shall provide, as a component of the
utilization management program, a discharge planning
program to evaluate a Plan member’s health care needs
in order to arrange for appropriate care, services and
resources to effect an appropriate timely discharge from
an inpatient setting, and recommendation of less
intensive settings for care and treatment as appropriate.
Discharge planning is an inherent part of the utilization
management process. The Proposer shall assess cases
proactively and concurrently at each review stage. The
Proposer shall demonstrate the effectiveness of this
program.

39. The Proposer shall provide a case management
program which facilitates individual assistance to Plan
member(s) experiencing complex, acute, chronic illness,
or catastrophic injuries. The focus of the program shall
be early identification of potential long-term cases and
includes the coordination of all services provided during
the member’s continuum of care.

40. The Proposer shall identify Plan member(s) with
complex and exceptional needs due to chronic or
catastrophic illness or injury and provide proactive and
intensive case management (ICM) to optimize the most
effective available benefit coverage and resources. The
case management program shall provide individual
assistance to Plan member(s) experiencing complex,
acute or chronic illness, or catastrophic injuries. The
focus of the program shall be early identification of
potential long-term cases and includes the coordination
of all services provided during the member’s continuum
of care.




COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management   21
41. Proposer shall submit a brief description of its ICM
program and the types of conditions the program
addresses. Proposer shall report quarterly and annually
on the activities of the ICM program and shall provide a
sample report in its response to this RFP.

42. Proposer shall ensure that case management is a
collaborative process which assesses Plan member
needs and plans, implements, coordinates, monitors and
evaluates options and services for Plan member(s)
within the benefit design. Collaboration shall take place
with the clinical care team. For the purpose of this
section, clinical care team means all health care
professionals working with a Plan member and his or her
family plan member(s) .
43. Proposer shall provide, through the expertise and
management of the case manager, in collaboration with
the clinical care team, a plan of care that shall be
designed for a member with special needs or
catastrophic health problems in an effort to achieve an
optimal health status level. Catastrophic cases shall be
evaluated to determine if on site case management is
warranted.
44. Proposer shall ensure that case management
service for Plan member(s) shall be integrated with the
medical management program. The Proposer shall
demonstrate the effectiveness of their integrated
program.
45. All identified cases shall be reviewed by the case
manager, to determine if Plan member(s) meet case
management criteria and would benefit from case
management interventions.
46. The Proposer shall ensure that Plan member(s) will
be identified for possible case management by your
utilization review staff, attending physician, appropriate
hospital staff and the Plan member or the Plan member’s
family. The Proposer’s utilization review staff will utilize
specific criteria, financial factors and pharmacy
information in the case management identification
process.
47. At the County of El Paso's discretion, designated the
County of El Paso staff shall refer Plan member(s) for an
evaluation to the case management program when the
County of El Paso has been contacted by the Plan
member(s) for assistance with their health care
problems.




COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management   22
48. The Proposer shall maintain triggers for identifying
those specific services and diagnoses which are known
to benefit from case management interventions and must
be referred for targeted case management. These
services and diagnoses include but are not limited to:

   a. Reactive airway disease (e.g. asthma,
   emphysema) with a history of frequent emergency
   room visits or hospitalizations
   b. Multiple admissions
   c. Multiple emergency visits
   d. Oncology cases
   e. Organ transplant
   f. Pre-Natal (any pregnancy-related condition and
   NICU neonate)
   g. Chronic kidney disease
   h. End stage renal disease
   i. Any specialty program and
   j. Disease management program (Diabetes,
   congestive heart failure, coronary artery disease,
   hypertension, and depression)




COUNTY OF EL PASOe6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Medical Management   23
C. DISEASE MANAGEMENT PROGRAMS
Services Below Should Be Included in the Disease Management Base Administrative Fee


A = Agree; D = Agree With Deviations; N = No                      A/D/N   Explanation
1. The Proposer shall provide NCQA and URAC accredited,
comprehensive, disease management programs for Plan
member(s) with chronic conditions. Disease management is
defined as a system of coordinated health care interventions
and communications for populations with conditions in which
self-care efforts are significant. Disease management:

     a. Supports the physician or practitioner/patient
     relationship and plan care
     b. Emphasizes prevention and exacerbations and
     complications utilizing evidence-based practice guidelines
     and patient empowerment strategies
     c. Evaluates clinical, humanistic, and economic
     outcomes on an on-going basis with the goal of
     improving overall health
2. The disease management programs shall include the
following elements:
     a. Population identification processes
     b. Evidence-based practice guidelines
     c. Collaborative practice models to include physician and
     support-service providers
     d. Patient self management education (may include
     primary prevention, behavior modification programs, and
     compliance/surveillance)
     e. Process and outcomes measurement, evaluation, and
     management
     f. Routine reporting /feedback loop (may include
     communication with patient, physician, health plan and
     ancillary providers, and practice profiling).
3. The Proposer shall provide Disease Management
Programs for Plan member(s) with reactive airway disease,
diabetes, cardiovascular disease (CVD), cancer, obesity,
depression, hypertension, hyperlipidemia, and
musculo/skeletal disorders. Each Disease Management
Program shall include criteria as agreed upon by the County
of El Paso and Proposer for inclusion in a program.
4. To identify Plan member(s) for participation in Disease
Management Programs, the Proposer shall use medical and
prescription drug claims information, predictive modeling,
referrals from other medical management units, physician
referrals and member self–referrals.




COUNTY OF EL PASO         e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Disease Mgmt        24
5. Plan member identification for the Disease Management
Program is to be accomplished at a minimum through
monthly sweeps of medical and prescription drug claims data
with identifiable claim codes for the condition(s) as well as
NDC and/or other drug categorization codes like GPI and
GCN for pharmacy. Data to be reviewed and analyzed
includes, but is not limited to, office visits, hospitalizations,
emergency room visits and pharmacy utilization.

6. Other methods of referrals shall include ongoing referrals
from the Proposer’s Case Management and Utilization
Management, as well as from treating physicians. In addition,
Plan member(s) may self–refer into the Disease
Management Program.
7. The Proposer shall provide disease specific interventions
to Plan member(s) identified for the Disease Management
Program. Such interventions shall include, but are not limited
to, notification letters sent to Plan member(s) ’ physicians;
brochures, education newsletters and reminders mailed to
Plan member(s) ’ homes; and a telephonic health coaching
team consisting of registered nurses, respiratory therapists,
behaviorists, pharmacists, dieticians and exercise
physiologists. Health coaching consists of telephonic
education and support.
8. Plan member(s) shall be sent an introductory letter with
disease specific education and asked to call a toll–free
number to speak with a health coach who shall provide
information about the condition and the Disease
Management Program.
9. The Proposer shall make outreach calls to all identified
Plan member(s) to ask them to participate in health
coaching. The Proposer shall initiate telephonic outreach
within 10 days of your receipt of the Disease Management
Program referral. The Proposer shall mail letters explaining
health coaching to Plan member(s) who cannot be contacted
by telephone or who opt out of health coaching.

10. The Proposer’s RN health coach shall review identified
needs with Plan member(s) , prioritize those needs and
coordinate education calls with other plan member(s) of the
health coaching team who shall help the Plan member(s)
address self–care needs and set short–term goals for Plan
member(s) .
11. The Proposer shall offer screening for depression to
Plan member(s) who are in any Disease Management
Program or any other Plan member. Plan member(s) who
agree to depression screening shall be asked questions
related to depression by the health coach. Plan member(s)
who answer positively to any of the questions shall be
referred to Behavioral Health for further screening. Plan
member(s) who screen positive for depression shall be
referred to qualified mental health professionals by
Behavioral Health.


COUNTY OF EL PASO          e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Disease Mgmt   25
12. The Proposer shall provide quarterly progress and
annual outcomes reports for each Disease Management
Program. Outcomes reporting shall be used to evaluate the
success of the program. Outcomes reporting measurement
categories shall include improvement in clinical outcomes,
utilization rates of emergency room visits, acute inpatient
hospital days, condition specific admissions, Plan member
health status, member survey results, medication
compliance, applicable HEDIS and other clinical measures
based on available data, and financial outcomes showing
changes in medical cost trends. The methodology and
reporting will be approved by the County of El Paso.

13. The Proposer shall provide a dedicated and fully
integrated Disease management program Customer Contact
Center designed to enable and encourage consumers to use
medical care appropriately, positively impact Plan member(s)
health status, retain plan member(s) in the disease
management program, and reduce medical cost. The
program shall consist of a 24-hour a day, seven days a week
telephone-based health information, clinical assessment,
triage, health counseling and referral service, staffed by
experienced registered nurses.

14. The Proposer will provide a prenatal care outreach
program to encourage prenatal care and to manage high risk
pregnancies. At a minimum the program components will
include the following:
    a. Initiation of services in the first trimester of pregnancy

     b. Healthy pregnancy education/information provided to
     patient
     c. Screens for maternal risk factors
     d. Case management provided to high risk patients
15. The Disease Management system shall be based on
clinical algorithms that are used by nurses and physicians, in
conjunction with their professional judgment, to evaluate
individual Plan member(s) need to access medical services.
The Disease Management System shall utilize a
computerized database (including paid drug claims),
symptom-based algorithms or physician generated guidelines.

16. The Disease management program shall support and
refer Plan member(s) to disease and case management
programs.
17. The Disease management program shall be specifically
designed to assess caller needs by registered nurses,
provide guidance on accessing medical services, and direct
callers to the right level of care at the most appropriate time
based on their medical needs.




COUNTY OF EL PASO          e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Disease Mgmt   26
18. The impact the Disease management program has on
the choices made by Plan member(s) shall be measured by
tracking member satisfaction and performing annual
outcomes measurement studies. Results of member
satisfaction will be shared with the County of El Paso
annually.
19. In order to assure the quality of the Disease
management program, the Proposer shall provide quarterly
activity reports and annual outcomes reports for each
disease management program. Activity reporting will be in the
form designated by the County of El Paso.




COUNTY OF EL PASO        e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Disease Mgmt   27
D. PROVIDER NETWORK
All Services Below Will Be Included in the Provider Network Fee

A = Agree; D = Agree With Deviations; N = No               A/D/N   Explanation
1. The Proposer shall provide for a full pass-through to
the County of El Paso of all network-contracted savings
(e.g. discounts) achieved for In-Network providers.
(Shared services agreements, subrogation recoveries,
etc. are not included within this definition.) Member
deductibles, coinsurance, and copays will be calculated
on amounts reflecting the full discount.
2.The Proposer shall provide transparency of pricing
information to the County of El Paso staff. Such
transparency shall include, but is not limited to, the
compensation and prices that it pays for care and services
to providers in the health care program with which the
County of El Paso contracts. The Proposer shall also
disclose the terms of pay-for-performance models of
reimbursement. The Proposer shall agree to notify the
County of El Paso staff within 5 business days of the
execution of new contractual compensation terms
between the Proposer and its contracted provider. The
Proposer shall participate with the County of El Paso in
the development of information regarding the overall costs
of services for common episodes of care and the
treatment of common chronic conditions.

3. The Proposer shall not terminate any Hospital or
health care facility from the network (or a Hospital or
health care facility may not terminate the Proposer) that
were in place at the time the original contract was
awarded, unless the Proposer has notified the County of
El Paso in good faith and attempted to develop a method
of delivering continuity of care for people who may be
adversely affected by the in-network change.
4. No more than 25% of In-Network providers shall have
Closed Practices. Network directories shall indicate which
providers are not accepting new patients. Customer
service representatives shall identify closed provider
practices when plan member(s) contact call center.

5. Plan member(s) can access specialty services under
the plan without the requirement of a referral from a PCP.

6. Provider contracts shall stipulate that participating
providers may not balance bill the member or employer.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Provider Network     28
7. Provider contracts shall stipulate that adherence to all
precertification and appropriateness review requirements
is the responsibility of network providers for all services
rendered in-network. Plan member(s) will be responsible
for pre-certification and appropriateness review for all
services rendered by non-network providers.

8. The Proposer shall have a web site on the Internet that
plan member(s) can access for accurate information
about the provider network. The online directory shall be
updated or totally refreshed at least monthly. The
Proposer shall affirmatively survey providers regularly or
otherwise affirmatively ensure that information on
locations, telephone numbers, and acceptance of new
patients is accurate.
9. The Proposer shall perform an annual provider
satisfaction survey. The Proposer will share aggregate
results of the survey with the County of El Paso.
10. The Proposer shall include Centers of Excellence
(Center of Excellence defined as those centers for which
there are specific credentialing criteria for the facility and
physicians), or an equivalent alternative, to perform highly
specialized, high-cost procedures such as transplants,
burns, cancer, etc.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Provider Network   29
E. AUDIT SERVICES
All Services Below Will Be Included in the Audit Administrative Fee

A = Agree; D = Agree With Deviations; N = No                 A/D/N    Explanation
1. Proposer shall provide dedicated fraud and abuse staff to
the County of El Paso. The Proposer shall submit quarterly
reports to the County of El Paso listing cases referred for
potential fraudulent practice(s). Potentially fraudulent
practices reported by the County of El Paso, Plan
member(s), providers or Proposer's staff shall be reviewed
and results of the review documented in a quarterly report.
The Proposer shall investigate suspected fraudulent
practice(s) by any entity or individual.

2. Proposer shall conduct, on an annual basis, a provider
network audit to include all provider types (e.g. physician,
hospital, auxiliary services). Proposer shall conduct an audit
of 10% random sample selection of provider types.
Proposer shall report findings to the County of El Paso 60
days after completion of audit.




COUNTY OF EL PASO          e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Audit Services   30
F. IMPLEMENTATION PERFORMANCE
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No         A/D/N       Explanation
1. The Proposer shall agree to provide a dedicated
implementation and exit transition team, which shall
include an implementation/exit transition manager
and at least two experienced implementation/exit
transition specialists that shall provide assistance
during the pre-implementation and implementation or
exit transition process subject to performance
guarantees.

2. The Proposer shall maintain an
implementation/exit transition work plan documenting
all implementation/exit transition issues, actions, due
dates and responsible parties.




              e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Implementation Performance
COUNTY OF EL PASO                                                                    31
G. TERMINATION PERFORMANCE
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No             A/D/N       Explanation
1. Proposer shall have contingency plan(s),
procedures, and systems in place to provide backup
service in the event of strike, natural disaster, or
backlog.
2. The Proposer shall agree to work collaboratively
with any vendor contracted with the County of El Paso
in order to ensure consistent integration and
administration of the County of El Paso health benefits
program. If necessary, the Proposer shall agree to
carve out the following benefits (in fact and in written
materials) from their administration of the program
including: behavioral health/EAP, pharmacy, population
health management, disease management, COBRA
and online enrollment.




               e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Termination Performance
COUNTY OF EL PASO                                                                  32
H. Pharmaceutical Benefits Manager Capabilities

1.0 Administrative and Account Management Services
All Services Below Will Be Included in the Base Administrative Fee
A = Agree; D = Agree With Deviations; N = No                     A/D/N Explanation
1. The Proposer will assign an Executive that has
accountability and authority for the quality of service and
compliance to the County of El Paso’ PBM requirements. The
Proposer will provide the County of El Paso a minimum of sixty
(60) days advance notice of any changes to your Account
Management team.
2. The Proposer will provide an Account Management team to
support and provide expert advice to the County of El Paso
staff regarding the administration of the Self-Funded health
plans pharmacy program. The Proposer will make formal
presentations and participate in various workshops, provide
expert advice and analyses of proposed federal and state
legislation that may impact the pharmacy program.

3. The Proposer will provide a dedicated implementation team
which will include an implementation manager and at least two
experienced implementation specialists that will provide
assistance during the transition/pre-implementation and
implementation process.
4. The Proposer will maintain an implementation work plan
documenting all implementation issues, actions, due dates and
responsible parties.
5. The Proposer will implement new programs or benefit
changes year round, as required by the County of El Paso.
6. The Proposer will provide the County of El Paso staff
access to an online tool that contains prescription drug
information, information on plan administration components
including eligibility, prior authorizations, pharmacy locator,
patient profiles, pharmacy and direct claims history, and drug
coverage, subject to Health Insurance Portability and
Accountability Act of 1996 (HIPAA) standards and other legal
limitations. The Proposer will provide training and ongoing
support services to the County of El Paso staff.
7. The Proposer will provide for the County of El Paso
approval an initial plan design benefit coding document for your
internal quality control process to ensure accurate and ongoing
administration of the County of El Paso pharmacy benefit
program. The Proposer will maintain a documented quality
control and pre-implementation document and provide it to the
County of El Paso for review and approval prior to
implementation of any benefit or program change.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities         33
8. The Proposer will provide, upon the County of El Paso
request and at your own expense, an agreed upon number of
staff and materials as determined jointly by you and the County
of El Paso for at least 20 open enrollment benefit fairs, health
fairs, and member outreach programs throughout the calendar
year. Benefit fairs are typically held between Septmber 1st and
October 31st. Health fairs and member outreach programs are
held at various times throughout the year.


2.0 Eligibility
All Services Below Will Be Included in the Base Administrative Fee
A = Agree; D = Agree With Deviations; N = No                       A/D/N Explanation
1. The Proposer will maintain eligibility requirements in
accordance with HIPAA standards.
2. The Proposer will maintain enrollment/eligibility for Plan
member(s) by each plan, group file structure.
3. The Proposer will provide the County of El Paso staff with
access to your eligibility database for Plan member(s).
4. Based on the eligibility files you receive, the proposer will :

     a. Add coverage for plan member(s) who have joined the
     plan within 48 hours of receipt of eligibility data?
     b. Update member information (e.g. address changes)
     within 48 hours of receipt of eligibility data?
     c. Notify appropriate party of eligibility issues within 24
     hours of receipt of eligibility data?
5. The Proposer will provide immediate online real-time
manual eligibility updates for urgent requests by the County of
El Paso staff or Medical Administrator.
6. The Proposer will maintain an eligibility system that will
provide information to retail and mail service pharmacies for
the purposes of fulfillment and dispensing of prescriptions for
eligible plan member(s).
7. The Proposer will receive the County of El Paso's HIPAA
compliant eligibility data through electronic transmission from
the County of El Paso’ Medical Administrator on a daily basis.
The Proposer will have the capability to capture both the 9-digit
SSN and the unique alphanumeric Healthcare ID in your
eligibility system.
8. The Proposer will support a monthly eligibility reconciliation
process. This process includes: a monthly full eligibility file will
be received from the Medical Administrator for purposes of
eligibility reconciliation, running the file against the Pharmacy
Administrator's full eligibility file, identifying any discrepancies,
and providing discrepancies to the Medical Administrator(s) for
correction.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities           34
9. The Proposer will support the County of El Paso terms for
the eligibility reconciliation process. These terms include: a
discrepancy variance of no greater than one percent of enrolled
plan member(s) as acceptable, and administrative fees shall
be withheld or penalties shall be assessed against you and the
Medical Administrator until eligibility is reconciled. the County
of El Paso will be notified of all discrepancies.


10. The Proposer will have the capability to provide the
Medical Administrator with relevant information needed, as
determined by the County of El Paso, for the Medical
Administrator (or the Proposer) to create an integrated ID card.

11. If the County of El Paso at any time desires a separate
pharmacy ID card, do you have the capability to produce a
pharmacy ID card with the County of El Paso logo? Do you
have the capability to accept eligibility feeds from the Medical
Administrator with the unique alphanumeric Healthcare ID for
creation of the cards? Do you have the capability to send ID
cards for distribution to plan member(s) within 3 business days
or less of receipt of data? Would you be responsible for any
cost to reproduce ID cards if related to your errors or your
initiated changes?


3.0 Plan Member(s) Services
All Services Below Will Be Included in the Base Administrative Fee
A = Agree; D = Agree With Deviations; N = No                     A/D/N Explanation
1. The Proposer will provide a dedicated team to include
customer service staff and supervisors with:
    a. Minimum two years of experience with you required for
    supervisors
    b. Minimum one year of experience with you required for
    customer service representatives
    c. Formal training and ongoing quality monitoring required
    for customer service representatives
    d. Automated tracking of workload by customer service
    representative; and
    e. Customer service staffing adequate to consistently
    achieve or exceed performance standards




2. The Proposer will have the capability to provide a tracking
system for the County of El Paso specific member/provider
telephone, written and email inquiries and provide weekly
reports of call volume, first call resolution rates, average wait
time, abandonment rates, and response time to resolve
written/email member inquiries.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities         35
3. The Proposer will have the capability to provide special
telephone services for member consultations with a registered
pharmacist, provide a TDD number for hearing impaired Plan
member(s) , and a dedicated customer service phone number
for plan member(s) residing inside and outside the continental
US.
4. The Proposer will have the capability to provide to Plan
member(s) the ability to communicate customer service issues
and/or inquiries through telephone or email.
5. The Proposer will have the capability to implement and
maintain on-line access to year-to-date cumulative benefit
statements separately for each individual plan member, and
access to online accounts and the capability to maintain these
accounts at an individual level.
6. The Proposer will have the capability to implement and
maintain a pharmacy claim appeals process as described in
the County of El Paso Self Funded Benefit Booklet. These
booklets are modified and amended as needed in accordance
with the County of El Paso policies and procedures. The
Proposer will have the capability to handle initial claim
determinations and first level appeals, including physician
requested urgent appeals. The County of El Paso will make
the final determination for second level and final appeals.

7. The Proposer will perform an annual member service
satisfaction survey with a mutually agreed upon survey tool and
methodology.

4.0 Network Access & Management
All Services Below Will Be Included in the Base Administrative Fee
A = Agree; D = Agree With Deviations; N = No                     A/D/N Explanation
1. The Proposer will assure that its information systems are
compliant with the requirements of the HIPAA standards for
acceptance of claim transactions in the applicable industry
standard NCPDP format.
2. The Proposer will assure integrated real-time point-of-
service (POS) processing of claims, denials, and re-bills for
retail and mail service claims. The Proposer will provide
online real-time pharmacy adjudication that is accessible from
a device in the pharmacy or other provider facility, such as a
personal computer, credit card POS device, or touch-tone
telephone.
3. The Proposer will provide member eligibility and drug
coverage information through POS electronic transmission to a
dispensing retail pharmacy.
4. The Proposer will provide participating pharmacies with a
pharmacy services toll-free telephone number to address
questions from retail pharmacies.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities         36
5. The Proposer willassure that DUR programs are integrated
at retail and mail order with POS edits that provide
communication and education to pharmacists and prescribers.
The Proposer will take action with pharmacists and prescribers
who do not appropriately comply with your DUR programs.

6. The Proposer will require participating pharmacies to
comply with all contract provisions, including but not limited to
DUR messaging, submission of usual and customary (U&C)
price, and MAC pricing. This includes the fact that U&C must
be input at the point-of-service before the amount to be
charged is determined.
7. The Proposer will process electronic POS and paper retail
claims in accordance with the County of El Paso’ contract
terms, copay structure, and plan design in the County of El
Paso Benefit Booklet in effect on the date the claim is incurred.
 The Proposer will accept and process all direct reimbursement
claims from subscribers and governmental agency subrogation
claims. Only claims that are received within 12 months from the
prescription fill date will be eligible for payment.

8. For incorrect payments, the Proposer will make reasonable
efforts to recover any overpayments or reimburse any
underpayments to the County of El Paso in accordance with
applicable law and the County of El Paso policies and
guidelines regarding collection and/or reimbursement of such
payments.
9. The Proposer will provide annual reporting of its network
management performance and auditing to the County of El
Paso. The Proposer will provide reporting on submission of
U&C price compliance, DAW overrides, generic substitution,
formulary compliance, fraud and abuse detection, responses to
DUR messaging and audit recoveries.

10. The Proposer will provide, upon request, the County of El
Paso with sample participating pharmacy contracts for the
County of El Paso’ review.
11. The Proposer will have the capability to conduct onsite
audit of at least 4% and desk audits of at least 25% of
participating retail network pharmacies on an annual basis.
12. The Proposer will have the capability to provide access to
the distribution of specialty pharmaceuticals with discounted
pricing, clinical management and patient counseling.


5.0 Mail Order Pharmacy Services
All Services Below Will Be Included in the Base Administrative Fee
A = Agree; D = Agree With Deviations; N = No                     A/D/N Explanation
1. The Proposer will electronically track a maximum out-of-
pocket co-payment by calendar year, if necessary.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities         37
2. The Proposer will assure that appropriate member
education materials and brochures are included with mail
service orders.
3. The Proposer will provide alternative approaches to
minimize the need for plan member(s) to request new
prescriptions during transition. Please describe your resources.

4. The Proposer will provide receipts to plan member(s) that
show total cost, amount paid by member, and amount paid by
the plan for each prescription.
5. The Proposer will not charge the County of El Paso or plan
member(s) for the additional cost of expedited delivery, if the
prescription order delay is caused by the Proposer.

6. The Proposer will assure that 100% of mail order
prescriptions will be imaged and entered when received at mail
service. The Proposer will electronically track 100% of all mail
order prescriptions throughout the filling process, on a timely
basis, from the point the prescription is received until it is
shipped to the member.
7. The Proposer will contact prescribers and/or plan
member(s) via a telephone call or email within 24 hours for all
incomplete mail order prescriptions that require additional
information.
8. The Proposer will provide both email and telephone
voicemail capabilities to communicate to plan member(s) their
mail order has been received and the date when order has
been shipped to member.
9. The Proposer will accept early refill orders and suspend or
“queue” these orders in your system until the earliest refill date
for processing.
10. The Proposer will accept major credit cards and store
credit card number(s) by member account for future mail order
prescriptions.
11. The Proposer will accept new prescriptions from
prescribers’ offices via telephone and/or facsimile.
12. The Proposer will enable Plan member(s) to refill mail
service prescriptions through mail, Web site, telephone,
subject to compliance with all applicable federal and state and
local laws and regulations.
13. The Proposer willmaintain computerized control of
ingredient pricing through the use of a single, auditable industry
resource as the Drug Topics Red Book or First Data Bank Blue
Book both for mail order and retail prescriptions.

14. The Proposer will provide access to the distribution of
specialty pharmaceuticals with discounted pricing, clinical
management and patient counseling.
6.0 Clinical and Formulary Management
Programs/Specialty Pharmacy
All Services Below Will Be Included in the Base Administrative Fee



COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities   38
A = Agree; D = Agree With Deviations; N = No                      A/D/N Explanation
1. The Proposer will provide a basic Concurrent DUR program
that is integrated for retail and mail order claims. The Proposer
will provide a concurrent review that includes: drug-drug
interactions, inappropriate dosage and duration, over- and
under- utilization, therapeutic duplication, and drug-age edits.

2. The Proposer will provide a basic Retrospective DUR
program that shall review utilization patterns among
prescribers, pharmacists and plan member(s) , and those
associated with specific drugs or groups of drugs on at least a
quarterly basis. The assessment would include, but shall not
be limited to:
    a. Monitoring for therapeutic appropriateness
    b. Over-utilization and under-utilization
    c. Appropriate use of generic and preferred products
    d. Therapeutic duplication
    e. Drug-disease contraindications
    f. Drug-drug interactions
    g. Incorrect drug dosage or duration of drug treatment
    h. Clinical abuse/misuse
3. The Proposer will send letters addressing the above
assessment results to plan member(s) and prescribers, as
appropriate.
4. The Proposer will conduct a member disruption analysis
and expected savings analysis upon recommendation and at
least 60 days prior to the implementation of any plan design
change or new DUR or Utilization Management (UM)
program(s).
5. The Proposer will provide a specialty pharmacy program
that provides clinical management, patient counseling, and
dispensing of specialty drugs and all related ancillary products.
The Proposer will provide the County of El Paso the option of
implementing a voluntary specialty pharmacy program or retail
lockout.
6. The Proposer will provide an integrated predictive modeling
application and enhanced DUR program that uses medical and
pharmacy claims data to prevent adverse drug outcomes. The
Proposer will provide the County of El Paso with reporting
associated with the clinical outcomes and cost savings
associated with this program. Please provide sample reports.

7. The Proposer will analyze claims and clinical programs on
an ongoing basis and present recommendations to the County
of El Paso, during quarterly clinical and financial meetings.
This analysis would include: an overview of additional clinical
management opportunities as well as an assessment of the
effectiveness of the management programs currently in place,
prescription drug issues, trends, new products and service
offerings to the County of El Paso.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities          39
8. The Proposer will notify the County of El Paso 90 days in
advance of any changes to the formulary in effect for Plan
member(s) and any changes in drug-to-drug interventions.
You agree to conduct targeted member specific
communications 60 days in advance of any formulary changes.

9. If the County of El Paso implements various clinical
programs, do you have the capability to discuss all relevant
interventions and edits that pertain during a single contact with
the prescriber?
10. The Proposer will maintain an independent Pharmacy and
Therapeutics (P&T) committee, whereby voting plan
member(s) are not employees of your organization or a
pharmaceutical manufacturer. Your P&T committee would be
responsible for developing clinical guidelines and
recommendations for formulary status and therapeutic
interchanges. Do you have the capability to provide the County
of El Paso with your P&T meeting minutes as soon as they
become available?
11. The Proposer will replicate the existing programs that are
currently implemented including Dosage Optimization controls
and Over The Counter drug options allowed using generic co-
pays.
12. The Proposer will provide recommendations and support
relative to effective strategies for minimizing member disruption
prior to implementation of new programs and/or changes in
benefit.

7.0 Systems and Data Reporting Management
All Services Below Will Be Included in the Base Administrative Fee
A = Agree; D = Agree With Deviations; N = No                      A/D/N Explanation
1. The Proposer will provide electronic clinical and financial
reporting for all levels of the account structure, with subtotals
and in total, at least quarterly, with financial and clinical
components easily determinable. The Proposer will provide
claim reports based on the County of El Paso reporting
requirements within 10 business days of the end of each month.

2. The Proposer will coordinate with the County of El Paso’
contracted vendors as appropriate, including electronic feeds
of information if necessary (e.g., claims/precertification
information, COBRA eligibility, claims for FSA reimbursement,
paid claims history to the County of El Paso Medical
Administrator and financial claims history to consultants, etc?).

3. The Proposer will provide reporting for the purposes of
monitoring and reconciling performance guarantees.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities          40
4. The Proposer will supply the County of El Paso (and if
requested, their consultant) with sophisticated online reporting
and modeling (plan design, clinical and financial) tools. The
Proposer will provide initial training for the County of El Paso
staff and ongoing user support to manage the prescription drug
program.
5. The Proposer will provide the County of El Paso with an
integrated pharmacy database that you will maintain for a
minimum of 3 years. This database will include, but may not
be limited to mail, retail and specialty pharmacy claims. You
shall provide training and ongoing support to the County of El
Paso staff for the use of this database.
6. The Proposer will provide information on a drug by drug
basis of earned rebates to the County of El Paso upon request.

7. The Proposer will provide prescription drug claim level
detail, all reports, billings, rebate records, performance
measures, service concerns and issues, or any other
communication, to the County of El Paso in a manner mutually
agreed upon by both parties.

8.0 Plan member(s) and Employer Communications
All Services Below Will Be Included in the Base Administrative Fee
A = Agree; D = Agree With Deviations; N = No                     A/D/N Explanation
1. The Proposer will provide member communication materials
and/or enrollment materials on an annual basis at a minimum.
All communication materials shall be made available to Plan
member(s) upon reasonable request by customer service and
via your Web site.
2. In accordance with the County of El Paso direction and
review, you will have the capability to prepare, publish and
distribute appropriate communications to plan member(s).
These materials should include, but not be limited to,
communications such as:
     a. An informational brochure which describes the Retail
     Service Program, Mail Service Program, and Therapeutic
     Interchange Program;
     b. A medical profile questionnaire requesting information
     on drug allergies, chronic medical conditions, and other
     pertinent information specific to each plan member;

    c. Mail service order form and return envelope; and
    d. member outreach materials regarding patient safety,
    generic drugs, etc.
    e. Specialty Pharmacy communications
3. The Proposer will be willing to allow the County of El Paso
to review and approve all the County of El Paso plan member
communications before mail out.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities         41
4. The Proposer's customer service representatives will be
able to provide the following services to “prospective” plan
member(s) during the County of El Paso annual open
enrollment period and year-round services to newly enrolled
public agency prospective plan member(s) and new hires:
locating a participating pharmacy, information on the County of
El Paso’ plan design, help determining if a drug is on your
formulary; and applicable copay. The Proposer will have the
capability to provide similar support for prospective plan
member(s) via your Web site.
5. The Proposer will accommodate a direct link from the
County of El Paso’ Web site and the County of El Paso’ health
plan Web site.
6. The Proposer will provide member communication materials
to include participating pharmacies, and prescribers.

7. The Proposer will provide disease management
communication materials upon the County of El Paso request
for designated programs.
8. The Proposer will send additional mailings (not listed above)
to plan member(s) as requested by the County of El Paso.
Such mailings must have the approval of the County of El
Paso. The Proposer will be responsible for all mailing and
postage costs.

9. Medicare Part D
All Services Below Will Be Included in the Base Administrative Fee

A = Agree; D = Agree With Deviations; N = No                       A/D/N Explanation
1. Do you have the capability to be able to support the County
of El Paso decision to receive the federal drug subsidy in 2009
(and beyond as requested by the County of El Paso) by
providing the following services to ensure compliance with the
Centers for Medicare and Medicaid Services (CMS)
requirements, including but not limited to:
    a. Track and submit claims data eligible for the subsidy to
    CMS for all employer groups under the County of El Paso,
    and its contracting agencies
    b. Calculate, or provide information necessary for the
    County of El Paso to calculate, subsidy amounts for
    individual contracting agencies and schools
    c. Perform annual reconciliation to adjust for actual
    rebates, discounts and price concessions
    d. Provide creditable coverage notification to Medicare-
    eligible retirees
    e. Store claims, utilization management and eligibility data
    for the period required by CMS




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities           42
   f. Develop at least two reports which measure recoveries
   from the subsidy calculations? One report will show the
   dollars recovered from CMS allocated to the various
   County of El Paso purchasing organizations? Another
   report will show the number of claimants by size of annual
   claims
   g. Estimate the value of CMS reimbursements related to
   the subsidy during the County of El Paso’ rate renewal
   process each year
   h. Provide claims data necessary to support audit
   processes
   i. Coordinate with the County of El Paso's previous vendor
   as needed to support annual reconciliation for 2009

   j. File required application to CMS if necessary in 2009 and
   beyond
2. Do you have the capability to provide all analysis and data
necessary for the County of El Paso to evaluate other Medicare
Part D options for 2009 and beyond?
3. For Medicare Part D options, do you have the capability to:

   a. Act as Third Party Administrator of a self-funded PDP

     b. Support The County of El Paso application process to
     become a PDP
     c. Offer a The County of El Paso-specific, fully-insured,
     plan-administered PDP
4. Offer a fully insured Medicare Advantage Plan comparable
to the current Buy Up option.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, PBM Capabilities   43
I. COBRA Administration
All Services Below Will Be Included in the Base Administrative Fee or a separate fee

A = Agree; D = Agree With Deviations; N = No                   A/D/N   Explanation
1. Proposer will administer COBRA and/or equivalent
services for the County of El Paso. Proposer will assume
liability for COBRA and/or equivalent violations or
penalties.
2. Proposer will archive actual COBRA and/or equivalent
related forms for a period of 8 years.
3. Proposer will maintain a system for tracking regulatory
changes that may affect the County of El Paso and will
communicate changes in the regulatory environment to the
County of El Paso.
4. Proposer will provide the a COBRA and/or equivalent
procedures manual.
5. Proposer will provide an initial and all subsequent
required notices to newly and currently covered
employees. Proposer will also also send notices to a
separate address for spouses/dependents.
6. Proposer will provide a 1-800 number to handle
questions from members.
7. Proposer will perform an eligibility audit of the current
COBRA and/or equivalent continuants when service
begins
8. Proposer will provide monthly billing and collection of
continuation contributions.

9. Proposer will verify eligibility and that the continuant
does not have other coverage prohibiting the continuation
of coverage through the County of El Paso.
10. Proposer will send HIPAA certificates with proof
upon loss of active employee coverage.

11. Proposer will send HIPAA certificates, with proof,
when COBRA and/or equivalent coverage terminates.




COUNTY OF EL PASO          e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, COBRA Admin       44
J. HIPAA Administration
All Services Below Will Be Included in the Base Administrative Fee or a separate fee

A = Agree; D = Agree With Deviations; N = No                  A/D/N   Explanation

1. Proposer will be compliant with all HIPAA regulations.
2. Proposer will provide a copy of all HIPAA policies to
the County of El Paso.
3. Proposer will demonstrate to the County of El Paso that
it has formal procedures for training all personnel who are
provided access to PHI.

4. Proposer will provide notice of all HIPAA forms to be
used by the County of El Paso and its beneficiaries.

5. Proposer will provide adequate proof that it has proper
procedures and controls to confirm that any subcontractors
or business associates is HIPAA compliant.

6. Proposer will indemnify the County of El Paso from
penalties associated from HIPAA non-compliance.




COUNTY OF EL PASO          e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, HIPAA Admin       45
L.SECTION 125 and 132 PLAN ADMINISTRATION
Services Below Should Be Included in the Section 125 and 132 Plan Administrative Fee


A = Agree; D = Agree With Deviations; N = No                      A/D/N   Explanation
1.    Proposer will provide approved communications to
help maximize plan participation. Provide Samples.
2.    Proposer will provide daily claims processing.
3.    Proposer will provide provide participant status
account inquiry via the internet.
4.    Proposer will provide direct deposit of claims
reimbursement.
5.    Proposer will provide a 24-hour toll-free automated
information line for participants.
6.    Proposer will provide toll-free technical support for the
County of El Paso.
7.    Proposer will provide Internet Based Open Enrollment
for FSA participants.
8.    Proposer will provide the County of El Paso with
updates of relevant legislative and regulatory changes.

9.     Proposer will provide direct pay to day care providers.
10. Proposer will provide non-discriminatory testing
services.
11. Proposer will provide toll-free customer service for
participants.
12. Proposer will provide a customized Plan Document and
Summary Plan Description for the plan.
13. Proposer will provide the capability to offer a debit card
for reimbursement use.
 14. Proposer will provide administrative support and claims
 processing support for the Premium Only Plan, the Flexible
 Savings Account, and Dependent Care Assistance Plan,
 and the Parking and Transportation as described in the
 current SPD.
 15. Proposer will provide adequate personnel for
 enrollment assistance for up to 20 enrollment meetings.




COUNTY OF EL PASO e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, Section 125 Plan            46
M. ON SITE CLINIC SERVICES AND ADMINISTRATION
Services Below Should Be Included in the On Site Clinic Base Administrative Fee


A = Agree; D = Agree With Deviations; N = No                     A/D/N   Explanation
1. The proposer warrants that it can provide properly
supervised administration of a primary walk-in health care
clinic and will provide documentation verifying the credentials,
degrees, licenses and proof of liability and malpractice
insurance coverage.
2. The clinic will be fully staffed on a 5 hour per day basis at
a location to be determined by the County of El Paso on any
scheduled work day.
3. The Proposer shall provide all personnel, equipment,
furniture and supplies necessary to operate the clinic. The
cost of these materials will be included in the base
administrative fee.
4. The Proposer shall be responsible for compliance with all
HIPAA privacy and security requirements and assumes all
liabilities related to the practice of medicine.
5. The Proposer will provide monthly tracking reports
summarizing the frequency and type of services provided.
6. The Proposer will assist the County of El Paso in the
collection of Health Risk Assessments, analysis of the data,
and provide recommendations for program considerations.
(Provide samples of forms, resources used and sample
recommendations generated from similar prior projects)

7. The Proposer shall provide content for communication
pieces that can be used educational and information efforts
with the plan members to help develop relationships between
Plan member(s), providers, and the County of El Paso, and
to support preventive health care behaviors. The Proposer’s
communication plans shall be subject to approval by the
County of El Paso.
8. The Proposer agrees that any information or records
collected cannot be sold to any other party.
9. The Proposer will not only provide basic clinic services,
but also wellness screenings.
10. The Proposer will work in cooperation with any wellness
or disease management programs and efforts by
communicating and coordinating member involvement and
awareness.
11. The Proposer will be able to administer EKG tests.




COUNTY OF EL PASO                           e6a92a2a-fd0e-44d3-92b9-66fee196931b.xls, On Site Clinic   47

								
To top