This bid is for medical claims audit services for a self-funded employee health plan based at 500 E Capitol Ave, Pierre, SD 57501.
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What the job is
Audit periods: Three annual audits covering July 1, 2027–June 30, 2030, with separate findings, reports, recommendations, and supporting work papers for each year.
Claims screening: Screen 100% of paid medical claims, approximately 314,300 annually, for processing and payment accuracy, financial accuracy, 14- and 30-day turnaround, and recovery potential.
Annual samples: Review 200 claims using combined financial stratified/attribute statistical sampling, emphasizing high-dollar claims; 50 inpatient diagnosis-related group (DRG) claims for processing and questionable coding; and 20 out-of-network claims for payment and contractual compliance.
Performance review: Evaluate Wellmark's plan compliance, controls, negotiated provider rates, and claims data accuracy; compare results with industry benchmarks and self-reported performance.
Standards and privacy: Independent audit under GAGAS with statistically valid sampling, HIPAA compliance, a Business Associate Agreement, and a Wellmark nondisclosure agreement. Services and data storage must remain within the continental United States.
Pricing: Provide a breakdown by annual audit, including all direct and indirect costs, professional services, conference calls, and travel.
XL Eagle