State of Delaware Department of Human Resources

The buyer seeks professional services for medical and prescription insurance audit services. The selected vendor will conduct contract compliance reviews of medical and pharmacy claims processed by the Plan's third-party administrators and pharmacy benefit manager. Services include electronic claim reviews, operational reviews, financial comparisons, and written reports with recommendations. The contract term is for three years with two optional one-year extensions.

• 1/14/2025 - Intent to Submit Proposal Deadline
• 1/16/2025 - Mandatory Pre-Proposal Meeting
• 1/21/2025 - Questions Due
• 1/28/2025 - Responses to Questions
• 2/13/2025 - Proposal Due Date
• 3/4/2025 - Notification of Finalists
• 3/19/2025 - Finalist Interviews

• Experience auditing Blue Cross Blue Shield and Aetna plan contracts
• Experience auditing CVS plan contracts
• Prior experience directly related to requested services
• Ability to perform required scope within requested timeline

• Conduct contract compliance reviews of medical claims processed by Plan's medical TPAs
• Perform electronic review of 100% of claims processed within review period
• Conduct target claims selection to validate electronic query results
• Review operational policies, procedures, and internal quality control measures
• Provide financial comparison of amounts paid to amounts invoiced
• Deliver written report of findings with recommendations
• Conduct contract compliance reviews of pharmacy claims processed by Plan's PBM
• Perform rebate review of all payments from manufacturers to PBM
• Conduct MAC list review of top fifty utilized drugs
• Provide post-audit support for resolving open issues with TPAs