South Dakota Posting Board #26RFP19878

Medical Claims Audit Services for South Dakota State Employee Health Plan

The State of South Dakota's Bureau of Human Resources and Administration (BHRA) is seeking a qualified vendor to conduct a comprehensive audit of medical claims processing for the State Employee Health Plan, administered by Wellmark Blue Cross Blue Shield of South Dakota. - Government Buyer: - State of South Dakota, Bureau of Human Resources and Administration (BHRA) - OEM/Vendor Mentioned: - Wellmark Blue Cross Blue Shield of South Dakota (administrator and subject of audit) - Services Requested: - Medical Claims Audit Services for three consecutive fiscal years - Electronic screening of 100% of paid medical claims each year - Judgment reviews of 50 inpatient DRG hospital claims per year - Review of 20 out-of-network claims per year - Assessment of compliance with plan provisions, controls, provider rates, quality, timeliness, and data accuracy - Adherence to Generally Accepted Government Auditing Standards (GAGAS) and industry-standard methodologies - Compliance with HIPAA and detailed IT/security requirements - Execution of a Non-Disclosure Agreement (NDA) with Wellmark - Unique/Notable Requirements: - Auditor must maintain independence and relevant experience - Use of statistically valid sampling and sufficient documentation for findings - Three-year contract term with two optional one-year renewals - Each audit period results in a separate report and recommendations

Description

The Bureau of Human Resources & Administration (BHRA) of South Dakota is soliciting proposals for a performance review of medical claims processing performed by Wellmark Blue Cross Blue Shield of South Dakota. Wellmark administers the State's self-funded medical and pharmacy plans covering approximately 12,150 state employees and COBRA participants, with a total of about 26,800 plan participants including dependents. The audit will cover three 12-month audit periods from July 1, 2027, to June 30, 2030, and aims to assess compliance, procedures, controls, quality, timeliness, and accuracy of claims processing. The selected auditor must execute a Non-Disclosure Agreement with Wellmark and follow Generally Accepted Government Auditing Standards (GAGAS).

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