Posted Date : June 03,2020
Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID : MB-4243
Government Authority located in Ohio; USA based organization looking for expert vendor for pharmacy benefit manager audit services.
[A] Budget: Looking for proposal
[B] Scope of Service:
Vendor needs to provide pharmacy benefit manager audit services will analyze the claims dataset to validate the correct application of plan design to ensure claims were processed in accordance with the plan set-up documents including co-payments, coinsurance, and exclusions, as well as other cost management features such as quantity level limits and step therapies. For certain edits, the Selected Auditor may test a statistically valid random sample of the results from the electronic analysis to validate findings.
- Determine if pharmacy claims are being adjudicated in accordance with the correct pricing terms (e.g. discounts, dispensing fees, administrative fees) for each review period.
- Determine the accuracy of pharmacy claims adjudication with respect to plan design provisions (including by way of example only, co-payments, coinsurance, quantity limits, excluded medications, prior authorizations, step therapy programs, reversed and reprocessed claims, Medicare B).
- Evaluate the accuracy of manufacturer rebates received by the Rx Administrator and credited to OPERS.
- Evaluate the Rx Administrator’s administration of retiree drug subsidy (RDS). OPERS participated in this program in 2016 with a Medicare eligible population of 2,336 lives.
- The Selected Auditor must request paid claims data from ESI covering the time period of the audit, and aggregate the discounts achieved for both brand name drugs and generic drugs.
- The Selected Auditor will request a second dataset from ESI covering the time period of the audit that will represent a detailed claims file of all retail network pharmacy reimbursements. Using this file, the Selected Auditor will compare the network pharmacy reimbursement amounts to the invoiced amount and identify any claims where the discount was not passed through properly and calculate the aggregated discrepancy.
- For more information describe in documents.
[C] Eligibility:
- Onshore (USA Organization Only);
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office location.
Budget :
Deadline to Submit Proposals: June 26,2020
Cost to Download This RFP/RFQ/RFI/Solicitation/Tender/Bid Document : 5 US$
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Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID : MB-4243
Government Authority located in Ohio; USA based organization looking for expert vendor for pharmacy benefit manager audit services.
[A] Budget: Looking for proposal
[B] Scope of Service:
Vendor needs to provide pharmacy benefit manager audit services will analyze the claims dataset to validate the correct application of plan design to ensure claims were processed in accordance with the plan set-up documents including co-payments, coinsurance, and exclusions, as well as other cost management features such as quantity level limits and step therapies. For certain edits, the Selected Auditor may test a statistically valid random sample of the results from the electronic analysis to validate findings.
- Determine if pharmacy claims are being adjudicated in accordance with the correct pricing terms (e.g. discounts, dispensing fees, administrative fees) for each review period.
- Determine the accuracy of pharmacy claims adjudication with respect to plan design provisions (including by way of example only, co-payments, coinsurance, quantity limits, excluded medications, prior authorizations, step therapy programs, reversed and reprocessed claims, Medicare B).
- Evaluate the accuracy of manufacturer rebates received by the Rx Administrator and credited to OPERS.
- Evaluate the Rx Administrator’s administration of retiree drug subsidy (RDS). OPERS participated in this program in 2016 with a Medicare eligible population of 2,336 lives.
- The Selected Auditor must request paid claims data from ESI covering the time period of the audit, and aggregate the discounts achieved for both brand name drugs and generic drugs.
- The Selected Auditor will request a second dataset from ESI covering the time period of the audit that will represent a detailed claims file of all retail network pharmacy reimbursements. Using this file, the Selected Auditor will compare the network pharmacy reimbursement amounts to the invoiced amount and identify any claims where the discount was not passed through properly and calculate the aggregated discrepancy.
- For more information describe in documents.
[C] Eligibility:
- Onshore (USA Organization Only);
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office location.
Budget :
Deadline to Submit Proposals: June 26,2020
Cost to Download This RFP/RFQ/RFI/Solicitation/Tender/Bid Document : 5 US$