REQUEST FOR EMPLOYEE BENEFITS RELATED PROPOSALS
Nashville-Davidson County Metro Government
NOTE: This document is for instructional purposes only. It has been
edited from the original and may not be the current version in use.
CONTENTS
Dental--includes organization information, reporting, etc.
Vision Care
Managed Prescription Drug
Managed Mental Health/Substance Abuse
Preventative Wellness Program
Health Risk Appraisals
Financial Underwriting
Cost Exhibits
8.0 DENTAL QUESTIONNAIRE
Please complete a separate questionnaire response for each plan option you are
proposing:
Traditional dental plan
Managed dental plan
8.1 ORGANIZATIONAL STRUCTURE AND EXPERIENCE
1. Please provide the following information about each of the key members on
your proposed Metro account team.
a. Name(s)
b. Location(s)
c. Key role(s) and responsibilities
d. Time commitment for installation of the program and, where applicable,
ongoing service to Metro
2. Provide a resume for each team member listed above, including a
description of the individual s experience with similar projects.
3. Please complete the following chart, based on your current book of business:
[chart]
4. Where is the group office located that will pay dental claims?
5. Will a dedicated claims examiner be assigned to the Board s account?
6. Please complete the following chart for the claims office that would
administer Metro's claims:
[chart of staff by experience]
7. Please list five (5) governmental clients for which you pay claims from the
local office listed above (include employer name, address, number of
employees, and contact name and telephone number).
8. Please list five (5) references for current clients who have similarly
sized populations for programs comparable to those you propose to the
Board (include contact name, telephone number, and brief description of
the organization).
9. Please list two (2) clients who have recently elected to leave your
organization s network. Why? Provide a contact name and telephone
number.
10. Please provide your company s most recent rating from each of the
following:
a. A.M. Best
b. Moody s
c. Duff & Phelps
d. Standard & Poor s.
8.2 REPORTING
1. Please complete the following chart to indicate the dental plan reports
that you will provide Metro. Note any deviations in Section 12.0.
[chart]
2. a. What is the turnaround time for special request reports?
b. Is there an additional cost for special reports?
8.3 TECHNICAL APPROACH
A. Systems
1. Please provide a complete description of your claim processing system:
a. What procedures are in place to document receipt of claims?
b. What quality control procedures are included in the system?
c. Are all functions automated? If not, describe any manual operations.
d. Can a claims processor override the system? If yes, please describe
how and when this occurs.
e. How long do you maintain dental history in the computer?
f. Do you maintain dental history information in hard copy form?
g. How long do you maintain a terminated employee's file in the system?
h. Does your firm use a paperless claims system?
i. Are plan summaries maintained on-line through your system?
2. Is the administration of COB an integral part of your on-line claim
payment system?
3. Does your system maintain a listing of eligible employees/pensioners
on-line? If so, how frequently is the file updated?
4. Metro requests that dependent information, including name, Social Security
number, sex, and date of birth, be maintained on-line. Will your
system accommodate this requirement?
5. Is the employee/pensioner and dependent identification system linked to the
employee/pensioner Social Security number?
6. What edits are on-line to ensure payments are limited to eligible members?
7. Please provide information about how you process eligibility updates, as
follows.
a. Can you process eligibility updates via tape-to-tape exchange?
b. What record format would you require? Please attach a sample of your
format.
8. It will be necessary to track partially or totally fulfilled deductible
carry-over and accumulation toward plan maximums from the prior
administrators.
a. Please confirm that you have this capability.
b. Describe your method of transmitting history from prior claim
administration.
9. Can an on-site terminal be installed at Metro for inquiry and eligibility
purposes? Is there an additional charge for this service?
10. How will your dental system interface with the medical claims system for
benefit integration purposes?
B. Claims Administration
1. Is a toll-free telephone number available to Board Office staff and
employees/pensioners for claim questions and assistance? State the
hours of operation and time standards.
2. How does your company maintain eligibility data?
3. What hours are you available to verify eligibility?
4. Do claim processors handle inquiries from participants regarding benefit
payments, or is there a separate customer service unit to handle such
requests?
5. If a claim is denied, how do you notify the claimant?
6. What appeals process is in place for a participant whose claim is initially
denied?
7. Can you suspend and reinstate coverage of employees and/or dependents upon
request by the Board?
8. How much advance notice of a benefit revision do your require?
9. How would you handle a retroactive benefit revision?
10. What is the typical turnaround time for claims?
11. What was the error rate for the designated office during:
a. Calendar year 1993?
b. Calendar year 1994?
12. What are your claim office s performance standards for:
a. Financial accuracy?
b. Payment incidence accuracy?
c. Procedural accuracy?
13. When other group coverage is not indicated on a dependent claim
submission, what guidelines and procedures do you follow in conducting
further investigations?
14. Regarding your EOB capabilities:
a. Do you provide the name and telephone number of a customer service
representative on the EOB for participants who have questions?
b. Can you provide copies of EOB to the provider, patient and employer?
c. In the event a patient loses an EOB, can you provide a duplicate?
15. Regarding payment processes:
a. How often are checks/EOBs printed?
b. Do you bulk pay to providers? If so, how often?
16. What type of claims are automatically flagged for review before
disbursement?
17. Do you employ your own dental consultants, or do you use outside
consultants?
18. Regarding reasonable and customary (R&C) charges:
a. What R&C percentile do you utilize in determining benefit allowance?
b. How often do you update your profiles?
19. Do you have the capability of paying at a percentile specified by the
Board?
20. Will you make R&C data available to the Board upon request?
21. What specific action is taken when a claim for benefits exceeds your R&C
level?
22. What is your company s turn-around time for pre-certification forms?
23. What is your company s policy regarding audits by outside firms, or Metro
Internal Audit Division, for the services provided by your company and
the charges submitted by you?
C. Managed Dental Care Networks
1. Enclosed is a diskette with the addresses (5-digit zip codes) of all
eligible Metro employees. Please use this data to provide a match with
your network(s).
a. Please describe how distances between employees/pensioners and providers
are determined. At a minimum, the match should report the number of
employees/pensioners within each zip code who have one, two, or three
dentists within three (3) miles.
b. Please list all zip codes where, for each criteria selected, a match
does not occur.
c. Please complete the chart provided in Attachment 3.
2. Please provide the following enrollment information for the network that
provides services to the Metro area.
3. Please provide an ASCII file and five (5) hard copy directories of dentists
in the applicable network areas. Include the geocoded location of each
provider on the ASCII file.
4. Regarding your network provider directory:
a. How do you communicate changes in your network s providers (additions
and deletions) to plan participants?
b. Does your network provider directory list providers who are no longer
accepting new patients (and, if so, is this fact clearly indicated)?
c. Are specialists listed?
5. Can employees request to add dentists to the network? If yes, what is
the process?
6. Please describe how the following situations would be handled in your
network:
a. Members traveling temporarily outside of their home network
b. Dependent children attending school away from their home network
c. Member who works in a network location, but resides in a non-network
area
7. Are the networks owned or leased by your firm and do these arrangements
vary by geographic location?
8. Indicate which of the following are verified/reviewed during the dentist
selection/credentialing process: [chart with accreditations, liscenses,
etc.]
9. Who conducts the credentialing process and what are the qualifications of
the person(s) or organization(s) responsible for conducting this
review?
10. Specify the proportion of participating network dentists who are board
certified/ eligible and have graduated from an accredited U.S. college
of dentistry/D.D.S. program: [chart]
11. Describe the extent of your liability coverages, including malpractice,
E&O, and total liability.
D. Quality Assurance
1. Describe your quality assurance program. How long has it been in effect?
2. Is your quality management program identified as a separate function
within your organization? Please provide a resume of the individual
responsible for managing the process.
3. Specify the documented procedures that are conducted in the quality
assurance and review of a physician s performance:[chart]
4. How many patient caregivers were reprimanded during the past 12 months for
failure to follow your firm s quality assurance process? What
specialties did they represent?
5. How many patient caregivers have been dismissed from your organization
during the past 12 months for failure to follow your firm s quality
management process? What specialties were represented?
6. Does your network monitor treatment outcomes? If yes, please describe your
program.
7. Please describe your procedure for handling participant grievances about
the network or claims.
8. On what percentage of claims do you normally perform quality review and
how do you select the sample? Is the quality review done on a
pre-disbursement basis?
9. Describe the quality-assurance reports you will provide, and their
frequency, to the Board.
10. Are you willing to fund an independent survey, commissioned by the Board,
in lieu of your own member (patient) satisfaction survey?
11. Cite the three most frequent complaints and appeals by patients. What
action did your company take to improve service.
12. Regarding enrollees who leave your plan:
a. Does your plan survey ex-enrollees to learn why they have left your
plan?
b. If no, why?
c. If yes, state the three most frequent reasons for leaving your plan.
13. Regarding patient complaints:
a. In 1994, how many complaints (per 1,000 enrollees) did you receive?
b. How many appeals (per 1,000 enrollees) did you have?
14. What is the average number of days from receipt of appeal or complaint to
resolution?
15. Are your doctors, nurses, and member services staff familiar with your
appeals process?
9.0 STAND-ALONE PROGRAMS QUESTIONNAIRE
Please complete the appropriate questionnaire section for the carve-out option
you are quoting.
9.1 VISION CARE
1. Please provide the following information about your proposed Metro account
manager.
a. Name
b. Location
c. Key role(s) and responsibilities
2. Will a dedicated claims examiner be assigned to the Board s account?
3. Where is the group office located that will pay vision claims?
4. Please list five (5) references for current clients (government clients are
preferred) who have similarly sized populations for programs comparable
to those you are proposing to the Board (include contact name,
telephone number, and brief description of the organization).
5. Please list two (2) clients who have recently discontinued using your
services and explain why. Provide a contact name and telephone number.
6. Please provide your company s most recent rating from each of the following:
a. A.M. Best
b. Moody s
c. Duff & Phelps
d. Standard & Poor s.
7. a. Describe the vision services plan you are proposing for Metro (e.g.,
traditional plan, network plan, discount plan).
b. Attach copies of policies and brochures that are applicable to the
program you are proposing.
8. (Network Plans Only) Enclosed is a diskette with the addresses (5-digit
zip codes) of all eligible Metro employees. Please use this data to
provide a match with your network(s).
a. Please describe how distances between employees/pensioners and providers
are determined. At a minimum, the match should report the number of
employees/pensioners within each zip code who have one, two, or three
network locations within three (3) miles.
b. Please list all zip codes where, for each criteria selected, a match
does not occur.
c. Please complete the chart provided in Attachment 4.
9. Please describe how participants access care. Is a claim form or approval
code required?
10. (Network Plans Only) Are providers listed in a printed directory, or can
participants call to speak to a customer service representative about
the network in their area?
11. Please provide the frequencies that services and supplies be obtained
under the plan for:
a. examinations
b. lenses
c. frames
d. contact lenses
12. (Network Plans Only) Does your answer to the question above change if
non-network providers are used?
13. (Network Plans Only)
a. What are the benefits under your plan if a non-network provider is
used?
b. Please include any reimbursement schedule of benefits.
14. Are there any conditions that apply to the use of contact lenses under the
plan?
15. Please list the limitations and exclusions under your plan.
16. Would all active and retired employees and their dependents be eligible
under your plan?
17. Do your quoted premiums represent a firm quotation, as required in
Section 3.2?
18. Please explain the renewal methodology you will apply.
19. What extension of benefits provision applies when the master policy
terminates?
20. What are your minimum participation requirements?
21. Outline your quality assurance program.
9.2 MANAGED PRESCRIPTION DRUG
1. Please provide the following information about your proposed Metro account
manager.
a. Name
b. Location
c. Key role(s) and responsibilities
2. Will a dedicated claims examiner be assigned to the Board s account?
3. Where is the group office located that will pay prescription drug claims?
4. Please list five (5) references for current clients (government clients are
preferred) who have similarly sized populations for programs comparable
to those you are proposing to the Board (include contact name,
telephone number, and brief description of the organization).
5. Please list two (2) clients who have recently elected to discontinue using
your services and explain why. Provide a contact name and telephone
number.
6. Please provide your company s most recent rating from each of the following:
a. A.M. Best
b. Moody s
c. Duff & Phelps
d. Standard & Poor s.
7. Enclosed is a diskette with the addresses (5-digit zip codes) of all
eligible Metro employees. Please use this data to provide a match with
your network(s).
a. Please describe how distances between employees/pensioners and retail
outlets are determined. At a minimum, the match should report the
number of employees/pensioners within each zip code who have one, two,
or three locations within three (3) miles.
b. Please list all zip codes where, for each criteria selected, a match
does not occur.
c. Please complete the chart provided in Attachment 5.
8. Describe your contracting process for inclusion in your pharmacy network.
Will you solicit non-participating pharmacies at Metro s request?
9. Please describe your process and resources for on-going network management
(e.g., contract renewals, addition retail outlets). How would you
communicate with Metro about any proposed pharmacy-related network
changes?
10. Please describe how you integrate your services with claims payers.
11. What data systems do you use for patient management, quality assurance,
client reporting, interface with claims payers, and claim processing?
12. Please indicate which of the following features are available on-line in
each network pharmacy: [chart]
a. What percentage of your network pharmacies have on-line capabilities?
b. What percentage of claims are typically submitted electronically?
c. Are your administrative systems currently electronically integrated to
share information on-line in real time, as well as, comprehensive
management reporting?
d. How will eligibility data be transferred from Metro to your
organization?
e. How often are updates accepted?
13. How will you handle coordination of benefits between Metro and other plan
sponsors?
14. Do you offer incentive programs to pharmacists or patients to maximize
generic dispensing? If yes, please describe.
15. Does your organization have a process in place for prospective drug
utilization review? If yes, please describe?
16. Under your mail order drug program, what mail service do you use to
deliver participant orders?
17. If a participant is not at home when the mail order prescription drugs
are delivered, what is your procedure to ensure delivery?
18. How do you determine the average wholesale price (AWP) of prescription
drugs?
19. Please complete the following chart: [chart]
20. Do your quoted administrative fees or premiums represent a firm
quotation, as required in Section 3.2?
21. Describe the financial arrangement(s) you are proposing for Metro:
a. Insured vs. self-funded
b. Reserve requirements, if any
c. Services included in administrative fee
d. Banking arrangements, if applicable.
22. Please explain the renewal methodology you will apply.
23.a. Please provide a listing of the reports you will provide and their
frequencies.
b. On what basis would you charge for ad-hoc reports?
24. What extension of benefits provision applies when the master policy
terminates?
9.3 MANAGED MENTAL HEALTH/SUBSTANCE ABUSE
1. Please provide the following information about each of the key members on
your proposed Metro account team.
a. Name(s)
b. Location(s)
c. Key role(s) and responsibilities
d. Time commitment for installation of the program and, where applicable,
ongoing service to Metro
2. Provide a resume for each team member listed above, including a
description of the individual s experience with similar projects.
3. Will a dedicated claims examiner be assigned to the Board s account?
4. Where is the group office located that will pay claims?
5. Please list five (5) governmental clients for which you pay claims from the
local office listed above (include employer name, address, number of
employees, and contact name and telephone number).
6. Please list five (5) references for current clients who have similarly
sized populations for programs comparable to those you are proposing to
the Board (include contact name, telephone number, and brief
description of the organization).
7. Please list two (2) clients who have recently elected to leave your
organization s network. Why? Provide a contact name and telephone
number.
8. Please provide your company s most recent rating from each of the following:
a. A.M. Best
b. Moody s
c. Duff & Phelps
d. Standard & Poor s.
9. Enclosed is a diskette with the addresses (5-digit zip codes) of all
eligible Metro employees. Please use this data to provide a match with
your network(s).
a. Please describe how distances between employees/pensioners and providers
are determined and list the types of caregivers who are included. At a
minimum, the match should report the number of employees/
pensioners within each zip code who have one, two, or three providers
within three (3) miles.
b. Please list all zip codes where, for each criteria selected, a match
does not occur.
c. Please complete the chart provided in Attachment 6.
10. Do you provide toll-free telephone access? What are your hours of
operation? Is 24-hour assistance available? Please describe how calls
are handled during and after hours, specifying whether calls are
answered by clerical staff or clinician, whether a clinician is
on-site, and the amount of time to return the call if a clinician is
not available.
11. Provide an overview of your process of managing individual clients.
Please indicate how each case is handled, including frequency of
follow-up review, and provide specifics on patient, clinician, claims
payers, and client organization responsibilities. In addition,
differentiate between emergency and non-emergency cases; inpatient and
outpatient.
12. How long after an initial call do participants receive service? Please
describe inpatient vs. outpatient; emergency vs. non-emergency; waiting
time for initial assessment; and initial provider appointment after
assessment.
13. What is the average caseload for each of your case managers and
assessors? (Please differentiate between new and ongoing cases;
inpatient and outpatient; psychiatric and substance abuse.) What is
your organization s ratio of assessors to covered lives; case
managers to covered lives?
14. Please describe situations in which a face-to-face meeting would take
place for assessment and utilization management instead of a telephone
call (specify percentage of emergency and non-emergency situations).
If your organization provides in-person assessment for non-emergencies,
please indicate the average and maximum number of sessions, and whether
short-term counseling is provided.
15. Are members of your staff available for on-site visits with clinicians,
employees, or dependents?
16. How do you maintain patient confidentiality? How do you guarantee that
confidentiality is maintained?
17. What protocols are in place for handling claimants who exhibit both
medical and psychiatric conditions (i.e., coordination with
medical/surgical review)?
18. What criteria do you use in initial case management assessment and
referral (including level of care indicators)?
19. At what point during outpatient treatment does utilization management
begin? Please describe your provisions to prevent conflict of interest.
20. What follow-up procedures are in place for patients who do not complete
their recommended treatment?
21. Describe your appeal mechanisms for clinicians and patients.
22. Does your organization have a financial interest in any treatment
facilities? If yes, please describe your provisions to prevent
conflict of interest.
23. Please provide a listing of the medical reports included in your
administration fee (include frequency of report, e.g., monthly,
quarterly, annually). In addition, comment of your ability to provide
on-line access to claim information.
24. Do your quoted administrative fees or premiums represent a firm
quotation, as required in Section 3.2?
25. Please describe in detail the elements of your financial quote(s).
Include an outline of any risk-sharing arrangements you are proposing
under the self-funded approach.
26. Please explain the renewal methodology you will apply.
27. What extension of benefits provision applies when the master policy
terminates?
28. With whom do you have E&O liability coverage and for what amount?
29. Does your E&O liability coverage provide legal counsel for defense of
The Metropolitan Government?
9.4 PREVENTIVE/WELLNESS PROGRAM
1. Please describe the program features you offer for preventive/wellness
services as smoking cessation, weight control, stress and hypertension
management, and prenatal care.
2. What is the cost for these services?
3. In what way would the Board be involved with implementation and ongoing
program management?
4. Have you determined the cost/benefit of the initiatives you are proposing?
Please describe.
9.5 HEALTH RISK APPRAISALS
1. Please describe the health risk appraisal features you offer. Include such
information as program format (e.g., questionnaire with follow-up phone
call), Metro s involvement, reporting, and participant communication
materials.
2. What is the cost for these services?
3. In what way would the Board be involved with implementation and ongoing
program management?
4. For the programs you have referred to other employers, what percent of
enrollees complete an appraisal? (Provide results fro each of the last
three year.)
5. How does your program monitor health status over time?
11.0 COST PROPOSAL
11.1 FINANCIAL/UNDERWRITING QUESTIONNAIRE
Please answer separately for each medical and dental plan option you are
proposing. Also, please note that some questions apply only to certain
plan options, as indicated in specific questions below.
1. Do your quoted administrative fees or premiums represent a firm quotation,
as required in Section 3.2?
2. (HMO and Dental Options Only) Please explain how you developed the rates
and claim projections for your quotation. In your response, outline
the manner in which you evaluated historical claim data, the
credibility applied, the projected level of paid claims in year one of
the program, and your estimated expenses. For the premium rates you
provide, please indicate: [chart]
3. What inflation/utilization trend factors do you currently apply in
projecting expected claims? Please split your trend factors into
inflation, utilization, hospital cost shifting, leveraging, intensity,
and specifically identify any other components of your trend factors.
Provide the information separately for in- and out-of-network
programs: [chart]
4. What would your normal IBNR be for Metro s program? Please specify your
formula.
5. (HMO and Dental Options Only) Do you require the establishment of any
reserve other than incurred but unreported claim reserves? If so,
please describe in detail.
6. (HMO and Dental Options Only) Please explain the renewal methodology you
will apply.
7. How is your ASO fee calculated?
8. Are printing costs included in your ASO fee? What printed materials are
provided? If these costs are not included, please state your
additional charges for printing.
9. Is there an advance deposit requirement? If so, how is the amount
calculated?
10. Identify the reimbursement arrangement(s) for participating network
primary care providers or dentists: [chart]
11. (HMO Options Only) Please provide the community-rated monthly premium for
your book of business by rate tier as of January 1 for the last four
years. Please exclude Medicare rates [chart]
11. Confirm the reimbursement arrangement(s) for participating specialists:
[chart]
12. Indicate the reimbursement arrangement(s) for participating hospitals:
[chart]
13. For each option quoted, please provide the estimated composite monthly
rate per employee/pensioner for the following aggregate stop loss (ASL)
coverage options:
110% ASL ___________
115% ASL ___________
120% ASL ___________
14. Are you willing to provide aggregate stop loss coverage for plans that
your organization does not underwrite/administer?
15. If Metro has a third-party stop loss administrator, are you willing to:
a. File stop loss claims on behalf of The Metropolitan Government?
b. Provide the necessary documentation for stop loss claims?
c. Handle questions from the Board and reinsurer regarding a claim in
order to expedite settlement?
d. Allow audits by the stop loss carrier?
16. (Medical Options Only) What are the costs associated with providing the
medical conversion option?
17. (HMO Options Only) What extension of benefits provision applies when the
master policy terminates?
18. With whom do you have E&O liability coverage and for what amount?
19. Does your E&O liability coverage provide legal counsel for defense of The
Metropolitan Government?
20. Provide an estimate of COB savings for your book of business (average)
for the calendar year ending December 31, 1994. Where applicable,
identify Medicare savings separately.
21. (Medical Options Only) Please describe any guaranteed dollar savings
under your hospital bill audit program and the guidelines for those
savings.
22. (Medical Options Only) Will you guarantee savings from your UR program?
If yes, explain how savings are guaranteed and how they will be
documented.
23. (HMO and Dental Options Only) Can you administer premiums as outlined in
Section 5.1, item 6? Please be specific.
24. (HMO Options Only) How does your HMO option integrate with Medicare?
11.2 COST EXHIBITS
Please complete the cost exhibits, based on the following assumptions:
Medical
Approach I Assume current medical enrollment
Approach II Assume 45% PPO or POS; 55% HMO
Approach III Assume 40% PPO or POS; 60% HMO
Approach IV Assume 35% PPO; 65% POS/HMO
NOTES:
a. When multiple HMOs are offered, please assume that you will receive a
proportionate number of enrollees.
b. When in- and out-of-network coverage is available, please assume that 80%
of care will be delivered in-network, 15% out-of-network, and 5%
out-of-area.
[Since exhibits are primarily tabular, the remainder of this document has not
been uploaded.]