State Health Plan For Teachers And State Employees

Buyer is soliciting proposals from qualified companies to perform medical claims audits. The contract includes standard medical claims audits, focused medical claims audits, and additional medical claims audits. Buyer requires a vendor with expertise in medical claims auditing with a proven track record of auditing self-funded plans of similar size and complexity. The vendor must perform comprehensive reviews of claims processed by the Plan's TPA to determine if claims were adjudicated correctly.

• 4/14/2025 - Issue RFP
• 4/18/2025 - Deadline for Written Questions
• 4/23/2025 - Response to Questions
• 5/16/2025 - Proposal Due Date
• 1/1/2026 - Services Begin

• Five years experience providing Medical Claims Audit Services
• Experience with at least one client with 250,000+ covered lives
• Valid third-party security certifications or assessment reports
• HIPAA compliance
• Financial stability

• Perform standard audits of 1,000 stratified claims per year (250 quarterly)
• Determine financial, payment, and processing accuracy of claims
• Conduct focused audits on targeted claim types
• Review provider contracts for appropriate claim adjudication
• Validate allowed charges and network status
• Identify claim errors and root causes
• Recommend corrective actions for the TPA
• Monitor collections process for overpaid claims
• Produce detailed audit reports with findings and recommendations
• Participate in quarterly meetings to review audit findings