Request for Proposal s45
Total Page：16
File Type：pdf, Size：1020Kb
Attachment 2
Scope of Services
for
RFP 14-187-JBW-Non-TWU 234 Employee Dental Insurance SEPTA RFP 14-187-JBW-Non-TWU 234 Employee Dental Insurance Contract Attachment 2
INTRODUCTION TO SCOPE OF SERVICES & PROJECT BACKGROUND
The Southeastern Pennsylvania Transportation Authority (SEPTA) was created as an agency and instrumentality of the Commonwealth of Pennsylvania in 1964. As a “Governmental Entity”, SEPTA is exempt from ERISA benefit rules. SEPTA provides mass transit services to riders in the five county Southeastern Pennsylvania region.
The SEPTA workforce includes approximately 1,700 non-bargaining unit supervisors, administrators and management (“SAM”) employees. SEPTA employs approximately 2,400 Non-TWU 234 union employees who work in skilled crafts and trades (operators, mechanics, etc.); and who are members of 13 different collective bargaining units.
SEPTA requests from qualified firms Proposals for Dental Insurance for “SAM” employees and all Union employees; except for Transport Workers Union (TWU) 234. The total SEPTA employees covered under this contract will be approximately 4,100. The five (5) plans include a Dental Maintenance Organization (DMO). SEPTA plans to award one contract for the five (5) plans. This five year contract will begin on or about December 1, 2015.
SEPTA requests that Proposers submit Price Proposals (Contract Attachment 3) for BOTH self-insured AND fully insured Dental Insurance plans.
SCOPE OF SERVICES: NOTES
CONFIDENTIALITY – No employee data from this RFP shall be shared with outside parties, for purposes other than responding to the RFP, without the prior written approval of the Project Manager.
DENTAL PLAN EXPERIENCE – See Scope Exhibit # 1.
SEPTA’s DENTAL PLAN SUMMARIES- See Scope Exhibit # 2.
For the Dental Plans Proposed:
NOTE 1: SEPTA Employee Dependents are also covered.
NOTE 2: The Indemnity/PPO coverage must match the 13 Labor Contracts. See Scope Exhibit # 3.
The Dental Maintenance Organization (DMO) is optional for SEPTA employees. SEPTA RFP 14-187-JBW-Non-TWU 234 Employee Dental Insurance
SCOPE OF SERVICES QUESTIONNAIRE:
Please reference the question/requirement numbers below in your answer. Place your answers following the requirement/question.
Network Size & Characteristics
1. Are the proposed networks owned by your company? If so, please elaborate.
2. Please describe your service area for this network. Be specific including counties, zip codes, etc. Do you have any plans for expansion of your service area?
3. How many dentists are added to the network each year? How many dentists leave the network?
4. What is the network ratio of dentists to specialists?
5. In addition to Dentist/Doctor listings, do you maintain additional data on providers that will be available to members?
6. Please provide Geo-Access mapping for each of your proposed networks utilizing the following parameter: 2 network dentists within 5 miles.
Usual & Customary (UCR) Payment Schedule
7. What is the average network specialist discount you have achieved?
8. Provide the percentile of UCR at which you reimburse for all claims that are not paid according to the fee schedule. What source do you use to establish UCR? What is your frequency of update?
9. Do you share negotiated discounts with Plan Participants?
Proposed Dental Plan Benefits as compared to and/or Exceeds Current SEPTA Plan Benefits;
10. No existing plan Participant will lose benefits as a result of a change in administration. Please confirm acceptance.
11.Waive active at work provision and pre-existing condition limitations for existing participants. Please confirm acceptance. SCOPE OF SERVICES QUESTIONNAIRE: (Continued)
12. Dental Benefits must be, at a minimum, duplicated exactly as currently provided. If you deviate from the current benefits you must clearly state which provisions of the Plan you are unable to duplicate.
Plan Administration Standards
13. What is your company’s dental care philosophy? Why should we consider selecting your organization as our dental plan vendor?
14.What type of banking arrangements do you offer?
15.State what variations between the assumed and actual final enrollment would necessitate a rate clarification.
16.Contract, booklets and certificate must be prepared by the carrier. Drafts will be required within 30 days of effective date. Please confirm acceptance and acceptance of liability for damages caused to SEPTA if your firms does not meet this date.
17.Provide notice of rate change by September 1 of each year. Please confirm acceptance.
18.In case of a work stoppage or strike SEPTA will cancel coverage and take a prorated monthly credit. Please confirm acceptance.
19.Detail your conversion efforts, including how you will obtain deductible information for a December 1, 2015 implementation.
20.Provide list of firms with which you will subcontract services for this SEPTA contract.
21. Indicate location where the claims are processed and paid.
22.Please provide us information about your routine training programs for new hires.
23.Is there an exclusive toll-free customer service telephone number for addressing payment and Member services?
24.List the business hours of telephone accessibility for the office or offices you are proposing. Indicate total number per hours per week for each list task listed separately. a. Utilization review b. Case management c. Claims/customer service
25.How do you service Member inquires? Include description of your logging, tracking and follow-up systems, etc.
SCOPE OF SERVICES QUESTIONNAIRE: (Continued)
26.Provide a description of the system you utilize to perform each of the following functions: a. Eligibility (employee and dependent) b. Claims processing and record keeping c. Utilization statistics
27.Are Member satisfaction surveys conducted annually?
28.Please describe how customer service and claims functions relate.
29.Please indicate the automated features of the customer service and claim processing system.
30.When was the system introduced? How many lives are currently processed on the system in the proposed claim office?
31.What percentages of claims are filed electronically?
32.How many claims processors/Member Service Representatives will be assigned to SEPTA’s account? Will they also work on other accounts?
33.Please describe what are your daily claims-paying production standards.
34.At what frequency and under what conditions can employees change providers?
35.Are Members required to follow a pre-authorization process? Please describe the procedure employees and dependents must follow to access your network.
Please respond yes or no to each component of the following questions. If the answer is no, please provide an explanation.
36.During 2014, Financial Dollar Accuracy was 99% or greater.
37.During 2014, Procedural accuracy was 98% or greater.
38.During 2014 90% of claims were processed in 10 business days or less. 39.During 2014, written correspondence responsiveness was 90% within 10 days and 100% within 30 days.
40.Contracted network providers are required to submit claims on behalf of eligible beneficiaries.
SCOPE OF SERVICES QUESTIONNAIRE: (Continued)
41.Provider Directories: a. Are printed with updates at least quarterly and are available to Members upon request. Please confirm acceptance.
b. Are provided during open enrollment to each employee plus an extra 10% volume to SEPTA. Please confirm acceptance.
c. Indicate if providers no longer accept new patients. Please confirm acceptance.
d. Indicate which providers have evening & weekend hours. Please confirm acceptance.
e. Are accessible on the Dental Plan’s Internet web page to Members. Please confirm acceptance.
42. If Participants reside outside of the service area, but work within the area, will they be allowed to access this network?
43.Do you have quality and utilization management programs? If so, please describe.
44.Can you provide cost and utilization reports? Can you provide customized reports? Is there a cost associated with the reports?
45.How will you administer claims for work-in-progress, if you take over as Administrator?
46.Please describe any clinical guidelines used by your network.
47.Please provide us with the name, phone number, email address of the primary contact at your organization should there be any questions concerning your responses in this Proposal.
48. A designated Account Representative must be assigned to SEPTA who has the responsibility and authority to manage the entire range of services discussed in this RFP. Identify key members of the account management team, their roles, and their time commitments, both pre- and post-implementation.
Book Of Business: Scale, Client Type, Mix Of Group Sizes
49.How many employees are covered by your organization’s insured plans?
50.Provide your firm’s volume of dental insurance business for 2014, 2013 and 2012.
SCOPE OF SERVICES QUESTIONNAIRE: (Continued)
51.What has been the dis-enrollment rate for each of the past three years compared with the net gain or loss during the same period?
52. Please provide three current references: a.i.1. Coverage provided a.i.2. Length of time coverage in force a.i.3. Name address, email and phone number of individual at organization who SEPTA may contact.
53. Describe any features of your organization that distinguish it from its competitors.
Responsibility Factors
54.Provide copies of your most recent financial statements (income statement & balance sheet).
55.Describe any merger/acquisition plans or other major organizational changes under consideration by your firm.
56.Provide your company’s most recent rating or filing (identify date) for: A.M. Best, Standard & Poor’s, Fitch and Moody’s. If your rating has changed within the past 12 months for any rating agencies, discuss changes. SEPTA RFP 14-187-JBW-Non-TWU 234 Employee Dental Insurance
Usual, Customary & Reasonable (UCR) Reimbursement Chart Please complete the following chart for Southeastern PA and Southern NJ. Submit each separately in Excel. Include all rows even if not applicable
Your UCR CDT_CD PROC_DESC CLASS Payments D0120 PERIODIC EXAM 1 D1110 ADULT CLEANING 1 D0220 FIRST PERIAPICAL X-RAY 1 D0274 4 BITEWING X-RAYS 1 D1208 TOPICAL APPLICATION - FLUORIDE 1 D0230 ADDITIONAL PERIAPICAL X-RAY 1 D1120 CHILD CLEANING 1 D8083 MONTHLY ORTHO 4 D2392 COMPOSITE FILLING 2 D2391 COMPOSITE FILLING 2 D0140 LIMITED ORAL EXAM 1 D0150 COMPREHENSIVE EXAM 1 D0272 2 BITEWING X-RAYS 1 D0210 COMPLETE SERIES OF X-RAYS 1 D4910 PERIO CLEANING 1 D1351 SEALANT-PER TOOTH 1 D4341 PERIO SCALING 2 D2750 PORCELAIN CROWN 3 D7140 TOOTH EXTRACTION 2 D7210 SURG EXTRACTION 2 D0330 PANORAMIC X-RAY 1 D2393 COMPOSITE FILLING 2 D2950 CORE BUILD-UP 2 D8093 MONTHLY ORTHO 4 D1206 FLUORIDE VARNISH 1 D2150 AMALGAM FILLING 2 D9110 EMERG. PAIN RELIEF 1 D2954 POST&CORE PREFAB 3 D2331 RESIN FILLING 2 D3330 ROOT CANAL THERAPY 2 D2330 RESIN FILLING 2 D2332 RESIN FILLING 2 D2140 AMALGAM FILLING 2 D2752 PORCELAIN CROWN 3 D2740 PORCELAIN CROWN 3 D2335 RESIN FILLING 2 D2920 RECEMENT CROWN 3 D4381 PERIO (GUM)ANTIMICROBIAL TX 2 D9230 ANALGESIA 2 D3320 ROOT CANAL THERAPY 2 D4342 PERIO SCALING 2 D6750 ABUTMENT CROWN 3 D1203 FLUORIDE - CHILD 1 D9310 CONSULTATION 2 D7240 IMPACTED TOOTH 2 D8063 MONTHLY ORTHO 4 D2160 AMALGAM FILLING 2 D2394 COMPOSITE FILLING 2 D9220 GENERAL ANESTHESIA 2 D6240 BRIDGE PONTIC 3 D6010 Surgical Implants 3 D9221 GENERAL ANESTHESIA 2 D0460 PULP TEST 1
DENTAL PROVIDER NETWORK
Please complete the grid below by indicating the total number of participating dentists for each county. If a dentist has more than one office location in a county, only count that dentist once. For group practices, count every dentist.
Indemnity/PPO County General Specialists Orthodontis Other Total Practice ts Bucks Chester Delaware Montgomer y Philadelphi a Camden Burlington Gloucester TOTAL DMO County General Specialists Orthodontis Other Total Practice ts Bucks Chester Delaware Montgomer y Philadelphi a Camden Burlington Gloucester TOTAL
Note:
Please provide information on your networks for the following locations/zip codes:
19050 19111 19082 08081 18974