Specifications include, but are not limited to: Contractor will perform audits on claims paid by the following vendors: Blue Cross and Blue Shield of Vermont for medical and behavioral health care claims, Express Scripts PBM for prescription drug claims and Commercial and EGWP claims, and Northeast Delta Dental for dental claims, and provide an audit of the Prescription Drug Claims Technology vendor. Audit scope includes the following: 1. Evaluate vendors’ performance for the audit period in accordance with the provisions of the State health plan documents, the contractual agreements between vendor and State, and State’s benefit summary plan descriptions. 2. Include review of (specific to the State’s contract): (1) vendor operations; (2) customer and client service; (3) claim adjudication and payment; (4) obtaining of guaranteed provider discounts and (5) the vendors’ application of participating provider agreements and all other service and financial agreements in order to maximize savings to the State’s health plans. 3. In areas where vendors are obligated to coordinate with each other, evaluate the transfer and reconciliation of enrollment data, claims data, common medical deductible administration, disease management and large case management programs. i. Evaluate all areas for which there are contractual performance guarantees against those guarantees, to determine whether vendor did or did not meet the guarantee for the applicable time period. Guarantees are generally assessed quarterly and paid annually.
