6414 - Administrative Servies Only (ASO) for Medical and Pharmacy Benefits, 4.Drawings/ Plans (8)Medical Claims Pricing & Network Analysis
After receipt and initial evaluation of the vendor quotes, responding entities may be requested to provide data for a claims pricing and network analysis. McGriff, Seibels & Williams
will provide a claim file to all finalists to calculate discounts and costs, as well as network status of the providers and claims.
We recognize your organization may require a non-disclosure agreement to cover release of the pricing data. In order to expedite any needed file exchange if your organization is selected
as a finalist, please include any required non-disclosure agreement (NDA) with your response to this RFP, along with a document indicating your acceptance of the pricing instructions
below. If you cannot include an actual agreement, please include a document indicating your non-disclosure policy, as well as your acceptance of the pricing instructions below if you
are selected as a finalist.
THE FOLLOWING ONLY APPLIES IF YOU ARE REQUESTED TO SUBMIT A RE-PRICING FILE
Due to differences in the way carriers, TPAs and other vendors handle their repricing process, McGriff, Seibels and Williams has developed an independent methodology for analyzing potential
savings and network disruption. It is important that you follow the procedures in this document. Failure to submit a complete detailed pricing file will be taken into consideration
during the decision-making process. If you have any questions, please speak with your McGriff contact as soon as possible.
We recognize the sensitive nature of detailed pricing and network data. This information will only be used in a summary format by McGriff and its clients. No detailed information will
be shared with any outside parties. We also understand that network membership and contracts are subject to change at any time and the data you return represents a best estimate only.
Please re-price the claims and determine network participation on a prospective basis. The service and admission dates are provided for your reference only. You should handle the claim
as if it were happening with current network participation and discounts in place. To avoid confusion due to differing uses of terms such as “eligible” and “allowed”, we use the phrases
PreDiscount and PostDiscount. PreDiscount is the amount of charges after any non-covered amounts have been removed. You can assume all PreDiscount amounts are eligible for payment.
PostDiscount refers to the amount of the claim after all discounts have been applied. Assume no coordination of benefits or Medicare payments to be applied.
The accompanying tab-delimited file contains the following fields:
Field
Description
RecordID
Unique record identifier
ClaimantID
Unique claimant identifier (de-identified)
Claimant Relationship
Relationship to employee
Claimant Gender
Gender
Claimant Date of Birth
CCYYMMDD
Claimant State
Home address where available
Claimant ZIP Code
Home address where available
Provider Type
From claim dump
Provider Tax ID
From claim dump. Uses TIN.
Provider NPI
From claim dump.
Provider Name
From claim dump, extra white space removed to standardize format
Provider State
From claim dump
Provider ZIP Code
From claim dump
TransactionID
ClaimID from claim dump
Diagnosis Code - Primary
From claim dump
Diagnosis Code - Secondary
From claim dump
Procedure Code Type
From claim dump
Procedure Code
From claim dump
Procedure Modifier Code
From claim dump
Revenue Code
From claim dump
Date of Service Begin
From claim dump, CCYYMMDD
Date of Service End
From claim dump, CCYYMMDD
Admission Date
From claim dump, CCYYMMDD
Discharge Date
From claim dump, CCYYMMDD
Discharge Status
From claim dump
# of Units of Service
From claim dump
Place of Service
From claim dump
Type of Service
Facility, Professional, Other
Claim Category
Inpatient/Outpatient/Professional/Other
Pre Discount Amount
All eligible charges.
Records with adjustments and $0-charge amounts are included in order to identify any bundling opportunities.
The file you return must also be a line-by-line file. Do not delete any records from the file. At minimum, the return file should contain the following fields:
Field
Description
RecordID
Retain from incoming file. Used to cross-reference
PreDiscountAmount
Retain from incoming file
Considered
Y/N - Indicate if re-pricing and disruption were completed for this record
DiscountPct
Discount percentage applied to claim line
PostDiscountAmount
Re-priced amount applied to claim line
ProviderNetworkStatus
In/Out. Indicate if provider is a member of the proposed network.
NetworkClaimIndicator
In/Out. Indicate if claim would be processed in-network or out-of-network.
If you prefer, you may append these fields onto the original file layout. Please submit your return file in either Excel or tab-delimited text format, with headers included. Feel free
to compress the file into .zip format if you wish.
Also, please include documentation as to the level of detail your organization uses (actual contract, standard contract, 3-digit zip, 5-digit zip, market area, etc.) to determine pricing
and discounts. If you mark any records as not considered, please document the reason for the exclusions.
Thank you for your assistance with this project. Please contact us if you have any questions regarding the file layouts or data.