1.

REQUEST FOR PROPOSALS (RFP) 22-490 INSURANCE PRODUCER

SERVICES FOR PROPERTY AND CASUALTY INSURANCE
I will require the following for the above RFP
i) COMPANY PROFILE
A complete company profile, to include, but not be limited to the date of establishment, mission
statement, type, and confirmation of company’s legal entity form, company’s organizational
structure/chart, principals’ names and titles, company size in relation to industry, number of employees,
company history, financial position, and all relevant current and past experience on similar projects in
comparable K-12 school districts and references for those projects. Also include the educational
background for staff that will be assigned to this project, including the company’s overall experience in
providing the requested services within this solicitation.
ii) REFERENCES (MANDATORY REQUIREMENT)
The names and contact phone numbers of at least three (3) current clients, preferably clients comparable
to DCSD, for whom your company is providing or has provided services as defined within the scope of
work. Note: The References will be contacted.
iii) BROCHURES, CATALOGS, MANUALS, WEBSITES, LITERATURE
Provide brochures, catalogs, manuals, website materials, industry literature, DVDs, and any other
marketing and informational media which will support and enhance our submission value.
Additionally, provide the following attachments filled as required/ or rather provide the following
information: Name of Engaging Authorized Person, Engaging Person’s Position/Title, Authorized person
E-mail address, Company Official Telephone Number/ Engaging Person’s Telephone Number.
1. Certificate of Insurance (Mandatory Requirement)
2. Company Financial Statements and Company Annual Reports
3. Attachment A – Cost Proposal Form (Mandatory)
4. Attachment B - Insurance Producer Questionnaire (Mandatory)
5. Attachment E – Critical Paragraphs (Mandatory Requirement)
6. Attachment F – Offeror’s Client Reference Form (Mandatory Requirement)
7. Attachment G - Statement of Confidentiality and Non-Disclosure (Mandatory Requirement)
8. Attachment H – Suspension and Debarment Certification (Mandatory Requirement)
9. Attachment I – Immigration & Security Certification (Mandatory Requirement)
10. Attachment K – Signature Page (Mandatory Requirement)
2. Request for Proposals RFP Item #22-247 Self-Funded Health Insurance
Services (Administrative Services) For Augusta, Georgia – Human
Resources Department
i) Qualifications & Experience of the Firm
Provide the company’s primary business interest and/or operations including organization and
affiliations. Firm’s History, Staff Experience & Resumes – Provide a brief history of the firm
including staff members’ experience, resume, and accomplishments that are relevant to the scope
of work stated in this RFP.
A list of all subcontractors that are to be utilized by your company to perform the scope of
services listed in this RFP (if any).
Provide a biographic overview of the Company’s key principles.
Note: (A Company Profile Can Work for this section)
ii) Organization and Approach:
General information on your organization and management process to include the following: line
of authority, who will have overall responsibility for implementation of the project, who will be
responsible for ongoing support. (The proposal will state who would perform specialized
services that may be needed)
An organizational chart indicating the level of professional seniority of each member. (I can
assist make one if you do not have one)
Provide information on individuals as well as related corporate experiences related to this RFP.
The information should include all persons the firm proposes to engage in the task, their
professional experience, and licensing status. Individuals designated as primary responsible
parties shall be clearly identified as such.
Provide a description of any limitations relative to facilities, staff personnel, on-going
projects/contracts, etc.
(THIS WHOLE QUESTIONNAIRE WILL NEED TO BE FILLED, IF POSSIBLE, PLEASE
PROVIDE AVAILABLE INFORMATION)
ATTACHMENT 6: General Information Questionnaire

Name of TPA/Carrier:

GENERAL INFORMATION QUESTIONNAIRE

Question Response
1. Please provide complete contact information
for the primary contact for your organization
with respect to this RFP, to include name, job
title, physical address, e-mail address, telephone
number, and fax number.
2. Provide a brief summary of statistics
regarding your organization to include:
A. Current ownership

B. Description of any recent (last

two years) or anticipated merger
C. Number of years your company
has been in operation and paying
medical claims.
3. Please describe how you bring value to your
clients and what differentiates your organization
from your competition.
4. Augusta would like the flexibility of
working with a vendor who can provide
customized solutions to their challenges.
Please provide an example of a customized
solution that you have provided to one of your
large clients (2000+
employees).
5. Please provide your corporate mission
statement and describe your core values.
6. Describe any previous or pending material
lawsuits in the last 10 years.
7. Please confirm that Augusta may terminate this
contract without cause after one year with 90
days’ notice.
8. Please confirm that your organization is
compliant with all current HIPAA Privacy,
HITECH, Transactional Standardization, and
Security
Regulations.
EXPERIENCE, REFERENCES, AND RESOURCES
1. Please provide the number of self- funded
municipalities that you currently have a
TPA/ASO
contract within the State of Georgia

2. Of the self- funded municipalities that you

have a TPA/ASO contract with, how many
currently have On-Site Clinics?

3. Please provide the number of clients that you

currently have a TPA/ASO contract with that
also
utilize Everside as their On-Site Clinic vendor.
4. Please confirm that you will allow the On-Site
Clinic to have referring capabilities to other In-
network providers.
5. Provide the following statistics for your firm
based on the actual performance with respect
to your self-funded employer group clients for
the following measures for the last two
calendar
years:
2019 2020
A. Number of medical claims
processed each year
B. Dollar amount of paid medical
claims for each year
6. Describe any internal resources that may add
value to Augusta, as well as any potential
charges for those services. Such resources might
include but are not limited to: medical director,
creative services, legal staff, actuaries, wellness
staff, data- mining reporting, printing, mailing,
travel cost etc. Any costs not included in the
TPA/ASO administrative fee must be clearly
identified and must be included in your proposed
total expected
and maximum liability cost proposal.
7. Please confirm that you will be able to set up
eligibility feeds with the On-Site Clinic Vendor.
8. With respect to plan documents and plan
design:
A. Please identify the internal or
external resources or software
you
use to produce plan documents.
 B. Identify the advance notice you
require to implement plan changes.
9. Please list three references for active clients
and two for clients who have terminated within
the last 2 years. Please include name, job title,
physical address, e-mail address, telephone
number, number of employees covered,
industry, and assigned Account Executive.
Please also indicate the date the relationship
began for active clients, and the date it both
began and ended for
former clients.

10. In addition to the implementation timeline

you submit with your proposal, please describe
the implementation process and the composition
of the implementation team.

11. It is AUGUSTA’s anticipation that the

following services will be included at no
additional charge beyond the proposed
administrative fee. Please confirm these services
will be provided at
no additional cost.
A. ID cards mailed to employees home
address
B. SPD’s will be created and mailed
to employee’s home address the
first year and any amendments
that may
be needed in future years
C. All PPACA required notifications
will be created and mailed to
employee’s home address, if
required by PPACA
to be provided in hard copy
D. Actuarial fees to certify COBRA
rates
E. A supply of printed Provider
Directories
F. Assistance at Open Enrollment
Meetings and Wellness Events.
No travel costs will be billed to
AUGUSTA.
G. Hard Copy EOB’s mailed to
employee’s home address
H. Disease Management Services
I. 24 hour Nurse line
 J. Basic Wellness Program
K. Medical Administrative Services
L. Network Access Fees
M. Utilization Management
N. Case Management
O. COBRA Administration Fees that
include
1. Notifications must be sent
automatically when a
qualifying event happens –
such as a new
hire, termination etc.
2. Reports
P. HIPAA Administration Fees
Q. All implementation fees
R. Connectivity fees with Payroll Vendor
(ADP)
S. Connectivity fees with On-Site Clinic
Vendor (Everside)
T. All other services deemed to be a
standard part of “day to day” business
practices

12. Please provide an overview of the Wellness

Program that you intend to offer AUGUSTA.
Please include as many details as possible on the
services and any Wellness dollars that you
intend to provide to AUGUSTA to support their
Wellness
initiatives.
13. If there are additional fees for any of the
wellness services you have listed in your
Wellness Program, please provide those fees in a
clear and
concise manner.
14. Please segregate your self-funded employer
groups for whom you administer medical
benefits
by size:
A. % with less than 500 employee lives
B. % with 500-999 lives
C. % with 1,000+ lives
15. Please confirm you are willing to offer
Performance Guarantees and what those
guarantees are as well as the amount at risk for
each item
REPORTING AND PLAN ADMINISTRATION
INFORMATION
1. Confirm that you have included with
your proposal in a properly labeled
appendix the following documents:
A. Specimen administrative
services agreement

B. Organizational chart and detailed

resumes for staff to be dedicated to
this account
C. Sample of most robust annual
management reporting package
D. Sample Explanation of Benefits
E. Implementation timeline using
09/01/2022 as the start date
F. Most recent audited financial
statement
2. Except where otherwise indicated, please
provide the following information for the
specific claim service center to which Augusta
will be assigned:

A. Identify where the day to day service

center will be located.
B. Indicate the number of years the
service center has been in operation
and adjudicating self-funded
medical
claims.
C. Indicate the total number of self-
funded employer group clients
with medical coverage serviced by
that
office
D. Indicate the total number of
employees lives covered under
self- funded employer group
clients that are managed by that
service center
3. For the specific claim service center to which
AUGUSTA will be assigned, provide the
following
information:
A. Provide the average number of
covered lives per examiner
B. Confirm the number of dedicated
claims examiners and customer
service representatives who will
be
 assigned to Augusta account
C. Furnish the turnover rate
and average tenure for the
claims
examiners
4. Provide the following statistics specifically for
the service center to which Augusta will be
assigned based on the actual performance of
that service center with respect to your
employer group clients for the following
measures for the
last two calendar years:
2019 2020
A. Medical claim turnaround time for
all claims (must provide % within
10 business days or 14 calendar
days, and % within 23 business
days or 30 calendar days.)

B. Medical claim processing accuracy

percentage (only claims with no
data entry or payment errors are to
be classified as accurate)
C. Medical claim financial processing
accuracy (% of claims with
no payment errors)
D. Medical financial payment accuracy
(based on absolute dollar value of
errors – amount of overpayments
plus underpayments, not the net of
the two)
E. Average speed of answer

F. First call resolution rate

G. Current medical claim backlog in
calendar days
H. Describe methodology used in
computing turnaround time.
5. Please advise whether you record all calls to
your customer service representatives.
6. Describe in detail your company's quality
assurance and internal audit procedures and
programs. What percentage of all claims
processed are audited? Please provide details on
how the audit process differs for individuals
with varying experience levels. To whom does
your in-
house audit/quality assurance staff report?
7. Please describe any quality awards or
certifications your organization has received in
the last 2 years.

8. In addition to incentivizing quality service

through your proposed performance
guarantees, please provide AUGUSTA with a
clear explanation of the level of liability your
organization will accept for administrative
errors that lead to overpayment and/or non-
reimbursement that is
unrecoverable.
9. It is AUGUSTA’s expectation that they will
have full right to audit using an auditor of their
choosing and with no restrictions on the claims
to be audited. We expect that 24 months of
claims will be assessed in the audit. This will
likely include both a random sample audit and a
data- mining audit of 100% of claims. This may
include an implementation audit 6 months
beyond the initial effective date. Other focused
audits may include large claim and/or stop loss
claim audits, as well as an operational review.
Please confirm that you will agree to these terms,
will not restrict the scope of the audit or the
selection of the auditor, and you will not charge
AUGUSTA for
supporting these audits.
10. Please describe in detail your Appeals Process,
who oversees the appeals and whether or not a
Medical Director is directly involved in high level
denied appeals.

11. Please confirm the hours of availability for

your toll-free customer service line, and
confirm whether this line will be dedicated to
Augusta inquiries only.

12. Please confirm that a dedicated account

executive will be assigned to AUGUSTA’s
account, and confirm the availability of the TPA
staff to regularly meet with AUGUSTA staff. In
addition to regularly scheduled quarterly
meetings, periodic
ad hoc meetings may be necessary.
13. With respect to the account executive who
will be assigned, please provide the following
information
A. Number of years experience in
employee benefits
 B. Number of years with your
organization
C. Number of assigned clients in total
and the number assigned with
more
than 1,000 employees
14. With respect to health promotion activities,
please describe your ability to administer
incentives, and coordinate with AUGUSTA’s
On-
Site Clinic vendor.
15. Describe your claims hardware and software
systems: name and developer of the systems, how
long in use, most recent upgrade, and any
anticipated changes. Please also confirm that you
are utilizing the most recent version available
from your system vendor.
16. Confirm that you will use all HIPAA EDI
mandated code sets (ICD, CPT, HCPS, NCPDP,
ADA). Pease further confirm that you will enter
all ICD-9/10 and CPT codes including the 2 -
digit CPT modifier codes. If only a limited
number of diagnoses or CPT codes will be
entered into the claim system, please identify the
limit.
17. Please provide details on your claims
editing capabilities:
A. Percentage of available edits that
are “turned on”
B. Percentage of NCCI standards
that you have implemented in
your
Coding
C. Provide a summary of the edits that
are applied
D. Percentage of claims that are
impacted by these edits
E. Percentage of claim dollars
affected by the edits

18. Please provide:

A. The number of fields that are
assessed to detect duplicate charges,
and the number of matches that
result in the generation of an edit
B. The percentage of all medical
claims in 2017 that were identified
as
 Duplicates
19. If you utilize a separate entity to identify
additional claim edits whereby the client is
charged a percentage of savings, are there any
efforts within your firm to hard code those edits
within your claim system so that the client will
not continue to pay the vendor a percentage of
savings for repetitive coding edits?
20. Are claim adjustments processed under new
claim numbers referenced back to the original
claim number or under the original claim
number with a suffix attached? Can the claim
system identify the number of claim
adjustments processed quarterly by coverage
and plan type?
21. Please describe in detail your processes for
detecting and investigating COB. Please be sure to
include any automated support for this function.
22. Describe your process for detecting potential
subrogation opportunities and for initiating
investigation. Is this performed in-house or by a
contracted vendor? If so, who is the contracted
vendor? How often is data sent for
investigation? What data fields are used to
trigger investigation? Does the process or
software recognize follow-up services for
previously investigated claims so that duplicate
calls or requests are not sent to
employees unnecessarily?
23. With respect to claims that are incurred
after termination of coverage (i.e., eligibility
termination is processed after effective date of

that termination, and claims incurred after that

termination date have previously been paid):
A. What is the process for identifying
these overpayments?
B. Is this a manual or automated
process?
C. How is the follow up process
managed on collecting
those overpayments?

24. Please describe your fraud detection and

prevention programs, including the extent to
which automated.
25. Please describe any automated prospective or
retrospective claim reviews not mentioned
elsewhere and explain how those programs would
assist AUGUSTA in controlling costs.
26. Provide the information below regarding
automation:
A. The percentage of self-funded
medical claims received via EDI
in
2017
B. The percentage of self-funded
medical claims that were
auto-
adjudicated in 2017
C. Based upon AUGUSTA’s plan
design, quantify the expected
deviation from your book of
business auto-
adjudication rate
D. Does your system provide for
scanning all paper claims
and
correspondence upon receipt?
E. If so, is the scanned claim data
fed into the claims system on an
automated basis?
27. Please confirm whether you will load
historical medical and prescription drug claims
at the
member level.
28. Please describe any web-enabled solutions
that would be provided in the following areas,
along with any additional cost. Please include
screenshots or a link to a demo website with
your proposal.
A. Member access to plan and
claims data

B. HR staff access to plan and

claims data

C. HR staff access to online

eligibility changes

D. HR staff and consultant access

to online reporting
29. Please confirm that if a billing discrepancy is
discovered that is more than 120 days in arrears
and the error of the sole responsibility of the
TPA, Augusta will not be invoiced.

30. Please describe your disaster recovery

procedures. Please include your anticipated
downtime in the event that the entire TPA was
destroyed in a natural disaster. Please also
advise what your anticipated down time would
be in the event that the TPA lost power for an
extended period of time. Please also advise
whether you conduct mock disaster recovery
tests, and if so, with what frequency and what
result. Please advise specifically how you
provide for system redundancies. With respect
to the backup removable hard drives that are
physically removed from the premises each
night, please
advise where they are taken.
31. Confirm that AUGUSTA will be given
access to any data maintained by the TPA when
requested.
32. What is your charge for Ad Hoc reporting?
Please provide a list of what you would consider
Ad Hoc reports.
33. Please advise whether there will be a
designated data analyst assigned to AUGUSTA’s
account.
34. Please advise as to your ability to assess
the impact of potential plan changes by
applying
actuarial modeling to AUGUSTA’s claim data.
35. Please confirm your ability to generate a
monthly report of solicited refunds for
overpayments identified by your staff as well
as unsolicited refunds received from providers
and
subscribers, and refunds actually collected.
36. If claims exceed 50% of the specific stop loss
deductible, how often are updated claim
reports sent to the stop loss carrier?
37. Please confirm whether all claims
examiners adjudicate transplant claims, or if
instead, only a specially trained group of
examiners handles
them.
38. Please advise under what circumstances
itemized hospital bills are requested, and the
action taken on such bills.
39. Please confirm whether your examiners
independently verify the accuracy of the
number
of units of anesthesia billed on in network claims.
40. Please describe your claim processing and
customer service model. Do the examiners
perform all functions or are they segregated?
41. Please confirm under what circumstances a
paper EOB will not be generated.
42. Please confirm that you can generate a zero
dollar claims for services rendered in the On-site
Clinic
43. Please confirm that you can work with all
major PBM’s
FINANCIAL AND COST INFORMATION
1. Please provide the following information
regarding usual and customary rates (UCR) for
physicians, facilities, and allied providers:
A. Which resource provides your
UCR data and how frequently
are
updates loaded?
B. Please confirm whether you
maintain UCR data for all
providers including
facilities.
C. Please describe any unique solutions
you have developed for your clients
where UCR is derived from criteria
other than a data warehouse such
as Ingenix.
2. For the network you are proposing, list the
average network discounts for southeast region
for the following service categories. The discount
information below may be provided by state if
not available for the southeast region. Does your
percentage include zero dollar claims?

Professional Services: %

Inpatient Hospital: %

Outpatient Hospital: %

Other: %
3. Please describe all additional vendors whose
cost-containment services will be offered to
Augusta (i.e., subrogation services, hospital
audit services, out of network negotiations,
etc.). Please provide a brief summary of the
services offered, actual historical financial
results (savings generated), the fee charged, and
the portion of the fee, if any, that is payable to
the TPA.

4. For any external vendors to whom services are

outsourced, please provide an overview of how
your organization provides oversight to ensure
high quality performance. Please indicate if
actual audits are performed of outsourced
service providers. If so, on what frequency are
those audits performed, and what performance
guarantees are in place?

5. Please explain here any requirements

specified in this RFP that you will not satisfy or
that will incur charges in addition to those
quoted in your pricing response. If not
specifically disclosed in your proposal, no
additional fees will be paid
under this contract.
6. Confirm your agreement to provide
your renewal fees by July 1st of each year
7. Please detail all sources of remuneration for
your TPA received based upon your medical
ASO client relationships other than the
administrative
fees disclosed in your cost proposal.
8. Please confirm you are willing to include a
$2.25 pepm fee to pay for AUGUSTA’s Benefit
Consultant. This fee can be built into your
administrative fee but if not built into the
administrative fee it must be disclosed as a line
item on your cost proposal and included in your
total expected and maximum liability figures.
9. Please confirm that you have no other broker
or consulting fees built into your proposed
fees other than those listed above.
RFP #22-247 Self-Funded Health Insurance Services (Administrative Services)

RFP Due: Tuesday, April 19, 2022 @ 11:00 a.m.