RFP Checklist for Self Funded



RFP Checklist for Current 51+ Self-Funded GroupsA. Group InformationLegal Name: FORMTEXT ?????Website: FORMTEXT ?????Address: FORMTEXT ?????Industry: FORMTEXT ?????Waiting Period: FORMTEXT ????? max is 90 days as of 1/1/2014ER Contrib % FORMTEXT ????? EE FORMTEXT ????? dependentsEffective Date: FORMTEXT ?????# Full-Time EEs: FORMTEXT ????? active FORMTEXT ????? COBRA FORMTEXT ????? wait perNotes: FORMTEXT ????????B. General Items FORMCHECKBOX Employee Census- to include gender, date of birth, home zip and below noted information: FORMCHECKBOX All eligible full-time eligible employees including those not electing coverage and those in waiting period with date of hire FORMCHECKBOX Waivers with other coverage noted (Medicare, Medicaid, Tricare military, parents, spouse) FORMCHECKBOX COBRA participants with census info and effective date of COBRA coverage FORMCHECKBOX Medical family tier (EO, ES, EC, EF) and medical plan election FORMCHECKBOX Work location for each employee if multi work sites with full address FORMCHECKBOX 2. Breakdown of Class Divisions – If applicable. Does the group have different benefits, employer contribution levels and/or waiting periods for a specific class of employees and, if so, please describe. FORMCHECKBOX 3. Plan Document and Summary Plan Description / Benefit Summaries – For all lines of coverage and all plans offered. FORMCHECKBOX 4. Renewal- for admin and stop loss FORMCHECKBOX 5. Stop Loss Policy Schedules – Copy of current specific stop loss and aggregate stop loss policy schedules. FORMCHECKBOX 6. Administration Agreement / Schedules – Copy of current administration agreement and fee schedule breakdown. FORMCHECKBOX 7. Most Recent Billing Statements – Copy of most recent carrier billings for each benefit line, if available.C. Current Carrier and Prior Carrier History 3+ YearsEff DateTermed DateCarrierCoverage Type FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????D. Plan Design Change Requests FORMCHECKBOX Plan Design Changes Requested- if any changes to deductibles, coinsurance, out-of-pocket max, Rx, etc. please advise: FORMTEXT ????? FORMCHECKBOX Stop Loss and/or Administrative Changes Requested – if any changes to ASL, ISL or administration please advise: FORMTEXT ?????E. Claims Reporting FORMCHECKBOX Medical Utilization Report- summary reporting FORMCHECKBOX Aggregate Report – for last 2 years FORMCHECKBOX Specific Stop Loss Claims- for last 2 years if possible FORMCHECKBOX Detailed Claim Listing including Rx if possible, if not possible need separate Rx claims data- Full listing of each claim for each member for the last 24 months if possible, at least last 12 months, with member name, diagnosis and paid date. FORMCHECKBOX Case Management Open Case Listing- For all large claims currently under case management FORMCHECKBOX Letter or prognosis report for each large claimant with detailed medical notes- patient name, member ID, group, referral source, referral reason, date case opened, reporting period. Will provide history of claim, current medical status/treatment plan, prognosis and case management interventions. ................
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