Specifications include, but are not limited to: ❖ Operational Review to explore the day-to-day administrative policies, procedures, and internal quality control measures critical to minimizing financial loss and maintaining participant satisfaction levels. Review of the vendor’s SOC-1 report is to be supplemented with a questionnaire specific to administration of the State’s Plan. Topics include, but are not limited to: ➢ Divisions of staff and administrative functions assigned to the State Plan, with identification of any outsourced services; ➢ Eligibility receipt, timely update, reconciliation procedures, and system interfaces; ➢ Detection of other coverages (i.e., coordination with group and Medicare benefits, workers’ compensation, third party liability); ➢ System edits for detection of coding errors (i.e., unbundled or upcoded medical services, inconsistent drug codes) and alerts for claims requiring manual review and processing; ➢ Procedures employed to identify potential fraud and abuse (i.e., over utilization of physical therapy, over utilization of certain medical procedures/surgeries, etc.); ➢ Coordination with departments related to claim administration (i.e., medical review, preauthorization, case management); and ➢ Maintenance of provider files and fee schedules with distinction between contracted and non-network providers for medical claims, and application of appropriate generic vs. brand and formulary vs. non-formulary drugs. ❖ Financial Comparison of amount paid on the data file to amounts invoiced and paid by the State. ❖ Electronic Review of All Claims (100%) processed within the contract compliance review period should explore system capabilities and the accuracy of plan set-up. Queries should include, but may not be limited to: ➢ Potential duplication of payments; ➢ Member eligibility (based on vendor’s data file layouts); ➢ Reimbursement of expenses excluded or limited by plan design; ➢ Appropriate patient cost-shares (i.e., copayment, deductible, coinsurance); ➢ Consistency in coordination of benefits, including subrogation and workers' compensation; and ➢ Special programs such as limits and coinsurances on In-Vitro Fertilization.