Specifications include, but are not limited to: The Board desires to contract with an auditor that specializes in providing medical claims and performance audit services to large, self-insured health plans, and has prior experience directly related to the services requested in this RFP. The Medical Claims Auditor is expected to provide the following services: A. At the request of the Board, at least annually perform a comprehensive and objective medical claims and performance audit of the Plan’s medical claims third party administrator. This shall include determining if the medical claims were adjudicated according to contractual standards, appropriate Plan benefits, and industry standards. The medical claims and performance audit must be based on a statistically valid stratified random sample that achieves a minimum 95% confidence level +/- 3%. The audit must include a review of the medical claims processed by the medical claims third party administrator, including readjudicating medical claims to evaluate the administrator’s processes and systems relating to such areas as: eligibility, coding, pricing (including proper application of allowable charge and discount arrangements), deductible accumulators, identification of duplicate bills, application of Plan benefits, COB, subrogation, medical necessity, ineligible/eligible charges, compliance with the Plan Document, timeliness of processing, interaction with other auditors, and file documentation. A detailed operational audit of the medical claims third party administrator shall include, but is not limited to, the following: a. Operational review of medical claim payment procedures b. Forms and communication process c. Training programs and employee evaluation process d. Exception processing, security and override procedures relating to approval of claims and access to records e. Cost containment procedures f. Quality procedural manuals provided to claims processing, customer service, etc. g. Internal audit process h. Mail receipt and tracking i. Evaluation of the security of records and data j. Evaluation of customer service, including communication of the Plan’s benefits, policies, and procedures; audit of performance guarantees related to call answering response time and abandonment rate k. Compliance with HIPAA/HITECH Act