Specifications include, but are not limited to: General Administration & Services Administration of the plan must comply with all applicable state and federal statutes, rules, regulations, and UT System policies including the Privacy and Security requirements of the Health Insurance Portability and Accountability Act (“HIPAA”), the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, and the Age Discrimination in Employment Act (“ADEA”), and all amendments thereto. Contractor must administer the plan in a manner consistent with all applicable laws and regulations, as well as with the requirements set forth by UT System in this RFP. Contractor must provide all services associated with the administration of the plan and may recover the cost of compliance with the requirements associated with general administration and services only by making provision for such cost in Section 6. Contractor must provide general administrative support, legal and technical assistance, quality assurance, and certain reporting as required for the operation of the Fully Insured Short-Term Disability Insurance and Long-Term Disability Insurance plans. Cost Containment Contractor must have comprehensive cost containment programs in place that includes the following elements at minimum: Application and pre-authorization review; Misuse of program, overpayments, wrongful or incorrect payments; Unusual or extraordinary charges and unnecessary STD or LTD treatment; Condition management and rehabilitation services; Coverage management; Utilization management; Written description of its comprehensive Fraud Detection plan with its response. Contractor understands that UT System may develop further policies in connection with the detection and prevention of fraud or abuse of the STD and LTD plans. Contractor must comply with all applicable state and federal laws, regulations, and protocols and must also comply with all UT System policies, which may be updated as necessary. Contractor must have the ability to effectively collaborate with other UT insurance Contractor partners to the benefit of the member and the program. Contractor is responsible for costs associated with program activities and any associated litigation. Provision for such costs should be made by Contractor when determining their proposed administrative fees (ref. Section 6 of this RFP). Contractor may use program information to profile patients only for the purposes of offering, implementing, and administering its educational program. Only non-personally identifiable participant information may be used by Contractor to administer, evaluate, and improve its educational program and care management programs. Performance Monitoring UT System expects Contractor to proactively identify and address variances from targeted performance standards. Quarterly administrative performance reporting will be required. A template for the required format of the quarterly Administrative Performance Report is included as APPENDIX FIVE. Required information must be provided on a mutually agreed schedule and in the format prescribed by UT System or Contractor will be subject to financial penalty. Additionally, UT System may request customized reports on an ad hoc basis. Such reports must be provided in a timely manner at no additional cost to UT System. As part of the contracting process, specific performance standards with meaningful financial penalties must be established. At a minimum, the following areas must be addressed: Customer Service Standards: Call handling; Written inquiries; Complaints; Member surveys. Minimizing call center and website outages Timeliness: Annual Enrollment materials; Required reporting and datasets, including claims, vendor self-bill, eligibility, administrative performance, and emergency update processing. Accuracy: Plan design implementation Claims adjustment Processing of Evidence of Insurability Contractor must provide the underwriting support and appropriate staff, including qualified and duly licensed medical doctors in good standing with the state of Texas, to service the EOI function. Contractor will average processing EOI applications as follows: 85% of EOI applications to be processed within fifteen (15) days of receipt; 98% of EOI applications to be processed within thirty (30) days of receipt; Average processing time should be less than fifteen (15) days Processing of claims Contractor must agree to pay financial penalties as negotiated during the contracting process if the associated performance standards are not met. Additionally, Contractor should be aware that compliance with performance requirements will be a key consideration during any future contract renegotiations. UT System staff or UT System’s consulting actuary may, from time to time, request that Contractor provide additional information specific to the medical plan. Contractor must cooperate with and act in good faith in working with the consulting actuary and must be prepared to respond to these requests promptly. Contractor must accumulate enrollment, utilization, cost, and claims payment statistics and develop reports for the plan as is typically done in the course of plan administration, but no less frequently than on a monthly basis. Contractor must provide copies of such reports upon request by UT System along with results of any audits conducted in connection with the reports.
