dental questionnaire · web viewquestionnaire instructions to offerors: ***do not alter the...

Questionnaire Instructions to OFFERORS:***DO NOT ALTER THE QUESTIONS OR QUESTION NUMBERING***

Please complete all appropriate sections of the questionnaire.

Provide answers to the questionnaires in Word format.

Provide an answer to each question even if the answer is “not applicable” or “unknown.”

Answer the question as directly as possible. If the question asks, “How many…” provide a number. If the question asks, “Do you…” indicate Yes or No followed by any additional brief narrative explanation to

clarify.

IMPORTANT: Be concise in your response. Use bullet points as appropriate. Reconsider how to word any response that exceeds 200 words in length so that the response contains the most important points you want displayed. Referring the reader to an attachment for further information should be avoided or used on a limited basis. Any response that does not directly address the question, but only contains marketing information will be considered non-responsive.

OFFERORS will be held accountable for accuracy/validity of all answers.

Remember, RFP responses will become part of the contract between the successful OFFEROR and the EUTF.

The submission of a proposal will be deemed a certification that the OFFEROR will comply with all requirements set forth in this RFP. If a multiple option plan is being requested, it will be assumed that all answers apply equally to all options. If this is not the case, separate answers should be provided for each option.

NOTE: Answers to the questions must be provided in hard copy and WORD format on CD

DO NOT PDF or otherwise protect the CD

DENTAL QUESTIONNAIRE

GENERAL INFORMATION

OFFEROR RESPONSE

1. Do you agree that if this proposal results in your company being awarded a contract and if there are inconsistencies between what was requested in the RFP and what is contained in your proposal response that any controversy arising over such discrepancy will be resolved in favor of the language contained in the RFP, unless specifically modified by the contract?

Yes No (Please explain in Attachment 5, Exceptions)

2. Do you agree to perform all of the services contained in this RFP? If there are any exceptions to these requirements, please specify in Attachment 5 as a separate section to your proposal, a complete explanation of each exception, titled, Exceptions. Failure to agree to perform the services required in this RFP may result in your proposal being deemed incomplete.

Yes No (Please list all exceptions in Attachment 5, Exceptions)

3. Do you agree to all the terms and conditions in Section I of this RFP?

Yes No (Please list all exceptions in Attachment 5, Exceptions)

4. Verify that all deviations from the requested plan design and coverage are included in the tables in Section V.


5. Is your organization currently or in the near future undertaking any mergers, acquisitions, sell-offs, change of ownership, etc?

Yes (Please explain)No

6. The EUTF requires written notification of renewal actions 240 days preceding the expiration of the contract. Confirm your agreement to this requirement.


7. What are the most recent ratings for your company by the following:

Standard and Poor's - Rating

Standard and Poor’s - Date

Duff and Phelps - Rating

Duff and Phelps - Date

A.M. Best - Rating

A.M. Best - Date

Moody’s - Rating

Moody’s - Date

GENERAL INFORMATION

OFFEROR RESPONSE

Has there been any downgrade in your ratings in the last two years?If your firm is not rated, submit documentation of a similar nature which attests to your firm’s financial stability.


8. Confirm that you will provide the following minimum reporting requirements:a) Monthly Enrollment Reportsb) Monthly Claim Reportsc) Quarterly Utilization Reportsd) Semi-Annual Utilization Reportse) Annual Utilization Reports


9. Does your company, including any affiliates, subsidiaries, or principals of the company, have any pending or has had any legal actions against the State of Hawaii, the EUTF Board, or any EUTF Trustee within the last five years? If yes, describe in detail.


A. ORGANIZATIONAL EXPERIENCE AND STABILITY

Network Ownership and Background

1. Name of Parent Company, if any:

2. Identify service team:a) Day to day contactb) Underwritingc) Billingd) Local overall account managemente) Location of your local telephone service office

and number of stafff) Location of your walk-in customer service office

and number of staff

3. What is the location of the office that would handle the general servicing of this account? Provide a brief biography and location of the senior officials responsible for the overall service of the account and for the day-to-day operations.

4. Is your firm anticipating restructuring or reorganization in the next year? If yes, please explain. (Include any major staff relocations or office closings.)

5. In the past 12 months has your organization closed any network services areas in the State? If yes, please list the centers.

6. In the past 12 months has your organization closed/consolidated or relocated any customer service or claims offices? If yes, please list the offices?

GENERAL INFORMATION

OFFEROR RESPONSE

7. Has your organization acquired, been acquired by, or merged with another organization in the past 24 months? If yes, please explain.

Financial Condition of Organization

Hawaii Membership Profile/Client Base

8. Please provide annual Membership counts for three years.

National PPO 2017 2016 2015

Hawaii PPO 2017 2016 2015

9. Please provide the percentage client retention rates requested below (Group Accounts Only):

Client Retention Rates

PPO Fully Insured Plans 1 year 2 years 3 years

Self-Insured Plans 1 year 2 years 3 years

Termination Rates

PPO Fully Insured Plans 1 year 2 years 3 years

Self-Insured Plans 1 year 2 years 3 years

B. ADMINISTRATIVE SERVICES

Account Service

1. Do you agree to notify the EUTF immediately if the network loses any accreditation, licenses, or liability insurance coverage?


2. Are there any Special Conditions outlined in Section I that you cannot meet?

Yes (Please explain in Attachment 5, Exceptions)No

GENERAL INFORMATION

OFFEROR RESPONSE

3. Payment Options: EUTF to Vendor (Choose only one)

a) Electronic Fund Transferb) Manual Invoicingc) Both options available

4. Will you transfer enrollment cards, claim information, and other administrative records to any carrier/TPA that would replace you in the event of termination of this contract and at no charge?


5. a) What on-line services/functions will be made available to the EUTF administrative staff via the Internet? (List all that apply)

Claims Summary Billing History Premium Rates Provider Directory Eligibility Summary Enrollment Counts Plan Details Address Changes Other

b) What on-line services/functions will be made available to the EUTF members via the Internet? (List all that apply)

Claims Summary Provider Directory Plan Details Address Changes Other

c) Provide name of website and sample password, if applicable:

6. For each of the services listed below, please indicate if the service is available and if the cost is included in the basic fee. If not, please provide any additional fee that may apply.

a) SPDs Included in basic fee Not available Indicate additional cost

b) Claims Forms Included in basic fee Not available Indicate additional cost

c) EOBs Included in basic fee Not available Indicate additional cost

GENERAL INFORMATION

OFFEROR RESPONSE

d) Network Directory Included in basic fee Not available Indicate additional cost

e) Other, please describe Included in basic fee Not available Indicate additional cost

7. Will you provide customized employee communication material at no additional cost? If not, what is the additional cost?

8. What communication materials (i.e., I.D. cards) are provided to the employee to identify them as a member? Please provide a sample.

9. Describe any other claim/management reports you would be able to supply regularly at no additional charge and the frequency with which it could be provided.

10. How long are records maintained in the system? How far back can the EUTF go to obtain historical information on its dental plan?

11. Do you record all procedures using the ADA code?

Audit Requirements

12. a) Do you agree to allow the EUTF the right to audit the performance of the plan and services provided?


b) Indicate what services, records and access will be made available to the EUTF at no additional charge.

c) Indicate frequency and notice requirements that are part of the right to audit provision and all other limitations or restrictions on the conduct of an audit.

13. Will you agree to an independent annual audit that measures performance through random sampling? Please include a copy of your audit policy.


14. Will you agree to provide a comprehensive data file to the auditor that will facilitate electronic analysis with target samples validated through the auditor’s review of supporting documentation of sufficient sample size to meet the auditor’s requirements to achieve the level of confidence determined by the auditor?


15. Confirm your understanding that results from an independent random claims sample will determine compliance with processing guarantees.


GENERAL INFORMATION

OFFEROR RESPONSE

16. Confirm your understanding that non-processing performance guarantees may be validated through an independent audit with such results determining the amount of any penalty due.


Member Service (i.e., Customer Service, Internet Access, etc.)

17. a) Will dedicated customer service representatives be assigned to this account?

b) Are customer service reps separated from the claim processing unit, or do claim processors have customer service responsibilities?

c) Do customer service reps have on-line access to up to date claim processing information?

d) Do customer service reps have authority to approve claims?

a) Yes No b) Yes No c) Yes No d) Yes No

(If NO, please explain in Attachment 5, Exceptions)

18. a) Confirm the cost of providing a toll-free number to be made available to participants to handle claims or other service issues is included in your quotation.

b) If not, would you agree to establish toll free 800 telephone lines for this group?

c) How many telephone lines do you expect to use?

d) What days and hours will the telephone lines be manned?

a) Yes No b) Yes No (Please explain in Attachment 5, Exceptions)

19. Indicate the ways in which your organization is able to accommodate the special needs of enrollees. (List all that apply)a) No special accommodationsb) Have a TDD (Telecommunications Device for the

Deaf) or other voice capability for the hearing impaired

c) We accommodate non-English special enrollees by contracting with an independent translation company

d) We maintain customer service staff with the ability to translate multiple languages, if so which languages?

20. Do you agree to receive and timely and accurately process as indicated in this RFP all of the enrollment and eligibility information in the format as provided by EUTF, without the EUTF making changes to its file format? (See Exhibit G )


21. Do your provider directories include the following: (List all that apply)a) Physician office address and phone number

a) Yes No b) Yes No

GENERAL INFORMATION

OFFEROR RESPONSE

b) Specialty designation (e.g., orthodontics)c) Doctor accepting new patientsd) Office hourse) Languages spoken in office

c) Yes No d) Yes No e) Yes No

22. How will complaints regarding quality/timeliness of care from participants or the client be handled?

23. Describe the grievance protocols in place for plan participants. Do you have a response time goal for which to respond to claim and other questions and complaints?

24. Is cost efficiency/effectiveness of participating providers measured? Describe process used.

25. How is the quality of care, provided by each of your network providers, monitored?

26. How would your company propose to integrate with a wellness total health management program if implemented by the EUTF for its participants?

27. Do you have a wellness program that will coordinate dental and health benefits with the EUTF’s overall wellness programs? If yes, please explain.

28. Will you work with EUTF to develop and promote plan benefits that are identified through claims data to be below the industry standard? If yes, will you pay for the cost of development, printing, and direct mail of promotions to all members identified?

Claims Processing

29. With regard to the claim offices that will be used, provide the following:

a) Location: _________________________

b) Average Claims/Processor/Day: _______

c) Annual Claim Volume: ______________

d) Provide number of: Processors Supervisors Managers

e) Average years of claims administration experience for: Processors Supervisors Managers

f) Annual turnover percent (%): Processors Supervisors Managers

GENERAL INFORMATION

OFFEROR RESPONSE

30. Describe the claims payment process from date of receipt to full adjudication of checks to providers or patients. If the process is different for network and non-network claims, please discuss separately. For example, do you batch process checks to network providers? If so, explain.

31. Based upon the latest 12-month period: (Please answer all parts of this question)

a) Average number of business days to process a claim from date received to date check/EOB issued:_________

b) What percent of all claims submitted (regardless of information provided on claim) are processed (from date received to date check/EOB issued) within 10 business days? %

c) What percent of all claims submitted (regardless of information provided on claim) are processed (from date received to date check/EOB issued) within 30 business days? %

32. Have you been penalized by any state for failing to meet state average claim turnaround requirements?a) Yes. List state where you were sanctioned in the

last 12 months: ____________________b) No

33. For the claim office proposed, please provide the following data for the latest 12 months:

a) Financial accuracy as a percent of total claims dollars paid (include over/underpayments)

b) Coding accuracy (claims without error) as a percent of total claims submitted

34. a) What are your procedures for recovery of the overpayments or duplicate payments?

b) Do you agree to return all recovered monies from overpayments or duplicate payments to client? (Choose only one) Yes, 100% of recovery Yes, less _____ recovery collection fee No, do not agree

35. a) Explain your COB procedures.

b) Do you pursue COB prospectively or retrospectively to payments?

c) How often are records updated for new information on other coverage?

GENERAL INFORMATION

OFFEROR RESPONSE

d) What is the average COB savings as a percent of total plan cost for: Active Retiree

e) Will you guarantee COB savings for (Answer yes or No): Active Retiree

36. Please provide, at a minimum, a description of the program, if there is a formal written program, and the total number of events per 1,000 covered lives on fraud detection programs for:a) Ineligible Claimantb) Assure that service billed is actually renderedc) Over billingsd) Is there a written program? Please include a full

description of the program and the total number of cases of fraud per 1,000 covered lives.

37. a) Do you retain dental consultants for the review of any unusual claims or charges?

Yes No

b) If yes, explain the method in which such consultants are used and describe their qualifications and any affiliations.

C. UNDERWRITING ISSUES – FULLY INSURED PLANS

1. a) Explain the methodology and data to be used for the renewal process. How will projected incurred claims be estimated for these plans?

b) What experience period(s) will be used for the first renewal?

c) What credibility will be given to each period of experience used?

2. Explain your methodology for establishing Incurred But Not Reported reserve?

3. Indicate the factors used to set the rates for the proposal.a) Annual Trend Factor ____% of expected claimsb) Reserve Factor ____% of expected claimsc) Margin____% of expected claimsd) Retention as a fixed cost PEPM or PRPM

4. Explain any other required reserves other than for IBNR. Indicate amounts, reason for reserve, is interest credited and whether reserves are refunded to the client upon policy termination.

GENERAL INFORMATION

OFFEROR RESPONSE

5. Detail any underwriting provisions if any (rules) you will impose on the EUTF.

D. ASO BANKING/CLAIM REIMBURSEMENT ARRANGEMENTS

1. Describe the way in which the banking arrangement works. Include explanations of the nature of the account from which claims are paid (e.g., in whose name it appears, where it will be, the timing of the call for funds [e.g., as checks are issued, as they are cashed]), any deposit amount required in the account, its term (weekly, monthly) how it is determined and any interest earned on the deposit, or on amounts held in the account until checks are cashed. In addition, please explain how excess deposits are handled during the term of the plan and when deposits are returned upon plan termination (including whether a deposit can be retained to pay for any deficit etc.). If banking charges are not included in your ASO fee, please provide an estimate of such charges and describe the basis on which they are made.

2. If your plan does not require the use of a special bank account but rather calls for funds on a single monthly bill, please explain the timing of such bill, when payment is due, the definition of claims due (checks issued or cashed) and what interest charges are made (or credits foregone) on such a program, relative to a conventionally-insured plan. If your plan is not funded through a special bank account but rather on a lump-sum basis, please explain any interest charges.

3. If your account is funded as needed, can the policyholder select a bank? Is there an added cost for such a bank? If so, how much?

4. How often are check registers and reconciliations furnished? What is in these reports (please provide a sample)?

5. Will you stock pile claims to a certain level before releasing them, so that the plan sponsor can fund claims less frequently?

6. How quickly and often must the plan sponsor make reimbursements to you?

7. What audits of reconciliations are done?

8. Do you verify bank transfers as they occur?

9. Provide a detailed list of services and supplies included in your proposed ASO fee.

E. NETWORK MANAGEMENT

Provider Relations Education

GENERAL INFORMATION

OFFEROR RESPONSE

1 A. For the City & County of Honolulu (Oahu) service area provide the number of Network Providers that have terminated their contract:

Provider Type Unknown

Total # of Terminations in the Past 12

Months

Terminations Equate to What % of

Your Contracted Providers?

% of Terminations That Are Voluntary

Most Common Reasons For

Termination (e.g. contract dispute,

death, moved)

PPO

General Dentists

Oral Surgeons

Orthodontists

Other Specialty Dentists

1 B. For the County of Hawaii service area provide the number of Network Providers that have terminated their contract:


Total # of Terminations in

the Past 12 Months

Terminations Equate to What %

of Your Contracted Providers?




death, moved)

PPO

General Dentists

Oral Surgeons

Orthodontists


1 C. For the County of Maui (including Kalaupapa) service area, provide the number of Network Providers that have terminated their contract:



the Past 12 Months






death, moved)

PPO

General Dentists

Oral Surgeons

Orthodontists


1 D. For the County of Kauai service area provide the number of Network Providers that have terminated their contract:



the Past 12 Months






death, moved)

PPO

General Dentists

Oral Surgeons

Orthodontists


Network Provider Relations2. Complete the following table. Check off those elements that are included in the provider selection process and

provide the percentage of network providers that satisfy the following selection criteria elements.

Criteria

Standard Selection Criteria

(check if yes)

Percentage of Providers that Satisfy Criteria Comments

Require Unrestricted State Licensure

Review Malpractice Coverage and History

Require full disclosure of current litigation & other disciplinary activity

Require Signed Application/Agreement

Require Hepatitis B (3) series of shots

Require dated examination of radiograph equipment

Require Current DEA Registration

Review adherence to state and community practice standards

On-site review of office location, appearance, and ease of access

Review hours of operation and capacity

Review Practice Patterns & Utilization Results

3. Describe the general credentialing process and minimum criteria for a dentist to be selected as a network provider. If the process differs by type of provider (i.e., primary care vs. specialists), please indicate and describe

separately.

4. Is malpractice coverage required to be maintained by all network dentists? List minimum amounts of coverage.

5. Describe the re-credentialing process, include timing and percentage of providers that are re-credentialed each year. Provide the number of years that a provider’s contract is in effect.

6. Are you willing to have random site visitations for some of the providers of the network by the clients dental consultant? If not, why not?

7. Describe your organization’s objectives/efforts with regard to provider relations. Is there an oversight committee that addresses provider relations issues?

8. How do you address “Any Willing Provider” laws? What procedures are in place to monitor network provider grievances?

9. What quality improvement programs are in place or have been implemented in the last 24 months? Describe how providers are educated about any quality improvement programs related to the delivery of care.

10. Describe specific examples of how your Quality Assurance program has led to improved dental care.

11. Are network providers required to perform a periodontal evaluation on EACH patient? If not, why not?

12. Provider AuditsDescribe the procedures in place to audit the quality of care being rendered by network providers. Include the following information:

Percent of Dentists Audited AnnuallyOn Site _____________Total _______________

Percent of Random Audits PerformedOn Site _____________Total _______________

Percent of audits performed or reviewed by independent agents. Provide name, credentials and role of independent auditors.____________%

Is the right to audit included in your standard provider contracts? (Yes/ No)

Percent of contracts terminated due to result of audit____________%

13. Is there a formal committee that sets quality assurance policy and reviews outcomes on a regular basis?

14. Describe any circumstances under which you would use the services of an independent claims auditor.

15. How do you prevent over and under treatment? Give examples.

16. Do you have a formal UR program consisting of pre-authorization? Are there written guidelines that are provided to network dentists?

17. Do you have established procedures for review determination, including qualified staff (e.g., primary reviewer is a practicing dentist) dentists that review all program denials, and patient appeals procedure?

18. Do you have an authorization procedure for referral to non-network providers? Do you monitor dentist referral patterns?

19. Is your claims and/or clinical information shared with medical providers and vice versa? If so, what value does this provide to the EUTF?

Provider Profiling

20. Do you have a mechanism for routinely investigating if a contracted provider has any disciplinary actions imposed by their State licensure medical board?


21. Do you compare individual network provider practice patterns against Best practices or averages on any of the following: (List all that apply)a) Referral rates to specialistsb) Rates of surgical procedure relative to peersc) Repeat procedures within given timeframesd) Unknown/do not track

22. Other than provider directories and access to providers via your website, what quality or practice pattern data about your contracted providers do you make available to plan participants?a) We provide _________________b) Nothing at this time

Network Structure

23. List any current federal, state and independent qualifications or accreditation your PPO has received.

24. Do general dentists in your networks act as gatekeepers for specialists’ service? Describe the referral process.

25. Describe how network dentists are reimbursed. Your answer should be consistent with the premium rates provided in the financial section of this proposal specification. Include any incentive based bonuses, withholds, etc.

26. Describe how network specialists in your networks are reimbursed. Your answer should be consistent with the premium rates provided in the financial section of this proposal specification.

27. What is used as the basis for reimbursing non-network providers?

28. How often are network fees and out-of-network allowances updated?

29. Do you prohibit network dentists from being direct owners, or having any financial involvement of outpatient facilities such as dental labs? If not, is there any monitoring of self-referrals to provider owned facilities?

30. Do you provide member support for answering provider credential questions that members may have? Do you have on-line access to your network provider listings and locations?

31. What assistance do you provide plan members if a network dentist terminates their contract during the plan year? How and when are members notified? What happens to patients who are receiving on-going treatment from that network provider?

32. Can the EUTF or participants nominate providers to be considered for inclusion in the network panel? If so, what is the process?

33. Are there any dental services or specialties which are not available in your network in any of the areas in which there are plan participants? If so, what are they? What provisions are made for patients requiring these services?

Network Information

34. What is the name of your network?

35. Is your network licensed in the State of Hawaii?

36. Do you anticipate a significant change in the size or location of your network in the next year that would impact this client’s population?

37. a) How often are network directories updated?

b) How often will revised directories be made available to the client?

c) Is your provider directory available on the internet? If so, at what web address?

38. a) State the number of employer groups currently utilizing your network in Hawaii.

b) How many employees and retirees does this represent?

39. Provide the number of general dentists and specialty dentists in your PPO Dental networks on the following table: (note: dentists should only be counted once, regardless of the number of specialties they have):

Number of Network Providers

Area General Dentists

Oral Surgeons


Orthodontists

ISLANDOahuHawaiiMauiKauaiMolokaiKauaiLanaiTotal State of Hawaii

F. COVERAGE AND CONTRACT ISSUES

General Contract Provisions

1. Will you agree to be bound by the terms of the RFP and your proposal until a final contract is executed?


2. Please confirm that your proposal, and plan designs offered, is in compliance with all federal and state laws and regulations that pertain to employee benefit programs, relevant state insurance regulations and other related laws, such as “Any Willing Provider” laws.


3. If the plan designs requested do not comply with any state or federal laws, please indicate which provisions in the proposal specifications are in conflict with specific laws and propose alternatives.

4. Do your provider contracts prohibit providers from balance billing patients for amounts over any negotiated charges? If yes, what is the contract wording?

Coverage Issues

5. Describe the coverage portability for members who temporarily reside, work or experience emergencies outside their home state.

6. Confirm your agreement to waive any and all pre-existing condition limitations/exclusions and any actively at work restrictions for members covered on the initial effective date of the contract as well as for any members who become eligible subsequent to the initial effective date of the contract.

7. Describe how treatment in progress will be covered if your plan is terminated during an episode of treatment. What services (i.e., root canal, crowns, etc.) are covered and for what amounts?

H. RECRUITING/CREDENTIALING/TERMINATION

1. How are providers recruited?

2. What is the annual turnover rate of the providers in your network?

3. What percent of providers in Hawaii are at full capacity and will no longer accept new patients?

4. Indicate the reasons for which a participating provider can be terminated and the number of occurrences within the past year.

5. a) At the end of a client’s contract, how is treatment in progress covered?

b) At the end of a participant’s eligibility, how is treatment in progress covered?

G. HIPAA QUESTIONS

1. a) Do you have a formal HIPAA compliance plan in place? (Answer Yes or No)

b) Attach a copy to your proposal.

2. a) Do you have a website that details information about your policies and procedures for accepting and sending EDI transactions?

b) Where does the copy of your Companion Guide for HIPAA EDI transactions reside?

3. Will your organization be issuing Notices of Privacy Practices as required by HIPAA to each new plan enrollee? At what cost?

dental questionnaire · web viewquestionnaire instructions to offerors: ***do not alter the...

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