HomeMy WebLinkAboutexhibit 2-scope of servicesAttachment A: Scope of Services
I. PROVIDER'S DUTIES
A. Claims Audit: Perform a claims audit by reviewing all paid claims. Audit shall also
include any large claimants, as well as potential large claimants during the period
specified.
B. Hospital Bill Audit: Perform a claims audit by reviewing all inpatient and outpatient
hospital bills.
C. DRG validation: Validate ICD-9-CM code assignment and sequencing to determine
appropriate DRG assignment.
D. Fraud & Abuse Detection: Perform an Audit of claims to determine if fraud or abuse that
has been transpiring, and/or determine whether there is a potential of fraud or abuse, and
recommend Mechanisms to eliminate same, if applicable.
E. COB Review claims that coordinate with other Plans to make sure payment was made
appropriately. This includes Medicare.
F. Third Party Liability — Review claims to confirm if any third party liability applies. This
includes Workers Comp, Auto Insurance, Law. Suits, etc.
G. Summary Plan Deicription and Contract — Confirm that Cigna is appropriately
administering the City plan per the Summary Plan Description and the Contract between
the City and Cigna. This information is attached or will be provided to the Provider.
H. Shall utilize its personnel and expertipe to aggressively recover from Cigna, as applicable,
any and all dollars determined to be overpaid by the City and require reimbursement to
the City.
I. Meet with Risk Management and other City staff on 441 on -going basis to provide status
reports of the claims audit
J. Shall conduct an onsite audit at Cigna within 90 days.
K. Provide any other services as normally and customarily required as part of a claims audit.
L. Shall provide a comprehensive written claims audit .of its findings & recommendations,
& present its study, including recoupment results, both orally & in writing, to the City in
a period not to exceed ninety (90) days after contract execution.
M. Shall provide to the City twenty (20) written copies of its Claims Audit upon completion.
A soft copy of its report shall also be provided via CD rom.
N. Should a second phase of a Claims Audit be authorized by the City, shall perform all
services identified above for an expanded period of time as determined by the City.
Should this additional service be authorized by the City, said contract with Provider shall
be renegotiated and amendment executed to include additional authorized service as
deemed necessary by the City.