BMI Audit Services LLC 2/5/2019 - Laserfiche WebLink

ATTACHMENT A 1. Scope of Services. Specific to this Agreement, Service Provider will provide the following Services for the City relative to health care claims administered by Healthcare Management and dental claims administered by WDS/Delta Dental ("Administrator"). • Service Provider will contact Administrator to review audit process and data needs. • Service Provider will review the City enrollment records versus Administrator eligibility records for the audit period to confirm that only those truly eligible for the plan were covered. • Service Provider will review all pertinent plan design documents in order to customize its electronic auditing tools. • Service Provider will electronically audit 100% of medical and dental claims paid by Administrator from January 1, 2017, through December 31, 2018. • Service Provider will produce exception reports identifying and organizing all claims potentially paid in error into error categories. • Upon review of all error categories, Service Provider will then judgmentally select up to 125 total claims that will provide the necessary information to support all claims within each error category. • Service Provider will then perform an on-site audit of those judgmentally selected claims at Administrator's claims payment location. Each on-site audited claim will be logged onto a worksheet detailing the reason for which Service Provider considers the claim was paid in error. • Administrator will be provided copies of all worksheets in order for them to reply to Service Provider's findings. Administrator will then return their responses back to Service Provider within a reasonable amount of time and all responses will be published in the Final Report. • Based upon the on-site findings and Administrator's responses, Service Provider will re-examine the full electronic file to determine if additional claims (those related by same patient and/or services) are to be included in the Final Report. • Service Provider will prepare and deliver the Final Report using detailed spreadsheets, narrative findings,and recommendations based on the electronic analysis,on-site audit reviews, and Administrator's responses. Page 7