SD State Employee Health Plan Medical Claims Audit
State of South Dakota > Bureau of Human Resources & Administration
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Submission Instructions
Description
The South Dakota Bureau of Human Resources and Administration is soliciting proposals for a performance review audit of medical claims processing performed by Wellmark Blue Cross Blue Shield of South Dakota for the State's self-funded employee health plans. The State Employee Health Plans cover approximately 12,150 employees and COBRA participants, with approximately 26,800 total participants including dependents. The plans include two low-deductible PPO plans and two high-deductible plans with Health Savings Accounts. Annual volume is approximately 314,300 medical claims and 282,700 pharmacy claims. Fiscal Year 2026 total health plan costs were approximately $160 million, including approximately $108 million in medical claims. The work includes auditing claims against plan provisions, reviewing Wellmark procedures and controls, negotiated provider rates, claims-processing quality and timeliness, performance guarantees, and the accuracy of claims data. The auditor must follow Generally Accepted Government Auditing Standards, industry-standard medical and pharmacy claims-audit methodologies, statistically valid sampling, HIPAA requirements, and applicable state and federal requirements. The selected auditor must execute a nondisclosure agreement with Wellmark and a Business Associate Agreement with the State. The scope covers three 12-month audit periods from July 1, 2027, through June 30, 2030, with electronic screening of 100% of paid medical claims, a 200-claim financial stratified/attribute sample, review of 50 inpatient diagnosis-related group hospital claims, and review of 20 out-of-network claims for each period. Separate findings, reports, recommendations, supporting documentation, and work papers are required for each audit period. Proposals must include an executive summary, detailed point-by-point response, cost proposal, relevant company qualifications and past-performance information, and resumes and references for key personnel.
Classification Codes
Smart Codes
Specifications
Timeline
Requirements
- Commercial General Liability — $1,000,000.00
- Professional Liability — $1,000,000.00
- Business Automobile Liability — $1,000,000.00
- Workers' Compensation
- Cyber Liability
- Minimum 3 references
- Within the last 3 years
- Client point of contact required for each reference
Documents
| Title | Date Posted |
|---|---|
| RFP Document | Sep 28, 2026 11:04 AM |
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