REQUEST FOR PPO, POS, AND HMO PROPOSALS
Nashvile-Davidson County Metro Government
NOTE: This document is for instructional purposes only. It has been
edited from the original and may not be the current version in use.
CONTENTS
PPO Proposals
Organizational Structure & Experience
Reporting
Technical Approach
Systems
Claims Administration
Managed Care Newworks
Utilization Review
Quality Assurance
POS Proposals
Similar subcatagories as above.
HMO Proposals
7.0 MEDICAL QUESTIONNAIRE
The following three sections Sections 7.0 (A), (B), and (C) are separate
questionnaires. Please complete the appropriate section, as follows, for
each medical plan option that you are proposing for Metro:
PPO Section 7.0 (A)
POS Section 7.0 (B)
HMO Section 7.0 (C).
For example, if you are proposing only an HMO option, complete Section
7.0 (C). But if you are proposing both a PPO and an HMO, you must
complete both 7.0 (A) and 7.0 (C). Please do not respond to any question
by referring to an answer provided in another section of
your questionnaire response.
7.0 (A) MEDICAL QUESTIONNAIRE FOR PPO PROPOSALS
This section, 7.0 (A) contains questions only for proposers of PPO options.
If you would also like to propose on POS or HMO options, you must also
complete the following sections:
POS Section 7.0 (B) HMO
Section 7.0 (C).
Please do not respond to any question by referring to an answer provided in
another section of your questionnaire response.
7.1 (A) ORGANIZATIONAL STRUCTURE AND EXPERIENCE
1. Please provide the following information about each of the key members on
your proposed Metro account team.
a. Name(s)
b. Location(s)
c. Key role(s) and responsibilities
d. Time commitment for installation of the program and, where applicable,
ongoing service to Metro
2. Provide a resume for each team member listed above, including a
description of the individual s experience with similar projects.
3. Please complete the following chart, based on your medical plan book of
business:
[chart]
4. Please complete the following chart for the claims office that would
administer Metro's claims:
[chart by job title and experience]
5. Will a dedicated claims examiner be assigned to the Board s account?
6. Where is the group office located that will pay medical claims?
7. Please list five (5) governmental clients for which you pay claims from the
local office listed above (include employer name, address, number of
employees, and contact name and telephone number).
8. Please list five (5) references for current clients who have similarly
sized populations for programs comparable to those you are proposing to
the Board (include contact name, telephone number, and brief
description of the organization).
9. Please list two (2) clients who have recently elected to leave your
organization s network. Why? Provide a contact name and telephone
number.
10. Please provide your company s most recent rating from each of the
following:
a. A.M. Best
b. Moody s
c. Duff & Phelps
d. Standard & Poor's.
7.2 (A) REPORTING
1. Please complete the following chart; indicate if you can provide the report
{ Y (yes) or N (no)}. If there is an additional cost for any report
not covered in your basic fee, please indicate the amount.
[chart]
2. a. Will you mail Metro s IRS 1099 forms for attending physician review?
b. Is this service part of your quoted fee?
c. If not, what is the additional charge, and is it included in your quoted
retention fee?
3. a. What is the turnaround time for special request reports?
b. Is there an additional cost for special reports?
7.3 (A) TECHNICAL APPROACH
A. Systems
1. Please provide a complete description of your claim processing system:
a. What procedures are in place to document receipt of claims?
b. What quality control procedures are included in the system?
c. Are all functions automated? If not, describe any manual operations.
d. Can a claims processor override the system? If yes, please describe
how and when this occurs.
e. How long do you maintain medical history in the computer?
f. 1. Do you maintain medical history information in hard copy form?
2. If yes, for what period of time?
g. 1. How long do you maintain a terminated employee s file in the
system?
2. How long do you maintain a terminated employee s file in hard copy
form?
h. Does your firm use a paperless claims system?
i. Are plan summaries maintained on-line through your system?
2. Is the administration of COB an integral part of your on-line claim
payment system?
3. a. Does your system maintain a listing of eligible employees/pensioners
on-line?
b. If so, how frequently is the file updated?
4. a. Metro needs employee, pensioner, and dependent information, including
name, Social Security number, sex, and date of birth. Will your
system accommodate this requirement?
b. If not, can your system be modified, at your cost, to capture this
date by June 1, 1995?
5. Is the employee/pensioner and dependent identification system linked to the
employee/pensioner Social Security number?
6. What edits are on-line to ensure payments are limited to eligible members?
7. Please provide information about how you process eligibility updates, as
follows.
a. Can you process eligibility updates via tape-to-tape exchange?
b. What record format would you require? Please attach a sample of your
format.
8. It will be necessary to track partially or totally fulfilled deductible
carry-over and accumulation toward plan maximums from the prior
administrators.
a. Please confirm whether you have this capability.
b. Describe your method of transmitting history from prior claim
administration.
9. a. Can an on-site terminal be installed at Metro for inquiry and
eligibility purposes?
b. Is there an additional cost for this service?
c. If there is an additional cost, please indicate the amount of the cost.
10. Do you presently classify medical conditions using ICD-9? If not, what
method do you use?
11. Please comment on the following data issues.
a. Do you have the capability of grouping claims for analysis by MDC?
b. Do you have the capability of grouping claims for analysis by DRG
category?
c. Does your system provide a capability for generating normative data
that can be used to compare the Board s plan to other plans of similar
size and structure?
12. Do you utilize the American Medical Association s current procedural
terminology (CPT)? If not, what terminology do you use?
13. How will your medical system interface with the dental claims system for
benefit integration purposes?
14. Do you have an electronic mail (e-mail) or Internet system that the Board
Office can access to enhance communication with your organization?
If yes, what type is it and what specifications (hardware and
software) would the Board need to use the system?
B. Claims Administration
1. Is a toll-free telephone number available to Board Office staff and
employees/ pensioners for claim questions and assistance? If so,
please state the hours of operation and time standards.
2. How does your company maintain eligibility data?
3. What hours are you available to verify eligibility?
4. Do claim processors handle inquiries from participants regarding benefit
payments, or is there a separate customer service unit to handle such
requests?
5. If a claim is denied, how do you notify the claimant?
6. What appeals process is in place for a participant whose claim is denied?
7. Can you suspend and reinstate coverage of employees, pensioners, and/or
dependents upon request by the Board?
8. How much advance notice of a benefit revision do you require?
9. How would you handle a retroactive benefit revision?
10. What is the typical turnaround time for claims?
[chart]
11. What was the error rate for the designated office during:
a. Calendar year 1993?
b. Calendar year 1994?
12. What are your claim office s performance standards for:
a. Financial accuracy?
b. Payment incidence accuracy?
c. Procedural accuracy?
13. When other group coverage is not indicated on a dependent claim
submission, what guidelines and procedures do you follow in conducting
further investigations?
14. Regarding your Explanation of Benefit (EOB) capabilities:
a. Do you provide the name and telephone number of a customer service
representative on the EOB for participants who have questions?
b. Can you provide copies of EOBs to the provider, patient, and employer?
c. If a patient loses an EOB, can you provide a duplicate?
15. Regarding payment processes:
a. How often are checks/EOBs printed?
b. Do you bulk pay to providers? If so, how often?
16. Please describe in detail how your plan would integrate with Medicare
(i.e., identify requirements for Metro and plan participants).
17. What type of claims are automatically flagged for review before
disbursement?
18. At what dollar amount must supervisory personnel approve a medical claim
payment?
19. What are your professional review mechanisms for:
a. Predetermination of benefits?
b. Medical necessity?
c. Appropriateness of care?
d. Quality of care?
e. Fraud detection?
20. Do you follow-up and secure a medical diagnosis if it is not provided on
the claim form? How is this accomplished?
21. If you use an outside consultant or service for medical review, who is
responsible for the cost?
22. Regarding reasonable and customary (R&C) guidelines:
a. What R&C percentile do you use in determining benefit allowances?
b. How often do you update your profiles?
23. Do you have the capability of paying at a R&C percentile specified by the
Board?
24. Will you make R&C data available to the Board upon request?
25. Please indicate your R&C level for the requested procedures by the
following zip codes: 37215, 37205, 37072, 37203, 37206.
a. Dilation and curettage of uterus
b. Tonsillectomy with adenoidectomy
c. Cholecystectomy
d. Appendectomy
26. What specific action is taken when a claim for benefits exceeds your
R&C level?
27. How would Metro recover subrogation settlements from you, if they are
received after your contract terminates?
28. What is your company s policy regarding audits by outside firms, or Metro
Internal Audit Division, for the services provided by your company
and the charges submitted by you?
29. Please provide the following information about your hospital bill audit
program:
a. How many auditors are on your staff?
b. What are your auditors qualifications?
c. What is the typical time frame for completing an audit?
d. Do you hold cases until you have several for the same hospital?
e. Do you have a prescreening process?
f. Is there a charge for prescreening?
g. If the patient s authorization to release information is not acceptable
to the providers, will you obtain another? What do you charge for
this service?
h. Do you conduct an exit interview with the hospital and agree on the
audit results?
i. Do you provide written confirmation to the hospital on all
discrepancies?
j. What is your re-audit ratio?
k. How do you charge for your audit services?
C. Managed Care Networks
1. Enclosed is a diskette with the addresses (5-digit zip codes) of all
eligible Metro employees. Please use this data to provide a match
with your network(s).
a. Please describe how distances between employees/pensioners and
providers are determined and list the types of physicians who are
included in the PCP and specialist categories. At a minimum, the match
should report the number of employees/pensioners within each zip code
who have one, two, or three primary care physicians (PCPs) within
three (3) miles.
b. Please list all zip codes where, for each criteria selected, a match
does not occur.
c. Please complete the chart provided in Attachment 2.
2. Please provide an ASCII file and five (5) hard copy directories of
hospitals and doctors in the applicable network areas. Include the
geocoded location of each provider on the ASCII file.
3. Regarding your network provider directory:
a. How do you communicate changes in your network s providers (additions
and deletions) to plan participants?
b. Does your network provider directory list providers who are no longer
accepting new patients (and, if so, is this fact clearly indicated)?
c. Are specialists and PCPs listed?
d. Are PCPs, specialists, and hospitals linked?
4. Explain how employees/pensioners change PCPs.
5. Can employees request to add physicians to the network? If yes, what is
the process?
6. If your proposed network arrangement is based on a gatekeeper model that
requires PCP approval for steerage to specialty and institutional
providers, please explain the process for referring patients to
specialists and hospitals. If your network is not based
on such a model, how is employee access to specialty care managed?
7. Please indicate the procedure a participant must follow to access the
following network services:
[chart by network--OBGYN, Home Health Care, etc.]
8. Does your firm restrict the number of managed care networks in which a
physician may participate when he or she is affiliated with your
company?
9. If a member is admitted to a network hospital by an out-of-network
provider, will reimbursement will be made at the negotiated level? If
not, how are these charges handled?
10. How do you provide coverage for necessary medical treatment not available
in your provider network?
11. Please describe your in-network chiropractic benefits.
12. How do you provide coverage for terminated employees and dependents in
and out of your service area who elect COBRA?
13. a. For what reason can you terminate coverage with an
employee/pensioner or covered dependent? Please outline your
procedure.
b. Are you willing to change your procedure so that coverage can be
terminated only with the approval of the Board?
14. On what basis will you provide extended coverage for disabled employees
and dependents when employment terminates?
15. On what basis will you provide extended coverage for disabled employees
and dependents if your contract with Metro terminates?
16. Please describe how benefits would be handled in the following situations:
a. Members traveling temporarily outside of their home network
b. Dependent children attending school away from their home network
c. Member who works in a network location, but resides in a non-network
area
17. Regarding network ownership:
a. Are your networks owned or leased?
b. Do these arrangements vary by geographic location?
18. Is your network accredited or certified by any independent third party
organizations (e.g., National Committee on Quality Assurance or Joint
Commission on Accreditation of Healthcare Organizations [JCAHO])?
Please describe.
19. Please state the number and names of any hospitals that your plan has
terminated agreement with in 1994?
20. a. Does your network plan to expand its service area in 1995?
b. If so, state the new cities and towns.
21. For the next plan year, will your plan make available group or non-group
coverage for Medicare-eligible participants?
22. Does your provider directory list whether each provider s office is
accessible to the handicapped?
23. Regarding your hospital agreements:
a. Does your plan have agreements with all hospitals to hold enrollees
harmless?
b. If not, please least applicable hospitals.
c. What percentage of hospitals have signed a hold-harmless agreement with
your plan?
24. During the physician selection/credentialing process, indicate which of
the following are verified/reviewed:
[chart]
25. Who conducts the credentialing process? Please indicate the
qualifications of the person(s) or organization(s) responsible for
conducting this review?
[chart of credential and background check on staff]
26. During the hospital selection/credentialing process, indicate which of
the following items are verified and/or reviewed:
[chart of accreditations, malpractice liabilities, etc.]
27. Specify the proportion of participating network providers who are
board-certified/eligible and have graduated from an accredited U.S.
college of medicine/M.D. program:
[chart of PCPs and specialists]
28. Describe the extent of your liability coverages, including malpractice,
errors and omissions (E&O), and total liability. If you are selected,
the Board will require documentation of such coverage.
29. Have there been any judgments or pending complaints for malpractice
claims paid by your managed care network(s)? Please provide
information about the types of providers involved and the size of the
judgment.
30. Please describe how prescription drugs are reimbursed:
At participating pharmacies
At non-participating pharmacies
In areas where there are no participating pharmacies.
31. Does your prescription drug program use a formulary? If so, please
describe it.
D. Utilization Review (UR)
1. Please list the UR and other cost-containment programs available through
your company and describe how they would be administered.
2. In reviewing proposed hospital admissions, what are the responsibilities of
the:
a. Physician?
b. Provider?
c. Patient?
d. Claims payer?
e. Your organization?
3. Are telephone conversations recorded?
4. Please describe how your UR program is integrated with the claims process.
5. What are the provisions for second level review when admission
authorization is initially denied?
6. What action is taken on non-medically necessary admissions?
7. Regarding non-approved services:
a. How is the patient advised of non-approved services?
b. In case of a dispute, how is the patient appeal process initiated and
who may initiate it?
8. What is your administrative process when the patient must be
hospitalized beyond the authorized length of stay?
9. What percentage of requests for admissions are reviewed by a physician?
10. Describe how your review process differs (if at all) for psychiatric and
chemical dependency admissions.
11. How do you evaluate the relative cost efficiency and appropriateness of
inpatient versus outpatient care?
12. a. If you provide a large case management program, describe its
objectives and procedures. List the type of cases you consider to be
ideal for successful case management.
b. If you provide a large case management program, is it managed by
telephone contact, personal contact, or a combination of both? Please
describe the program in detail.
13. Regarding case management:
a. What selection criteria do you use?
b. Who prepares treatment plans?
c. What are their credentials?
14. Has your organization been audited by an outside UR/audit firm to
determine the quality level and cost-effectiveness of your services?
If yes, please describe the outcome.
15. Do you have an employee/patient advocate program? Please describe.
16. What insurance is carried by your company to protect Metro from
litigation?
17. a. Have any of the principals of your firm ever been named in a lawsuit
dealing with management of cost containment programs?
b. If yes, please provide the details of each lawsuit.
E. Quality Assurance
1. a. Describe your quality assurance program.
b. How long has it been in effect?
2. a. Is your quality management program identified as a separate function
within your organization?
b. Please provide a resume for the individual responsible for managing
the process.
3. Specify whether the following procedures are included in the quality
assurance and review of a physician s performance:
[chart]
4. Please indicate the average waiting time members encountered in the
proposed network service area(s) for 1994:
[chart by urgent, elective, and routine procedures]
5. a. How many patient caregivers were reprimanded during the past 12
months for failure to follow your firm s quality assurance process?
b. List these by PCP, specialty, or other categories that you track.
6. a. How many patient caregivers have been dismissed from your organization
during the past 12 months for failure to follow your firm s quality
management process?
b. What specialties were represented?
7. a. Does your network monitor treatment outcomes?
b. If yes, please describe your program.
8. a. Please describe your procedure for handling participant grievances
about the network or claims.
b. At what point would you notify Metro of a grievance?
9. a. On what percentage of claims do you normally perform quality review
and how do you select the sample?
b. Is the quality review done on a pre-disbursement basis?
10. How do you monitor outpatient and ambulatory care claims to determine
whether doctors are requiring an excessive number of tests and office
visits for individual patients?
11. Describe the quality-assurance reports, including reporting frequency,
that you will provide to the Board.
12. Are you willing to fund an independent survey, commissioned by the
Board, in lieu of your own member (patient) satisfaction survey?
13. Cite the three most frequent complaints and appeals by patients. What
actions did your company take to improve service.
14. Regarding enrollees who leave your plan:
a. Does your plan survey ex-enrollees to learn why they have left
your plan?
b. If no, why?
c. If yes, state the three most frequent reasons for leaving your plan.
15. Regarding patient complaints:
a. In 1994, how many complaints (per 1,000 enrollees) did you receive?
b. How many appeals (per 1,000 enrollees) did you receive?
16. What is the average number of days from receipt of appeal or complaint
to resolution?
17. Are your doctors, nurses, and member services staff familiar with your
appeals process?
7.0 (B) MEDICAL QUESTIONNAIRE FOR POS PROPOSALS
This section, 7.0 (B) contains questions only for proposers of POS options.
If you would also like to propose on PPO or HMO options, you must also
complete the following sections:
PPO Section 7.0 (A)
HMO Section 7.0 (C).
Please do not respond to any question by referring to an answer
provided in another section of your questionnaire response.
7.1 (B) ORGANIZATIONAL STRUCTURE AND EXPERIENCE
1. Please provide the following information about each of the key members on
your proposed Metro account team.
a. Name(s)
b. Location(s)
c. Key role(s) and responsibilities
d. Time commitment for installation of the program and, where applicable,
ongoing service to Metro
2. Provide a resume for each team member listed above, including a
description of the individual s experience with similar projects.
3. Please complete the following chart, based on your medical plan book of
business:
[chart]
4. Please complete the following chart for the claims office that would
administer Metro's claims:
[chart by staff title and experience]
5. Will a dedicated claims examiner be assigned to the Board s account?
6. Where is the group office located that will pay medical claims?
7. Please list five (5) governmental clients for which you pay claims from the
local office listed above (include employer name, address, number of
employees, and contact name and telephone number).
8. Please list five (5) references for current clients who have similarly
sized populations for programs comparable to those you are proposing
to the Board (include contact name, telephone number, and brief
description of the organization).
9. Please list two (2) clients who have recently elected to leave your
organization s network. Why? Provide a contact name and telephone
number.
10. Please provide your company s most recent rating from each of the
following:
a. A.M. Best
b. Moody s
c. Duff & Phelps
d. Standard & Poor s.
7.2 (B) REPORTING
1. Please complete the following chart; indicate if you can provide the
report: Y (yes) or N (no). If there is an additional cost for any
report not covered in your basic fee, please indicate the amount.
[chart]
* POS out-of-network only.
[chart]
7.3 (B) TECHNICAL APPROACH
A. Systems
1. Please provide a complete description of your claim processing system:
a. What procedures are in place to document receipt of claims?
b. What quality control procedures are included in the system?
c. Are all functions automated? If not, describe any manual operations.
d. Can a claims processor override the system? If yes, please describe
how and when this occurs.
e. How long do you maintain medical history in the computer?
f. 1 Do you maintain medical history information in hard copy form?
2. If yes, for what period of time?
g. 1. How long do you maintain a terminated employee s file in the
system?
2. How long do you maintain a terminated employee s file in hard copy?
h. Does your firm use a paperless claims system?
i. Are plan summaries maintained on-line through your system?
2. Is the administration of COB an integral part of your on-line claim payment
system?
3. a. Does your system maintain a listing of eligible employees/pensioners
on-line?
b. If so, how frequently is the file updated?
4. a. Metro needs employee, pensioner, and dependent information,
including name, Social Security number, sex, and date of birth. Will
your system accommodate this requirement?
b. If not, can your system be modified, at your cost, to capture this
data by June 1, 1995?
5. Is the employee/pensioner and dependent identification system linked to the
employee/pensioner Social Security number?
6. What edits are on-line to ensure payments are limited to eligible members?
7. Please provide information about how you process eligibility updates, as
follows.
a. Can you process eligibility updates via tape-to-tape exchange?
b. What record format would you require? Please attach a sample of your
format.
8. It will be necessary to track partially or totally fulfilled deductible
carry-over and accumulation toward plan maximums from the prior
administrators.
a. Please confirm whether you have this capability.
b. Describe your method of transmitting history from prior claim
administration.
9. a. Can an on-site terminal be installed at Metro for inquiry and
eligibility purposes?
b. Is there an additional cost for this service?
c. If there is an additional cost, please set out the indicate the amount.
10.a. Do you presently classify medical conditions using ICD-9?
b. If not, what method do you use?
11. Please comment on the following data issues.
a. Do you have the capability of grouping claims for analysis by MDC?
b. Do you have the capability of grouping claims for analysis by DRG
category?
c. Does your system provide a capability for generating normative data
that can be used to compare the Board s plan to other plans of similar
size and structure?
12.a. Do you utilize the American Medical Association s current procedural
terminology (CPT)?
b. If not, what terminology do you use?
13. How will your medical system interface with the dental claims system for
benefit integration purposes?
14.a. Do you have an electronic mail (e-mail) or Internet system that the
Board Office can access to enhance communication with your
organization?
b. If yes, what type is it and what specifications (hardware and
software) would the Board need to use the system?
B. Claims Administration
1. a. Is a toll-free telephone number available to Board Office staff and
employees/pensioners for claim questions and assistance?
b. If so, please state the hours of operation and time standards.
2. How does your company maintain eligibility data?
3. What hours are you available to verify eligibility?
4. Do claim processors handle inquiries from participants regarding benefit
payments, or is there a separate customer service unit to handle such
requests?
5. If a claim is denied, how do you notify the claimant?
6. What appeals process is in place for a participant whose claim is denied?
7. Can you suspend and reinstate coverage of employees, pensioners, and/or
dependents upon request by the Board?
8. How much advance notice of a benefit revision do you require?
9. How would you handle a retroactive benefit revision?
10. What is the typical turnaround time for claims?
[chart]
11. What was the error rate for the designated office during:
a. Calendar year 1993?
b. Calendar year 1994?
12. What are your claim office s performance standards for:
a. Financial accuracy?
b. Payment incidence accuracy?
c. Procedural accuracy?
13. When other group coverage is not indicated on a dependent claim
submission, what guidelines and procedures do you follow in conducting
further investigations?
14. Regarding your Explanation of Benefit (EOB) capabilities:
a. Do you provide the name and telephone number of a customer service
representative on the EOB for participants who have questions?
b. Can you provide copies of EOBs to the provider, patient, and employer?
c. If a patient loses an EOB, can you provide a duplicate?
15. Regarding payment processes:
a. How often are checks/EOBs printed?
b. Do you bulk pay to providers? If so, how often?
16. Please describe in detail how your plan would integrate with Medicare
(i.e., identify requirements for Metro and plan participants).
17. What type of claims are automatically flagged for review before
disbursement?
18. At what dollar amount must supervisory personnel approve a medical claim
payment?
19. What are your professional review mechanisms for:
a. Predetermination of benefits?
b. Medical necessity?
c. Appropriateness of care?
d. Quality of care?
e. Fraud detection?
20. Do you follow-up and secure a medical diagnosis if it is not provided on
the claim form? How is this accomplished?
21. If you use an outside consultant or service for medical review, who is
responsible for the cost?
22. Regarding reasonable and customary (R&C) guidelines:
a. What R&C percentile do you use in determining benefit allowances?
b. How often do you update your profiles?
23. Do you have the capability of paying at a R&C percentile specified by the
Board?
24. Will you make R&C data available to the Board upon request?
25. Please indicate your R&C level for the following procedures by the
following zip codes: 37215, 37205, 37072, 37203, 37206.
a. Dilation and curettage of uterus
b. Tonsillectomy with adenoidectomy
c. Cholecystectomy
d. Appendectomy
26. What specific action is taken when a claim for benefits exceeds your
R&C level?
27. How would Metro recover subrogation settlements from you, if they are
received after your contract terminates?
28. What is your company s policy regarding audits by outside firms, or Metro
Internal Audit Division, for the services provided by your company and
the charges submitted by you?
29. Please provide the following information about your hospital bill audit
program:
a. How many auditors are on your staff?
b. What are your auditors qualifications?
c. What is the typical time frame for completing an audit?
d. Do you hold cases until you have several for the same hospital?
e. Do you have a prescreening process?
f. Is there a charge for prescreening?
g. If the patient s authorization to release information is not acceptable
to the providers, will you obtain another? What do you charge for
this service?
h. Do you conduct an exit interview with the hospital and agree on the
audit results?
i. Do you provide written confirmation to the hospital on all
discrepancies?
j. What is your re-audit ratio?
k. How do you charge for your audit services?
C. Managed Care Networks
1. Enclosed is a diskette with the addresses (5-digit zip codes) of all
eligible Metro employees. Please use this data to provide a match
with your network(s).
a. Please describe how distances between employees/pensioners and
providers are determined and list the types of physicians who are
included in the PCP and specialist categories. At a minimum, the
match should report the number of employees/pensioners within each
zip code who have one, two, or three primary care physicians (PCPs)
within three (3) miles.
b. Please list all zip codes where, for each criteria selected, a match
does not occur.
c. Please complete the chart provided in Attachment 2.
2. Please provide an ASCII file and five (5) hard copy directories of
hospitals and doctors in the applicable network areas. Include the
geocoded location of each provider on the ASCII file.
3. Regarding your network provider directory:
a. How do you communicate changes in your network s providers
(additions and deletions) to plan participants?
b. Does your network provider directory list providers who are no longer
accepting new patients (and, if so, is this fact clearly indicated)?
c. Are specialists and PCPs listed?
d. Are PCPs, specialists, and hospitals linked?
4. Explain how employees/pensioners change PCPs.
5. Can employees request to add physicians to the network? If yes, what is
the process?
6. If your proposed network arrangement is based on a gatekeeper model that
requires PCP approval for steerage to specialty and institutional
providers, please explain the process for referring patients to
specialists and hospitals. If your network is not based
on such a model, how is employee access to specialty care managed?
7. Please indicate the procedure a participant must follow to access the
following network services
[chart by type of service]:
8. Does your firm restrict the number of managed care networks in which a
physician may participate when he or she is affiliated with your
company?
9. If a member is admitted to a network hospital by an out-of-network
provider, will reimbursement will be made at the negotiated level? If
not, how are these charges handled?
10. How do you provide coverage for necessary medical treatment not available
in your provider network?
11. Please describe your in-network chiropractic benefits.
12. How do you provide coverage for terminated employees and dependents in
and out of your service area who elect COBRA?
13. a. For what reason can you terminate coverage with an employee/pensioner
or covered dependent? Please outline your procedure.
b. Are you willing to change your procedure so that coverage can be
terminated only with the approval of the Board?
14. On what basis will you provide extended coverage for disabled employees
and dependents when employment terminates?
15. On what basis will you provide extended coverage for disabled employees
and dependents if your contract with Metro terminates?
16. Please describe how benefits would be handled in the following situations:
a. Members traveling temporarily outside of their home network
b. Dependent children attending school away from their home network
c. Member who works in a network location, but resides in a non-network
area
17. Regarding network ownership:
a. Are your networks owned or leased?
b. Do these arrangements vary by geographic location?
18. Is your network accredited or certified by any independent third
party organizations (e.g., National Committee on Quality Assurance or
Joint Commission on Accreditation of Healthcare Organizations
[JCAHO])? Please describe.
19. Please provide the number of new PCP hires and net percent
increase/decrease in 1994.
20. Please provide the number of new specialist hires and net percent
increase/decrease in 1994.
21. Please provide the number and percent of all PCPs who left your plan in
1994:
a. voluntarily
b. involuntarily
22. Please provide the number and percent of all specialists who left your
plan in 1994.
a. voluntarily
b. involuntarily
23. Please provide the percent of all enrollee physician visits with a:
a. PCP
b. specialist
NOTE: Total of (a) and (b) should be 100%.
24. Please state the number and names of any hospitals that your plan has
terminated agreement with in 1994?
25. a. Does your network plan to expand its service area in 1995?
b. If so, state the new cities and towns.
26. For the next plan year, will your plan make available group or non-group
coverage for Medicare-eligible participants?
27. Does your provider directory list whether each provider s office is
accessible to the handicapped?
28. Regarding your hospital agreements:
a. Does your plan have agreements with all hospitals to hold enrollees
harmless?
b. If not, please least applicable hospitals.
c. What percentage of hospitals have signed a hold-harmless agreement
with your plan?
29. During the physician selection/credentialing process, indicate which of
the following are verified/reviewed:
[chart by credentials and background check]
30. Who conducts the credentialing process? Please indicate the
qualifications of the person(s) or organization(s) responsible for
conducting this review?
31. During the hospital selection/credentialing process, indicate which of the
following items are verified and/or reviewed:
[chart by accreditation, liscense, etc.]
32. Specify the proportion of participating network providers who are
board-certified/eligible and have graduated from an accredited U.S.
college of medicine/M.D. program:
[chart by PCPs and Specialists]
33. Describe the extent of your liability coverages, including malpractice,
errors and omissions (E&O), and total liability. If you are selected,
the Board will require documentation of such coverage.
34. Have there been any judgments or pending complaints for malpractice
claims paid by your managed care network(s)? Please provide
information about the types of providers involved and the size of the
judgment.
35. Please describe how prescription drugs are reimbursed:
At participating pharmacies
At non-participating pharmacies
In areas where there are no participating pharmacies.
36. Does your prescription drug program use a formulary? If so, please
describe it.
D. Utilization Review (UR)
1. Please list the UR and other cost-containment programs available through
your company and describe how they would be administered.
2. In reviewing proposed hospital admissions, what are the responsibilities of
the:
a. Physician?
b. Provider?
c. Patient?
d. Claims payer?
e. Your organization?
3. Are telephone conversations recorded?
4. Please describe how your UR program is integrated with the claims process.
5. What are the provisions for second level review when admission
authorization is initially denied?
6. What action is taken on non-medically necessary admissions?
7. Regarding non-approved services:
a. How is the patient advised of non-approved services?
b. In case of a dispute, how is the patient appeal process initiated and
who may initiate it?
8. What is your administrative process when the patient must be hospitalized
beyond the authorized length of stay?
9. What percentage of requests for admissions are reviewed by a physician?
10. Describe how your review process differs (if at all) for psychiatric and
chemical dependency admissions.
11. How do you evaluate the relative cost efficiency and appropriateness of
inpatient versus outpatient care?
12. a. If you provide a large case management program, describe its objectives
and procedures. List the type of cases you consider to be ideal for
successful case management.
b. If you provide a large case management program, is it managed by
telephone contact, in person, or a combination or both? Please explain
this program in detail.
13. Regarding case management:
a. What selection criteria do you use?
b. Who prepares treatment plans?
c. What are their credentials?
14. Has your organization been audited by an outside UR/audit firm to
determine the quality level and cost-effectiveness of your services?
If yes, please describe the outcome.
15. Do you have an employee/patient advocate program? Please describe.
16. What insurance is carried by your company to protect Metro from
litigation?
17. a. Have any of the principals of your firm ever been named in a lawsuit
dealing with management of cost containment programs?
b. If yes, please provide the details of each lawsuit.
E. Quality Assurance
1. a. Describe your quality assurance program.
b. How long has it been in effect?
2. a. Is your quality management program identified as a separate function
within your organization?
b. Please provide a resume for the individual responsible for managing the
process.
3. Specify whether the following procedures are conducted in the quality
assurance and review of a physician s performance:
[chart]
4. Please indicate the average waiting time members encountered in the
proposed network service area(s) for 1994:
[chart of urgent, elective, and routine procedures]
5. a. How many patient caregivers were reprimanded during the past 12
months for failure to follow your firm s quality assurance process?
b. List these by PCP, specialty, or other categories that you track.
6. a. How many patient caregivers have been dismissed from your organization
during the past 12 months for failure to follow your firm s quality
management process?
b. What specialties were represented?
7. a. Does your network monitor treatment outcomes?
b. If yes, please describe your program.
8. a. Please describe your procedure for handling participant grievances
about the network or claims.
b. At what point would you notify Metro of a grievance?
9. a. On what percentage of claims do you normally perform quality
review and how do you select the sample?
b. Is the quality review done on a pre-disbursement basis?
10. How do you monitor outpatient and ambulatory care claims to determine
whether doctors are requiring an excessive number of tests and office
visits for individual patients?
11. Describe the quality-assurance reports, including reporting frequency,
that you will provide to the Board.
12. Are you willing to fund an independent survey, commissioned by the Board,
in lieu of your own member (patient) satisfaction survey?
13. Cite the three most frequent complaints and appeals by patients. What
action did your company take to improve service?
14. Regarding enrollees who leave your plan:
a. Does your plan survey ex-enrollees to learn why they have left your
plan?
b. If no, why?
c. If yes, state the three most frequent reasons for leaving your plan.
15. Regarding patient complaints:
a. In 1994, how many complaints (per 1,000 enrollees) did you receive?
b. How many appeals (per 1,000 enrollees) did you have?
16. What is the average number of days from receipt of appeal or complaint
to resolution?
17. Are your doctors, nurses, and other member services staff familiar with
your appeals process?
7.0 (C) MEDICAL QUESTIONNAIRE FOR HMO PROPOSALS
This section, 7.0 (C) contains questions only for proposers of HMO
options. If you would also like to propose on PPO or POS options, you
must also complete the following sections:
PPO Section 7.0 (A)
POS Section 7.0 (B).
Please do not respond to any question by referring to an answer provided
in another section of your questionnaire response.
7.1 (C) ORGANIZATIONAL STRUCTURE AND EXPERIENCE
1. Please provide the following information about each of the key members on
your proposed Metro account team.
a. Name(s)
b. Location(s)
c. Key role(s) and responsibilities
d. Time commitment for installation of the program and, where applicable,
ongoing service to Metro
2. Provide a resume for each team member listed above, including a
description of the individual s experience with similar projects.
3. Please complete the following chart, based on your medical plan book of
business:
[chart]
4. Please complete the following chart for the claims office that would
administer Metro's claims:
[chart by staff title and experience]
5. Will a dedicated claims examiner be assigned to the Board s account?
6. Where is the group office located that will pay medical claims?
7. Please list five (5) governmental clients for which you pay claims from the
local office listed above (include employer name, address, number of
employees, and contact name and telephone number).
8. Please list five (5) references for current clients who have similarly
sized populations for programs comparable to those you are proposing to
the Board (include contact name, telephone number, and brief
description of the organization).
9. Please list two (2) clients who have recently elected to leave your
organization s network. Why? Provide a contact name and telephone
number.
10. Please provide your company s most recent rating from each of the
following:
a. A.M. Best
b. Moody s
c. Duff & Phelps
d. Standard & Poor s.
7.2 (C) REPORTING
1. Please complete the following chart; indicate if you can provide the
report { Y (yes) or N (no)}. If there is an additional cost for any
report not covered in your basic fee, please indicate the amount.
[chart]
2. a. Will you mail Metro s IRS 1099 forms for attending physician review?
b. Is this service part of your quoted fee?
c. If not, what is the additional charge, and is it included in your quoted
retention fee?
3. a. What is the turnaround time for special request reports?
b. Is there an additional cost for special reports?
4. The Board will place an extraordinary emphasis on the delivery of uniform,
high quality, timely and measurable data reporting by the prospective
network administrator. Please disclose your ability to adhere to
HEDIS (2.0) reporting formats.
7.3 (C) TECHNICAL APPROACH
A. Systems
1. Please provide a complete description of your claim processing system:
a. What procedures are in place to document receipt of claims?
b. What quality control procedures are included in the system?
c. Are all functions automated? If not, describe any manual operations.
d. Can a claims processor override the system? If yes, please describe
how and when this occurs.
e. How long do you maintain medical history in the computer?
f. 1. Do you maintain medical history information in hard copy form?
2. If so, for what period of time?
g. 1. How long do you maintain a terminated employee s file in the
system?
2. How long do you maintain a terminated employee s file in hard copy
form?
h. Does your firm use a paperless claims system?
i. Are plan summaries maintained on-line through your system?
2. Is the administration of COB an integral part of your on-line claim
payment system?
3. a. Does your system maintain a listing of eligible employees/pensioners
on-line?
b. If so, how frequently is the file updated?
4. a. Metro needs employee, pensioner, and dependent information, including
name, Social Security number, sex, and date of birth, to be maintained
on-line. Will your system accommodate this requirement?
b. If not, can your system be modified, at your cost, to capture this
data by June 1, 1995?
5. Is the employee/pensioner and dependent identification system linked to
the employee/pensioner Social Security number?
6. What edits are on-line to ensure payments are limited to eligible members?
7. It will be necessary to track partially or totally fulfilled deductible
carry-over and accumulation toward plan maximums from the prior
administrators.
a. Please confirm whether you have this capability.
b. Describe your method of receiving history from the prior claim
administrator.
8. a. Can an on-site terminal be installed at Metro for inquiry and
eligibility purposes?
b. Is there an additional cost for this service?
c. If there is an additional cost, please indicate the amount.
9. Do you presently classify medical conditions using ICD-9? If not, what
method do you use?
10. Please comment on the following data issues.
a. Does your system have the capability of grouping claims for analysis
by MDC?
b. Does your system have the capability of grouping claims for analysis by
DRG category?
c. Can your system generate normative data that can be used to compare the
Board s plan to other plans of similar size and structure?
11.a. Do you utilize the American Medical Association s current procedural
terminology (CPT)?
b. If not, what terminology do you use?
12. How will your medical system interface with the dental claims
system for benefit integration purposes?
13.a. Do you have an electronic mail (e-mail) or Internet system that the
Board Office can access to enhance communication with your
organization?
b. If yes, what type is it and what specifications (hardware and
software) would the Board need to use the system?
B. Claims Administration
1. a. Is a toll-free telephone number available to Board Office staff and
employees/pensioners for claim questions and assistance?
b. If so, please state the hours of operation and time standards.
2. Please provide information about how you process eligibility updates, as
follows:
a. Can you process eligibility updates via tape-to-tape exchange?
b. What record format would you require? Please attach a sample of your
format.
3. What hours are you available to verify eligibility?
4. Do claim processors handle inquiries from participants regarding benefit
payments, or is there a separate customer service unit to handle such
requests?
5. If a claim is denied, how do you notify the claimant?
6. What appeals process is in place for a participant whose claim is denied?
7. Can you suspend and reinstate coverage of employees, pensioners, and/or
dependents upon request by the Board?
8. How much advance notice of a benefit revision do you require?
9. How would you handle a retroactive benefit revision?
10. What is the typical turnaround time for claims?
[chart]
11. What was the error rate for the designated office during:
a. Calendar year 1993?
b. Calendar year 1994?
12. What are your claim office s performance standards for:
a. Financial accuracy?
b. Payment incidence accuracy?
c. Procedural accuracy?
13. When other group coverage is not indicated on a dependent claim
submission, what guidelines and procedures do you follow in conducting
further investigations?
14. Regarding your Explanation of Benefit (EOB) capabilities:
a. Do you provide the name and telephone number of a customer service
representative on the EOB for participants who have questions?
b. Can you provide copies of EOBs to the provider, patient, and employer?
c. If a patient loses an EOB, can you provide a duplicate?
15. Regarding payment processes:
a. How often are checks/EOBs printed?
b. Do you bulk pay to providers? If so, how often?
16. Please describe in detail how your plan would integrate with Medicare
(i.e., identify requirements for Metro and plan participants).
17. What type of claims are automatically flagged for review before
disbursement?
18. At what dollar amount must supervisory personnel approve a medical claim
payment?
19. What are your professional review mechanisms for:
a. Predetermination of benefits?
b. Medical necessity?
c. Appropriateness of care?
d. Quality of care?
e. Fraud detection?
20. Do you follow-up and secure a medical diagnosis if it is not provided on
the claim form? How is this accomplished?
21. If you use an outside consultant or service for medical review, who is
responsible for the cost?
22. Regarding reasonable and customary (R&C) guidelines:
a. What R&C percentile do you use in determining benefit allowances?
b. How often do you update your profiles?
23. Do you have the capability of paying at a R&C percentile specified by the
Board?
24. Will you make R&C data available to the Board upon request?
25. Please indicate your R&C level for the requested procedures by the
following zip codes: 37215, 37205, 37072, 37203, 37206.
a. Dilation and curettage of uterus
b. Tonsillectomy with adenoidectomy
c. Cholecystectomy
d. Appendectomy
26. What specific action is taken when a claim for benefits exceeds your
R&C level?
27. How would Metro recover subrogation settlements from you, if they are
received after your contract terminates?
28. What is your company s policy regarding audits by outside firms, or
Metro Internal Audit Division, for the services provided by your
company and the charges submitted by you?
29. Please provide the following information about your hospital bill audit
program:
a. How many auditors are on your staff?
b. What are your auditors qualifications?
c. What is the typical time frame for completing an audit?
d. Do you hold cases until you have several for the same hospital?
e. Do you have a prescreening process?
f. Is there a charge for prescreening?
g. If the patient s authorization to release information is not acceptable
to the providers, will you obtain another? What do you charge for
this service?
h. Do you conduct an exit interview with the hospital and agree on the
audit results?
i. Do you provide written confirmation to the hospital on all
discrepancies?
j. What is your re-audit ratio?
k. How do you charge for your audit services?
C. Managed Care Networks
1. Enclosed is a diskette with the addresses (5-digit zip codes) of
all eligible Metro employees. Please use this data to provide a match
with your network(s).
a. Please describe how distances between employees/pensioners and
providers are determined and list the types of physicians who are
included in the PCP and specialist categories. At a minimum, the
match should report the number of employees/pensioners within each
zip code who have one, two, or three primary care physicians (PCPs)
within three (3) miles.
b. Please list all zip codes where, for each criteria selected, a match
does not occur.
c. Please complete the chart provided in Attachment 2.
2. Please provide the following enrollment information for the network that
provides services to the Metro area.
[chart]
3. Please provide an ASCII file and five (5) hard copy directories of
hospitals and doctors in the applicable network areas. Include the
geocoded location of each provider on the ASCII file.
4. Regarding your network provider directory:
a. How do you communicate changes in your network s providers (additions
and deletions) to plan participants?
b. Does your network provider directory list providers who are no longer
accepting new patients (and, if so, is this fact clearly indicated)?
c. Are specialists and PCPs listed?
d. Are PCPs, specialists, and hospitals linked?
5. Explain how employees/pensioners change PCPs.
6. Can employees request to add physicians to the network? If yes, what is
the process?
7. If your proposed network arrangement is based on a gatekeeper model that
requires PCP approval for steerage to specialty and institutional
providers, please explain the process for referring patients to
specialists and hospitals. If your network is not based
on such a model, how is employee access to specialty care managed?
8. Please indicate the procedure a participant must follow to access the
following network services:
[chart by network service--OBGYN, SNF, HHC, etc.]
9. Does your firm restrict the number of managed care networks in which a
physician may participate when he or she is affiliated with your
company?
10. If a member is admitted to a network hospital by an out-of-network
provider, will reimbursement will be made at the negotiated level? If
not, how are these charges handled?
11. How do you provide coverage for necessary medical treatment not available
in your provider network?
12. Can your HMO offer enhanced physical therapy benefits? If yes, please
provide a summary of both standard and enhanced options.
13. Please describe your in-network chiropractic benefits.
14. a. How do you provide coverage for terminated employees and dependents
in and out of your service area who elect COBRA?
b. Are you willing to change your procedure so that coverage can be
terminated only with the approval of the Board?
15. For what reason can you terminate coverage with an employee/pensioner or
covered dependent? Please outline your procedure.
16. On what basis will you provide extended coverage for disabled employees
and dependents when employment terminates?
17. On what basis will you provide extended coverage for disabled employees
and dependents if your contract with Metro terminates?
18. Please describe how benefits would be handled in the following situations:
a. Members traveling temporarily outside of their home network
b. Dependent children attending school away from their home network
c. Member who works in a network location, but resides in a non-network
area
19. Regarding network ownership:
a. Are your networks owned or leased?
b. Do these arrangements vary by geographic location?
20. Is your network accredited or certified by any independent third party
organizations (e.g., National Committee on Quality Assurance or Joint
Commission on Accreditation of Healthcare Organizations [JCAHO])?
Please describe.
21. Please provide the number of new PCP hires in 1994. What percentage
increase/decrease is this over 1993?
22. Please provide the number of new specialist hires in 1994. What
percentage increase/decrease is this over 1993?
23. Please provide the number and percent of all PCPs who left your plan in
1994:
a. voluntarily
b. involuntarily
24. Please provide the number and percent of all specialists who left your
plan in 1994.
a. voluntarily
b. involuntarily
25. For Staff and Group Model HMOs:
a. Name any centers closed to new patients in 1994.
b. Name any centers closed to new patients in 1995.
26. Please provide the percent of all enrollee physician visits with a:
a. PCP
b. specialist
NOTE: Total of (a) and (b) should be 100%.
27. Please provide the names of any hospitals with whom you terminated your
agreement in 1994.
28.a. Does your network plan to expand its service area in 1995?
b. If so, state the new cities and towns.
29. For the next plan year, will your plan make available group or non-group
coverage for Medicare-eligible participants?
30. Does your provider directory indicate whether providers offices are
accessible to disabled individuals?
31. Regarding your hospital agreements:
a. Does your plan have agreements with all hospitals to hold enrollees
harmless?
b. If not, please list applicable hospitals.
c. What percentage of hospitals have signed a hold-harmless agreement with
your plan?
32. During the physician selection/credentialing process, indicate which of
the following are verified/reviewed:
[chart]
33. Who conducts the credentialing process? Please indicate the
qualifications of the person(s) or organization(s) responsible for
conducting this review?
34. During the hospital selection/credentialing process, indicate which of
the following items are verified and/or reviewed:
[chart of accreditation, liscense, malpractice coverage, etc.]
35. Specify the proportion of participating network providers who are
board-certified/eligible and have graduated from an accredited U.S.
college of medicine/M.D. program:
[chart by PCPs and specialists]
36. Describe the extent of your liability coverages, including malpractice,
errors and omissions (E&O), and total liability. If you are selected,
the Board will require documentation of such coverage.
37. Have there been any judgments or pending complaints for malpractice
claims paid by your managed care network(s)? Please provide
information about the types of providers involved and the size of the
judgment.
38. Please describe how prescription drugs are reimbursed:
a. At participating pharmacies
b. At non-participating pharmacies
c. In areas where there are no participating pharmacies.
39. Does your prescription drug program use a formulary? If so, please
describe it.
40. Please complete the following chart showing total number of enrollees by
age and sex.
[chart]
D. Utilization Review (UR)
1. Please list the UR and other cost-containment programs available through
your company and describe how they would be administered.
2. In reviewing proposed hospital admissions, what are the responsibilities
of the:
a. Physician?
b. Provider?
c. Patient?
d. Claims payer?
e. Your organization?
3. Are telephone conversations recorded?
4. Please describe how your UR program is integrated with the claims process.
5. What are the provisions for second level review when admission
authorization is initially denied?
6. What action is taken on non-medically necessary admissions?
7. Regarding non-approved services:
a. How is the patient advised of non-approved services?
b. In case of a dispute, how is the patient appeal process initiated and
who may initiate it?
8. What is your administrative process when the patient must be hospitalized
beyond the authorized length of stay?
9. What percentage of requests for admissions are reviewed by a physician?
10. Describe how your review process differs (if at all) for psychiatric and
chemical dependency admissions.
11. How do you evaluate the relative cost efficiency and appropriateness of
inpatient versus outpatient care?
12. If you provide a large case management program, describe its objectives
and procedures. List the type of cases you consider to be ideal for
successful case management.
13. Regarding case management:
a. What selection criteria do you use?
b. Who prepares treatment plans?
c. What are their credentials?
14. Has your organization been audited by an outside UR/audit firm to
determine the quality level and cost-effectiveness of your services?
If yes, please describe the outcome.
15. Do you have an employee/patient advocate program? Please describe.
16. What insurance is carried by your company to protect Metro from
litigation?
17. Have any of the principals of your firm ever been named in a lawsuit
dealing with management of cost containment programs? If yes, please
provide the details of each lawsuit.
E. Quality Assurance
1. Describe your quality assurance program. How long has it been in effect?
2. Is your quality management program identified as a separate function
within your organization? Please provide a resume for the individual
responsible for managing the process.
3. Specify the documented procedures that are conducted in the quality
assurance and review of a physician s performance:
[chart]
4. Please indicate the average waiting time members encountered in the
proposed network service area(s) for 1994
[chart by urgent, elective, routine procedures]
5. How many patient caregivers were reprimanded during the past 12 months for
failure to follow your firm s quality assurance process? What
specialties did they represent?
6. How many patient caregivers have been dismissed from your organization
during the past 12 months for failure to follow your firm s quality
management process? What specialties were represented?
7. Does your network monitor treatment outcomes? If yes, please describe
your program.
8. Please describe your procedure for handling participant grievances about
the network or claims. At what point would you notify Metro of a
grievance?
9. On what percentage of claims do you normally perform quality review and
how do you select the sample? Is the quality review done on a
pre-disbursement basis?
10. How do you monitor outpatient and ambulatory care claims to determine
whether doctors are requiring an excessive number of tests and office
visits for individual patients?
11. Describe the quality-assurance reports, including reporting frequency,
that you will provide to the Board.
12. Are you willing to fund an independent survey, commissioned by the Board,
in lieu of your own member (patient) satisfaction survey?
13. Cite the three most frequent complaints by patients and actions your
company has taken to improve service.
14. Regarding enrollees who leave your plan:
a. Does your plan survey ex-enrollees to learn why they have left your
plan?
b. If no, why?
c. If yes, state the three most frequent reasons for leaving your plan.
15. Regarding patient complaints:
a. In 1994, how many complaints (per 1,000 enrollees) did you receive?
b. How many appeals (per 1,000 enrollees) did you have?
16. What is the average number of days from receipt of appeal or complaint
to resolution?
17. Are your doctors, nurses, and member services staff familiar with your
appeals process?