SD State Employee Health Plan Medical Claims Audit
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Description
Wellmark Blue Cross Blue Shield of South Dakota (“Wellmark”) has been administering the State’s self-funded medical and pharmacy plans since July 1, 2021. Approximately 12,150 State employees and COBRA participants enrolled in four (4) State of South Dakota State Employee Health Plans (“SDSEHP”) which includes 2 low-deductible Preferred Provider Organization (“PPO”) plans and 2 high-deductible plans which offer a Health Savings Account (“HSA"). The total number of plan participants including spouses and dependent children is approximately 26,800. As of May 1, 2026, 65.00% of plan members were enrolled in the high-deductible health plans and 35.00% were enrolled in the low-deductible plans. Annual paid claims volume is approximately 314,300 medical claims and 282,700 pharmacy claims. For Fiscal Year 2026 (ended on June 30, 2026), the SDSEHP paid a total of approximately $160 million in total health plan costs (medical claims, prescription drug claims, and administrative fees), of which approximately $108 million was for medical claims alone.The Bureau of Human Resources & Administration (“BHRA”) is soliciting proposals from vendors who can conduct a performance review of medical claims processing performed by Wellmark. The auditor selected through this RFP process will be required to execute a Non-Disclosure Agreement “(NDA”) with Wellmark.All written questions should be sent to: Peggy.Canter@state.sd.us, only emailed questions will be accepted.Each offeror may submit questions via email concerning this RFP to obtain clarification of requirements. No questions will be accepted after the date and time indicated in the above schedule of activities. Email questions to the email address listed above with the subject line “RFP#26RFP19878”. The questions and their answers will be sent to all offerors that submitted Letters of Intent, submitted questions, or requested the questions and answers via email before the proposal submittal date and will be sent by the date and tim…