DENTAL MINIMUM REQUIREMENTS
ALL VENDORS MUST COMPLETE THIS SECTION.
The following are proposal specifications. Please complete the following chart by responding in the right-hand
column. If you disagree with any of the criteria, you may not be considered. If the criteria do not apply to the
services you are quoting, please indicate “N/A.”
ENTER VENDOR NAME:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
You have reviewed and accept the Plan’s eligibility provisions
outlined in the RFP.
You must be licensed in New Mexico or willing to obtain a license
in New Mexico.
Agree
Disagree
Agree
Disagree
Self-funded Quotes: ASO fees must be guaranteed for a minimum
of two (2) years from the effective date. A third year rate
guarantee is preferred. Fees must be the same for Years 1 and 2.
Fully Insured Quotes: Vision rates must be guaranteed for a
minimum of two (2) years. A three (3) or four (4) year guarantee is
preferred.
The rates/fees/premiums should be calculated NET of
commissions.
Renewal rates and fees must be submitted 120 days prior to the
contract renewal date.
You have included detailed plan summaries for all quoted plans.
Self-funded Plans: You completed the network analysis sections
(Attachments 10 and 11) in their entirety, in the format requested.
The vendor will be responsible for producing the
Booklet/Certificate of Coverage / Summary Plan Description. The
client reserves the right to review/revise the Booklet/COC/SPD
prior to finalization.
Vendor agrees to provide a booklet draft within 60 days of the
effective date.
Vendors may be required to attend open enrollment meetings.
Vendor agrees to provide all standard reports to the client.
The client must be able to access reports online.
Insured coverage must be provided on a no-loss/no-gain basis for
all covered participants so the current group does not suffer a loss
of benefit solely due to the transfer of coverages to your firm.
You must agree to waive the “actively at work” provision for the
currently enrolled. The master contract will reflect the
elimination of the actively at work restriction or deferred effective
date for all initially enrolled active or inactive employees and
dependents. This will include only initial eligibles (those eligible
on the effective date of the contract) including COBRA continuees.
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Agree
Disagree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Agree
Agree
Agree
Disagree
Disagree
Disagree
Disagree
Agree
Disagree
16.
17.
18.
19.
20.
21.
22.
You are in compliance with all HIPAA Privacy, Electronic Data
Interface (EDI) and Security requirements.
Your contract must require no more than a 30-day notice of
termination by CNM. Your contract cannot prohibit the group
from terminating coverage at any time. There must be no
penalties for late notification or for termination off anniversary.
Vendor agrees to provide performance guarantees. Provide
details within your proposal.
You have specifically listed all deviations from the RFP and
coverage requirements on the Offeror’s Additional Terms and
Conditions.
NOTE: Deviations MUST be listed; you cannot simply make a
“general” reference to section(s) of the proposal.
You completed all questionnaires and exhibits in full and in the
format requested (e.g., Word or Excel – not PDF).
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree
Insurance premium tax does not apply to public entity employers
including, but not limited to, cities, counties, school districts,
etc. If selected, premium tax will not be charged.
Vendor agrees to attend annual health and wellness fairs hosted
on site at CNM.
Agree
Disagree
Agree
Disagree
GENERAL QUESTIONNAIRE
ALL VENDORS MUST COMPLETE THIS SECTION.
ENTER VENDOR NAME:
General
1.
Do you carry an Errors & Omissions policy?
2.
Do you carry a comprehensive general liability policy?
3.
Does your company carry a fidelity bond?
Organizational Strength
4.
What is the normal lead-time required to implement a group?
5.
Finalists will be required to provide a formal and detailed
implementation plan.
6.
What mediums do you accept for plan enrollment?
7.
Do you offer online eligibility maintenance for all clients?
8.
 If so, is there a charge?
 Is there a charge for hard copy maintenance?
For insured coverages: for the first and each renewal year, what
periods of time will be used as the basis for determining renewal
recommendations?
9.
When are premiums/fees due under your policy?


10.
11.
12.
What is the grace period?
If premium is paid after the grace period, is a penalty and/or
interest charge assessed??
 If yes, explain in detail.
What percentage of claims is auto-adjudicated through your system?
Will you agree to offer a Performance Guarantee with financial
penalties?
 If yes, indicate what percentage or dollar amount you are putting
at risk. Include your proposed performance guarantee in your
proposal.
Yes
Yes
Yes
No
No
No
Agree
Disagree
Yes
No
Yes
No
Yes
No
Which of the following tasks can members and plan sponsor
representatives perform online? You may indicate N/A if not
applicable to the line of coverage you are quoting.
Members





Enrollment (New Hires and Open Enrollment)
Changes in Status
Billing (Plan Administrators only)
Claim inquiry
Provider search
N/A
Plan Sponsor
13.
14.
15.
16.
17.
18.
19.
20.
21.
 Access provider directories
 Physician/provider cost and quality comparison
 ID card request
 Electronic EOB
 Terminations
 Other
Is there an additional cost for online services?
 If yes, describe.
BRIEFLY describe the services you offer to support the client’s human
resources / benefits team.
Are you able to provide data that benchmarks the client’s experience
against the following :
 Your book of business
 National norms
 Similar sized municipalities
Please provide cost to provide benchmark reports, if any.
Provide a list of all standard and optional reports available and
associated costs (if any). Please provide sample reports.
Report
Frequency
Additional Cost?
Standard?
Indicate amount.
Optional?
What is the lag time on reports from your firm?
Does the client/consultant have the ability to access your database in
real time for purposes of:
 Tracking plan experience
 Utilization patterns
 Other available plan information
 How is this ability provided?
 Is there an additional charge to the client?
 If so, what is the charge?
Briefly describe your company’s experience with public sector clients,
including school districts, public higher education organizations, and
public entities in New Mexico.
How many colleges and universities are current clients?
Please provide the following information.
(New Mexico public sector employers are preferred.)


22.
Three (3) current client references
At least one of these references should be from a client of similar
size. Provide  Client Name
 Contact
 Address
 Telephone number
 Type of coverage (e.g., medical, life)
 Approximate # of employees covered by each contract
Please provide the following information.
(New Mexico public sector employers are preferred.)
Yes
Yes
Yes
Yes
No
No
No
No
Comments
Yes
Yes
Yes
No
No
No
Yes
No


Two (2) former clients, who may be contacted.
Provide  Client Name
 Contact
 Address
 Telephone number
 Type of coverage (e.g., medical, life)
 Approximate # of employees covered by each contract
 Reason for termination
Client Management Team
23.
Describe your company’s client management structure.
24.
Describe how your company handles client management
responsibilities and transition when a member of the team:
 Goes out on extended leave (more than 2 weeks)
 Leaves the company
25.
Provide a brief bio detailing the experience and background of each
individual that would be assigned to the CNM account.
26.
Provide the office location (city) that each member of the account
management team works from.
27.
Does your company have a local office in the Albuquerque area?
 If not, what is the closest office?
28.
How many onsite meetings does the account team commit to
attending throughout the year for:
 Implementation
 Ongoing account management and reporting
 Open enrollment
29.
Will CNM be assigned a dedicated representative?
 How many other accounts will this individual service?
 What amount of time will the representative’s time will be
available to service the CNM account?
Network Accessibility
30. With regard to network directories, please respond to the following
items. (NOTE: Do NOT include a provider directory with your proposal.)



Are your directories available on the internet or a website?
If your provider directories are not available online, how frequently
are they updated and distributed?
How are members, plan sponsors and providers notified of
changes?
Yes
No
31.
Do you own your provider network, or do you subcontract?
Own
Subcontract
32.
 If you subcontract, please identify network.
What is your provider retention rate and/or network turnover?
33.
Are you willing to add providers specifically requested by the client?
Yes
No
34.
Do the participating dentists have a contractual agreement not to
“balance bill” the patient?
Yes
No
35.
If a participating dentist refers a patient outside the network, are
benefits paid at the DHMO or Dental PPO level?
36.
Do you have differing network provider arrangements (e.g., “Preferred”
vs. “Participating”)?


Yes
No
If yes, describe.
If you do have different network provider arrangements, please
complete the following chart:
Network Discounts Available Network Discounts Available with NO
with plan design
plan design differentials
differentials
“Preferred” Provider
Yes
No
Yes
No
“Participating” Provider
Yes
No
Yes
No
DENTAL: FULLY INSURED PLANS –
QUESTIONNAIRE
DENTAL VENDORS MUST COMPLETE THE FOLLOWING QUESTIONNAIRE.
ENTER VENDOR NAME:
1.
Will you agree to have retention increase at general CPI
or some other factor, independent of dental trend?
2.
Will experience be based on actual paid claims (rather
than incurred or estimated incurred)?
3.
Is your quote fully pooled / experience rated or have
you proposed both?
▪
4.
If blended, specify percentage attributed to group's
experience.
For the first year and each renewal year, what periods
of time will be used as the basis for determining
renewal recommendations? Specify weightings to be
applied to applicable periods.
5.
Confirm that any adjustment of reserves will be
supported by / aligned with current triangulation
studies.
6.
In the event the account produces a deficit in any one
year, will your company seek, in any way, to recoup the
deficit? Please explain in detail.
Yes
No
Pooled
Experience Rated
Blended
Both
______ %
Yes
No
DENTAL: SELF-FUNDED PLANS
ADMINISTRATION QUESTIONNAIRE
DENTAL VENDORS MUST COMPLETE THE FOLLOWING QUESTIONNAIRE.
ENTER VENDOR NAME:
7.
The claims administrator agrees that the claims and
accompanying eligibility data produced in connection
with all the claim payment activities on behalf of the
client is and will be the property of the client. And, that
the client retains the right to request the full and
complete data in electronic format with proper notice
and at no additional cost.
Agree
Disagree
8.
You must provide access to all files on request (e.g., a
claims audit) and not to assess any fee for such access.
Agree
Disagree
9.
For services that are covered, confirm network
discounts are applied to any portion of the claim being
paid by the member (i.e. to satisfy deductible,
coinsurance, or because the maximum benefit has
been exceeded).
Concisely identify and comment on any major claim /
eligibility / reporting system changes or upgrades
planned in the next 12 to 24 months along with the
intended outcome.
10.
11.
You agree to reimburse services provided outside of
the U.S.
Yes
No
12.
Do you coordinate benefits? If yes:
Yes
No
▪
▪
Do you outsource this service?
Does your claim system readily identify potential
COB opportunities prior to claim payment?
▪ Do you (1) pend and pursue or, (2) pay and pursue
these types of claims?
Does the same person handle both claims processing
and customer service functions?
Yes
Yes
No
No
(1) Pend and Pursue
(2) Pay and Pursue
Yes
No
Confirm you utilize a claims quality assurance or review
process.
Agree
Disagree
▪
Yes
13.
14.
Do you have reviews conducted by an outside
agency?
No
15.
16.
17.
18.
19.
Confirm your system has edits for identification of
fraudulent claims and provide statistics as to results for
2012.
Audits:
▪ What is the frequency of your internal audits?
▪ What is the frequency of your external audits?
At termination, after the runout, how will you handle
the following:
▪ Claims in house, but not processed?
▪ Claims submitted after the runout period?
Confirm that you will provide final reports consistent
with your standard reporting to the client.
Can you provide electronic data interface with the
client’s Disease Management vendor(s) to supply
relevant data?
Agree
Disagree
Yes
No
Agree
Disagree
Yes
No
▪
20.
Any costs to provide this interface must be
reflected on the Dental Cost Attachment 9 B.
The existing administrator will pay run-out claims.
Your pricing should assume no run-in claims payment.
21.
Confirm that if you fail to meet timely payment
requirements for in-network providers, neither
patients nor the Plan will be liable.
22.
What is the standard percentile used as a basis to
determine UCR on out-of-network claims?
▪
How often is UCR updated?
_______ %