Pharmacy Benefit Administrator Claims and Performance Audit Services

Location:	Mississippi
Posted:	Apr 7, 2026
Due:	Apr 24, 2026
Agency:	Mississippi Division of Medicaid
Type of Government:	State & Local
Category:	Q - Medical Services R - Professional, Administrative and Management Support Services
Publication URL:	To access bid details, please log in.

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OFFICE OF PROCUREMENT

QUOTE REQUEST

PHARMACY BENEFIT ADMINISTRATOR

CLAIMS AND PERFORMANCE

AUDIT SERVICES

QR # 20260331

RFX # 3150006793

Issue Date: Friday, March 31, 2026

Question Deadline: Tuesday, April 14, 2026, by 2:00 p.m. CST

Response Deadline: Friday, April 24, 2026, by 2:00 p.m. CST

Procurement Contact:

Sharon Clark

Sharon.Clark@medicaid.ms.gov

P.O. Box 2222

Jackson, Mississippi 39225

DOM WELCOMES PARTICIPATION OF MINORITY BUSINESSES

1.0 PROCUREMENT OVERVIEW

1.1 Introduction

The Mississippi Division of Medicaid (DOM), Of�ice of Procurement, seeks a quali�ied,

experienced entity to provide professional accountants and/or auditors to conduct

pharmacy payment claims integrity review and performance audit services in support of

the agency’s Medicaid claims management functions. The selected Offeror must employ

duly licensed accounting and/or auditing professionals, and possess demonstrated

expertise in pharmacy payment claims auditing, integrity review, and performance review,

with a proven track record of delivering services directly aligned with the scope outlined in

this procurement.

DOM requires a comprehensive analysis of 100% of pharmacy paid claims data for a

speci�ied timeframe, with the objective of identifying potentially incorrect payments on a

case-by-case basis. In addition, the contractor must conduct global data analyses and

produce reports that highlight payment integrity trends across both current and historical

claims.

It is understood that any resultant contract awarded pursuant to this Quote Request (QR)

#20260331 is exempt from approval by the State of Mississippi’s Public Procurement

Review Board (PPRB), however, the contract will be subject to review by the Department of

Finance and Administration’s Of�ice of Personal Services Contract Review (OPSCR), for the

purpose of conducting a preliminary review and issuing a recommendation to ensure

compliance with applicable exempt contract requirements. DOM intends to award one

contract for the services required herein. DOM further reserves the right to reject any and

all quotes provided in response to this solicitation at any point of the evaluation, awarding

and/or contract execution process.

1.2 Authority

Medicaid Program

This solicitation is issued under the authority of Title XIX of the Social Security Act, as

amended, including applicable implementing regulations, and in accordance with the

Mississippi Code of 1972, as amended. All prospective contractors are presumed to be

familiar with the requirements of the aforementioned legal authorities as set forth in this

quote request. By submitting a valid, executed quote, each prospective contractor affirms

awareness and understanding of these requirements. DOM reserves the right to reject,

without further consideration, any quote that fails to comply with applicable statutory or

regulatory provisions.

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Medicaid is a joint federal and state program providing medical assistance to eligible

individuals, funded through a combination of state appropriations and federal matching

funds under Title XIX of the Social Security Act. Section 1902(a)(30)(A) of the Act (42

U.S.C. § 1396a(a)(30)(A)) mandates that state Medicaid agencies implement methods

and procedures to safeguard against unnecessary utilization of services and to ensure

efficiency, economy, and quality of care.

Pharmacy Medicaid Program

DOM administers the Pharmacy Medicaid Program under a State Plan approved by the

Centers for Medicare & Medicaid Services (CMS).

The MS Medicaid Pharmacy Program offers prescription drug bene�its to approximately

710,000 members and utilizes a contracted Pharmacy Bene�it Administrator (PBA) to

streamline and enhance the processing and management of pharmacy claims for all

Medicaid members, including those enrolled in managed care. In addition to the processing

of pharmacy point of sale (POS) claims, the PBA is responsible for various functions,

including pharmacy prior authorization (electronic and manual), call center administration,

and federal drug rebate administration (invoicing and collections).

While these services are outsourced, DOM retains ultimate responsibility for ensuring

compliance and accuracy in accordance with the following oversight mechanisms: the PBA’s

contract with DOM, applicable Mississippi Medicaid State Plan requirements, including the

impacts of State Plan Amendments effective during the audit time period, state rules and

regulations, and CMS federal guidance.

This Quote Request (QR) has been issued to procure the services of a licensed and

technically quali�ied Auditor to audit the performance and compliance of the PBA in

relation to the Mississippi Pharmacy Program. The primary objective of this engagement is

to verify that the PBA is accurately executing key functions, including claims processing,

rebate management, call center operations, and both member and provider appeals

processes. Additional areas subject to audit include pharmacy reimbursement appeals and

Third-Party Liability (TPL) management, as applicable to the pharmacy program.

The audit will validate �inancial terms, and rebate invoicing, as outlined in the PBA contract,

are properly applied and supported by adequate quality controls. DOM seeks to review and

audit pharmacy claims submitted to DOM, rebate revenues received, call center

performance metrics, and appeals procedures involving members and providers across all

program offerings.

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1.3 Term of Contract

The term for the services required herein shall commence on May 15, 2026, and expire on

May 14, 2031. The contract shall remain subject to the quoted pricing and the agreed-upon

terms and conditions for the duration of the contract term.

Quotes for the required services must be received by the DOM Of�ice of Procurement no

later than the deadline indicated. Contracts for services may not exceed �ive (5) years

unless otherwise permitted by law. Payment and performance obligations for future �iscal

years will be subject to the availability and appropriation of funds by the Mississippi

Legislature.

1.4 Contract Type and Compensation

The resulting contract will be a �irm �ixed-price agreement, under which the Contractor’s

proposed rates shall remain constant for the entire contract term. Invoices must be

submitted in a format prescribed by DOM and shall itemize all services provided in

alignment with the rates speci�ied in the Quote Form (F A).

1.5 Travel

Travel expenses will not be reimbursed.

1.6 Selected Vendor Requirements

The awarded vendor will be required to register with the Mississippi Accountability System

for Government Information and Collaboration (MAGIC) system. Registering with MAGIC

allows vendors to receive noti�ications for upcoming RFx opportunities based on your

entity’s product categories. Businesses can search the MAGIC system for upcoming RFxs,

respond electronically to some solicitations, receive purchase orders by email and receive

payments electronically. To register, visit:

https://www.dfa.ms.gov/dfa-of�ices/mmrs/mississippi-suppliers-vendors/.

1.7 Eligibility and Minimum Quali�ications

1.7.1 Organizations Eligible to Submit Quotes (Attachment A – Quote Form)

1. To be eligible to submit a quote, the Offeror must submit a completed and signed

“Attachment A – Quote Form.” This form shall include all required pricing,

certi�ications, and attestations. Any costs included elsewhere in the Offeror’s

submission will not be considered part of the contract and will not be paid.

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2. The Offeror must submit all narrative responses and documentation required under

Sections 1.7.2 Minimum Quali�ications and 1.7.3 Capability to Provide Services

as part of the proposal package.

Failure to complete and sign (1) and (2) above will result in the Offeror being deemed non-

responsive.

1.7.2 Minimum Quali�ications (Attachment B: Addendum 1) (No Page Limit)

The following minimum requirements are mandatory and must be addressed in full.

Offerors shall fully respond to and provide any necessary documentation of how their quote

response meets or exceeds each quali�ication as an addendum entitled, “Attachment B:

Addendum 1: Minimum Quali�ications”. Failure to meet or exceed any of the minimum

quali�ications, or failure to provide the necessary documentation, will result in the Offeror

being deemed non-responsive and will be disquali�ied from further consideration. Please

ensure that your vendor response includes the total number of years and types of

experience of your company to support how your company meets the minimum

requirement.

For the purposes of meeting these minimum requirements, unless otherwise speci�ied,

the term “Auditor” refers solely to the primary contracting Offeror and does not include

any proposed subcontractors.

1.7.2.1 Offeror Experience Requirement

1. The Offeror must demonstrate the ability to manage complex audit engagements,

including development and execution of detailed project management plans,

timelines, and deliverables. The Offeror must have experience producing

comprehensive audit reports, maintaining complete and accessible electronic

records, and providing supporting documentation (e.g., spreadsheets,

methodologies, and calculations) in client-approved formats. Experience presenting

�indings to executive leadership and providing advisory recommendations, including

legislative or legal support, is required. (Offeror to provide three (3) complex audit

projects of similar size and scope from the previous �ive (5) years and should include

client name, scope, and complexity of work, contractual time period and summary of

activities)

2. The Offeror must have a minimum of �ive (5) years’ experience performing large-

scale pharmacy claims audits, including high volume or up to full population (100%)

electronic claims re-adjudication. Experience must include evaluation of pricing

methodologies (e.g., NADAC, WAC, AAC, MAC), bene�it plan design validation, rebate

analysis, and compliance with Medicaid State Plans and applicable federal and state

regulations. (Offeror to provide two to three projects involving high-volume and/or

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This is the opportunity summary page. It provides an overview of this opportunity and a preview of the attached documentation.