Third Party Administrative Services Request for Proposals ? RFP Number 270-20260421TPAS - Rebid

STATE OF NORTH CAROLINA
STATE HEALTH PLAN FOR TEACHERS AND STATE EMPLOYEES
REQUEST FOR PROPOSAL #: 270-20260421TPAS
THIRD PARTY ADMINISTRATIVE SERVICES
Date of Issue: April 21, 2026
Proposal Opening Date: May 4, 2026
At 10:00 AM ET
Direct all inquiries concerning this RFP to:
Email: Sharon.Smith@nctreasurer.com
SHPContracting@nctreasurer.com
Phone: 919-814-4432
Sealed, mailed responses ONLY will be accepted for this solicitation
Ariba System Generated Solicitation #: Doc2142322766

Proposal Number: 270-20260421TPAS Vendor: __________________________________________
STATE OF NORTH CAROLINA
Request for Proposal #
270-20260421TPAS
______________________________________________________
For internal State Agency processing, including tabulation of Proposals, provide your company's eVP (Electronic
Vendor Portal) Number. Pursuant to G.S. 132-1.10(b), this identification number shall not be released to the public.
To prevent such release, Vendor shall ensure confidential information on this page is Redacted when submitting
Redacted versions of this document in accordance with the instructions herein.
This page shall be filled out and returned with your Proposal.
Failure to do so may subject your Proposal to rejection.
___________________________________________________
Vendor Name
______________________________
Vendor eVP#
Note: For a Contract to be awarded to you, Your company (you) must be a North Carolina registered
Vendor in good standing. you must enter the Vendor number assigned through eVP. If you do not have
a Vendor number, register at https://evp.nc.gov/
Sealed, mailed responses ONLY will be accepted for this solicitation.

Proposal Number: 270-20260421TPAS Vendor: __________________________________________
STATE OF NORTH CAROLINA
Department of State Treasurer, State Health Plan Division
Refer ALL Inquiries regarding this RFP to: Request fo r Proposal #: 270-20260421TPAS
Sharon Smith, Senior Manager of Contracting Proposals will be publicly opened: May 4, 2026, 10:00 AM ET
Sharon.Smith@nctreasurer.com
Using Agency: The North Carolina State Health Commodity No. and Description:
Plan for Teachers and State Employees 851017 - Health Administration Services
Requisition No.: N/A
EXECUTION
In compliance with this RFP, and subject to all the conditions herein, the undersigned Vendor offers and agrees to furnish and deliver any or all
items upon which prices are bid, at the prices set opposite each item within the time specified herein.
By executing this Proposal, the undersigned Vendor understands that false certification is a Class I felony and certifies that:
this Proposal is submitted competitively and without collusion,
none of its officers, directors, or owners of an unincorporated business entity have been convicted of any violations of Chapter 78A of
the General Statutes, the Securities Act of 1933, or the Securities Exchange Act of 1934, and
it is not an ineligible Vendor as set forth in G.S. 143-59.1.
Furthermore, by executing this Proposal, the undersigned certifies to the best of Vendor's knowledge and belief, that:
it and its principals are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from
covered transactions by any federal or state department or agency.
As required by G.S. 143-48.5, the undersigned Vendor certifies that it, and each of its subcontractors for any Contract awarded as a result of this
RFP, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes, including the requirement for each employer with
more than 25 employees in North Carolina to verify the work authorization of its employees through the federal E-Verify system.
G.S. 133-32 and Executive Order 24 (2009) prohibit the offer to, or acceptance by, any State Employee associated with the preparing of plans,
specifications, estimates for public contracts; or awarding or administering public contracts; or inspecting or supervising delivery of the public
contract of any gift from anyone with a contract with the State, or from any person seeking to do business with the State. By execution of this
response to the RFP, the undersigned certifies, for the Vendor's entire organization and its employees or agents, that the Vendor is not aware
that any such gift has been offered, accepted, or promised by any employees of your organization.
By executing this Proposal, the Vendor certifies that it has read and agreed to the INSTRUCTION TO VENDORS and the GENERAL TERMS AND
CONDITIONS incorporated herein. These documents can be accessed from the ATTACHMENTS section within this document.
Failure to execute/sign proposal prior to submittal may render proposal invalid and it MAY BE REJECTED. Late proposals shall
not be accepted.
COMPLETE/FORMAL NAME OF VENDOR:
STREET ADDRESS: P.O. BOX: ZIP:
CITY & STATE & ZIP: TELEPHONE NUMBER: TOLL FREE TEL. NO:
PRINCIPAL PLACE OF BUSINESS ADDRESS IF DIFFERENT FROM ABOVE (SEE INSTRUCTIONS TO VENDORS ITEM #21):
PRINT NAME & TITLE OF PERSON SIGNING ON BEHALF OF VENDOR: FAX NUMBER:
VENDOR'S AUTHORIZED SIGNATURE*: DATE: EMAIL:
VALIDITY PERIOD
Offer shall be valid for at least 180 days from date of bid opening, unless otherwise stated here: ______ days, or if extended by mutual
agreement of the Parties in writing. Any withdrawal of this offer shall be made in writing in accordance with the instructions herein.

Proposal Number: 270-20260421TPAS Vendor: __________________________________________
ACCEPTANCE OF PROPOSAL
If your Proposal is accepted, as described in more detail in Section 4.14 Contract Documents and Order of Precedence, all provisions of this RFP,
along with the written results of any negotiations, shall constitute the written agreement between the Parties. This Contract is not binding until
the Plan's Executive Administrator has signed this Acceptance of Proposal.
FOR STATE USE ONLY: Offer accepted and Contract awarded this________ day of __________, 2026, by
__________________________________________________________________________________________________________________
(Authorized Representative of the NC Department of State Treasurer, State Health Plan Division).
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Proposal Number: 270-20260421TPAS Vendor: __________________________________________
Contents
1.0 VISION AND BACKGROUND .................................................................................................... 8
1.1 CONTRACT TERM ........................................................................................................................ 9
2.0 GENERAL INFORMATION ........................................................................................................ 9
2.1 REQUEST FOR PROPOSAL DOCUMENT ............................................................................. 9
2.2 E-PROCUREMENT FEE .......................................................................................................... 9
2.3 NOTICE TO VENDORS REGARDING RFP TERMS AND CONDITIONS .............................. 9
2.4 RFP SCHEDULE .................................................................................................................... 10
2.5 PROPOSAL QUESTIONS...................................................................................................... 10
2.6 PROPOSAL SUBMISSION .................................................................................................... 11
2.6.1 RFP Phases for Submission ................................................................................................. 12
2.6.2 Minimum Requirements Proposal Submission .................................................................. 12
2.6.3 Technical and Cost Proposal Submission .......................................................................... 13
2.7 PROPOSAL CONTENTS ....................................................................................................... 14
2.7.1 Minimum Requirements Proposal Contents ....................................................................... 14
2.7.2 Technical and Cost Proposal Contents ............................................................................... 15
2.8 ALTERNATE PROPOSALS - RESERVED ............................................................................. 15
2.9 BID OPENING ......................................................................................................................... 15
2.10 DEFINITIONS, ACRONYMS, AND ABBREVIATIONS ........................................................... 15
3.0 METHOD OF AWARD AND PROPOSAL EVALUATION PROCESS ..................................... 20
3.1 METHOD OF AWARD............................................................................................................. 20
3.2 CONFIDENTIALITY AND PROHIBITED COMMUNICATIONS DURING EVALUATION ...... 20
3.3 PROPOSAL EVALUATION PROCESS .................................................................................. 20
3.4 EVALUATION CRITERIA AND METHODOLOGY ................................................................. 22
3.5 PERFORMANCE OUTSIDE THE UNITED STATES .............................................................. 23
4.0 REQUIREMENTS ..................................................................................................................... 23
4.1 PRICING .................................................................................................................................. 23
4.2 INVOICES ................................................................................................................................ 24
4.2.1 Administrative Fees .............................................................................................................. 24
4.2.2 Claims and Other Disbursements........................................................................................ 24
4.3 FINANCIAL STABILITY .......................................................................................................... 25
4.4 HUB PARTICIPATION - RESERVED .................................................................................... 25
4.5 VENDOR EXPERIENCE - RESERVED .................................................................................. 25
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Proposal Number: 270-20260421TPAS Vendor: __________________________________________
4.6 REFERENCES ........................................................................................................................ 25
4.7 BACKGROUND CHECKS ...................................................................................................... 25
4.8 PERSONNEL .......................................................................................................................... 26
4.9 VENDOR'S REPRESENTATIONS .......................................................................................... 26
4.10 QUESTIONS TO VENDORS - RESERVED ............................................................................ 26
4.11 AGENCY INSURANCE REQUIREMENTS MODIFICATION .................................................. 27
4.12 ADMINISTRATORS FOR THE CONTRACT .......................................................................... 27
4.13 CONFIDENTIALITY AND PROTECTION OF PLAN DATA ................................................... 27
4.14 CONTRACT DOCUMENTS AND ORDER OF PRECEDENCE .............................................. 27
4.15 DATA OWNERSHIP ................................................................................................................ 28
4.16 CONFLICT OF INTEREST ...................................................................................................... 28
4.17 VENDOR'S REPRESENTATIVE ............................................................................................. 28
4.18 DEBARRED, SUSPENDED OR EXCLUDED VENDORS ...................................................... 29
4.19 REGISTRATION AND CERTIFICATION ................................................................................ 29
4.20 PERFORMANCE GUARANTEES ........................................................................................... 29
5.0 MINIMUM, TECHNICAL, AND COST PROPOSAL REQUIREMENTS ................................... 30
5.1 MINIMUM REQUIREMENTS ................................................................................................... 30
5.1.1 Account Management Minimum Requirements .................................................................... 33
5.1.2 Project Management and Integrated Testing Minimum Requirements .............................. 33
5.1.3 Network Development & Management Minimum Requirements ......................................... 34
5.1.4 Product & Plan Design Minimum Requirements .................................................................. 34
5.1.5 Finance & Banking Minimum Requirements ......................................................................... 35
5.1.6 Member Experience Minimum Requirements ....................................................................... 36
5.1.7 Medical Management Minimum Requirements ..................................................................... 36
5.1.8 Enrollment, EDI and Data Management Minimum Requirements ....................................... 36
5.1.9 Claims Processing and Appeals Management Minimum Requirements ........................... 39
5.1.10 Claims Audit, Recovery and Investigation Minimum Requirements ................................ 39
5.1.11 Reporting Minimum Requirements ...................................................................................... 40
5.1.12 Population Health Services Minimum Requirements ......................................................... 40
5.2 TECHNICAL PROPOSAL REQUIREMENTS ......................................................................... 40
5.2.1 Account Management............................................................................................................ 41
5.2.1.1 Overview and Expectations .................................................................................................. 41
5.2.2 Project Management and Integrated Testing ...................................................................... 43
5.2.2.1 Overview and Expectations .................................................................................................. 43
5.2.3 Network Development and Management ............................................................................. 43
5.2.3.1 Overview and Expectations .................................................................................................. 43
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Proposal Number: 270-20260421TPAS Vendor: __________________________________________
5.2.4 Product and Plan Design ...................................................................................................... 45
5.2.4.1 Overview and Expectations .................................................................................................. 45
5.2.5 Finance and Banking ............................................................................................................. 47
5.2.5.1 Overview and Expectations .................................................................................................. 47
5.2.6 Member Experience ............................................................................................................... 48
5.2.6.1 Overview and Expectations .................................................................................................. 48
5.2.7 Medical Management ............................................................................................................. 50
5.2.7.1 Overview and Expectations .................................................................................................. 50
5.2.8 Enrollment, EDI and Data Management ............................................................................... 51
5.2.8.1 Overview and Expectations .................................................................................................. 51
5.2.9 Claims Processing and Appeals Management ................................................................... 53
5.2.9.1 Overview and Expectations .................................................................................................. 53
5.2.10 Claims Audit, Recovery, and Investigation ........................................................................ 54
5.2.10.1 Overview and Expectations ............................................................................................... 54
5.2.11 Reporting ............................................................................................................................... 56
5.2.11.1 Overview and Expectations ............................................................................................... 56
5.2.12 Optional Services ................................................................................................................. 63
5.2.12.1 Overview and Expectations ............................................................................................... 63
5.2.13 Additional Optional Services ............................................................................................... 64
5.2.13.3 Other Optional Services: ................................................................................................... 64
5.2.14 Transition of Services .......................................................................................................... 64
5.2.14.1 Overview and Expectations .............................................................................................. 64
5.3 COST PROPOSAL REQUIREMENTS .................................................................................... 65
6.0 CONTRACT PERFORMANCE, DELIVERABLES, PERFORMANCE GUARANTEES,
AND FEE REDUCTIONS .......................................................................................................... 66
6.1 Audits of Records and Performance .................................................................................... 66
6.2 Contract Compliance and Performance .................................................................................. 66
6.3 Notice of Deficiency .................................................................................................................... 67
6.4 Remedial Actions ........................................................................................................................ 67
6.5 Reduction in Fees ........................................................................................................................ 67
6.6 Payment of Fee Reduction ......................................................................................................... 68
6.7 Contract Performance Dispute Resolution ............................................................................... 68
6.8 Notice to External Agencies ....................................................................................................... 69
6.9 Publication of Contract Compliance Issues .............................................................................. 69
6.10 Right to Waive or Modify .......................................................................................................... 69
6.11 Performance Guarantee Timeliness Guidelines and Definitions .......................................... 69
6.12 Performance Guarantee Accuracy Definitions ................................................................... 70
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Proposal Number: 270-20260421TPAS Vendor: __________________________________________
6.13 Third Party Administration Performance Guarantees - Schedules I and II ..................... 71
LIST OF ATTACHMENTS AND EXHIBITS ......................................................................................... 75
ATTACHMENT A: COST PROPOSAL ................................................................................................ 77
Network Access ..................................................................................................................... 77
Access Reports ....................................................................................................................... 77
Providers by County ................................................................................................................ 79
Provider Listing ........................................................................................................................ 79
Network Pricing ..................................................................................................................... 79
Claims Repricing File .............................................................................................................. 79
Administrative & Program Fees ........................................................................................... 80
Trend and Network Pricing Guarantees .............................................................................. 81
Self-Funded Claims Projection ............................................................................................. 81
Clinical Quality Guarantee .................................................................................................... 81
Data Certification ................................................................................................................... 81
Attachments for Attachment A: Cost Proposal .................................................................. 82
ATTACHMENT B: INSTRUCTIONS TO VENDORS ........................................................................... 83
ATTACHMENT C: GENERAL TERMS AND CONDITIONS ............................................................... 88
ATTACHMENT D: CUSTOMER REFERENCE TEMPLATE ............................................................. 100
ATTACHMENT E: LOCATION OF WORKERS UTILIZED BY VENDOR ......................................... 101
ATTACHMENT F: CERTIFICATION OF FINANCIAL CONDITION .................................................. 102
ATTACHMENT G: PROPOSAL SUBMISSION INFORMATION ....................................................... 103
ATTACHMENT H: HIPAA COMPLIANCE QUESTIONNAIRE ......................................................... 104
ATTACHMENT I: BUSINESS ASSOCIATE AGREEMENT .............................................................. 105
ATTACHMENT J: ADMINISTRATORS FOR THE CONTRACT, HIPAA COMPLIANCE OFFICER,
AND INFORMATION SECURITY OFFICER .......................................................................... 106
ATTACHMENT K: DATA USE AGREEMENT (DUA) ..................................................................... 107
ATTACHMENT L: MINIMUM INFORMATION SECURITY REQUIREMENTS ............................... 108
ATTACHMENT M: RESERVED ...................................................................................................... 115
ATTACHMENT N: MINIMUM REQUIREMENTS RESPONSE ....................................................... 116
ATTACHMENT O: TECHNICAL REQUIREMENTS RESPONSE .................................................. 117
ATTACHMENT P: SUBCONTRACTOR IDENTIFICATION FORM ................................................ 118
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Proposal Number: 270-20260421TPAS Vendor: __________________________________________
ATTACHMENT Q: EVALUATION METHODOLOGY ..................................................................... 119
ATTACHMENT R: VALIDATION OF HIPAA AND SECURITY REQUIREMENTS ........................... 123
EXHIBIT 1: STATE HEALTH PLAN PREFERRED PROVIDER NETWORK ................................... 124
EXHIBIT 2: CURRENT PCP COPAY INCENTIVE SCENARIOS ..................................................... 125
EXHIBIT 3: DEPOSITS AND DISBURSEMENT PROCESS ............................................................ 126
EXHIBIT 4: ID CARD FRONT ........................................................................................................... 127
EXHIBIT 5: ID CARD BACK ............................................................................................................. 128
EXHIBIT 6: EOB SAMPLE PAGES .................................................................................................. 129
EXHIBIT 7: EOB SAMPLE PAGES .................................................................................................. 130
EXHIBIT 8: EOB SAMPLE PAGES .................................................................................................. 131
EXHIBIT 9: EOB SAMPLE PAGES .................................................................................................. 132
EXHIBIT 10: GROUP STRUCTURE ................................................................................................. 133
EXHIBIT 11: VENDOR DATA FEEDS .............................................................................................. 134
EXHIBIT 12: AUDIT & RECONCILIATION ....................................................................................... 135
EXHIBIT 13: SAMPLE AUDIT SCHEDULE ...................................................................................... 136
EXHIBIT 14: PCP SELECTION TOOL AND MAINTENANCE ......................................................... 137
EXHIBIT 15: CLAIMS PROCESSING PHANTOM PLAN - MEDICARE PART B ........................... 138
EXHIBIT 16: STATE HEALTH PLAN RECOVERY WORKFLOWS ................................................. 139
EXHIBIT 17: STANDARD REPORTS ............................................................................................... 140
EXHIBIT 18: MEMBER NAVIGATION .............................................................................................. 141
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Proposal Number: 270-20260421TPAS Vendor: __________________________________________
1.0 VISION AND BACKGROUND
VISION STATEMENT
The Plan seeks a partner who will help execute the Plan's strategy and has the technology, resources, and willingness to align
financial, health, and experience based incentives between Members, providers, and the Plan. The Plan's partner will provide the
base platform for improving health, and delivering an excellent Member and provider experience while fostering financial
sustainability for the Plan.
The Plan expects transparency and timeliness from its partner, whether the task is provider rates, risk arrangements, audits,
benefit changes or operational. It is critical that the partnership is built on trust where the Plan's Partners are fully aligned with
the Plan. Additionally, the Plan is focused on accountability and outcomes, and will hold a partner to its word on what it says it
can do and when it can be successfully executed. The Plan does not seek a partner who agrees with the Plan's requirements now
but intends to convince the Plan to do things its way or adhere to existing infrastructures. Success will require significant
resources and a commitment to growing in North Carolina.
The Plan expects operational excellence through best-in-class technology that allows for rapid improvements and supports
emerging provider payment models in real time. To that end, the Plan intends to have some ancillary services such as population
health management, managed by other Plan vendors to allow the TPA partner to focus on operations, claims adjudication, and
network development while allowing a dedicated team to focus on enhancing the Member experience and improving health.
Throughout the lifetime of the contract, the Plan may elect to have other services carved out.
If the Plan is successful, by 2032 all of the following goals will be met:
1. Access: Accessible and sustainable primary care, mental health care, ob-gyn, pediatric, and emergency support in every
county of North Carolina.
2. Action: All Plan Members have annual physicals, screenings, and know their critical lab numbers.
3. Improved Health: Measurable health status improvement in every county of North Carolina.
4. Best Value for Consumers: For elective and plannable services, a culture focused on the highest quality, lowest cost option.
5. Cost Containment: Members are leveraging the Plan's Preferred Provider Network with average out of pocket costs that
resemble what Members paid in 2022 and show Members the impact of making different choices.
6. Access to Quality Care: Through sustainable and predictable investments, all Plan Members will have access to quality
healthcare.
7. Consumerism: The pipeline of high cost, but lifesaving medical infusions are bought at scale through a consortium of large
employers, such as States, to optimize cost and access.
8. Relatable: Meet Plan Members where they are and communicate to them in ways they understand and can successfully
leverage.
9. Plan Awareness: Continually listening to Plan Members and providers to develop programs that reflect the changing needs
of membership.
10. National Network: For Members outside of North Carolina, a national network focused on innovative solutions to manage
costs and steer Members to the highest quality providers.
BACKGROUND
State Health Plan
The Plan provides health benefit coverage to approximately 750,000 teachers and school personnel, State employees, retirees,
current and former lawmakers, State university and community college personnel, and eligible Dependents. The services
outlined in this RFP are focused on the approximately 572,000 self-funded Members. The mission of the State Health Plan is to
improve the health and health care of North Carolina teachers, State employees, retirees, and their Dependents, in a financially
sustainable manner, thereby serving as a model to the people of North Carolina for improving their health and well-being.
Governance
The Treasurer, Executive Administrator, and the Board are designated as fiduciaries for the Plan. The powers and duties of the
Treasurer are set forth in statute at N.C.G.S. 135-48.30(a) and include setting benefits, premium rates, co-pays, deductibles,
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