Quick orientation: the renewal picture

• Tell me briefly how you currently run your annual renewal process for group medical, who owns each step, and the cadence.
• How large is your employee population for the plans under review? Options: 1,000–4,999, 5,000–19,999, 20,000–99,999, 100,000+
• What is your current annual medical premium trend target for next renewal? Options: <4%, 4–6%, 6–9%, >9%, No target set
• Which stakeholders must sign the final decision and who usually leads negotiations with brokers or consultants? Options: Benefits director, CFO, VP Total Rewards, External broker/consultant, Legal, Other
• Estimate the financial runway you need before a new vendor contract would be approved, in months. Options: 0–3 months, 4–6 months, 7–12 months, >12 months
• Describe any recent renewal surprises that changed budget or headcount plans.

Where the money actually goes

• What single forecasting failure on medical trend would make you walk away from a proposed solution this renewal?
• How much of your last year's trend came from pharmacy versus medical claims, in percentage points? Options: Mostly pharmacy (>60%), Balanced (40–60%), Mostly medical (>60%), Unsure
• Which three ICD categories or service lines drove the biggest cost increases last year? Options: Cardiology, Oncology, Orthopedics, Maternity, Behavioral health, Pharmacy specialty drugs, Other
• When you look at provider pricing outliers, which markets create the largest leakage in dollars?
• Tell me about a recent high-cost claim that required cross-team escalation, what happened and what was the result?
• If preserving employee access to their current providers became costly, what would be the acceptable trade-offs for your leadership? Options: Pay higher premiums, Limit changes to specific geographies, Offer continuity riders for select employees, Increase employee cost share, Other

Network and care experience in real life

• When a member cannot find an in-network provider nearby, what breaks downstream for your benefits team and employees?
• Estimate the number of employees in geographies where network adequacy has been reported as an issue. Options: None, <100, 100–999, 1,000–9,999, 10,000+
• List the top specialties or facility types your employees would prioritize, and approximate headcount affected.
• Walk me through a recent claims or prior authorization denial that led to an employee complaint, and how long it took to resolve.
• Do you have existing provider continuity protections in plan documents, and are they enforceable across states? Options: Yes, explicit and enforceable, Yes, but limited to certain states, No formal protections, Unsure
• Name two metrics you would use to judge whether a network change is causing member disruption. Options: Claims leakage by ZIP, Provider termination incidents, Member complaints per 1,000, Time to reassign PCP, Average distance to nearest in-network specialist

Clinical programs that actually bend trend

• If a clinical program failed to reduce ER visits by your target, what would you do next?
• Describe how you currently measure the ROI of care management or chronic disease programs, and who vets the calculation.
• List the chronic conditions that drive the most spend, and rank them by annual cost. Options: Diabetes, Cardiovascular disease, COPD/asthma, Cancer, Behavioral health, Musculoskeletal, Other
• Walk me through an example where a vendor clinical program missed expected outcomes, who raised the concern, and what corrective steps were taken.
• Would your CFO accept a guarantee tied to readmission reduction, and what level of accountability would be required? Options: Yes, with financial penalties, Yes, with shared savings only, No, must be operational metrics only, Unsure
• Who on your team must approve any clinical program protocols or patient-level data sharing? Options: Benefits director, Medical director, Legal, Compliance, Data/privacy officer, Other

What's getting in the way, and who else is on the table

• Explain why each alternative still looks viable and which one would be hardest to replace if you stayed with it.
• Provide the names or descriptions of the external vendors you have shortlisted or invited to bid. Options: Incumbent carrier, Regional carrier, National carrier, TPA-only, Pharmacy carve-in vendor, Broker-run private auction, Other
• Who owns the incumbent relationship internally and what would it take for them to recommend staying? Options: Benefits director, Procurement, CFO, HR leader, Consultant/broker, Other
• Give the top three reasons your procurement or benefits team might prefer an internal solution over an outside carrier. Options: Cost control, Fewer approvals, Custom workflows, Data ownership, Existing IT capabilities, Other
• Would a two-year trend guarantee matching your target stop the process, or are there other factors that would keep you searching? Options: It would stop the process, It would help but not stop the process, No, other factors matter more, Unsure
• Are any internal teams prepared to operate claims or pharmacy feeds if you chose a self-funded model? Options: Yes, fully resourced, Partial capability, need support, No, would require vendor handling, Unsure

Practical gates: data, systems, and timeline

• Identify the single technical dependency that would block a go-live inside your target enrollment window.
• Provide the category names for systems that must connect, for example HRIS, payroll, benefits admin, or EDI gateway. Options: HRIS, Payroll system, Benefits admin, Payroll-to-HRIS sync, Time and attendance, EDI gateway, Other
• Identify the owner of API access or SFTP credentials for those systems, and confirm whether they are authorized to share them.
• On a three-point scale, rate the readiness of your member and claims data: clean, needs work, high manual cleanup. Options: Clean, Needs work, High manual cleanup
• Do you have any regulatory approvals, union agreements, or multi-state filing needs that could delay data sharing or plan changes? Options: Yes, likely to delay, Possibly, depends on state, No formal approvals needed, Unsure
• Name the single resource gap that would kill the timeline if left unfilled, for example staffing, vendor mapping, or executive approvals.

Closing the loop: decision criteria and next steps

• Pinpoint the one remaining approval or policy that would prevent a near-term signature even if numbers look right.
• Select the metrics that must be included in a contract to trigger payment or guarantees. Options: Premium trend, ER visit rate, 30-day readmission rate, Network access incidents, Pharmacy spend trend, Clinical engagement rate
• Within how many weeks does your finance team need final pricing to commit to budget? Options: 0–2 weeks, 3–4 weeks, 5–8 weeks, >8 weeks
• Give the primary and backup owners on your side for implementation, including titles and contact roles.
• Are there legal or procurement gates that require more than routine review, such as union signoffs or multi-state approvals? Options: Yes, significant gates, Minor additional reviews, No, standard reviews only, Unsure
• By what date do you need a signed contract to meet your open enrollment or billing cycle? Options: Within 2 weeks, Within 1 month, Within 2–3 months, Flexible / no fixed date

• Clinical & Network Experience Session

• Confirm the current state and its cost
• Deliver a tailored provider access map for your top 10 employee ZIP codes showing in-network provider counts and typical travel times.
• You confirm that the assessed network coverage would prevent the employee disruption scenarios you described.
• You confirm that the clinical workflows shown would change utilization outcomes for the specific cases you raised, such as ER visits and readmissions.
• Map employee scenarios to network coverage
• Run claims and pharmacy analytics on a sample 6-month extract and deliver a one-page executive summary of top trend drivers and recommended interventions.
• You confirm that the pharmacy analytics shown surface the main trend drivers you need to control premium trend.
• Run clinical program workflows against your example cases
• Provide a de-identified sample claims and pharmacy extract for the requested 6-month period to enable the analytics run.
• Demonstrate pharmacy integration and analytics on trend drivers
• List the top five employee locations and three example clinical cases you want modeled in the next analysis.
• You agree on the remaining evidence needed before selection and the timeline for those deliverables.
• Validate the future state
• Confirm the decision timeline and who must validate the evidence before award.

• Clinical & Network Experience Session
• Clinical & Network Experience Deck
• Solution Brief – Clinical & Network Experience

• meeting
• slides
• document

• Administer Medical Claims Processing
• Provide National Provider Network Access
• Manage Provider Credentialing and Network Adequacy
• Administer Pharmacy Benefit Management
• Deliver Monthly Claims and Pharmacy Analytics Feed
• Operate Care Management for High-Cost Members
• Perform Utilization Management and Prior Authorization
• Coordinate Transitions of Care and Readmission Reduction
• Run Chronic Disease Management Programs
• Integrate Behavioral Health Services and Care Coordination
• Provide Dedicated Account Management and Client Support
• Deliver Renewal Pricing Proposal with Trend Guarantee

Administer Medical Claims Processing

• Which claim submission formats must be supported for your population (for example EDI 837 Institutional, 837 Professional, flat-file CSV of adjudicated lines)? Options: 837 Institutional, 837 Professional, 837 Dental, CSV line-level, Other
• How many paid claims and claim lines do you expect per month at go-live and at 12 months? Options: Less than 50k claims / 100k lines, 50k-250k claims / 100k-500k lines, 250k-1M claims / 500k-2M lines, More than 1M claims
• What turnaround SLA do you require for first-pass adjudication of clean claims (for example adjudicate clean electronic claims within 48 hours)? Options: 24 hours, 48 hours, 5 business days, Custom
• Who will supply initial member eligibility and census (for example an HRIS export with employee ID, DOB, plan code, hire date)?
• Confirm required remittance format for payment reconciliation (for example EDI 835, CSV with claim identifier and paid amount). Options: EDI 835, CSV remittance (column mapped), Both, Other
• Within which systems must claim-level integrations be validated (for example your payroll/Human Resources Information System (HRIS), benefits platform, or third-party stop-loss administrator)?
• List any specialized claim types that need separate handling at go-live (for example workers compensation crossover, COB/coordination of benefits, carve-out vendors).

Provide National Provider Network Access

• Which geographic coverage rule should we apply to test network adequacy by ZIP code or county (for example 95% of employee ZIP codes must have in-network access to a primary care provider within 30 minutes)? Options: NCQA standard, State-specific network adequacy, Custom distance/time matrix, Coverage by primary service area only
• How many named providers or NPIs must be maintained as in-network to avoid disruption for employees undergoing active treatment (please list NPIs or attach roster)?
• What percentage of your employee census must retain access to their current in-network specialist without a change in authorization requirement? Options: 90%+, 80-90%, 70-80%, Custom threshold
• Name any critical facilities or systems (for example specific hospital IDs or system names) that must be included in the network at go-live.
• Acceptance criteria for network adequacy: what measurable evidence will validate go-live (for example county-by-county ZIP coverage report showing X% access, provider directory match to provided NPI roster)?
• Are telehealth, behavioral health virtual visits, or urgent care sites required to meet the same travel-time coverage thresholds as brick-and-mortar providers? Options: Yes, same thresholds, Yes, relaxed thresholds, No, separate rules
• Specify whether you require continuity-of-care letters or outreach to affected employees when a PCP or specialist is out-of-network within the first 90 days. Options: Yes, continuity letters, Yes, provider assignment support only, No

Manage Provider Credentialing and Network Adequacy

• State the required primary source verification frequency for credentialing (for example every 36 months or at hire). Options: Initial only, Every 24 months, Every 36 months, Custom cadence
• Outline the provider roster update cadence you require for the public directory and for internal network files (for example weekly CSV, monthly API). Options: Daily API, Weekly CSV, Monthly CSV/API, Quarterly
• Describe any delegated credentialing relationships you expect to remain in place (for example delegated medical group credentialing versus central credentialing). Options: No delegation, Partial delegation, Full delegation
• Identify the provider directory fields you require in the feed (for example NPI, taxonomy, TIN, practice address, phone, accepting new patients flag).
• Specify required notification lead time for provider termination or contract change that impacts access (for example 30 days prior notice to affected members). Options: 7 days, 30 days, 60 days, Immediate
• Indicate the monitoring cadence for network adequacy reports you want (for example monthly county-level access exceptions delivered as CSV). Options: Weekly, Monthly, Quarterly, On-demand

Administer Pharmacy Benefit Management

• Describe the formulary design you require (for example 3-tier, 4-tier with specialty tier, step therapy rules) and any must-have excluded or preferred drug classes. Options: 3-tier standard, 4-tier with specialty, Custom tiering, Reference formulary provided
• Which pharmacy claims formats and standards must be supported for your integration (for example NCPDP SCRIPT for e-prescribing and NCPDP claim transactions)? Options: NCPDP claim formats, Batch CSV, API-based integration, Other
• Indicate whether you require rebate pass-through reporting and the level of transparency (for example gross vs net per NDC). Options: Gross and net per NDC, Aggregate rebate reporting, No rebate reporting required
• Specify required specialty pharmacy handling and whether you permit external specialty vendors or require in-network specialty distribution. Options: In-network specialty only, Allow external specialty vendors, Hybrid
• Provide your preferred prior authorization rules delivery method for pharmacy (for example real-time API, pre-populated CSV, portal) and expected decision SLA. Options: Real-time API, Portal, Batch file, Other
• Select the mail-order fulfillment options you require (for example 90-day mail order with NDC mapping, copay parity), and any required pharmacy network exclusions. Options: 90-day mail order, 30-day only, Mail-order specialty, No mail-order

Deliver Monthly Claims and Pharmacy Analytics Feed

• Format for the analytics feed: which of the following formats do you require for claims and pharmacy analytics delivery (for example line-level CSV, parquet to S3, or API)? Options: Line-level CSV, Parquet to S3/Redshift, Secure REST API, Other
• Cadence for reporting: what is the acceptable maximum lag for monthly feeds (for example 10 business days after month close)? Options: 3 business days, 5 business days, 10 business days, 15+ business days
• Acceptance criteria for data feeds: what evidence will validate feed completeness and accuracy (for example file-level row counts match ledger totals, field-level coverage > 99%, timestamped load manifest)?
• Owner for data integration: who in your organization will be the named technical contact for SFTP/API ingestion and field mapping approvals?
• Where will the analytics files be delivered or accessible (for example SFTP host, secure API endpoint, cloud bucket) and do you require encrypted transfer with specific cipher? Options: SFTP, Secure REST API, Cloud bucket (S3/Azure/GCS), Other
• Which reporting measures must be present in the monthly feed schema (for example claim paid amount, allowed amount, member age, diagnosis ICD-10, NDC for pharmacy)?

Operate Care Management for High-Cost Members

• Define the threshold for 'high-cost' member enrollment in care management (for example claims > $50,000 in 12 months or top 1% by spend). Options: Top 1% by spend, Claims > $50k/yr, Claims > $100k/yr, Custom threshold
• How will you authorize outreach to high-cost members (for example opt-in, opt-out, implied consent via plan SPD, signed consent form)? Options: Opt-in, Opt-out, Implied consent via SPD, Signed consent required
• What clinical artifacts must care managers access or produce (for example care plan in CCD, case notes, documented discharge summary), and in which format?
• Identify EHR or ADT integrations required for case-finding (for example HL7 ADT feeds from partner hospitals).
• Estimate target outcomes for high-cost care management over 12 months (for example reduce inpatient days by X, lower average claim per member by Y%).
• Indicate whether you require direct member-facing remote monitoring (for example device-supplied BP/glucose data integrated via FHIR) as part of chronic/high-cost management. Options: Yes, device integration required, Optional/phase 2, No

Perform Utilization Management and Prior Authorization

• Which service categories require prior authorization at go-live (for example advanced imaging CPT codes, outpatient surgery, DME above threshold)?
• What decision SLA do you require for standard prior authorization requests (for example 72 hours for routine, 24 hours for urgent)? Options: 24 hours urgent / 72 hours routine, 48 hours / 5 business days, Custom
• Which clinical criteria sources should be applied for determinations (for example InterQual, MCG, or custom clinical policy), and do you require visibility to applied criteria in the authorization response? Options: InterQual/MCG, Custom clinical policy, Combination
• How should prior authorization decisions be delivered to providers (for example portal, HL7 FHIR DocumentReference, automated fax/email)? Options: Provider portal, API/HL7, Secure email/fax, Other
• Authorization turnaround: who will own appeals and external review workflows and what timelines do you require for appeals handling?
• Which retrospective review windows should be enforced (for example 30/60/90 days after claim) and which services are excluded from retrospective review? Options: 30 days, 60 days, 90 days, Custom

Coordinate Transitions of Care and Readmission Reduction

• How should admission-discharge-transfer (ADT) data be delivered for transition-of-care workflows (for example HL7 ADT feed, daily CSV of admissions with member ID and facility)? Options: HL7 ADT feed, Daily CSV, No ADT feed available, Other
• What is your current baseline 30-day all-cause readmission rate for the population (provide numeric rate per 1,000 or percentage)?
• Which post-discharge interventions do you require as part of the program (for example pharmacist medication reconciliation within 48 hours, nurse follow-up call within 72 hours)? Options: 48-hour med reconciliation, 72-hour nurse call, In-home visit, Other
• Who will provide discharge rosters or ADT exceptions when a member is admitted out of network?
• Specify reporting needs for readmission reduction (for example weekly inpatient census, monthly readmission rate by facility) and delivery method.
• Indicate escalation rules for high-risk discharges (for example within 24 hours escalate to clinical director if no contact).

Run Chronic Disease Management Programs

• For which chronic conditions do you want targeted programs at go-live (for example diabetes with HbA1c tracking, congestive heart failure with BNP monitoring, COPD)? Options: Diabetes, CHF, COPD/Asthma, Chronic Kidney Disease, Other
• Which enrollment triggers should be used to enroll members (for example ICD-10 diagnosis in claims, medication fills, clinical lab thresholds)? Options: ICD-10 diagnosis from claims, Medication fills/patterns, Lab thresholds (HbA1c/creatinine), Provider referral
• What clinical metrics must the program track and report (for example percent with HbA1c < 8%, blood pressure control defined as <140/90)?
• Describe required device or remote monitoring integrations (for example Bluetooth glucometer data via FHIR, BP cuff uploads) and expected data ingestion cadence. Options: Real-time FHIR ingestion, Daily batch, Weekly summary, Not required
• What target improvement do you expect in 12 months for each condition (for example reduce uncontrolled HbA1c by X percentage points)?
• Identify who will own member consent and escalation to primary care for chronic program enrollment.

Integrate Behavioral Health Services and Care Coordination

• Which behavioral health services must be included in the integrated offering (for example outpatient therapy, intensive outpatient programs, crisis services)? Options: Outpatient therapy, Intensive outpatient, Crisis services, Inpatient behavioral health
• Does your plan require parity reporting or specialized behavioral health utilization reports for compliance purposes (for example MHPAEA parity metrics)? Options: Yes, parity reports required, No parity reporting required
• Which screening tools should be captured and reported for behavioral health measurement (for example PHQ-9 scores, GAD-7 scores) and how often? Options: PHQ-9, GAD-7, Other validated tools, Not required
• How should referrals into behavioral health care coordination be triggered (for example primary care referral, ED screening, claims-based flags)? Options: PCP referral, ED screening, Claims flag, Self-referral

• Master Services Agreement (MSA)
• Statement of Work (SOW) — Implementation
• Pricing & Trend Guarantee Exhibit
• Service Level Agreement (SLA) & Performance Remedies
• Data Use & Security Agreement (DPA)
• HIPAA Business Associate Addendum (BAA) — conditional
• Stop-Loss / Reinsurance Exhibit — conditional
• Implementation Change Order

• Go-live Health Check (weeks 1-4)
• First Measurement Review (weeks 4-10)
• Acceptance Gate Review (around day 90)
• Quarterly Outcomes Review
• Continuous Improvement Backlog Review (monthly operational)

• Update the shared issue and enhancement log with agreed priorities, owners, and resolution dates.
• Publish the acceptance record showing pass/fail per criterion and the captured buyer acceptance decision.
• Create remediation tickets for conditional or failed criteria with milestones and final re-evaluation dates.
• If applicable, produce the incumbent decommission checklist and schedule the decommission activities.
• Quarterly trend presentation
• Confirm whether network access incidents and 30-day readmission rate are improving or require further action.
• Ensure the shared issue log is current with clear owners and resolution dates for all active items.
• Agree the priority order for enhancement requests to be advanced in the next quarter.
• Re-confirm success criteria and ownership
• Deliver a concise quarterly outcomes report highlighting metric deltas and remediation progress.
• Schedule any targeted detailed review sessions for persistent high-impact issues.
• Metric delta review
• Ensure monthly premium trend and ER utilization rate deltas are tracked and any adverse movements have assigned remediation.
• Reduce the active improvement backlog by closing verified items and escalating blocked work.
• Confirm short-term operational commitments and dates for the next monthly checkpoint.
• Update and circulate the monthly metric snapshot and the updated backlog status.
• Close verified tickets and move conditional items to re-test with clear acceptance criteria.
• Flag any persistent or high-severity items for escalation to the quarterly Outcomes Review.
• Deployment validation documented and distributed with a clear owner for each item.
• Top go-live blockers identified with owners and target resolution dates.
• Confirmation that initial data feeds are producing expected records and no critical reconciliation gaps remain.
• Publish the deployment validation report capturing feed health, user access counts, and outstanding defects.
• Open remediation tickets for critical blockers with target resolution dates and escalate any that threaten core operations.
• Schedule the First Measurement Review for the first meaningful data window within weeks 4-10.
• Present first-cycle results
• Determine whether monthly premium trend and ER utilization rate are moving toward the targets and document any shortfalls.
• Assign specific corrective actions with owners and dates for each material gap.
• Confirm readiness and timeline for the Acceptance Gate meeting.
• Deliver the detailed metric pack showing methodology, baselines, and the first measurement window data.
• Open remediation tasks for data or operational gaps identified, with completion dates and acceptance criteria.
• Share the timeline and evidence requirements required for the Acceptance Gate meeting.
• Restate acceptance criteria and numeric targets
• Formal acceptance status recorded per acceptance criterion and the buyer's acceptance decision captured.
• Remediation plan documented with owners and firm resolution dates for any non-conformances.
• If replacing an incumbent, confirm a single owner will complete decommissioning or archival tasks on the agreed timeline.
• Review open issues and remediation progress
• Backlog burn-down and ticket status
• Present outcome data against each criterion
• Root-cause diagnosis for variances
• Deployment and data feed validation
• Enhancement request prioritization
• Document pass/fail per criterion and capture acceptance decision
• Test and verification of fixes
• Agree corrective actions and timelines
• Early adoption signals and usage patterns
• Agree immediate next actions
• Open blockers and defect triage
• Confirm path to Acceptance Gate
• Operational handoffs and next steps
• Agree remediation plan for failed or conditional items
• Agree immediate remediation actions
• Incumbent decommission check, if applicable