MB-3696 - USA (Texas) - Credit Balance Audit Recovery Services - Deadline January 27,2020

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-3696

Government authority located in Texas; USA based organization looking for expert vendor for Credit balance audit recovery services.

[A] Budget: Looking for Proposal

[B] Scope of Service:

(1) Vendor needs to provide balance audit recovery services.
- Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women.
- Children’s Health Insurance Program (CHIP) for the children of low-income parents, including CHIP
Perinatal program for unborn children of pregnant women who do not qualify for Medicaid STAR.
- Health Insurance Marketplace (HIM) plans that offer individual health coverage including preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
- Employee Retirement System of Texas (ERS) program that provides regional HMO coverage for State of Texas employees.
- Administrator for multiple collaborative safety net projects including Delivery System Reform
Innovation Projects (DSRIP), My Harris Health and other projects.
- Medicare regulations require all providers to report hospital credit balances quarterly. These regulations state "providers must develop and maintain documentation which shows that each patient record with a credit balance was reviewed to determine whether the credit balance is attributable to Medicare".
- Claims: - Community processes an average of 400,000 claims per month via the TriZetto QNXT™ Managed Care System (QNXT)with an average of 3,000 claims with credit balances. Community also utilizes an automated enrollment solution provided by Softheon, for Marketplace billing accounts receivables and reconciliation.
- Services: -
1. Credit Balance Refunds (Due to Overpayments): -
a. Vendor will forward all credit balance refund checks to Community, as appropriate.
b. All credit balance refunds will be accompanied by detailed audit findings, including other payer’s
c. Explanation of Benefits (EOB), necessary to apply the refund.
d. Vendor will assure that all provider refund checks are made payable to Community Health Choice,
2. Retraction Requests (Due to Adjustments on Overpayments): -
a. The vendor will submit all credit balance retraction requests to the designated Community
adjustment area(s) at a minimum once a month to be verified.
b. Retraction requests must include signed provider authorization, detailed audit findings and other
payer’s EOBs.
3. Initial Acceptance of Refunds: -
a. Community will review the refund packet(s) and deposit refund checks into the Community
account within three (3) business days of receipt. Refund is deposited directly into Community’s
b. Community will return the refund to the provider or the vendor for processing if Community
determines that the refund, in part or in its entirety is incorrect or Community will send a partial
refund as applicable.
4. Full Acceptance of Refunds: -
a. Full acceptance will be deemed to have occurred when the refund is processed by Community and
a claims adjustment is completed according to the audit findings.
b. A Deposit of provider refunds does not constitute full acceptance of any refund.
(2) A pre-proposal tele conference will be held on January 6 ,2020.

[C] Eligibility:

- Onshore (USA Only);

[D] Work Performance:

Performance of the work will be Offsite. Vendor needs to carry work in their office location.

Expiry Date : Monday, 27 January, 2020

Pre-proposal Conference Date : Monday, 6 January, 2020

Category : Medical Billing and Coding

Country : USA

State : Texas

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