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MB-4600 - USA (Virginia) - Medical Administrator and Pharmacy Benefit Manager Services - Deadline October 30,2020

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-4600

Government Authority located in Virginia; USA based organization looking for expert vendor for medical administrator and pharmacy benefit manager services.

[A] Budget: Looking for Proposal

[B] Scope of Service:

(1) Vendor needs to provide medical administrator and pharmacy benefit manager services
- seek to procure Medical benefit services as a group, to include Medical Administration, and a Pharmacy Benefit Manager (PBM),
- Aggressively engage in efforts to improve the health of the employee population and their covered dependents, including wellness improvement, incentive programs, health risk assessment and chronic care management,
- Spreading risk across Consortium participants to reduce individual group cost volatility,
- Obtaining the best pricing for health care services by taking advantage of available medical, pharmaceutical, and provider network discounts for employees and their dependents,
- Implementing progressive coverage elements (i.e. value-based benefit designs and using the best providers incentives) to encourage and reward participants who seek high value care,
- Offerors may submit proposals for Medical Administrator, Pharmacy Benefit Manager or both,
- Administer any changes to plan design, benefit additions as stipulated in the current or future plan description, including but not limited to: network models, specific benefit changes to deductibles, co-insurance, changes required by regulatory compliance of the Contractor and lifetime maximums,
- Provide the Consortium the right to interview and agree to the intended replacement of the primary account executive or account manager. The Consortium shall approve of proposed replacement before they become primary account executive or account manager for the Consortium,
- Designated Account Executive – Responsible for overall account relationship including strategic planning in relation to plan performance, consultative services, recommendations for benefit design and cost containment opportunities, overseeing contractual services under the Contract, and managing all other Contractor staff working on this account,
- Designated Account Manager – Responsible for overseeing and managing day-to-day activities pertinent to the Consortium account,
- A designated toll-free number or other designated free telephone service that is staffed with live customer service representatives from at least 8 a.m. to 6 p.m., Monday to Friday (excluding State of Virginia holidays) EST, to assist Participants with eligibility, claim filing, and medical plan questions,
- A secure online website and mobile tool for Providers to: Verify in “real time” the eligibility status of members, Providers must have standardized electronic health record data model designed to support interfacing to clinical decision support (CDS) systems, Access Medical and potentially Drug history for their patients and their lab values or other encounter data, Submit claims and pre-certification information,
- Prepare, produce, and distribute Participant communications materials and administrative forms, including but not limited to: enrollment forms, enrollment brochures, newsletters, claim forms and checks, certificates of insurance, Participant booklets, identification cards, provider directories, announcement forms, Summary of Benefit Coverages (SBC’s), Summary Plan Descriptions (SPD’s) and any other forms required for proper administration,
- Provide a designated claims processing unit for the Consortium account, comprised of no more than 25% of staff with less than two years’ experience in claims processing,
- A Claim Payment shall: Accurately calculate benefits payable in accordance with the medical plan; investigate claims when charges are unusual,
- Issue payments directly to Participants or providers,
- Generate an Explanation of Benefits (EOB) and provide to Participant,
- Apply claim control and systematic procedures to trigger reviews and identify when Participants or providers have been overpaid,
- The Consortium shall have the ability to establish how recognized charges for Out of Network claims are determined,
- Contractor will coordinate with an external vendor (pharmacy, HSA, EAP, wellness, data vendor) to collect data necessary to perform care, case and health management as applicable,
- Waive the actively-at-work clause and cover current and future disabled’s and COBRA beneficiaries as actives until they are no longer eligible for coverage at the Consortium,
- Claim Appeals:
- Provide the necessary structure and resources, including the use of an independent reviewer, required to review all types of claims using accepted review standards at no additional cost to the Consortium,
- Allow the Consortium to review, edit and customize appeal templates used for the Consortium Participants to ensure compliance and consistency with established Consortium procedures,
- Consumer Design and HSA Capabilities:
- Administer an employee’s record in the eligibilit

[C] Eligibility:

Onshore (USA Organization Only);

[D] Work Performance:

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

Expiry Date : Friday, 30 October, 2020

Question Answer Deadline : Thursday, 15 October, 2020

Category : Medical Billing and Coding

Country : USA

State : Virginia

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