MB-5238 - USA (California) - Workers Compensation Managed Care Services - Deadline May 28,2021

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-5238

Government Authority located in California; USA based organization looking for expert vendor for workers compensation managed care services.

[A] Budget: Looking for Proposals

[B] Scope of Service:

(1) Vendor needs to provide workers compensation managed care services including bill review, utilization review, nurse case management, and telephonic injury triage reporting
- Bill Review:
- Provide bill review services in compliance with all applicable laws and regulations, and in accordance with the highest industry standards.
- Analyze and reduce bills that are in excess of charges of those allowed by the State's Division of Workers' Compensation Fee Schedule.
- Provide an Explanation of Review (“EOR”) to providers for all bills reviewed.
- Further reduce the cost of bills in accordance with the District contracted Preferred Provider Organizations (“PPO”) network.
- Request needed documents for incomplete bills from providers.
- Verify all billing Current Procedural Terminology (“CPT”) codes comply with actual treatment provided.
- Monitor and Identify duplicate bills. Return those previously reviewed bill(s) to providers along with EOR marked duplicate. Send zero payment EOR to provider and provide justification for zero payment.
- Review appeals of medical bills from providers and make appropriate recommendations.
- Review testimony and/or other professional services on all medical bill issues on litigated cases including justification of payment and payment amount, up-coding or down-coding, and any other required services related to this contract,
- Investigate all medical liens including any previous payments and cause of liens; determine liability and amount of liability, if any; assist with negotiation of liens; and assisting if a lien requires court appearance.
- Utilization Review (UR):
- Provide utilization review services in compliance with all applicable laws and regulations, and in accordance with the highest industry standards.
- Provide timely reports to the District's identified Third-Party Administrator (“TPA”) outlining utilization review requests, certifications, non-certifications, and costs/savings,
- Nurse Case Management:
- Provide nurse case management services in compliance with all applicable laws and regulations, and in accordance with the highest industry standards.
- Work with District's workers' compensation TPA to coordinate medical care on cases where nurse case management is assigned.
- Support the District's return to work and modified duty programs and achieving permanent and stationary status,
- Provide timely reports to the District outlining nurse case management activity, costs, and savings,
- Injury Triage Reporting:
- Intake of calls from injured employees or those who are assisting them.
- Obtain pre-designated information.
- Assist employees in determining the level of care that is needed.
(2) All the questions must be submitted no later than May 14, 2021.

[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, 28 May, 2021

Question Answer Deadline : Friday, 14 May, 2021

Category : Medical Billing and Coding

Country : USA

State : California

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