Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-7884

Government Authority located in Virginia; USA based organization looking for expert vendor for third party administration health claims processing services.

[*] Budget: Looking for Proposal

[*] Scope of Service:

(1) Vendor needs to provide third party administration health claims processing services.              
- Develop and maintain a statewide and national network of institutional and professional providers (including dentists, agency providers and local ambulance squads) who, by contract, agree to accept discounted charges as payment in full for covered services
- Dedicate a Customer Service Unit for the DOC to provide customer service to the DOC finance and health services units, to include review of inmate coverage as requested, provide copies of provider claims as requested, dispute provider claims as requested, and any other requests submitted for claims review and processing;
- Accept both computerized and manual eligibility updates. The format is agency (SQL Server Information Services package). Ability to receive updated enrollment data transmitted twice a week and reflect updated coverage for all DOC inmates;
- Directly receive computerized and manual claims from any community providers used by a DOC facility without the DOC having to receive and send the claim to the Contractor;
- Administer claims reimbursement to community providers and ensure best available rate reimbursement, with no patient liability, within 2 months of claim receipt;
- Provide Explanation of Benefits (EOBs) to community providers after reimbursement of claims;
- Administer special provider arrangements between the DOC and selected providers;
- Suppress sending of agency and other member level correspondence to the DOC or individual;
- Provide customized detail claims information, in both hard copy and electronically, that segregates claims into the following Facility Outpatient, Facility Inpatient, Provider Outpatient, Provider Inpatient, Provider Using Telemedicine, Dental and Pharmacy;
- Discern all telemedicine claims submitted for special identification and for reporting purposes;
- Provide Member IDs specific to each DOC inmate;
- Provide financial forecasts (i.e., projections on medical care costs, trend analysis, etc.) to include assessment of inflation rates and utilization trends for the DOC population;
- Provide efficient and effective benefit coordination with Medicaid and other potential payment - Provide financial forecasts (i.e., projections on medical care costs, trend analysis, etc.) to include assessment of inflation rates and utilization trends for the DOC population;
- Provide efficient and effective benefit coordination with Medicaid and other potential payment options;
- Providers continue to meet Contractor’s selection and screening criteria;    
- Providers maintain sufficient liability insurance;
- Provider contracts remain in force;
- Provider discounts are secured to reduce costs; and
(2) All questions must be submitted no later than November 29, 2023.

[*] Eligibility:

Onshore (USA Organizations Only)

[*] Work Performance:

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

Expiry Date : Friday, 5 January, 2024

Question Answer Deadline : Wednesday, 29 November, 2023

Category : Medical Billing and Coding

Country : USA

State : Virginia

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