Behavioral Health Management Services

The vendor required to provide behavioral health program in conformance with the plans’ documents, all applicable laws and regulations, and in accordance with all the requirements outlined in this request for proposal and the offeror’s response thereto.
- Provide, as part of the behavioral health services contract, a comprehensive evidence-based tobacco cessation program as proposed to plan members.
- Tobacco cessation program shall help members stop using cigarettes, electronic nicotine delivery systems (e-cigarettes, vape pens, etc.), cigars, pipes and smokeless tobacco.
- The program should integrate one-on-one coaching, care navigation, training and digital tools to improve access, engagement and outcomes across a broad spectrum of neurodivergent needs for members with or without a formal diagnosis. 
- Payment will be made as a claim on a fee-for-service basis to be invoiced in the same manner as other claims. 
- The services provided as part of the behavioral health services contract shall include, at a minimum, claims processing, utilization management, disease management, receipt of eligibility data, cost containment, customer services and reporting.
- Account and personnel management
•    The account representative shall be knowledgeable about all aspects of the behavioral health program, including all behavioral health support programs.
•    Consultant to peba in the operation of all aspects of the behavioral health program by assisting peba in the ongoing review of the programs, and advising of new trends, techniques and programs.
•    The third-party medical claims administrator and the pharmacy benefits manager for the plans to integrate customer services, care and utilization management, claims processing and data reporting.
•    Legal developments including, but not limited to, regulatory, administrative, statutory and judicial developments relating to behavioral health management.
- Claims processing and payment
•    Process all behavioral health claims (claims includes requests for prior authorizations and continuing stay reviews, where applicable) incurred on and after January 1, 2027, and up to and including December 31, 2031, in accordance with this RFP and all applicable statutory and plan provisions.
•    Process all claims and appeals for the plans that were incurred during the term of the contract at no additional charge for a period of twelve (12) months.
•    Shall receive, date and control claims within twenty-four (24) hours of receipt.
•    Determine whether a claim is payable as a medically necessary and covered service under the terms of the plans.
•    Clinical reviewers must spend an adequate amount of time on each review, cursory reviews and reviews that do not consider the patient’s history are unacceptable.
•    Identify any instance where coordination of benefits, including medicare, workers' compensation or subrogation, applies and take appropriate action to recover claims payments or other costs.
•    Maintain the necessary data link with the plans’ third-party medical claims administrator or any successor, for application of deductible credit and out-of-pocket limits with the medical plan.
•    Transmit in real time, or near-real time, the data necessary to coordinate application of plan provisions, such as deductibles and out-of-pocket limits to the third-party medical claim’s administrator.
- Behavioral healthcare provider networks
•    Operate and maintain a network of participating behavioral health providers that treat both adult and pediatric members to include psychiatrists, clinical psychologists, masters-level therapists and nurse practitioners
•    This network of providers should also include providers that deliver measurement-informed care, utilizing ongoing patient progress data to guide clinical decisions and improve outcomes.
•    Provide a continuum of treatment services and settings for delivery of medically necessary covered inpatient and outpatient behavioral health services at contracted fee-for-service rates.