Inmate Medical Billing Services

The vendor is required to provide inmate medical billing services for include:
• Implement procedures that maximize claims processing efficiencies, including claim adjudication and scrubbing (reviews for accuracy, coding errors, and charge adjustments).
• The vendor shall institute an efficient method to communicate with the city regarding custodial status of any individual related to a claim.
• The city is solely responsible for determining and validating custodial status.
• The vendor shall receive and process all claims electronically within thirty (30) calendar days of receiving the claim.
• The vendor's claims processing solution shall support online, real-time adjudication and inquiry of claims.
• The vendor shall re-price all in-custody claims according to the state's Medicaid rates.
• The vendor will be responsible for notifying providers of these adjustments and justifications with the appropriate remark code(s).
• The vendor shall be responsible for rejecting all claims for anyone determined to be not in the city's custody and notifying providers with the directed appropriate remark code(s).
• Claims adjudication (processing and payment) is a key component of the process.
• Vendor must work with the city to verify whether the patient was in custody on the date of service of the claim.
• If the patient was not in custody, the claim is denied.
• If the patient was in custody on the date of service, the claim is then adjudicated according to CMS (centers for medicare and Medicaid) standards, including the NCCI (national correct coding initiative) guidelines.
• Medicare standards and generally accepted health care industry practices to identify and deny payment for claims with cosmetic procedures, duplicate charges, experimental procedures, incidental procedures, inclusive care, invalid and modifier combinations, invalid codes, mutually exclusive procedures, obsolete codes, unlisted procedures, unbundling and all other non-covered reimbursement drivers.
• Provide and enable editing to prevent duplicate entry and payment of claims.
• Vendor shall edit claim detail identifying all error codes for claims that fail edit processing at initial processing of the claim to minimize the need for multiple re-submissions of claims.
• Vendor shall perform auditing based on the provider number and procedures performed.
• Vendor shall perform diagnosis editing by line item. only eligible charges are allowed, and those charges are priced according to the state's Medicaid rate.
• Relating to coordination of benefits (cob): the vendor shall not interfere with any arrestee's insurance coverage outside of the exact approved claim date and time of service.
• Relating to claim run-off: following the termination of the contract for any reason, the vendor must continue to process and pay claims which are incurred during the term of the contract.
• These costs will be accounted for in the administrative fees.
- Non-Mandatory Pre-Qualification Meeting Date: May 01, 2025
- Questions/Inquires Deadline: May 05, 2025