Laboratory Claims Management Services

The Vendor is required to provide a payment integrity program that offers cost containment services to include laboratory benefit management.
- The solution should reduce costs to agency by managing the use of and payment for laboratory testing.
- This includes not adding administrative burden, delaying patient care, deterring growth and innovation within the diagnostics industry, or limiting physician or patient choice for their health care management.
- Provide optimization of billing for laboratory services.
• Identify information derived from historical claims.
• Identify certain criteria where claims could be pended or put on hold for processing.
• Send claims files to agency for review.
• Provide trend reductions.
• Reduce downstream costs.
• Improve overall measures of quality.
• Identify new opportunities for savings.
• Provide reimbursement management.
• Evaluate tests for patients.
• Provide a clinical team to review appeals and support peer review requests.
• Provide support for denials.
- Evaluate current state of laboratory testing.
- Manage the use of testing by determining when a prior authorization is required from a physician before a test can be ordered.
- Review clinical evidence and medical necessity to determine outcomes for prior authorizations.
- Help develop policies that include determining coverage, reimbursement, and claims payments,
i.e., control testing by controlling the funding and payment for lab services.
- Guide physicians toward clinically actionable tests for members.
- Improve result interpretations and treatment decisions.
- Improve lab efficiency by reviewing lab protocols to ensure robust policies are followed.
- Assist in agency code identification and usage, facilitating full reimbursement for lab services.
- If agency identifies any claims (such as COVID blood draw and rapid testing) for the proposer to review, proposer shall coordinate efforts to identify this criteria.
- Agency turnaround time of 5 business days for review must be met.
- Prevent unnecessary testing and recommend labs that perform reliable testing.
- Provide a team of clinical and legal support services that help determine policies based on different sources such as agency codes, evidence-based literature, laboratory, and medical policies, thus promoting higher quality results.
- Educate providers if there is an error or otherwise incorrect claim filing, reducing such instances to reduce financial impact to agency.
- Use all appropriate safeguards to prevent unauthorized use or disclosure of agency data, including member protected health information (“phi”).
- Offshore services. All services shall be provided within the states or a territory of the states.
- This requirement applies to proposer’s employees, subcontractors, and location where agency.
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: May 12, 2025