Third Party Contract Management and Billing Service

The Vendor is required to provide and manages the enrollment and applications to hundreds of third-party prescriptions plans so that the department pharmacy can adjudicate claims for prescription third party payments.
- Provide management for all Medicare D payers, including rate negotiation, claim inquires and credentialing.
- Claims reconciliation, specifically, pharmacy claims review and editing tools designed to improve reimbursement accuracy and reduce payer auditing risks.
- Contract Administration:
•    Create and manage contracts for pharmacy services.
•    Conduct negotiations with pharmacy benefit managers (PBMs) and wholesalers to secure favorable pricing and terms.
•    Ensure contracts comply with state and federal regulations, including but not limited to:
- Compliance Monitoring:
•    Monitor compliance with all federal and state pharmacy benefit regulations.
•    Conduct regular audits of prescription drug claims to ensure correct payment and utilization.
•    Develop and implement corrective action plans for non-compliance findings.
- Pharmacy Benefit Design:
•    Assist department in designing pharmacy benefit plans that promote the appropriate, safe, and cost-effective use of medications.
•    Implement formulary management strategies and prior authorization protocols to enhance quality while controlling costs.
- Claims Processing:
•    Provide claims processing services, ensuring accuracy and timeliness in adjudicating pharmacy claims.
•    Ensure integration with existing state health information systems to streamline operations.
•    Maintain detailed records of claims data for performance analysis, financial forecasting, and reporting purposes.
- Data Analytics and Reporting:
•    Provide performance analytics related to pharmacy utilization and spending.
•    Prepare and submit quarterly and annual reports on pharmacy trends, savings, compliance, and outcomes.
•    Implement an electronic reporting dashboard for department stakeholders.