Third Party Claims Administrator Services

The vendor is required to provide third-party medical claims administrator capable of delivering high-quality, employee-centered service while supporting the municipality’s commitment to responsible financial management.
- Administrative services
• Establish, maintain, and update master record file(s).
• Provide and update administrative manuals.
• Prepare and print all plan documents:
o Group policy and plan document
o Administrative services only (ASO) contract
o Policy amendments
o Certificates
o Summary plan description (SPD)
o Summary of benefits and costs (SBC)
o Other documents as may be required by federal state and local laws
• Furnish all standard forms to be used in connection with the administration of the plan:
o Enrollment forms
o Claim forms
o Id cards
o EOBS
o Any additional forms proposer wishes to review.
• Confirm if the above documentation is created in house or if any or all documents are outsourced.
o If outsourced, provide a list of outsourced services along with name, address and descriptions of the company providing the services.
• Review, in a consultative capacity, summary plan descriptions and other similar material to be distributed to plan participants.
• Assist in establishing plan claims payment account and monitor status of account balance.
- Claims processing services
• Provide instructions outlining proper claim submission techniques.
• Current percentage of claims that are submitted electronically
• Determine if benefits are payable.
• Maintain and update eligibility file.
• Notify claimant and service provider of claims payment decisions.
• Administer the plans' coordination of benefits (cob) provision.
• Coordinate payment of benefits with Medicare when applicable.
• Review claims submitted for medical services that appear excessive and establish medical necessity for services rendered or expenses incurred.
• Make available the services of field claim consultants and professional services resources for the evaluation of complex claims.
• Maintain peer review relations.
• Discuss disputed charges with providers when appropriate.
• Make reports to the IRS and furnish separate statements to providers of medical services as required by the internal revenue code regarding amounts paid to such providers.
• Maintain and store claim detail data elements for statistical analysis.
• Online claim viewing access to participants.