Third Party Liability and Coordination of Benefits Services

The Vendor is required to provide comprehensive third party liability and coordination of benefits (TPL/COB) solutions that encompass the following core functional areas:
1. Identification and verification of third-party coverage
• Innovative data mining and matching techniques to identify unreported active commercial insurance, Medicare, and Tricare coverage.
• Processes for continuous, real-time (or near real-time) verification of member coverage to minimize the latency between a member obtaining other insurance and the state’s systems being updated.
2. Prospective cost avoidance
• Strategies for seamlessly interfacing with the state's Medicaid management information system (MMIS) and state Medicaid enterprise technology system (METS) and eligibility (impact) systems to maintain highly accurate, up-to-date TPL files.
• Methods for reducing false-positive TPL hits that improperly delay member care or burden providers.
3. Retrospective recovery (pay-and-chase)
• Capabilities in identifying and recovering funds for claims previously paid by Medicaid where a liable third party existed.
• Expertise in managing complex billing and recovery processes with commercial carriers, Medicare
4. Technological and modular integration
• System architecture that aligns with the centers for Medicare and Medicaid services (CMS) and state Medicaid enterprise systems.
• Use of advanced analytics, artificial intelligence (AI), or machine learning (ML) to predict TPL and streamline workflows.