The Vendor is required to provide workers compensation (WC), motor vehicle accident (MVA), and third-party liability (TPL) services for its hospital (HB) and professional (PB) billing and collections.
- Health has an extensive network of off-campus ambulatory locations throughout the County that provide physician clinic services (primary, express, and specialty care), urgent care, imaging, infusion, laboratory, and other health care services.
- Claims management
• Monitoring and working claim billing and follow-up inventory tasks from epic work queues.
• Processing billing edits and submitting electronic and paper claims.
• Submitting claims with medical records or other attachments, as needed for the purpose of invoice reimbursement (electronic or paper).
• Placing appropriate liens on workers compensation accounts to gain access to reimbursement.
• Manage and communicate legal hearing processes and associated paperwork.
• Coordinate and manage patient/employer outreach to obtain supporting and/or necessary information needed to bill clean claims and collect full expected reimbursement for services invoiced.  
• Work with patient and/or patient’s employer to obtain all necessary documentation to support claim.
- Insurance accounts receivable (A/R)
1. Follow-up
• Validating claim receipt/status (including any claims that had to go out on paper).  
• Monitor and manage claim filing receipt and adjudication processing for electronic and paper submitted invoices.
• Manage and coordinate timely follow-up and AR balance resolution for all in-scope inventory assigned:
• Monitor and document claim processing status in the epic account at minimum every 30 calendar days where no transaction or correspondence has been received from payor.
• Follow-up on accounts where no response has been received from payor.
• Monitor and document claim dispute actions and status in the epic account at minimum every 30 calendar days where claim denials are received from payor.
• Follow-up on denied accounts (see further detail under “denial management”) including contacting payers, reviewing contract terms provided, and cross-walking CPT codes based on client instruction.
- Denial management – worked out of epic work queues
• Review and appeal denials.
• Coordinate and manage timely dispute and appeal submissions according to agency reimbursement contracts.
• Partner with agency coding and operational teams to resolve coding denials and denials needing operational input.
• Partner with agency internal operational teams to obtain coding changes or other claim data changes needed to rebill or dispute claim denials.
• Review and address underpayment issues.
• Manage and trend claim underpayment issues in observance of agency reimbursement contracts and payor billing guidelines.  
• Use payor appeal/dispute methods to pursue full expected reimbursement for services invoiced.
- Contract Period/Term: 3 years
- Pre-Proposal Date: February 5, 2025
- Questions/Inquires Deadline: May 13, 2025