The vendor is required to provide online payment transaction services for social services for include:
• Claim management solutions.
• Customer service solutions, service portal.
• Audit and fraud prevention.
• Data reporting and analytics, knowledge management.
• Planning and implementation.
• Opportunities and annual updates.
• Accessibility design.
• Invoicing and reimbursement.
1. Claims management solution
a. Dental and denture services
• Adjudicate and pay eligible claims on behalf of the plan sponsor, the city.
• Coordinate benefits between the country dental and denture care plan and the city of schedule.
• Manage multiple fee schedules and policies and their limits within an agreed upon timeline
• Change fee guides and policies as requested by the city within a mutually agreed upon timeline.
• Determine the payable amount to be the lesser of either the dental and denture provider’s charge or the city’s approved limit.
• Verify procedure codes, fees and limits of codes per claim using fee schedules and any of the city’s policies, to determine eligible treatment frequencies and maximums prior to processing payment to the dental and denture provider.
• Verify limits per client, per claim, based on frequency, dollar amount, benefit and calendar year.
• Track treatments per client, by using the FDI world dental federation notation for numbering teeth (two numbers to represent the tooth in its quadrant and position) as well as tooth surface (labial, palatal, mesial, distal and incisal).
• Hosted solutions as well as additional services as part of the proposed offerings within the vendor's data center.
2. Customer service
a. Dental and denture services
• Accept and manage claims from dental v denture providers, whether electronic or manual (paper copy).
• It is the proponent’s responsibility to ensure all submissions or correspondence pertaining to claims are handled through a secure and encrypted method with the dental and denture provider.
• Pay eligible claims to dental and denture provider via electronic fund transfer or cheque.
• Notify dental and denture provider of an approved claim and provide details on payment remittance.
• Respond to dental and denture provider’s queries and concerns on claim payment status, denied or adjusted claims.
• Manage disputed claims, when denied or adjusted with the dental and denture provider.
• Develop a documented complaints and dispute resolution process.
• Liaise with dental and denture providers regarding treatment, eligibility, policy and fee schedules, claims processing and provider concerns.
• The overall customer experience by providing our residents and providers with enhancements that improve interactions and follow up through a modern, multichannel customer service contact center.
3. Audit and fraud prevention
• Ensure accredited fraud protection services are in place on the cash management accounts making payments to the dental and denture providers and landlord and tenants.
• The city has the right to audit the proponent’s compliance with the contract terms and regulatory requirements, including any sub-contracting services.
• Proponent will set up audit logs, monitoring compliance with data retention policies, and generating audit reports.
• Proponent will record customer interactions (e.g., phone calls, emails, web submissions) within the system for case tracking and auditing purposes.
• The solution as designed, configured, and implemented will ensure compliance with municipal audit and record-keeping policies, with configurable case reports (e.g., open cases, resolved cases, case by type, case by ward).
• The solution as designed and configured will have implemented version control systems to track revisions, restore previous versions if required, and audit for changes.
• The solution as configured and implemented will provide audit reports available to track case activity, timestamped notes, and report on integrity of all entries from open to close for use in legal cases.
• The proponent will be expected to perform related audit and certification work that may be required by various ministries and agencies of the provincial and federal government.
• The implemented solution will maintain an audit log of user interactions for transparency and compliance purposes.
a. Dental and denture services
• Assign a unique identifier for each claim received.
• Reject duplicate claims automatically.
• Confirm client eligibility for the dental and denture program for each claim submitted.
• Verify dental and denture provider’s license code and specialty code prior to claim payment.
• Ensure program compliance tracking measures are in place.
• Monitor and report to the city, any concerns of recipient and provider noncompliance, misuse, abuse, or fraud in real time.
b. Rent supplement program
• Assign unique identifiers for each respective tenant and landlord.
• Monitor any submission changes.
• Monitor and report to the city, any concerns of tenant and landlord noncompliance, misuse, abuse, or fraud.
4. Data, reporting and analytics
• The solution as designed, configured, and implemented will support dashboard and report drill-down functionality, allowing users to move from high-level metrics to detailed case data.
• The solution as configured and implemented will have reports and dashboards that will process data in real-time or near real-time and automatically update as new data is entered.
• The solution as designed, configured, and implemented will support reports that can be run on a schedule and support automated data exports in various formats.
• The solution as configured, and implemented will support role-based access controls that will restrict sensitive report data, and options for secure sharing through email or collaboration tools
• The solution as designed, configured, and implemented will provide data visibility control based on user roles or organizational requirements (e.g., restricting access to certain case types and case detail records).
• The solution as designed, configured, and implemented will support configurable security settings to control access to specific customer relations management (“crm”) entities (e.g., for confidential case records) and data masking and hiding policies for specific entities or fields as required.
• The implemented solution will identify trends, patterns, and anomalies in customer data and present insights through dashboards or reports.
• The solution will scale easily and seamlessly to accommodate future business growth in the number of users (e.g., 100 additional users), increased data volume, and the addition of new service modules and integrations.
• The solution as designed, configured, and implemented will comply with data privacy regulations and adhere to industry standard
• The solution as designed, configured, and implemented will have data retention policies that align with the city's record-keeping standards, supporting retention periods and public records compliance.
• The solution as designed and implemented will have proper data backup configured for regular automated backups, ensuring that data can be restored if lost or corrupted (e.g., daily, weekly, incremental)
• The solution tools and processes will accommodate other data migration and synchronization with existing systems or databases, including support for bulk import/export in various formats (e.g., csv, excel, xml).
• The solution as designed, configured, and implemented will provide reporting and analytics on contact and account data (e.g., service history, interaction trends, contact frequency, and by geographical wards).
• The solution as configured, and implemented will automatically log all interactions and allow staff to add manual notes with categorization and tagging for easy review and retrieval.
• The solution as designed and implemented will provide integration with external communication platforms (e.g., microsoft cloud and local email servers, and microsoft teams phone system) for connected and seamless data capture.
• The solution implemented will provide a configurable user interface for staff to manage contacts, accounts, and recent activities efficiently for their area of responsibility and interest.
5. Planning and implementation
• Provide at kick-off a documented plan for engagements with the various business stakeholders during the implementation including feedback loops, that clearly identifies tasks and timelines, roles and responsibilities of city and proponent.
• The plan will include a roll-back plan and contingencies plan to address any critical errors or failures during the migration as well as any potential risks to the implementation project and how they’ll provide an appropriate response plan for each risk.
• The proponent will conduct thorough integration testing in partnership with the city’s resources to ensure data integrity and consistency across all integrations.
6. Opportunities and annual updates
• Provide a business continuity plan to identify risks, maintain viable recovery strategies and plans, and ensure the continuity of service delivery through training, exercising, maintenance and review.
7. Accessibility design
• The successful proponent shall format all reports and communications to service users to meet the city's guide to accessible documents
• The solution as configured and implemented will ensure compliance with communication consent management and allow customers to manage their communication preferences.
- Contract Period/Term: 5 years
- Questions/Inquires Deadline: June 24, 2025