The vendor is required to provide secondary insurance coverage and healthcare claims administration services to inmates in accordance with the following:
- Provide access to its provider network of healthcare providers and health claims processing services to incarcerated individuals in the care and custody of correctional housing facilities under the authority of the county.
• Develop and maintain a statewide and national network of institutional and professional providers (including but not limited to dentists, physical therapists, podiatrists, durable medical equipment (DME) providers, and local ambulance squads) who, by contract, agree to provide services onsite and offsite, as defined below.
o Onsite services: physical therapy (PT) and occupational therapy (OT) rehabilitative care, podiatrist, OBGYN (capital woman’s health).
o Offsite services: dialysis (DAVITA), oral surgery off-site, and in ova healthcare systems. • The credentialing of providers, maintenance of the network and communications with providers shall be the responsibility of the contractor.
• The contractor and the providers must include a claims submission timeliness criteria for reimbursement.
• Dedicate a customer service unit for the adult detention center (ADC) to process claims, determine eligibility and provide customer service to the ADC finance and health services units, to include review of inmate coverage as requested, provide copies of provider claims as requested, dispute provider claims as requested, and any other requests submitted for claims review and processing.
• Accept both computerized and manual eligibility updates.
• Ability to receive updated enrollment data transmitted twice a week and reflect updated coverage for all ADC inmates.
• Administer claims reimbursement to ensure the best available rate reimbursement, with no patient liability.
• Administer special provider arrangements between the ADC and selected providers.
• Provide customized detail claims information, in both hard copy and electronically, that segregates claim into the facility outpatient, facility inpatient, provider outpatient, provider inpatient, dental and pharmacy;
• Provide monthly reports by covered patient, detailing claims paid (including in-network and out-of-network costs) for each of the following categories:
o Inpatient facility claims
o Outpatient facility claims
o Professional provider claims
o Dental claims
o Retail pharmacy claims
• Provide an annual utilization report that includes the following information by age, group and sex:
o Current and prior year comparisons
o Service rates for inpatient, outpatient and professional services
o Expenditures by facility and provider
o Average length of stay for inpatient admissions
o Prescription drug detail
o Age and sex demographics of claims paid
• Provide an annual report summarizing and analyzing costs incurred for the county fiscal year (july1 through June 30).
• Provide costs and claim data for each type of service by defined age groups and sex demographics.
• Provide clinical and financial reports to the county to meet their budget and administrative needs.
• Provide insurance cards specific to ADC.
• Provide member ids specific to each ADC inmate;
• Provide financial forecasts (i.e., projections on medical care costs, trend analysis, etc.) to include assessment of inflation rates and utilization trends for the ADC population;
• Provide efficient and effective benefit coordination with Medicaid and other potential payment options;
• Provide a monthly utilization report, that should include length of stay, and any specialty services (i.e., surgery, etc.)
• Purchase additional managed care products (
i.e., discount on referrals to out-of-network doctors, discount for in-office patient treatment at set times, etc.).
• Provide claims analysis ad hoc as requested by the ADC (health services administrator (HSA), director of health and human services (HHS), admin staff, support services major).
• provide health claims processing including, but not limited to, the following:
o Maintaining a system for reviewing the continuing healthcare expenditures for services provided;
o Providing utilization management on a consultative basis (i.e., improvements for care, payment incentive review, quality of care rendered, etc.);
• Provide claims submittal training on the contractor’s billing system to the sheriff’s office staff.
- Contract Period/Term: 3 years
- An Optional Pre-Proposal Conference Date: May 01, 2025
- Questions/Inquires Deadline: May 16, 2025