Health Care Revenue Cycle Management and Electronic Health Records Solutions

The vendor is required to provide electronic health records (EHR) solutions and healthcare revenue cycle management (RCM) services for delivering solutions that support the secure management of student health information, insurance claims processing, and compliance reporting.
- Electronic health records (EHR) capabilities:
1. Scheduling, student data, and portal access:
a. Online appointment scheduling:
•    Ability to interface with, at minimum, sis, workday, oracle and element 451, slate, and salesforce, to ensure patient is a student.
•    Ability to develop and modify information required for students to establish profiles to schedule.
•    Ability to collect required information via online forms or fields prior to scheduling.
•    Ability to generate automated reminders via text message. 
b. Student data integration and verification:
•    Customizable forms to collect required student information prior to scheduling.
•    Secure portal for scheduling, uploading forms, and submitting insurance documentation.
c. Student portal and mobile app:
•    Act-compliant portal and preferably a mobile app where students can view records, notify and confirm scheduling, upload documents, message clinicians, and access test results.
2. Clinical documentation and workflow:
a. Documentation and workflow efficiency:
•    Streamlined processes for documenting daily treatment and rehabilitation sessions.
•    Capability to create and modify custom evaluation templates.
•    Ability to tailor visit templates by encounter type (e.g., primary care, mental health, women’s health, athletic training, etc.). includes support for clinical decision support tools and templates.  
•    Support for importing, storing, and exporting images.
•    Web-based platform that can be accessed while off-campus.
b. Mental health and counseling notes:
•    Functionality to document behavioral health visits in a secure and confidential manner, with access control to restrict sensitive records.
c. Form builder and workflow automation:
•    Ability to build electronic forms (e.g., consent forms, health history, primary insurance coverage, athletic participation status), automate routing, and digitally collect signatures
3. Integrated care tools
a. Integrated telehealth:
•    Native or integrated telehealth functionality compliant with acts, with secure video conferencing and documentation workflows.
b. Integrated e-prescribing (ERX):
•    Integration with sure scripts or other e-prescription platforms to send prescriptions to local or campus pharmacies, with support for controlled substances (EPCS).
•    Ability to integrate with the prescription drug monitoring program (PDMP).
•    Ability to provide allergy warnings and drug interactions. 
c. Immunization compliance tracking:
•    Ability to upload and track immunization records.
•    Ability to integrate and verify with state immunization registries is preferred.
•    Ability to verify compliance.
d. Occupational health tracking:
•    Functionality for tracking staff or student workers’ occupational health requirements (e.g., tb testing, annual physicals).
e. Health education and outreach tools:
•    Support for mass communications, targeted messaging, and student health campaigns (e.g., flu shot clinics, wellness events).
4. Interoperability, reporting, and communication
a. Claims management and reporting:
•    Ability to export data for insurance claims in industry-standard formats.
•    Customizable reporting capabilities, including but not limited to daily injury logs, claims reports (submitted, status, paid, etc.), attendance tracking, and participation status.
•    Preference for the ability to generate reports using aggregate data from the system participants.
b. Interoperability with campus systems:
•    Integration with the campus student information system (sis), examples include learning management system (LMS), and identity management for seamless user authentication and record synchronization.
c. Secure messaging:
•    Act-compliant internal and external messaging between students and providers, with audit logging.
- Health care revenue cycle management (RCM) capabilities
1. Patient registration and insurance verification
•    Capture and maintain accurate demographic, insurance, and eligibility information for students (and, if requested by the institution, faculty and staff).  
•    Perform real-time insurance eligibility checks, upon student arrival and registration, and monthly thereafter to ensure students remain covered, including coverage levels, co-pays, deductibles, prior authorization requirements, and coordination of benefits.  
•    Verify all student health insurance coverage and support institutional policies for coverage verification, indigent care, and documentation.  
•    Provide notice to participating departments if coverage is no longer valid.
•    Manage credentialing and empanelment of university clinicians with payer organizations. 
•    Support verification workflows including confirming the accuracy and completeness of information submitted for a claim, ensuring the policy is valid, and that the services or incident fall under the coverage terms
2. Charge capture and coding:
•    Record all billable services, procedures, and supplies provided by campus healthcare providers.   
•    Certified CPT and ICD-10 coders must review clinical documentation for coding accuracy.
•    The system must automatically update with icd-10 changes and end-user updates no later than January 1st of the following year, at no charge to the university or institution.
•    Support integration with existing EHR systems and assist in creating encounter forms to align charge capture with institutional workflows. 
3. Claims preparation, scrubbing, and submission:
•    Generate and submit claims in compliance with payer requirements 
•    Include claim scrubbing for coding accuracy, modifier use, duplicate detection, and other payer-specific edits.
4. Claims tracking, adjudication, and denial management:
•    Track all submitted claims from acknowledgment through adjudication, with visibility into unbilled or unpaid claims  
•    Provide dashboards and alerts for rejected, denied, or pended claims requiring follow-up.  
•    Assume responsibility for follow-up on all rejected, denied, or unpaid claims, including appeals.
•    Perform denial analysis and reporting to reduce recurring issues.  
•    Notify institutions promptly when processing errors occur.  
•    Facilitate reporting on claims acceptance and first pass resolution rates.  
•    Identify, categorize, and report denied or rejected claims.  
•    Automate workflows for correcting errors, resubmitting claims, and appealing denials.
•    Provide root-cause analysis to reduce recurring denials (e.g., coding errors, eligibility issues, missing documentation).  
5. Payment posting and patient responsibility:
•    Post payments received from insurance carriers or third parties, including reconciliation with explanation of benefits (EOB) and electronic remittance advice (era).  
•    Ensure that all payments are remitted directly to the institution.   
•    Develop and supply templates that enable institutions to communicate with parents and guardians regarding insurance claim processes, explanation of benefits, and requirements for remitting outstanding balances to the university for services provided.    •    Support secondary claim submission, when requested by the institution, where primary insurance does not cover the full charge.  
•    Provide transparency into patient balances while respecting institutional policies and practices on co-payments and sensitive visit exclusions.
•    Provide remittance advice for insurance companies payments made to allow campus and audits to reconcile claims to payments.   

- Contract Period/Term: 1 year