Third-Party Administrator Services

The vendor is required to provide third-party administrator that is currently administering health insurance benefits.
- The Prospective Contractor shall currently provide Medical Management services to a minimum of 50,000 Participants.
- The prospective contractor shall have an advanced claims analytics/predictive modeling software platform; an “advanced claims analytics/predictive modeling software platform” is designed to query and explore the plans’ health care related data to identify chronic conditions; this gives the user the ability to do in-depth queries and combine data sets which will identify risk mitigation opportunities within the data while statistically validating the outcome efficacy of the chosen solutions.
- Enrollment and changes made during the annual Enrollment period must become effective at the beginning of the new Plan Year
- Provide adequate resources to investigate unusual incidents and develop corrective action plans.
- Provide all health insurance services (self-funded) described throughout this with the understanding that the health insurance services may be selected on an a la carte basis.
- The Contractor shall serve as TPA, interpret and define medical coverage policies, eligibility of benefits, and defined Member assistance.
- Provide a blank copy of all provider/facility contracts that will be used during the life of any resulting contract, including special programs such as: value-based programs, accountable care organization, and global payment arrangements.
- Provide all fee schedules used for claims adjudication process, as well as denial codes and meanings, on award of any resulting contract during implementation phase. Contractor shall include fee schedules for all special programs such as: value-based, accountable care organization, and global payment arrangements.
- Provide Transparent administration of all Services required by this, including, but not limited to, claims adjudication process, financial reporting, administration, and reimbursement practices and procedures, and shall make available all aspects of the Contractor’s operation and/or financial accounting for department review regardless of confidentiality, proprietary, or exclusive rights and/or privileges.

- Contract Period/Term: 1 year