Third Party Administrator to bill State Medicaid Services

The Vendor is required to provide the a third-party administrator (TPA) versed in billing a state medicaid agency for specific healthcare services provided to inmates 90 days prior to release from jail.
- Services include:
• Identify, inform, and resolve documentation and transmission errors and issues preventing the TPA from transforming encounter documentation into complete, error-free claims.
• transform, as necessary, encounter documentation received from the contracted providers of healthcare services into appropriately formatted ANSI ASC x12n 837i v.5010 electronic claims or ub04 or CMS-1500 paper claims that conform with department medical fee-for-service (FFS) claims submission requirements.
• Collaborate with the agency the medical transformation (CalAIM) Coordinator and the agency Finance team to design, implement, and oversee revenue cycle management (RCM) processes wherein the reconciliation of payment received for submitted claims is appropriately incorporated and, as appropriate, payment to the agency contracted providers and/or the TPA is administered.
• Appropriately investigate and, as necessary, resolve and resubmit rejected and denied claims while simultaneously addressing the root cause(s) to eliminate or reduce future-like occurrences.
• Provide the agency CalAIM Coordinator and agency Finance team with mutually agreed upon recurring reports summarizing billing services provided, including but not limited to:
1. Claims submitted and related status, charge payment received, errors, rejected and denied claims, charge, and claim lag time, accounts receivable summary and detail reports, A/R days, and average time of claim resolution each month.
2. Quarterly and annual trend reports.
• Implement an electronic bi-directional interface predicated on ANSI ASC x12n 270/271 enrollment/eligibility verification transactions with department automated eligibility verification system (AEVS) to ensure that only claims for specific healthcare services delivered to individuals who qualify for 90-day pre-release services with an active JI aid code on the date of service are submitted to department for reimbursement.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: March 10, 2025