Third Party Claims Data Matching Services

The vendor is required to provide both pre-payment services and post-payment recovery services for coordination of benefits (cob) and third-party recovery.
- This should include, but is not limited to, data matching, direct bill, and disallowance procedures for cob post-payment recovery.
- The vendor will conduct data matching with “insurers” as defined in department 58-12-26 which includes, but is not limited to insurance companies, employers, third party administrators, and pharmacy benefit managers.
• The vendor will demonstrate their ability to conduct a national match between insurer information and the department’s file using a format agreeable to the insurer and the vendor
• The vendor will demonstrate their ability to receive from and submit data matches to the department’s sftp site in the format specified by the department
• Successful data matching is limited to circumstances where insurance coverage is located for a client during the period of time, they were a Medicaid-eligible recipient.
- Frequency of data match shall be no less than once per month.
- The vendor shall establish and provide the timeline of data match activities.
- Vendor must demonstrate its procedures to ensure the accuracy and reliability of insurer data match information before providing data to the department.
- Provide reports of data match at least monthly and will provide established procedures for dispute resolution including notice to the department for unresolved issues
- Include at a minimum: the names of insurers contacted for data matches, the date when those insurers were contacted and the date they provided data matches, the number of successful data matches provided and sorted by each insurer, the client names on successful data matches and those insurers who did not respond to the request for data matches.
- Vendor will not utilize department’s federal tax identification number (tin) without prior authorization.
- Web applications or other information verification systems requiring the tin, the vendor will request the department to enroll in applications, at no cost to the department, and request department to grant vendor access to application.
- The vendor will not use state equipment, supplies, or facilities, unless otherwise agreed upon.
- The vendor will refund/credit the cost of the data match if, within 60 days of the data match, it is discovered the match was made in error.
- Vendor will receive department information via the department’s sftp site at regularly scheduled intervals to be determined by department and vendor.
- Vendor will demonstrate their ability to perform cob post-payment recovery services. direct billing:
• The state will provide the vendor member data, provider data, insurance data and paid claims data no less than once per month.
• Vendor will be responsible for identifying claims owed by a third-party payer.
• Vendor will bill claims to PBMS (pharmacy benefit managers)/carriers or providers for recovery
• Vendor will support a lockbox to securely deposit recovered monies from PBMS and carriers or providers.
• Vendor will report the recovered dollars and specific client and claim information to the state no less than once per month.
• Vendor will wire transfer the monthly amount due to the state.
• The state will process direct vouchers to reimburse the vendor for services rendered.
• Vendor will have a thorough denial and appeal review process.
- Vendor will demonstrate their ability to perform cob post-payment recovery services. disallowance:
• The state will provide the vendor member data, provider data, insurance data and paid claims data no less than once per month.
• Vendor will be responsible for validation, provider mailing, provider follow-up and provider appeals process to identify offset amounts for future claims.
• Vendor will report the disallowance offset amounts and specific client and claim information to the state no less than once per month.
• The state will use the disallowance offset amounts to either offset on future claims or collect the amounts due from providers via checks to tie to specific claims.
- Vendor will maintain a provider portal for all PBMS and carriers, providers, and the state to allow for a secure data environment with real time access and on-demand reporting.
- The portal will contain at a minimum:
• The portal will maintain medical record/documentation and claims data;
• The portal will maintain provider contact information;
• The portal will monitor progress and tracking data;
• The portal will have the ability to communicate directly within the portal;
• The portal will have to create on-demand reporting and have real-time access
- Provide established procedures for dispute resolution including notice of unresolved issues to the department within 30 days.
- Contract Period/Term: 2 years
- Questions/Inquires Deadline: March 11, 2025