Third Party Administrator Implementation Services

The vendor is required to provide third-party administrator services.
- Provide insurance benefit management, pharmacy benefit management, rebate administration, 340b administration, reporting and analytics, clinical programs, and eligibility management.
- This project is to improve efficiency, compliance, and client outcomes while decreasing administrative burdens.
- Improved efficiency and cost savings
• A TPA will simplify insurance benefit management, including premium payments, medical claims processing, and reconciliation.
• Pharmacy benefit management (PBM) services will guarantee accurate adjudication, coordination of benefits, and reimbursement.
• Automated tracking and processing of rebates will maximize financial returns from drug manufacturers.
- Enhanced compliance and accountability
• The TPA will offer expert oversight in regulatory compliance for insurance, pharmacy, and 340b programs.
• Monthly and quarterly reports on adherence, utilization, and performance will enhance data- driven decision-making.
• The contractor will oversee all aspects of eligibility verification and documentation to ensure effective service delivery.
- Reduction in administrative burden
• Outsourcing complex administrative functions will enable department staff to concentrate on direct client services and program development.
• A dedicated help desk offered by the TPA will assist clients and healthcare providers with inquiries related to claims, benefits, and pharmacy.
• The TPA will provide secure remote access to an integrated system for monitoring eligibility and processing claims.
- Strengthened provider and client support
• The TPA will handle provider enrollment, claims payment, and network expansion to ensure comprehensive access to care.
• Implementing client adherence programs, such as medication therapy management (MTM) and pre-exposure prophylaxis (prep) support, will enhance health outcomes.
• The TPA will distribute and manage client ID cards to ensure streamlined access to covered services.
- Insurance benefit management (IBM)
• Facilitate premium payments and claims reconciliation with insurance carriers.
• Provide secure online access for real-time eligibility tracking and payment monitoring.
- Pharmacy benefit management (PBM)
• Manage a statewide pharmacy network, including retail, mail order, and specialty pharmacies.
• Process and adjudicate claims with participating pharmacies and coordinate benefits.
• Conduct pharmacy audits and reimbursement tracking to ensure fiscal integrity.
- Rebate administration services
• Handle all aspects of drug rebate programs, including invoicing, collections, and dispute resolution.
• Provide detailed rebate reports to department for financial tracking and forecasting.
1. Detailed rebate report summaries
2. Pending rebate reports
3. Rebate forecast reports
4. Rebate manufacture dispute reports
- 340b administration services
• Manage eligibility, inventory, and wholesaler relationships for 340b program compliance.
• Conduct regular audits to ensure adherence to federal and state regulations.
- Contract Period/Term: 2 years
- Questions/Inquires Deadline: July 17, 2025