Third Party Administrator Services

The vendor is required to provide to serve as a third-party administrator (TPA) for its employee group health, vision, and dental insurance benefits.
- Eligibility and enrollment: managing member enrollment, changes, and terminations, ensuring compliance with plan documents and applicable regulations.
- Provide explanation of the TPA'S approach to eligibility and enrollment management, including the ability to handle electronic eligibility data.
- Claims administration: processing medical claims accurately and efficiently, including managing provider relations, conducting claims adjudication, and handling appeals.
- Provide a comprehensive overview of the TPA'S claims administration process, including claim adjudication procedures, quality control measures, and auto-adjudication rates.
- specify if the claims system is leased, owned, or outsourced and list any involved vendors.
- Customer service: providing comprehensive customer service to plan members and agency benefits administration staff, including a dedicated toll-free number and online portal access. 
- Bilingual (Spanish) communication capabilities are preferred.
- The TPA'S customer service model, including call center operations (hours, location, bilingual capabilities), online portal features for members and administrators, and service level agreements (SLAS).
- Provider network management: managing and maintaining relationships with provider networks, ensuring adequate access for plan members within the city, and surrounding areas.
- Utilization management: implementing and managing utilization review programs, including pre-certification, concurrent review, and case management, to ensure appropriate and cost-effective healthcare utilization.
- The TPA must describe their data reporting and predictive modeling capabilities.
- Contract Period/Term: 5 years
- Pre-Proposal Conference Date: July 30, 2025
- Questions/Inquires Deadline: August 05, 2025