Medical Claims Admin Services

The vendor is required to provide medical claims admin services for include:
- Medical claims administration
1. Core claims and eligibility administration
•    Medical claims adjudication and payment integrity
•    Eligibility file processing and sharing
•    Cobra administration
•    ESRD medicare coordination
•    Subrogation and recovery
•    Out-of-network claims administration and savings programs
•    Pre-adjudication audit capabilities
•    Compliance with aca and other regulatory reporting
•    Development and distribution of plan documents, summaries, and custom id cards
2. Provider network management
•    Maintenance of a national provider network
•    Transparent and effective provider contracting and relations
•    Administration of a site of care program for select transfusions designed to direct care to the lowest intensity clinically appropriate site of care
•    Accurate and timely updates to provider lookup tools
•    Tiered network administration
•    Support for direct contracting arrangements
•    Administration of site of service (SOS) and other high-value care programs
•    Implementation and management of value-based and episode-of-care contracting
•    Customized high-performance network for non-bargained plan offerings
•    Behavioral health network adequacy and access
3. Clinical care and population health services
•    Utilization management and prior authorization
•    Member education and engagement regarding treatment options
•    Integration with PCI and other programs for coordinated care
•    Identification and outreach for chronic conditions and high-risk member management
•    Access to expert medical opinions and second opinions
•    Treatment decision support and clinical guidance
•    Virtual consultations and telephonic nurse line
•    Complex case management
•    Early identification and engagement for high-cost claimants
•    Appeals management and medical necessity determinations
•    Access to lab data and admission and discharge alerts
•    Integration with third-party and digital point solutions
•    Hep chronic condition management and education
- Member advocacy and health enhancement program administration 
1. Member services and navigation
•    Central call center with extended hours and escalation protocols
•    Non-telephonic path for member assistance (i.e., live chat, ai-generated support)
•    Assistance with benefits, claims, provider search, and appointment scheduling
•    Customizable, mobile-friendly benefits portal branded “care compass”
•    Integrated provider lookup tools and plan resources
•    Secure single sign-on to access all vendor platforms
•    Employer tools and editable messaging functions for office staff
2. Open enrollment support
•    Online plan selection and enrollment system with integration to PeopleSoft
•    Interactive decision support tools for members
•    Staffing for virtual and in-person open enrollment events
•    Call center staff training on open enrollment topics
3. Member communications and program support
•    Execution of ad hoc outreach campaigns and educational initiatives by postal mail and e-mail
•    Administration of temporary or pilot programs as needed
•    Coordination and referral to digital point solutions and third-party services
4. Health enhancement plan (HEP) administration
•    Claims-based tracking of preventive and chronic care identification and compliance
•    Member self-monitoring tools (web and app) for hep completion
•    Direct provider outreach to confirm completed but unprocessed services
•    Ongoing member education and engagement on hep requirements
•    Communications strategy including compliance reminders and penalty notifications
•    Dedicated team of clinical and customer service professionals
5. Care management and clinical services
•    Chronic disease outreach and care coordination (especially hep chronic condition members)
•    Data sharing from providers, Connie, and lab sources
•    Real-time member monitoring and support for er or inpatient discharges
•    Complex case management and nurse support line
•    Appeals and prior authorization support
•    Integration with PCI and providers of distinction programs
•    Identification of care gaps, risk stratification, and patient navigation
- Primary care initiative (PCI) program administration
1. Program administration and operations
•    Management of provider group contracts and reconciliation processes
•    Engagement support (webinars, meetings, performance reviews)
•    Seamless integration with other vendor partners (advocacy, point solutions, pharmacy, etc.)
•    Maintenance of monthly attribution and provider panel updates
•    Development of protocols for provider referrals to third-party services
•    Full automation and integration of all program reporting by July 1, 2026
2. Reporting and analytics
•    Real-time quality and financial performance reporting
•    Monthly claims data feeds (including third party pharmacy)
•    Weekly or daily sharing of pre-certification data for attributed members
•    Identification and outreach of high-risk and at-risk members
•    Comprehensive population health tool with:
o    Access for providers and office
o    Integration of formulary and pricing data -potential cost opportunities, utilizing alternative, high-value medications such as those reported by agency
o    Stratification by race, ethnicity, language, and agency
o    Incorporation of providers of distinction designations
•    Benchmarked performance reporting
•    Technical specifications for financial and quality targets are released 30 days before the start of the Reconciliation period, giving provider groups advance notice of the coding and methodology of how quality is being measured.
3. Staffing and technical resources
•    Dedicated clinical team for provider engagement and performance analysis
•    data analyst to support ad hoc and program reporting
•    Project management resources to ensure timely delivery of program enhancements
•    Dedicated contracting staff for provider agreements
•    Allocation of hours and support from technical, economic, and it teams as needed
•    Office approval of finalist candidates for key roles and replacement hiring within agreed timeframes
- Municipal employees health insurance program (MEHIP)
•    Provide third party administration and record keeping services for the MEHIP;
•    Develop and maintain a website for the MEHIP that contains information on the program, plans
•    Available and permits potential customers to obtain on-line rate quotes;
•    Collect and account for all premiums collected and disburse funds to the appropriate health care
•    Carrier authorized to provide coverage through the program;
•    Develop professional marketing materials and maintain sufficient supplies to vigorously market the program;
•    Develop a strategic marketing plan that includes, attending marketing meetings, giving presentations
•    To potential participants, outreach to business organizations, non-profit organizations, broker and trade groups;
•    Respond to all quote inquiries from broker and client regarding quote, differences in plan designs, and MEHIP in general. 
•    Obtain clarifications from carrier and transmit to broker when census of data changes;
•    When sold, verify rates with all parties, provide broker all relevant setup materials including MEHIP
•    Customized forms, plan summaries, SBC's, business associate agreements between administrator and group. 
•    Obtain printed material from carrier and distribute employee kits when requested. 
•    Answer all questions from group, broker or participants regarding plans and benefits.
•    When requested, conduct on-site employee meetings for sold cases.
•    Obtain signed installation documents, transmit to carrier, including checking enrollments for completeness, following up with group if not complete, securing binder check, completing communication sheet for the carrier and completing internal processes to enroll group.
•    Update the billing system with the new group, plans and rates. group can offer multiple plan options
•    Regardless of size.
•    Update the billing system with enrollment data. enter enrollment from paper forms when required by carrier or employer group.
•    Act as liaison with the carrier during the entire installation process. including printing temporary id cards if carrier does not enroll group in a timely manner, contacting providers to confirm coverage, obtaining written benefit confirmations from carrier for scheduled procedures);
•    Provide cobra administration services;
•    Provide account maintenance services.

- Contract Period/Term: 3 years
- Questions/Inquires Deadline: August 7, 2025