Medical Claims Management Services

The vendor is required to provide medical claims management for medical insurance reimbursement.
- Contract intake and payment system implementation
•    Implement and maintain systems to intake certain agency provider contracts and manage associated payments. 
•    This will require the selected proposer (hereinafter referred to as “contractor”) to understand the terms and conditions of the contracts between third-party vendors and the county on behalf of agency and the associated cost, prices, and rates that are payable by the agency under those contracts. 
•    Conduct quarterly contract review meetings with agency to ensure contract terms, reimbursement rates, and operational workflows remain current. 
•    This includes the contractor providing to agency all information and reports requested by agency, including reports relating to the claims adjudicated, processed, or reprocessed, by the contractor over a given period of time.
- Eligibility processing
•    The ability to navigate agency epic electronic health records system to review patient admission and discharge information for the purpose of determining payment sources for payment of third-party vendors for services rendered or goods provided under the contracts and to determine eligibility for payment of the third-party vendors. 
•    Apply defined county-specific rules to determine eligibility for claims payment. 
•    Coordinate data flow from eligibility determination into the claims adjudication system.
- Claims intake and processing
•    Manage all incoming claim files through:
o    837p electronic claim files.
o    Centers for medicare and medicaid services (CMS) 1500 paper forms, including scanning and office conversion.
•    Store and archive raw 837p flies in an electronic data interchange (EDI) system.
- Provider data management
•    Verify and load provider national provider identifier (NPI) information to ensure proper claims routing and processing
- Claims adjudication and payment
•    Adjudicate claims submitted by third-party vendors to agency, based on eligibility and contract terms. 
•    County-defined invoicing processes to authorize and release claims payment funding.
- Retroactive claims reprocessing
•    Reprocess claims where the original claim was improperly processed due to the county entering into new contracts or amendments to contracts with updated pricing or other new terms and conditions.

- Contract Period/Term: 5 years
- Questions/Inquires Deadline: September 2, 2025