Medical Billing and Claims Management Services

The vendor is required to provide medical billing and claims management services for the review and processing of claims.
1. Records management software system for division and vendor staff use
•    Provide electronic records management of victims' files. 
•    Use includes but may not be limited to create and view victim client files, maintain provider information, organize documents, review claims, update claim statuses, send communications, record notes, manage payment information, search, apply multiple levels of approval for transactions, and run robust dynamic and ad hoc and template data reports. 
•    Division staff should be able to assign system access, access levels, and terminate user access.
2. Application receipt and review. 
•    Receive victims’ applications and backup documentation from victims and providers, allowing for a variety of submission formats to accommodate victims’ situations. 
•    Review applications for eligibility, allowability, and completion. 
•    Establish victim client file. 
3. Claims review and bill negotiation
•    Provide claims and medical billing review for allowability, errors, fraud, waste, and abuse. contact providers to request additional documentation as needed. answer provider questions. negotiate with insurance companies and providers. 
•    Examples of allowable costs include medical and hospital, dental, vision, physical therapy, counseling, chiropractic, ambulance, bio-hazard cleanup, funeral expenses, relocation allowance, and lost wages
•    Review must include checks for: 
o    Allowable costs
o    Adherence to fee schedule
o    Miscoding
o    Unnecessary treatment 
o    Excessive treatment
o    Bundling, unbundling and re-bundling
o    Allowable treatment
o    Duplicate payments
o    Drugs and supplies allowances (based on national drug code fee schedule)
4. Payment processing
•    Provide the means for authorized users to process payments to individuals and providers through a variety of methods (paper, electronic payment transfer, etc.).
•    Prevent payments from exceeding authorized levels established by the state. 
•    As levels may change throughout a fiscal year due to program funding, the system must also be able to dynamically accept changes in payment levels for processing future claims as well as being able to project the effect of such changes on the current claims inventory.
•    Payment batches must be able to be segregated for processing by tier and payment type to enable prioritization.
•    Monitor and prevent duplicate payments. correct as needed. 
•    Allow for two levels of division approval on each payment. 
•    The system must allow authorized users to suspend or make exception payments on a case-by-case basis and provide a means to document the reasons for exception.  
•    At all times during the payment process, users must be able to view all supporting documents and claim information.
•    The system must provide division staff with the ability to schedule payments based on available funding. 
•    Scheduling must be allowed based on bill type and service dates. 
•    The system must also permit the program to reduce payments by selected percentages based on bill type and service dates.
•    The system must track and provide reporting on all subrogation payments received. 
•    A Breen formula calculator must be built into the system that allows users to determine appropriate subrogation payment amounts. 
•    Calculated results should be stored in the system to provide documentation for review by administrators.
•    Vendor must maintain a treasury management account at a bank selected by the state treasurer’s office for the purposes of payment issuance. 
•    Reconcile account monthly and provide detailed reporting to the administrative services division. 
•    Reports must include payments cleared, payments outstanding and payments voided. 
•    Process stops payments as required.
•    Check printing and mailing services are required. 
•    All payments approved by the program are to be mailed each week. 
•    Positive pay files must be uploaded to the bank treasury management system each week.
5. Communications. 
•    Customized communications to victims and providers. 
•    Communications must be recorded in the victims’ electronic records. 
•    Example communications subjects include claim approvals and denials, subrogation, closure, document requests, claim status, etc.

- Contract Period/Term: 1 year
- Questions/Inquires Deadline: August 28, 2025