Medical Claim and Billing Clearinghouse Services

The vendor is required to provide medical claim and billing clearinghouse services for include:
- Electronic claims submission and management
•    Facilitate the secure electronic submission of medical claims to various payers, including medicare, Medicaid, agency managed care plans, and commercial insurance companies.
o    Claims submission includes primary, secondary, and tertiary claims.
•    Accept claims data and submit to payers in the required ANSI x12 837 formats.
•    Provide real-time tracking with claim status updates through the submission cycle.
•    Provide proof of timely filing.
•    Ensure compliance with all applicable federal and state regulations, including act standards, to maintain the confidentiality and security of protected health information (phi).
- Claim scrubbing and validation
•    Implement claim scrubbing tools to identify and correct errors in claims prior to submission, reducing claim rejections and denials.
•    Provide detailed claim rejection information and correction instructions.
•    Allow for claim editing directly into the system for correction and resubmission purposes.
•    Validate claims against payer-specific requirements and industry standards to ensure accuracy and compliance.
- Payer enrollment
•    Provide resources for streamlined enrollment with newly identified payers.
•    Provide real-time enrollment status.
•    Provide payer connections to a minimum of 2,000 different payers.
- Electronic remittance advice (era) management
•    Provide electronic remittance advice and ANSI x12 5010 compliant 835 files to streamline the posting of payments and adjustments.
•    Provide access to remittance advices as they are issued by the payer.
•    Provide historical access to remittance advices for a minimum of 2-years from the date the document is issued.
- Denial management and reporting
•    Provide tools and support for tracking and managing claim denials, including root cause analysis and corrective actions.
•    Offer detailed reporting on denial trends and payer-specific issues to inform continuous improvement efforts.
- Compatibility with existing systems
•    Platform must be compatible with both Zoll rescue net and image trend billing bridge systems.
•    Provide technical support and assistance during the implementation phase to facilitate smooth system integration.
- Compliance and security
•    adhere to all relevant federal and state regulations, including act, to ensure the confidentiality and security of phi and compliancy of claim submissions.
- Training, maintenance, and support
•    Offer training programs for department staff on the use of the clearinghouse services and tools.
•    Provide ongoing technical maintenance and support to address any issues or questions that may arise during the contract term.
- Clearinghouse information technology (IT) safeguards
•    The service provider must demonstrate robust information security and compliance practices suitable for handling protected health information (PHI) and other sensitive data.
o    Multi-factor authentication: ensure systems and user access are capable of supporting multi-factor authentication for all users accessing phi or sensitive data.
o    Independent security certification: provide evidence of an independent third-party audit or certification demonstrating the effectiveness of its information security controls.
o    Equivalent independent security certification or assessment demonstrating comparable information security controls.
o    The service provider shall provide a signed attestation or formal statement confirming compliance with the stated certification(s).
o    Continuous cybersecurity monitoring: maintain continuous cybersecurity monitoring, detection, and response capabilities to safeguard against unauthorized access, intrusion, or data loss.
o    Data residency: ensure that all phi and related sensitive data is stored and processed exclusively within the country.

- Contract Period/Term: 1 year
- Questions/Inquires Deadline: September 10, 2025