Third Party Administrator Medical Network Case Management Telemedicine Services

The Vendor is required to provide medical TPA-third party administrator, medical network, case management and telemedicine.
- A full-time Employee of the Employer who regularly works 30 or more Hours of Service per week (as defined by their Employer) and the elected members of the Governing Board of the school district will be eligible to enroll for coverage under this Plan once he/she completes a waiting period of 30 days from the date he or she completes at least one hour of service with the Employer.
- Participation in the Plan will begin as of the first day of the month following completion of the waiting period provided all required election and enrollment forms are properly submitted to the Plan Administrator.
- If an Employee has an employment contract with the Employer for the upcoming school year, eligibility for the Employee and their covered family members will continue during the months of June, July, and August.
- The Plan Administrator reserves the right to require such evidence as it deems necessary that a Domestic Partner satisfies the above eligibility requirements.
- TPA Services & Medical Network: Medical Plan Administration
•    General Administration
•    Pay all fees to all vendors for the medical, PBM, vision, utilization management, dental plans, and
•    Consultant fees, and provide an accounting of the payment of these fees monthly to the Client, their consultant and the Trust’s accountant/administrator.
•    Please include an implementation credit of $20,000 to be paid to the District within 60 days after the effective date.
•    Account Management
•    Provide a designated Account Manager and Account Management Team.
•    Customer Service
•    Provide customer service to answer inquiries on claims, eligibility, provider network, services, coverages, or other inquiries from participants Monday through Friday from 8:00 AM to 4:30 PM 
•    Provide prompt response to all telephone inquiries from plan participants and service providers.
•    Provide a toll-free number.
•    Open Enrollment Support
•    Prepare and provide Benefit Presentations and materials (Summary of Benefits documents, other pertinent plan information, as requested).
•    Attend Open Enrollment Meetings in Gilbert, Arizona, if needed, as requested.
•    Provide employee giveaways and raffle items at a quantity as requested by the District.
•    Telemedicine
•    Provide 24/7 telemedicine.
•    Booklets, Identification Cards, Certificates, Forms & Communication/Education Materials
•    Prepare Plan Document and amendments, as needed.
•    Prepare the Summary of Benefits and coverage (SBC’s) for all plans and provide Benefit Plan Booklets which describe the benefits and provide claims filing instructions.
•    Provide enrollment materials and claim forms.
•    Produce and mail medical ID cards.
•    Provide bilingual communication/educational materials.
•    Provide data to the Prescription Benefit Manager (PBM) for Identification Card generation.
•    Provide HIPAA Privacy Notices.
•    Claims Administration
•    Provide claim forms.
•    Receive claims and process payments of benefits in accordance with the plan designs for all claims incurred
•    Provide weekly claims billing invoices to the client.
•    Correspond with participants and providers if additional information is needed to complete processing of claims.
•    Prepare and file with the stop-loss carrier any specific and or aggregate stop-loss violation and annually provide information for disclosure including but not limited to case manager notes, current course of treatment and precertification of any surgeries, hospital stays or transplant, and any claims paid or pending more than $50,000.
•    Coordinate benefits payable under the Plan and with other benefit plans, if applicable.
•    Provide notice to the Participants regarding the reason(s) for denial of benefits (which are denied) and provide for the review of such denied claims.
•    Provide notice to the Participants in the form of an explanation of benefits resulting from claims transactions.
•    Provide 1099 forms (as applicable).
•    Perform Recovery of Payments of $25 or more.
•    Administer a Fraud and Abuse Detection Program.
•    Provide Full Claims Fiduciary Services (all levels of appeals).
•    Provide at least 3 Organizations for external claims review when needed.
•    Eligibility/Enrollment Administration
•    Administer eligibility based on GPS EBT’s eligibility criteria
•    Receive data from the District’s online enrollment system, iVisions (Tyler Technologies).
- TPA Services & Medical Network: Network Access
•    The current medical program includes access to PPO network providers and discounts. It is the District’s intent to continue to incorporate these services into the medical plan administration.
•    Provide a network that includes enough providers for acute hospitals, health care professionals, ancillary providers such as durable medical equipment, skilled nursing facility, home health, rehabilitation, hospice, transplant centers of excellence, and behavioral health providers.
•    Reporting Requirements
•    Attend meeting and present Annual Benchmark Utilization Report.
•    Provide the reports defined in the Reporting section of the RFP.
•    Provide the functionality to generate Ad Hoc Reports.
•    Provide reports requested by the Trust’s consultant within 2 business days if they are not available in the tool provided.
•    Secured Internet Access
•    Access to Eligibility Administration Portal for Employer/Employee.
•    Access to Portal for Employee to view claims, benefits, providers etc.
•    Employer and/or Designated Consultant access to Claims Data Reporting Portal.
•    Interface/Coordination with GPS EBT’s Vendors
•    Interface with the District’s consultant, medical, dental and vision networks, stop-loss provider, PBM, utilization management vendor, auditors, and legal counsel.
•    Receive and send/receive data to/from the PBM on a routine basis.
•    Coordinate data and reporting with the stop loss vendor.
•    Interface with the COBRA vendor if applicable.
•    Receive data from the District’s online enrollment system, iVisions (Tyler Technologies).
- TPA Services & Medical Network: Wellness Benefits Administration
•    Wellness Programs/Services
•    24/7 Nurse Call Line
•    Health Coaches
•    Smoking Cessation Counseling
•    Onsite Flu Shots
•    Onsite Mobile Mammography
•    Onsite Mobile Prostate Specific Antigen Blood Test
•    Health Pregnancy Healthy Babies
•    Discount Services
•    Provide discounted programs for participants that include:
•    Gym Memberships
•    Acupuncture
•    Massage
•    Weight Loss Programs
•    Vitamins
- Medical Utilization & Case Management
•    Utilization Management (UM) including Precertification Services
•    Diagnostic tests and surgical procedures – more than $1,000.
•    Durable Medical Equipment (other than breast pumps covered as a preventive service) – more than $1,000.
•    Hospice care – facility admissions
•    Inpatient admissions, including inpatient admissions to a skilled nursing facility, extended care facility and rehabilitation facility and inpatient admission due to a mental disorder or substance use disorder.
•    Provide Healthcare Blue Book or equivalent service.
•    Note any shared savings programs or carve-outs; District currently has a dialysis carve-out.
•    Concurrent Review
•    Determine the appropriateness and level of care for ongoing stays. Since most of the ongoing stays for the current network are contracted with a DRG reimbursement, concurrent review is established if a member moves to a lower level of care that is reimbursed on a per diem basis such as long-term acute care, skilled nursing, or inpatient rehabilitation.
•    Retrospective Review
•    For medical necessity where precertification is not obtained or the Medical Management Program
•    Administrator is not notified.
•    Comprehensive Case Management (CM) Program
•    Assist participants to learn more about their illness and risk factors and understand treatment options and expected outcomes.
•    Understand and wisely use their health benefits and case management services
•    Access other resources outside their insurance plan
•    Avoid more expensive care or duplication of services
•    Coordinate services among many different providers
•    Disease Management Programs
•    Asthma
•    Chronic Obstructive Pulmonary Disease (COPD)
•    Diabetes (Type 1 and 2)
•    Coronary Artery Disease (CAD)
•    Congestive Heart Failure
•    Carve-out Dialysis Program
•    Claim and UM Appeals
•    Manage all levels of the Appeal Process for services provided (no litigation). The District will make the final determination of appeals above level 1.

- Contract Period/Term: 1 year
- Questions/Inquires Deadline: September 22, 2025