Third Party Administrator Services

The Vendor is required to provide for a third-party administrator (TPA) for the employee medical plan claims administrative services.
- The TPA will act as an extension of the Plan Sponsor, providing claims administration, compliance, member support, reporting, and other related services to ensure effective, efficient, and compliant delivery of medical benefits.
- Claims Administration
•    Process all medical claims in accordance with plan provisions, federal/state regulations, and industry best practices.
•    Ensure accurate and timely adjudication, including coordination of benefits (COB), subrogation, medical necessity review, and overpayment recovery.
•    Maintain automated claim payment systems with robust audit and quality control processes.
•    Provide electronic Explanation of Benefits (EOB) to participants and maintain claim payment records.
•    Conduct internal claim audits and support independent external audit requests.
- Eligibility & Enrollment Management
•    Maintain eligibility data provided by the Plan Sponsor or enrollment platform.
•    Process adds, changes, and terminations within agreed service-level timelines.
•    Provide eligibility files to carriers, networks, and vendors as required.
•    Coordinate with COBRA administrator(s) and Medicare (where applicable).
- Customer Service & Member Advocacy
•    Operate a dedicated call center with toll-free access for members and providers.
•    Provide online member portals/mobile apps with claim, deductible, out-of-pocket, and ID card access.
•    Offer multi-language support where required.
•    Resolve escalated member/provider issues in a timely manner, documenting resolution steps.
•    Provide member communication materials.
•    Provide a Telehealth solution.
•    Provide health coaching and employee health programs.
•    Provide a member support concierge/care coordination/navigation services.
- Provider Network Integration
•    Administer benefits in conjunction with designated PPO or reference-based pricing (RBP) networks.
•    Provide provider lookup tools for members.
•    Coordinate with network partners for repricing, discounts, and dispute resolution.
•    Monitor and report on network performance (discount levels, disruption, and utilization).
- Medical Management Services
•    Pre-certification, concurrent review, and retrospective utilization review.
•    Case management for high-cost claimants.
•    Disease management, chronic conditions management, lifestyle management, and wellness program integration.
•    Coordinate with stop-loss carrier requirements for large case notifications.
- Compliance & Regulatory Services
•    Ensure compliance with acts, and other applicable regulations.
•    Provide HIPAA-compliant data security and breach notification protocols.
•    Generate federally required documents, including HIPAA certificates, 1095 reporting files, and SPD/SMM data feeds (as requested).

- Contract Period/Term: 3 years