Third Party Administrator Services

The Vendor is required to provide to obtain a Third-Party Administrator (TPA)/Carrier for its self-funded medical, dental, and vision coverage. 
- TPA services a Self-Funded, Bundled Healthcare Plan.
- Medical and Prescription Drug Plan for Active Employees and Retirees under age 65.
- Including services for:
•    HIPAA
•    COBRA
•    Utilization Review
•    Behavioral Health Services
•    Tobacco Cessation
•    Disease Management
•    FSA
•    CERA
- Dental Plan, both in network only and in and out of network options and a Buy-Up Plan (new plan option).
- Vision Plan, both in network only and in and out of network options.
- Employee Assistance Program.
- Wellness Program that includes Weight Loss and Smoking Cessation components. The Wellness Program may also include other programs.
- One Tier Plan Design that includes a Base Plan.
- Diabetes Management Program
- Prescription Drug Plan includes Variable Copay Plan
- Solutions for Gene Therapy Stop Loss
- Complete enrollment and eligibility via electronic transfer.
- Administer all services, including processing claims on the effective date of the contract.
- Manage claims by providing coordination of benefits, subrogation, Medicare coordination, and to challenge all disputed claims with providers.
- Manage claims by offering services of utilization review, large case management, wellness, and disease management programs.
- Provide a dedicated 1-800 customer service line specifically for employees of the City and a dedicated website for City employees.
- The City currently offers coverage to domestic partners. The selected vendor must allow domestic partners to be eligible for coverage.
Provide a network of physicians, hospitals and ancillary medical providers. Maintain a thorough, well documented credentialing procedure, and conduct an ongoing quality assurance program under the purview of a peer review committee.
- Provide utilization management services designed to authorize care with the fewest number of hospital days and/or elective surgeries without reducing the quality of care and patient satisfaction. Reviews to be conducted by staff consisting of registered nurses and a panel of physician advisors including specialists.
- Provide information on all programs that target treatment of chronic diseases, (i.e., diabetes, obesity, high-blood pressure etc.). Discuss health assessment surveys, nurse interventions and health outcome data, different therapies used to treat different diseases and dissemination of data to network physicians.
- Provide a prescription drug formulary developed by a panel of pharmacists and physicians taking into consideration safety, medical appropriateness, efficacy, and cost effectiveness.
- Review and revise summary plan descriptions and other similar material to be distributed to plan participants by the City.
- Make recommendations regarding eligibility for participation, acceptability of late entrants and extension of coverage under handicapped dependent provisions, reinstatement of participation or increase/decrease in benefits.
- Consult on plan provisions, plan design, impact of local, state, or federal legislation, new medical procedures/technology, emerging benefits trends, cost containment, and other ongoing services issues.
- Claims Processing Services
•    Furnish claim forms for out of network claims and all appeals.
•    Determine if benefits are payable.
•    Maintain a timely, accurate list of participating plan members for use in processing claims as provided by the Benefits Division. 
•    Notify claimant and service provider of claims payment decisions.
•    Administer the plans’ Coordination of Benefits (COB) provision.
•    Coordinate payment of benefits with Medicare when applicable.
•    Review claims submitted for medical services that appear excessive and/or establish medical necessity for services rendered or expenses incurred.
•    Assign field claim consultants and/or professional services resources for the evaluation of complex claims.
•    Maintain peer review relations.
•    Discuss disputed charges with providers when appropriate.
•    Make reports to the IRS and furnish separate statements to providers of medical services as required by the Internal Revenue Code regarding amounts paid to such providers.
•    Maintain and store claim data elements for statistical analysis such as diagnoses codes.
•    Provide online claim viewing access to participants and plan administrator.

- Contract Period/Term: 5 years
- Pre-Submittal Conference Date: October 6, 2025
- Questions/Inquires Deadline: October 7, 2025