Medical and Pharmacy Claims Reviewer Data Management and Technical Services

The Vendor is required to provide to ensure billing and payment accuracy, third-party administrator (TPA) contract compliance, payment responsibility, and clinical appropriateness of Claims.
- Increasingly complex reimbursement models, increased coding complexity, changing demographics, and a shift to managed care plans all represent changes in the healthcare industry and are expected to further increase the complexity of healthcare payments.
- Services include the following:
•    Medical Claims Reviewer and Data Management Services; and,
•    Pharmacy Claims Reviewer and Technical Services.
- Medical Claims Reviewer Services
•    Through the innovative use of data and analytics, improve the integrity and accuracy of program claims payments;
•    Provide regular, frequent, and ongoing review and oversight of 100% of medical claims through electronic analysis. Analysis shall include pre-payment claims review and post-payment claims review. Analysis shall also include ensuring TPA adherence to plan design, exclusions, and limitations, such as prior authorization and dollar limits; 
•    Adhere to the timeframe to select and communicate selection of pre-payment claims to the carrier within one (1) business day of receipt of the pre-payment claims data file;
•    Identify and eliminate systemic errors and overpayments, and assist in the coordination of recovery to ensure that only the required and appropriate amounts due and owed on claims are paid as a result of proper adjudication; 
•    Where applicable, verify claims as submitted are consistent with TPA clinical policies, evidence-based care guidelines, professional guidelines, and industry standards or best practices;
•    Verify that appropriate discounts and correct reimbursement procedures were followed by the program medical vendor(s);  
•    Verify that all claims, including out-of-state claims, have proper documentation, and undergo a thorough review process that considers the claim dollar amount, ensuring thoroughness for high-complexity diagnoses and services while maintaining efficiency for smaller claims;
•    Track all information related to a claim record, including but not limited to: claim number, provider id and name, member name and number, date(s) of service, date of claim, paid date, allowed amount, billed amount, paid amount, diagnosis code(s), procedure code(s);
•    Identify potential duplicate payments, including but not limited to, claims for the same services with different procedure codes or with the same or similar dates of service;  
•    Maintain a comprehensive record of all claim versions, including any adjustments or modifications.
•    Check for adherence to, and investigations of third-party liability;
•    Perform claims reviews to detect, prevent, and correct fraud, waste, and abuse and to facilitate accurate claim payment.  Reviews shall look for practices that directly or indirectly result in unnecessary costs to the program, including members.
- Examples include, but are not limited to:
•    Improper payment for services;
•    Payment for services that fail to meet TPA clinical polices or, when there is no clinical policy or evidence-based care guideline regarding a specific care issue, professionally recognized standards/levels of care;
•    Excessive billed charges or selection of the wrong code(s) for services or supplies;
•    Billing for items or services that should not have been or were not provided based on documentation supplied;
•    Unit errors, duplicate charges, and redundant charges;
•    Lack of sufficient documentation in the medical record to support the charges billed;
•    Experimental and investigational items billed;
•    Lack of medical necessity to support level of care, inpatient admission, services or days billed, according to TPA clinical policy or, when there is no clinical policy or evidence-based care guideline regarding a specific care issue, professionally recognized standards/levels of care;
•    Services billed are not covered per the member’s benefit plan;
•    Lack of objective clinical information in the medical record to support condition for which services are billed; and
•    Items not separately payable or included in another charge, such as routine nursing, capital equipment charges, reusable items, etc.
- Medical Claims Reviewer Guidance and Support
•    Review of contractor and department-generated reports to ensure integrity or to identify anomalies;
•    Ad hoc analysis, which may include but is not limited to reconciling data sets between the contractor and program medical vendors, assisting with complex data extractions, and responding to requests from the legislature, treasury leadership, or plan design committees;
•    Regular assessments of data analytics methodologies to identify and recommend optimizations that best support the program mission and strategic goals;
•    Support of any audit made of the data, analyses, or methodologies; 
•    Documentation and ongoing maintenance of the processes, methodologies, algorithms, and other tools or techniques employed;
•    Trend guidance on emerging trends identified as a result of the medical claims review; and
•    Provision of tailored training and project orientation for any applicable department staff.
- Data Hosting and Access
•    Maintains a secure and encrypted database environment;
•    Maintains secure, encrypted file transfer and data communications at all times; 
•    Develops and maintains a comprehensive and effective data backup and recovery plan to ensure the protection, availability, and integrity of the data in the event of a disaster or system failure;
•    Has ample size for program needs, designed for rapid data loading and business intelligence tools, and can be scaled; 
•    Has the ability to be securely connected to the program medical vendor(s) and designated parties servicing the program infrastructure and program internal data centers; and
•    Has the ability and capacity to scale with increasing data volumes.
- Data Analytics
•    Provide and maintain the technologies necessary to support the requirements of the contract;   
•    Apply business intelligence tools to the data to conduct a myriad of analyses, including, at a minimum, risk adjustment, identification and stratification, episode of care groupings, gaps in case analysis, and predictive modeling.  The contractor shall have a library of analytic tools to bring to this contract and also shall deliver ongoing additions, enhancements, and refinements to the library, as needed by program and in alignment with industry best practices.  The contractor shall also support the application of this intelligence to the data sets;
•    Deliver and maintain an analytics platform that provides standardized and customizable reports. The contractor shall manage and determine standard reports specific to each plan and any cross-plan regional reporting, such as  emergency department utilization, hospital re-admission rates by zip code, and gaps in providers and/or network adequacy; 
•    Provide an analytics team capable of developing and interpreting ad hoc reports addressing new or unanticipated reporting needs.  Examples of this might include comparing the network composition in a subarea of a region or assessing network capacity in a zip code cluster.  These tasks may be requested by the program and department staff;
•    Provide an overview and periodic updates on system configuration, administrative procedures, and development processes throughout all project stages;
•    Provide an analytics platform that supports multiple users; 
•    Provide ongoing training and relevant training materials to program and designated staff, supporting staff abilities to learn to generate and customize reports as well as to interpret the reports and results; and
•    Provide data analysis tools and platforms that offer predictive analytics and machine learning capabilities.
- Pharmacy Claims Reviewer
•    Provide the state with real-time, electronic, line-by-line, and claim-by-claim review of invoiced PBM pharmacy claims using an automated claims adjudication platform that allows for online comparison of PBM invoices along with auditing other aspects of the services provided by the PBM; and
•    Responsible for receiving and analyzing claims data files from the PBM on a twice-monthly basis, and additional data files, including but not limited to maximum allowable cost (mac), low-income subsidy (LIS), and specialty drug data, on a monthly basis.
•    Must cross-reference these files to ensure the correct application of contractual discounts. 
•    Identified discrepancies must be resolved with the PBM through the following channels: real-time adjustments, monthly payment adjustments, and annual reconciliations. 
•    A monthly report detailing the aggregated discrepancy numbers, derived from these various data sources, shall be provided to the state.
- Technical Services: Consulting
•    Clinical programs; 
•    Operations; 
•    Account management; 
•    Customer service/Member services;
•    Benefit management and plan design;
•    Claim management services;
•    Reporting; 
•    Formulary management
•    Business model; 
•    Pharmacy network; 
•    Formulary and Formulary disruption; 
•    Contract terms; 
•    Assistance with procurement of the PBM contract; and
•    Ad hoc requests from department.
- Deployment Plan
•    Proposed platform deployment effective date, which will be the proposed effective date for when the pharmacy claims reviewer platform and technical services shall become fully functional and available for use;
•    Testing and validation process to confirm all systems are properly configured to interact with one another. Testing should include system integration testing, performance testing, security testing, and exception handling;
•    Provide system documentation to support deployment, including system configuration details, technical overviews, and data flow diagrams;
•    Proposed service level agreements (SLAS) that establish expectations for system uptime, data processing timelines for the PBM invoice review, bug and defect resolution timelines, and contractor response time for addressing issues;
•    Deployment strategy, detailing how the functionality will be executed; and
•    Post deployment monitoring to track system performance and address issues after the system goes live.

- Contract Period/Term: 5 years
- Optional Pre-Quote Submission Conference Date: October 22, 2025
- Questions/Inquires Deadline: October 30, 2025