Medical TPA and Pharmacy Benefit Manager Services

The vendor required to provide third-party administrator (TPA) for the employee medical plan claims administrative services and pharmacy benefit manager services.
- Medical TPA
1. Plan documents 
•    Maintain a master file of plan documents, summary plan descriptions, plan booklets, benefit provisions, claims administration policies and guidelines, changes in plan benefits, and any other material needed to properly administer claims in accordance with the provisions of the plan applicable state and federal law.
2. Eligibility 
•    Maintain eligibility information to verify eligibility for benefits for plan participants and dependents. 
•    Eligibility to be transmitted electronically and manually, by the county or its designee. 
•    The administrator will be required to maintain name and address files by employee and dependent. 
•    The administrator will also monitor and track the eligibility status of dependent children over the age of 26.
3. Forms 
•    Design, print, deliver, and periodically update all forms and form letters used in connection with claims processing at administrator’s expense. 
•    The county reserves the right to approve and disapprove all forms and form letters. 
•    The forms required include, but are not limited to:
o    Explanation of benefits 
o    Third-party liability inquires
o    Coordination-of-benefits inquiries
o    Dependent eligibility letters 
o    Identification cards
4. Claims processing
•    Install historical data including, but not limited to, deductibles and lifetime maximums, from previous administrator. 
•    Maintain accurate claims records and files, which contain all pertinent claims, bills, correspondence, deductibles, benefits accumulated and maximums, coordination of benefits information, etc. 
•    Provide adequate security of patient information.
•    Review and examine claims (bills, invoices, and statements) submitted by plan participants or received from physicians, hospitals, pharmacies, labs, and any other eligible providers who have rendered care to eligible employees and their dependents. 
•    Procure any missing information immediately, by personal contact, telephone, or correspondence.
•    Determine reasonableness of charges and monitor the qualify, quantity, and utilization of professional, medical, and hospital care rendered, referring medical claims for “medical review” when necessary.
•    Pend or deny claims not eligible for payment and issue related correspondence.
•    Advise plan participants, dependents, or beneficiaries whose claims have been denied of the specific reasons for such denial, and the procedure for a review of the denial. 
•    Advise plan participants regarding the pending of a claim, the reasons for such action and the actions necessary to release the claim.
5. Customer service
•    Provide professional, courteous, and timely responses to telephone, written, in person inquiries and complaints from all sources. 
•    Such inquiries may include eligibility information, claims payment, benefit provisions, and related questions, from parties with authorized access to information such as plan participants, providers, legal counsel, the county, etc.
•    Furnish a toll-free telephone number for incoming customer service calls.
•    Provide assistance when requested with respect to special inquiries from the county which could arise involving claims processing for payment of claims.
•    Survey plan participants annually on their satisfaction with the service and provide results to the county.
•    Ensure accessibility for all participants by offering multiple language options and interpreter services (including telephonic and in-person interpretation) for Non-English speakers and individuals with limited english proficiency.
6. Prescription drug program
•    Coordinate eligibility, accumulators, processing, and reporting with the county’s pharmacy benefit manager. 
7. Case management 
•    Provide the services of a registered nurse and case manager (or a contracted case management agency) approved by the county, for chronic or catastrophic injuries and illnesses. 
•    Provide timely case management reports to the county. 
8. Utilization review services 
•    Provide hospital pre-admission certification; hospital concurrent utilization review; hospital length of stay monitoring; discharge planning services; preauthorization when requested by providers and plan participants, etc.
9. Coordination of benefits
•    Provide coordination of benefits in accordance with plan documents and federal and state law. Apply standard, non-duplication of benefits.
•    Follow the requirements of federal law concerning coordination of benefits with medicare and other applicable programs (e.g., Medicaid), as well as any relevant state regulations.
- Pharmacy
•    Strategic flexibility – align with a pharmacy benefit manager (PBM) that allows for partnership with other innovative disruptors to optimize benefit and reduce cost
o    Disruptors should not be standalone proposers but rather integrated partners 
o    These entities may, but will not be limited to, providing services such as specialty drug distribution, prior authorization outsourcing, or clinical formulary overlay
•    Transparency – confidence to attain competitive pricing and the understanding of accurate and reasonable PBM revenue 
•    Aligned incentives – mutual understanding of goals and objectives between county and PBM 
•    Regulatory – provide insight into the current regulatory landscape along with PBM’s proactive compliance strategy 
•    Partnership – identify a PBM partner who supports tailored and complex plan designs and specialty drug customization needs, as well as coverage for glp-1s for weight loss and secondary indications 
•    Maximize optimal member health outcomes through condition management, medication adherence, and pharmacy network support 
•    Optimal integration across partners – flexibility to partner with multiple point solutions and partners 
•    Utilization management – flexibility to carve out program components to align with county clinical strategies
•    Access to innovative pharmacies –county members can access lowest cost, and convenient pharmacies such as amazon and cost-plus drugs 
•    Custom clinical criteria – empowerment to define, implement, and manage utilization management strategies aligned with county’s specific goals 
•    Specialty pharmacy cost management – flexible, non-exclusive specialty pharmacy model that allows for independent management of specialty pharmacy services. 
•    Partner needs to be capable of supporting cost containment through collaborative relationships with multiple vendors and adaptive pricing structures, while enabling the use of third- party solutions tailored to county’s strategic needs.
•    Specialty copay assistance program – reduce out of pocket costs for members and reduce specialty spend by leveraging manufacturer programs 
•    Maintain the highest level of member satisfaction and engagement 
•    Maximize rebate transparency including visibility to GPO and manufacturer relationships 
•    Maximize formulary transparency 
•    Reporting transparency – PBM to provide clear, consistent, and scheduled reporting 
•    Implementation credits, audit credits, and an annual performance management fund 
•    PMPM guarantee – PBM should have the ability to provide a PMPM net trend or margin guarantee 
•    Full audit rights – secure full audit rights to ensure transparency, compliance, and accountability across all aspects of PBM operations.