Medical Administration, Stop Loss Administration and Pharmacy Administration Services

The Vendor is required to provide medical administration, stop loss administration and pharmacy administration services for include:
•    Provide medical TPA services only (and not pharmacy benefits or you would be willing to provide stop loss coverage only), indicate such.
•    Pricing and fees should be based on providing individual services (medical plan administration, pharmacy benefits management and stop loss coverage) and discounts for providing bundled services (including dental, employee assistance program and vision benefits, if applicable).
•    The mac is self-insured for purposes of medical benefits and is seeking a strategic health partner to administer 1) medical plan options, 2) pharmacy benefits, 3) opportunities to encourage health and well-being for members, 4) cost transparency, 5) access to a network of providers and 6) coordinated claims with health equity, our administrator of flexible spending and health savings accounts.
- The following services as needed and requested:
•    The medical claims administration services include maintaining a system for processing and adjudicating medical claims from hospitals, physicians, diagnostic laboratories and imaging services, and other providers according to plan benefits and TPA’s medical policy. 
•    Manage disability eligibility of plan participants, maintain accumulators for deductibles, coinsurance and out of pocket limits including amounts paid for pharmacy benefits administered by the plan’s pharmacy benefit manager, etc.
•    The provider network services include establishing and managing, including credentialing, and contracting, a preferred provider (PPO) organization in the state that will serve the mac and provide access to a nationwide provider network for services rendered outside of state. 
•    Services relating to medical management (utilization management, case management, etc.).