Network, Claims Administration and Medical Management Services

The Vendor is required to provide administrative, network, claims administration, medical management, and COBRA Services for a self-funded health plan.
- Responsible for all facets of the day-to-day operational administration of agency self-funded health plan including, but not limited to, implementation and delivery of third party administration of health claims; including creation and maintenance of a client specific network (currently known as First Choice Provider Program), national network services; population health management, including but not limited to disease management; a wellness program, call center operations, and general and advisory services regarding health plan design; support of current programs, and COBRA services.
- Provide innovative solutions for self-funded health program management, including efficient claims processing, network management and population health management.
- Also included in this proposal is day-to-day administrative services for the agency Flexible Spending plan (“FSA”) which includes the processing of flexible spending health care and dependent care claims for enrolled participants, substantiation of claims, administration of COBRA for terminated employees, and debit card administration.
- must be able to send and receive direct eligibility file feeds daily with the PBM (Pharmacy Benefit Manager) and have the ability to send and receive data to track individual or combined medical and prescription out of pocket maximums.