Third Party Administrator Services

The Vendor is required to provide third party administrator services for include:
- Overall administrative service requirements
•    Provide transparent administration of all services required, including, but not limited to, claims adjudication process, financial reporting, administration, and reimbursement practices and procedures.
•    Provide a single sign-on (SSO) trusted link between any secure online application and the arbenefits.org secure membership portal.
•    Provide a blank copy of all provider and facility contracts that will be used during the life of any resulting contract, including special programs such as: value-based programs, accountable care organization, and global payment arrangements.
•    Provide all fee schedules used for claims adjudication process, as well as denial codes and meanings, on award of any resulting contract during implementation phase.
•    Include fee schedules for all special programs such as value-based, accountable care organization, and global payment arrangements.
•    Responsible for any CMS-assessed interest and penalties arising from the contractor’s failure to timely and properly pursue and collect Medicare secondary payer (MSP) recoveries.
- Health insurance requirements
•    Maintain a network of physicians, hospitals, laboratories, and other service providers sufficient to support in-network coverage under the plan.
•    Serve as the third-party administrator (TPA) and shall administer eligibility and benefits, interpret and apply coverage policies in accordance with plan terms, and provide member support service
•    Administer the state’s benefit for active employees and retirees without modification until or unless authorized by the state in writing.
- Claims adjudication process requirements
•    Provide a comprehensive claims adjudication processing, payment services for the services
•    Provide division an electronic file containing the contractor’s fee schedules and allowed amounts applicable to the contractor’s (i) provider network, (ii) national network, and (iii) transplant network.
•    Disclose and provide division data elements and documentation for any arrangement or methodology that alters allowed amounts for adjudicated claims, including capitation arrangements, value-based payment programs, and other alternative payment initiatives.
•    Apply industry-standard coding edits and bundling and unbundling logic (e.g., multiple procedure and bilateral surgery logic; bundled lab panels), as applicable, as part of claims adjudication and payment.
•    Adjudicate and pay claims in accordance with applicable state and federal law, including requirements governing clean claims processing and payment timeliness.
- Medical management
•    Case management (cm) for medical health management (MH) and behavioral health management (BH) - assessment, planning, facilitation, evaluation, and advocacy by a clinical case manager to meet an individual’s and family’s health needs and to promote quality, cost effective outcomes.
•    Disease or condition management (DM) – provides nurse coaching to assist participants in the management of chronic conditions through education, including diabetes and weight management.
•    Utilization management (um) – the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called “utilization review.”
•    Predictive modeling through the use of advanced claims analytics software – the use of medical claims for analysis to assist in identification of participants with certain conditions to predict probabilities and trends to assist in lowering over-all cost to the plans.
- Nurse line services
•    Provide a toll-free nurse line service which recipients can contact with medical-related questions or concerns
•    These services must be accessible on a 24/7/365 schedule.
•    Staff assigned to manage the nurse line shall be registered nurses or other approved medical professionals and shall be fluent in English.
•    The nurse line services and phone numbers must be separate and independent from any customer service requirement stated.