Third Party Administrator Services

The Vendor is required to provide third party administrator (TPA) services for a self-funded medical plan to include vision.
- Dental may be administered by the TPA or carved out to a County-selected vendor.
- Self-Funded Health Plan Administration
•    County medical plan is self-funded (TPA administers; County funds claims).
•    Vision is fully administered as part of medical claims (not carved out; no separate vision administrator).
•    Current carve-outs (County-selected specialty vendors): PBM, EAP, Stop-Loss.
•    Dental may be administered by the TPA or carved out to a County-selected vendor (TPA coordinates if carved out).
•    Eligibility source system: Tyler ERP; eligibility updates required daily, with monthly reconciliation.
- Provide comprehensive third-party administrative services to support county’s self-funded health plan operations, including: accurate and timely claims administration; daily eligibility page 4 of 36 processing from Tyler ERP; multi-vendor coordination (PBM/EAP/stop-loss and any additional county selected vendors); consolidated reporting and analytics; financial/claims accounting reconciliation; and compliant participant administration (including cobra/continuation), for active employees, retirees, survivors, and continuation participants.
- Governance Model and “Carve-Out” Coordination
•    Maintain a Responsibility Assignment Matrix (RACI) defining responsibilities across County, TPA, PBM, EAP, Stop-Loss, and any other County-selected vendors.
•    Operate a formal vendor governance structure, including:
o    Standing operational meetings (monthly minimum),
o    Issue tracking with root-cause analysis and corrective action plans,
o    Escalation paths (operational and executive),
o    Change control (plan changes, file changes, system changes).
•    Ensure a “no wrong door” member experience (i.e., if a member calls the TPA for PBM/dental issues, the TPA provides warm transfer and accurate guidance without repeated member burden).
- Implementation, Transition, and Go-Live Support
•    Project management, timeline, milestones, and readiness/acceptance criteria.
•    Benefits configuration/build; testing; parallel runs (as required by County); go-live support.
•    Full integration setup with Tyler ERP and County-selected vendors (PBM, EAP, stop-loss; dental if carved out).
•    Training for HR/Benefits staff and Finance staff, including job aids and escalation procedures.
- Daily/weekly eligibility processing (required)
•    Active employees and dependents
•    Retirees and dependents
•    Survivors (surviving spouse/eligible dependents, where applicable)
•    COBRA/continuation participants
•    Coverage tier changes, demographic updates, and other required maintenance
- Benefits configuration and maintenance
•    Configure medical plan designs and embedded vision and medical Rx provisions (as defined by
•    County plan documents), including cost share, limitations, frequency rules, and accumulators.
•    Support multiple plans/tiers/classes (including bargaining unit distinctions if applicable).
- Claims adjudication and payment (medical + vision)
•    Intake, adjudication, pricing, payment, adjustments, voids/reissues, recoupments, Coordination of Benefits COB/subrogation (as applicable).
•    Vision claims are adjudicated and paid within the medical claims environment (not delegated to a vision carve-out administrator).
- Member and provider services
•    Customer service for medical and vision inquiries: benefits, claim status, Explanation of Benefits EOB interpretation, appeals intake, and escalation.
•    Member portal access for ID cards, claim/EOB history, accumulators, and plan information.
- Appeals and grievance administration (administrative support)
•    Maintain documented processes for appeals intake, tracking, communications, and County escalation, consistent with plan requirements and applicable federal rules for a non-federal governmental plan.