TPA and ASO and Pharmacy Benefit Manager Services

The Vendor is required to provide for administrative services only/third-party administrator (ASO/TPA) services, pharmacy benefit management (PBM) Services, or both service categories.
- These activities should include, but are not limited to, the following:
•    Subject to the exercise of professional judgment, the winning proposer shall accept and settle or deny all reported claims. Successful proposer will also be responsible for adjudication of claims appeals.
•    Furnish an electronic version of the certificates/booklets for the district to use on their website within 60 days of a new plan year.
•    Provide appropriate literature to describe the benefits being offered by the district to its employees.
•    Establish claims reporting procedures that are compatible with the needs and organizational structure of the
•    District and any authorized party by the district.
•    Attend meetings as requested by the school board
•    Develop procedures and coordinate eligibility data with the claims administrator.
•    Maintain the confidentiality requirements of state law by having adequate systems security features.
•    Prepare and furnish the district with annual loss data statistics. These loss data reports should include, but not be limited to, all administrative fees paid (if applicable) and claims paid.
•    Conduct monthly internal audits for claim accuracy and occurrence of mispayments. Report results to the district within ten (10) working days from the end of the reporting period.
•    Establish and maintain a toll-free customer service line for employees. This line should be operational from at least 8 a.m. To 6 p.m. (Central Standard Time). A voice mail system or equivalent system should be available to take off-hour or weekend calls, with call backs to occur within 24 hours of the next business day.
•    Administer plan on a detail billing remittance basis. Claims details related to billing shall be provided for all services for all billing cycles. Coordinate any needed audit activities or reconciliation requests made by the district.
•    Retain claims history online for minimum of 36 months from the last date of any claim activity pertaining to services rendered. All prior claims history incurred during the course of this contract must be captured in such a manner compatible for media storage and delivered to the district at their request. This data must be maintained for the full duration of the contract period and must also be available for transfer to the subsequent vendor, should the district elect to change vendors in the future.
•    Compare, maintain, and file with any applicable federal, state or local governmental agencies, any forms or reports as may be required from time to time by law.
•    Establish claim denial and grievance procedures which are clearly communicated to members. Grievance procedures should be consistent with all federal laws, rules and regulations.
•    Identify any additional fees for services to customize file feeds, agency reporting for medical and/or RX claim reports.
- Performance may be evaluated on a variety of issues, such as:
•    Timely delivery of finalized contracts for the selected program.
•    Timely delivery of plan documents.
•    Claims turnaround time.
•    Accuracy of claims and payments.
•    Quality and timeliness of claims experience reports.
•    Regularly scheduled vendor file feeds including successful confirmation of OE file processing.