Health Insurance Third Party Administer Services

The Vendor is required to provide for a medical insurance provider (third-party administrator “TPA” services) to provide services for active employees and eligible retirees.
- Provide Medical Insurance TPA responsible for Administration of their self-insured medical program for the City Administered Health Plan (CAP).
- The services provided shall include, but not be limited to the following:
•    Established company strategy and programs focused upon bridging the gap of health care inequities, and the social determinants to quality care for CAP plan members, i.e. identification of disparities of care in utilization outcomes, by cost, race, ethnicity, zip code, etc.
•    Ability to work collaboratively with other benefit providers in support of the City benefit strategy
•    Clinical programs- utilization management including case/ disease management, maternity, oncology, MSK and behavioral health
•    Timely processing, adjudicating and payment of medical claims.
•    Payment integrity – pre and post -pay edits to limit fraud and abuse, invoicing client for claim payment reimbursement
•    Developing and maintaining a network focused upon the social determinants of health as it relates to professional providers, facilities and ancillary services
•    Negotiating pricing plan and discounts
•    Utilization review
•    Care navigation programs and advocacy tools that steer high quality and value of care
•    Program reporting, including plan design recommendations and self-financing strategies
•    Align safety records of hospitals, ambulatory / surgical centers and providers with preferred provider list
•    Reporting of customer service scores for physicians and their offices personnel 
•    Member appeals process
•    Selection of health and wellness services i.e. diabetes/ pre-diabetes programs which are evidence and non-evidence based
•    Regulatory adherence to statutory requirements, including but not limited to HIPPA, COBRA, MHPAEA (parity), No Surprise Act, Transparency in Coverage, Gag Clause Attestation, etc.
•    Utilization of biosimilar and generics drugs in medical setting