Medical Administration Self-Funded Health Plan Services

The Vendor is required to provide medical administration services.
- All required reporting must support both combined and segregated views, clearly distinguishing results for the County and for the College.
- The Client’s goal is to develop a long-term strategy that incorporates plan management opportunities with access to the most appropriate and cost-effective provider networks.
- Primary requirements to meet this goal:
•    Provide a strategy incorporating network reimbursement/managed care capabilities into new or existing programs
•    Deliver accurate, responsive, and timely claims payment
•    Provide effective and accurate member services
•    Provide timely, standard reporting and data file feeds to county and/or subcontracted vendors to assist the client in managing its health Plan
- The client is looking to select and implement a claims administrator with plan management capabilities for self-funded medical programs.
- The Client’s intent to implement more restrictive plan design features within their medical plans but to enhance the management of these programs through access to strong, quality-based networks.
- Client to:
•    Select an administrator with a well-developed provider network to ensure employee access to high quality care through network physicians, hospitals, and providers
•    Maintain effective pre-admission certification, concurrent review, and case management programs for all employees regardless of in or out-of-network access
•    Maintain freedom of choice for the employees to those providers best able to offer both the quality care and utilization controls necessary to meet benefits and cost objectives
•    Maintain effective utilization management in all areas
- General account management services, including the following:
•    Online enrollment capability (with an independent vendor)
•    Direct claim verification of eligibility
•    Direct claims submission
•    Claim adjudication
•    HCRA Filing
•    Customer Services (employer, provider, or participant inquiries)
•    Medical Management services and reports
•    Annual financial accounting reports
•    Banking transfer, reporting and reconciliation services
•    Implementation
•    Communication services
•    Underwriting and actuarial services, including the following:
o    Development of Costs/Benefits Analysis for existing as well as alternative Plan Designs (example: Point of Service (POS) Program)
•    Renewal services
•    Regulatory compliance services
•    Managed Network Services (to include adjudication of non-network claims)
•    Utilization Review Services/Large Case Management
•    Disease Management/Wellness Plans and reporting
•    Fiduciary responsibility for second level appeals
•    Network access; primary and wrap-around
•    Subrogation
•    Vision
•    SPD and SBC production, printing, distribution, and updates
•    COBRA/HIPAA Administration
•    Stop loss reporting
•    Ad-hoc reporting
•    Download of data files to external vendors
- Printed instructions for completing any necessary forms as well as a description of whatever documentation must accompany the claim for processing. Initially, claim kits may be provided.
- A toll-free arrangement for employee and provider uses in obtaining the following service:
•    Proper administration of all Coordination of Benefits (COB), non-duplication, no fault and other subrogation provisions
•    Contact and communication with claimants and providers as required for resolving problems or responding to questions. Confirm whether or not customer service with claimants and providers is provided by the local office or if an external or off-shore service is utilized
- Auditing, upon request, of medical claims more than $25,000
- General claim utilization report identifying claims submitted, claims eligible, deductible, coinsurance assessments, R&C cutbacks, COB applications, network/non-network expenses and savings by type of service and major procedure category every six (6) months
- Monthly claim summary for active/COBRA population broken out by employee and dependent, location and group categories.