Medical Billing and Coding Revenue Services

The vendor is required to provide revenue cycle management (RCM) services, including but not limited to professional medical billing, coding, credentialing, compliance support, denial management, and financial performance reporting.
- Requirements:
1. Professional medical billing and coding services
•    Accurate, compliant medical billing and other medical reimbursement including charity care pool and other supplemental payment programs using CPT, HCPCS, ICD-10 standards. 
•    Claims scrubbing and pre-bill validation. 
•    Denial management and appeals. 
•    Back-end A/R collections and reporting. 
•    Contractor shall maintain logical and operational segregation of health data under the current shared tax identification number (TIN) structure and be capable of supporting a future transition to an independent health TIN.
2. Credentialing management
•    Full lifecycle credentialing for government and commercial payers. 
•    Council for affordable quality healthcare profile maintenance and proactive revalidation.
3. Key performance indicators
•    Submit monthly key performance indicators (KPI) report detailing metrics on days in A/R, denial rate, clean claim rate, net collection rate. 
•    Contractor shall propose smartie-aligned key performance indicators, including denial rate (≤10%), clean claim rate (≥95%), days in A/R (≤45), and compliance incident rate (0). 
•    These metrics will serve as the basis for monthly performance evaluations and payment eligibility. 
•    Provide data analytics and recommendations for continuous improvement. 
•    Monthly KPI reports shall be submitted electronically to the department.