Medical Administrative Services Organization, Third Party Administration and Pharmacy Benefit Manager Services

The Vendor is required to provide its third-party administrator (TPA) for its self-insured CITY healthcare plan and CVS is the current pharmacy benefit manager (PBM) accessed through the Employers Health PBM Consortium.
- Process all appropriate claims in a timely manner as determined by the provision of the plan documents, collective bargaining agreements, and plan administrative policies or guidelines. 
- Design, implement, and maintain such systems and procedures, consistent with industry standards, utilizing software for the application of GMIS, correct coding initiative and general claims edits, for the appropriate adjudication and payment of all claims for payment submitted under the CITY’s healthcare plans.
- Draft plan documents, summary plan documents, plan booklets, benefit provisions, identification cards, certificates of credible coverage as required under HIPAA, changes in plan benefits, and any other material needed to properly administer claims in accordance with the provisions of the plan, collective bargaining agreements, and state and federal law.
- Provide access to a network of qualified providers including providers serving the high poverty areas of the city. 
- Network providers shall be contractually obligated to meet the TPA’S credentialing standards including but not limited to maintenance of licensure and malpractice insurance.