Medical Plan Administration, Medical Provider Network Services

The Vendor is required to provide medical plan administration, medical provider network services for include:
•    Medical plan administration, case management, utilization review services, disease management, virtual healthcare options, and access to cost and quality transparency tools and resources 
•    Medical provider network
- Requirement
•    Offer competitive administrative fees 
•    Offer competitive network discounts 
•    Offer strong member access to providers across the continuum of care 
•    Offer minimal provider disruption 
•    Offer best-in-class claim processing, fraud-waste-abuse auditing, and large claim review 
•    Provide implementation and transition credits to offset the cost of changing vendors 
•    Provide wellbeing and engagement funds to help the city drive stronger employee engagement in the city’s wellness program 
•    Support program integration through seamless interfaces with the city’s other service providers 
•    Offer best-in-class health promotion services and programs 
•    Provide exemplary customer service team dedicated to the city, including easy to navigate internet and mobile app support 
•    Supply both automated and self-service reporting capabilities 
•    Offer an experienced account management team 
•    Agree to, and consistently exceed, aggressive performance standards 
•    Provide full data transparency, including unrestricted access to complete claims-level data in standard formats on a regular cadence, support for ad hoc reporting and analytics, and explicit acknowledgment that all data is owned by the city with no access limitations 
•    Demonstrate a comprehensive, proactive cost containment strategy, including ongoing innovation and implementation of programs to manage and reduce total cost of care 
•    Deliver high-quality, evidence-based clinical programs and report on measurable health outcomes and quality metrics to improve member health and care effectiveness 
•    Maintain full compliance with all applicable regulations and industry standards, including HIPAA, and demonstrate robust cybersecurity and business continuity protocols 
•    Ensure seamless coordination with pharmacy benefit management, including transparency, specialty drug management, and alignment of total cost of care strategies.