The Vendor is required to provide medical plan third party administrators and high value care solution organizations.
- Health plan administrator are expected to include but are not limited to the following:
• Account management
• Administrative services / claims adjudication
• Claims disputes and appeals
• Provider network services: maintaining a highly competitive network of providers providing multiple network solutions to drive additional savings while increasing quality of care
• Customer service, including a designated member service team, a designated toll-free number to the member call center, and online services
• Navigation/advocacy support
• Member communications – including identification cards, summary plan descriptions, summary of benefits and coverage, welcome packets, and other collateral.
• Reporting/record keeping capabilities with proven solutions to turn data into actionable recommendations
• Audits
• Data requirements/data transfers
• Care coordination/population management and engagement; care transitions
• Value-based health management services (including price and quality variation, accountable care, site of care, centers of excellence, bundled payments, advanced primary care models, etc.)
• Quality improvement
• Financial/banking requirements
• Willingness to coordinate with other vendors as appropriate through data sharing and integration including data warehousing to support optimal outcomes and quality of care
• Ability to accommodate alternative plan designs in the future
• Implementation support
- Provide multiple advanced primary care (APC) clinics that provide comprehensive, whole-person care and population health management. The APC clinics have the infrastructure to measure and report on prevention measures, chronic care measures, patient health outcomes and member experience. APC clinics offer robust access to care including after business hours, weekends and virtual care as a supporting modality. Clinics include behavioral health, either integrated onsite or through established referral mechanisms.
- Informed Referral Services to High Performing Providers for our members using multiple data sources (not just claims) and state-of-the-art tools combined with real-person high-touch supportive guidance to help members get appointments with the best providers to meet their health needs.
- Contract Period/Term: 5 years
