The Vendor is required to provide Third-Party Administrator (TPA) services for healthcare services associated with individuals under the supervision of the Department
- The County seeks a partner that can deliver efficient, compliant, and cost-effective administration of healthcare claims submission with adherence to all applicable federal, state, and local regulations.
- TPA that will manage agency claims administration for probation related healthcare services, including but not limited to:
• Claims Processing and Adjudication
• Payment Posting
• Denial and Appeals Management
• Reporting and Data Analytics
• Compliance
- Claims Processing and Adjudication
• Efficiently obtain encounter documentation pertaining to qualified 90-day pre-release, reentry encounters in a mutually agreed upon manner and format.
• Submit claims with a 95% first pass clean claim rate and within all timely filing limits.
• Appropriately investigate and resolve and resubmit rejected claims, as needed, while simultaneously addressing the root cause(s) to eliminate or reduce future-like occurrences. Including monthly follow up on outstanding claims, at minimum.
• Maintain Accounts Receivable Days (A/R Days) of 45 days of less.
- Payment Posting and Reconciliation
• Accurately record all payments issued to providers in the claims management system with a 98% or greater accuracy in payment posting.
• Conduct monthly reconciliation of payments against approved claims and County financial records. Provide detailed reconciliation reports to the County, including variance explanations and corrective actions within 10 business days of month end.
• Identify and correct discrepancies promptly (within 5 business days), including overpayments, underpayments, and duplicate transactions.
• Maintain audit-ready documentation and adhere to all applicable financial and regulatory standards.
- Denial and Appeals Management
• Review and document reasons for claim denials in accordance with plan rules and regulatory requirements. Notify County promptly of denial decisions and appeal rights, including detailed explanations. Issue denial notices to County within 5 business days of adjudication.
• Establish and maintain a formal appeals process, including timelines, documentation, and communication protocols. Resolve and respond to 90% of appeals within 30 calendar days of receipt.
• Ensure all denial and appeal procedures comply with HIPAA, state, and federal regulations.
• Provide monthly reports summarizing denial rates, appeal outcomes, and turnaround times by the 15th day of the following month.
• Maintain an impact able denial rate of 5% or less.
- Reporting and Data Analytics
• Deliver monthly, quarterly, and annual reports as mutually agreed upon. These reports must include detailed claims activity, account aging, payment accuracy, denial trends, appeals outcomes, and encounter/services counts. These standard reports will include any necessary reporting requirements as outlined by county, state, and federal regulations. Monthly reports are due by the 10th of each month.
• Custom Reports: Generate ad hoc reports to the County within 5 business days of request to address specific operational or compliance needs.
• Perform trend analysis, cost containment evaluations, and predictive modeling to identify opportunities for efficiency and improved outcomes.
• Ensure all reports meet regulatory requirements and are audit-ready with a 99% or greater accuracy.
- Compliance
• The TPA shall provide full cooperation and assistance to Shasta County during any external audit or compliance review related to healthcare services and claims administration.
• This includes furnishing requested documentation, facilitating access to systems and records, responding to auditor inquiries promptly, and ensuring all processes and data meet applicable regulatory and contractual standards.
• Act as the primary liaison with auditors, ensuring timely and accurate responses to all requests.
• Furnish all required records, reports, and system access necessary for audit completion
• Maintain processes and documentation in accordance with applicable regulations, including HIPAA, CMS guidelines, state and federal healthcare laws, and County contractual requirements.
• Implement corrective measures promptly for any deficiencies identified during audits.
- Contract Period/Term: 1 year
- Questions/Inquires Deadline: February 13, 2026
