Posted Date : November 26,2020
Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID : MB-4737
Government Authority located in Tennessee; USA based organization looking for expert vendor for third party administration services.
[A] Budget: Looking for Proposals
[B] Scope of Service:
Vendor needs to provide third party administration services for the state public sector health plans.
A.1. General
a. The Contractor shall provide all goods or services and deliverables as required,
described, and detailed below and shall meet all service and delivery timelines as
specified by this Contract.
b. The Contractor shall serve all Members, both statewide and nationally, through their
proposed Efficient Network and, at the State’s request, shall also offer their Broad
Network to Members.
c. The Contractor shall provide administrative services for Members of the State’s Plans,
who elect to enroll in one of the options offered by the State.
A.2. Definitions. For purposes of this Contract, definitions shall be as follows and as set forth in the
Contract.
a. Account Executive: Dedicated full-time employee of the Contractor who has primary
oversight and management of the Contract and all services, deliverables, and
requirements within.
b. Account Manager: Dedicated full-time employee of the Contractor who supports the
Contract primarily handling member services and issues including claims, benefits, and
provider concerns.
A.3. Implementation
a. The Contractor’s call center and other Information Systems, including but not limited to its
claims management system, shall be fully operational on January 1, 2022 (Go-Live).
b. The Contractor shall implement the Information Systems and other processes required to
process all medical claims and perform all other services described herein. The
Contractor shall work with the State to ensure that the Contractor satisfies applicable
requirements of this Contract, including requirements in the Plan Documents (which are
located on the State’s website and all applicable state and federal law.
A.4. Administrative Services
a. The Contractor, upon request by the State, shall review and comment on proposed
revisions to the benefits in the Plans. When so requested, the Contractor shall comment
in regard to:
(1) industry best practices;
(2) the overall cost impact to the Plans;
(3) any potential cost impact to the Contractor’s fee;
(4) impact upon utilization management performance standards;
(5) impact upon the Contractor’s performance;
(6) necessary changes in the Contractor’s reporting requirements; and/or
(7) system changes.
b. The Contractor shall provide advice and assistance with questions regarding effective
dates, benefits, cost-sharing and cessation of coverage as requested by the State,
Members, and providers
A.5. Staffing
a. The Contractor shall provide and maintain qualified staff to provide services required
under this Contract. The Contractor shall ensure that all staff, including the Contractor’s
employees, independent contractors, consultants, and subcontractors, performing
services under this requirement have the experience and qualifications to perform the
applicable services.
b. For its work under this Contract, the Contractor shall not use any person or organization
that is on the U.S. Department of Health and Human Services’ Office of Inspector
General (OIG) exclusions list. unless the Contractor receives prior, written approval from
the State.
A.6. Provider Network
a. The Contractor shall maintain a PPO Efficient Network that serves Members covered by
this Contract in all ninety-five (95) Tennessee counties, as well as Members residing or
traveling outside of the state. This Efficient Network shall provide high quality, cost
effective medical services, and adequate geographic and service access to Members.
Unless otherwise directed by the State, the network shall include other commercial
clients and cannot be established only for State Members. The Contractor shall contract
with medical providers including, but not limited to, primary care physicians, specialist
physicians, nurse practitioners/physician assistants, nurse midwives, hospitals (all levels
- primary, secondary and tertiary), skilled nursing facilities, urgent care facilities,
convenience clinics, state employee onsite clinics, laboratories, durable medical
equipment suppliers, and all other medical facilities, services and providers necessary to
provide covered benefits.
A.7. Member Services
a. All member services representatives handling inquiries related to the Plans shall be
familiar with the terms and provisions of the Plan Documents, including without limitation,
eligibility, benefits, excluded services and procedures, Deductibles, applicable costsharing, including Copayments a
[C] Eligibility:
- Onshore (USA Organization Only);
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office location.
Budget :
Deadline to Submit Proposals: December 07,2020
Cost to Download This RFP/RFQ/RFI/Solicitation/Tender/Bid Document : 5 US$
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Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID : MB-4737
Government Authority located in Tennessee; USA based organization looking for expert vendor for third party administration services.
[A] Budget: Looking for Proposals
[B] Scope of Service:
Vendor needs to provide third party administration services for the state public sector health plans.
A.1. General
a. The Contractor shall provide all goods or services and deliverables as required,
described, and detailed below and shall meet all service and delivery timelines as
specified by this Contract.
b. The Contractor shall serve all Members, both statewide and nationally, through their
proposed Efficient Network and, at the State’s request, shall also offer their Broad
Network to Members.
c. The Contractor shall provide administrative services for Members of the State’s Plans,
who elect to enroll in one of the options offered by the State.
A.2. Definitions. For purposes of this Contract, definitions shall be as follows and as set forth in the
Contract.
a. Account Executive: Dedicated full-time employee of the Contractor who has primary
oversight and management of the Contract and all services, deliverables, and
requirements within.
b. Account Manager: Dedicated full-time employee of the Contractor who supports the
Contract primarily handling member services and issues including claims, benefits, and
provider concerns.
A.3. Implementation
a. The Contractor’s call center and other Information Systems, including but not limited to its
claims management system, shall be fully operational on January 1, 2022 (Go-Live).
b. The Contractor shall implement the Information Systems and other processes required to
process all medical claims and perform all other services described herein. The
Contractor shall work with the State to ensure that the Contractor satisfies applicable
requirements of this Contract, including requirements in the Plan Documents (which are
located on the State’s website and all applicable state and federal law.
A.4. Administrative Services
a. The Contractor, upon request by the State, shall review and comment on proposed
revisions to the benefits in the Plans. When so requested, the Contractor shall comment
in regard to:
(1) industry best practices;
(2) the overall cost impact to the Plans;
(3) any potential cost impact to the Contractor’s fee;
(4) impact upon utilization management performance standards;
(5) impact upon the Contractor’s performance;
(6) necessary changes in the Contractor’s reporting requirements; and/or
(7) system changes.
b. The Contractor shall provide advice and assistance with questions regarding effective
dates, benefits, cost-sharing and cessation of coverage as requested by the State,
Members, and providers
A.5. Staffing
a. The Contractor shall provide and maintain qualified staff to provide services required
under this Contract. The Contractor shall ensure that all staff, including the Contractor’s
employees, independent contractors, consultants, and subcontractors, performing
services under this requirement have the experience and qualifications to perform the
applicable services.
b. For its work under this Contract, the Contractor shall not use any person or organization
that is on the U.S. Department of Health and Human Services’ Office of Inspector
General (OIG) exclusions list. unless the Contractor receives prior, written approval from
the State.
A.6. Provider Network
a. The Contractor shall maintain a PPO Efficient Network that serves Members covered by
this Contract in all ninety-five (95) Tennessee counties, as well as Members residing or
traveling outside of the state. This Efficient Network shall provide high quality, cost
effective medical services, and adequate geographic and service access to Members.
Unless otherwise directed by the State, the network shall include other commercial
clients and cannot be established only for State Members. The Contractor shall contract
with medical providers including, but not limited to, primary care physicians, specialist
physicians, nurse practitioners/physician assistants, nurse midwives, hospitals (all levels
- primary, secondary and tertiary), skilled nursing facilities, urgent care facilities,
convenience clinics, state employee onsite clinics, laboratories, durable medical
equipment suppliers, and all other medical facilities, services and providers necessary to
provide covered benefits.
A.7. Member Services
a. All member services representatives handling inquiries related to the Plans shall be
familiar with the terms and provisions of the Plan Documents, including without limitation,
eligibility, benefits, excluded services and procedures, Deductibles, applicable costsharing, including Copayments a
[C] Eligibility:
- Onshore (USA Organization Only);
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office location.
Budget :
Deadline to Submit Proposals: December 07,2020
Cost to Download This RFP/RFQ/RFI/Solicitation/Tender/Bid Document : 5 US$