Posted Date : April 06,2021
Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID : MB-5136
Government Authority located in Tennessee; USA based organization looking for expert vendor for medical claims audit services.
[A] Budget: Looking for Proposals
[B] Scope of Service:
(1) Vendor needs to provide medical claims audit services to provide medical and behavioral health claims audits for the state of each of its three third party administrators for medical and behavioral health claims.
- The contractor shall conduct audits that provide a comprehensive and objective review of claims processed by the third-party administrators’ services to determine if claims were adjudicated and paid according to contractual standards between the third-party administrators and the provider, plan benefits, and policies, and industry standards
- Financial accuracy: Financial accuracy is calculated by taking the total benefit dollars paid in the population, minus the sum of the weighted absolute value of the overpayments and underpayments, identified from the sample, divided by the total dollars paid in the population
- Payment accuracy, including coding accuracy: Claims payment accuracy is calculated by dividing the weighted number of correct benefit payments by the total number of payments in the sample population
- Processing accuracy, including benefit administration such as deductibles and co-pays: Claims processing accuracy is calculated by dividing the weighted number of claims processed without any type of error by the total number of claims in the sample population
- Benefits administration’s claims processing accuracy performance guarantee is 96% or higher
- Contractor will conduct concurrently two separate claims adjudication review audits
- Duplicate payments
- Coordinator of Benefits (COB) errors – Non-Medicare and Medicare
- Unbundling of services
- Payments for wrong place of service
- Absence of multiple procedure reductions
- Adherence to assistant surgeon pricing
- Claims Pricing-Comparison of amount paid to amount invoiced on claims
- Performance of the Audits shall be overseen and supervised on the contractor’s behalf by individuals who have at least five years’ experience in medical claims audit examinations
(2) A pre-proposal conference will be held on April 7, 2021.
(3) All question must be submitted no later than April 13, 2021.
[C] Eligibility:
Onshore (USA organization Only)
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office premises.
Budget :
Deadline to Submit Proposals: April 28,2021
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-5136
Government Authority located in Tennessee; USA based organization looking for expert vendor for medical claims audit services.
[A] Budget: Looking for Proposals
[B] Scope of Service:
(1) Vendor needs to provide medical claims audit services to provide medical and behavioral health claims audits for the state of each of its three third party administrators for medical and behavioral health claims.
- The contractor shall conduct audits that provide a comprehensive and objective review of claims processed by the third-party administrators’ services to determine if claims were adjudicated and paid according to contractual standards between the third-party administrators and the provider, plan benefits, and policies, and industry standards
- Financial accuracy: Financial accuracy is calculated by taking the total benefit dollars paid in the population, minus the sum of the weighted absolute value of the overpayments and underpayments, identified from the sample, divided by the total dollars paid in the population
- Payment accuracy, including coding accuracy: Claims payment accuracy is calculated by dividing the weighted number of correct benefit payments by the total number of payments in the sample population
- Processing accuracy, including benefit administration such as deductibles and co-pays: Claims processing accuracy is calculated by dividing the weighted number of claims processed without any type of error by the total number of claims in the sample population
- Benefits administration’s claims processing accuracy performance guarantee is 96% or higher
- Contractor will conduct concurrently two separate claims adjudication review audits
- Duplicate payments
- Coordinator of Benefits (COB) errors – Non-Medicare and Medicare
- Unbundling of services
- Payments for wrong place of service
- Absence of multiple procedure reductions
- Adherence to assistant surgeon pricing
- Claims Pricing-Comparison of amount paid to amount invoiced on claims
- Performance of the Audits shall be overseen and supervised on the contractor’s behalf by individuals who have at least five years’ experience in medical claims audit examinations
(2) A pre-proposal conference will be held on April 7, 2021.
(3) All question must be submitted no later than April 13, 2021.
[C] Eligibility:
Onshore (USA organization Only)
[D] Work Performance:
Performance of the work will be Offsite. Vendor needs to carry work in their office premises.
Budget :
Deadline to Submit Proposals: April 28,2021
Cost to Download This RFP/RFQ/RFI/Solicitation/Tender/Bid Document : 5 US$