Insurance Benefit and Medical Claims Management Services

The agency is seeking a vendor to provide insurance benefit and medical claims management services for clients living with human immunodeficiency virus. The selected vendor must develop and maintain a secure, HIPAA-compliant web portal that allows clients, providers, and case managers to upload paper-based insurance premiums and medical claims for payment. The solution must convert all information currently captured in paper-based forms into an electronic format to enable digital storage, search, retrieval, and processing. The agency requires the vendor to be a Centers for Medicare and Medicaid Services (CMS)-certified Enhanced Direct Enrollment (EDE) entity and securely integrate the EDE pathway in full compliance with CMS guidance. The scope of work includes processing initial binding premium payments within five business days of receiving a payment invoice, excluding weekends and state holidays. The vendor must also conduct outreach to clients to communicate changes to the health insurance marketplace and CMS as directed by the state. For medical claims management, the vendor must collect claim forms and supporting documentation, such as explanation of benefits, from clients, case managers, insurance companies, and healthcare providers. The vendor must contact healthcare providers and billing offices to assist with resolving incomplete claims and provide guidance on proper claim submission within five business days of receipt. Additionally, the vendor must operate a call center where inbound and outbound calls are recorded only with explicit caller consent and retained in compliance with HIPAA requirements. Only onshore organizations based in the United States are eligible to bid on this opportunity. The selected vendor must perform all work offsite at the vendor's own office location. The agency is looking for proposals to determine the budget, and bidders must submit all questions regarding this opportunity no later than June 5, 2026.