Healthcare and Drug Prescription Programs Services

The agency is seeking a vendor to provide comprehensive healthcare and drug prescription programs services. The selected administrator will handle the automated processing and payment of medical and prescription drug claims in accordance with plan documents and contracted network reimbursement fee schedules. The scope of work also requires the vendor to manage utilization review, case management, stop loss reporting, third party recovery, and the coordination of medical coverage. To support these services, the administrator must maintain a master file of plan documents, summary plan descriptions, plan booklets, benefit provisions, and claims administration policies. The provider is required to design, print, deliver, and periodically update all necessary forms and form letters at their own expense. Additionally, the agency requires a dedicated customer service operation to provide professional, courteous, and timely responses to inquiries and complaints from plan participants, providers, and authorized legal counsel. The program must feature a medical review system utilizing medical professionals acceptable to the agency. The utilization review services must include hospital pre-admission certification, hospital concurrent utilization review, hospital length of stay monitoring, discharge planning services, and preauthorization when requested. Only onshore organizations based in the United States are eligible to bid, and the performance of all work will take place offsite. The agency is currently looking for proposals to establish the budget and has not disclosed specific key dates or evaluation criteria in the initial request.