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. To solve the challenges of paper-based processing, the agency requires the development and maintenance of a secure, HIPAA-compliant web portal that allows clients, providers, and case managers to upload paper-based insurance premiums and medical claims. The selected vendor must convert all information from paper forms into an electronic format to enable digital storage, search, retrieval, and processing. The scope of work requires the vendor to be a Centers for Medicare and Medicaid Services certified Enhanced Direct Enrollment entity and securely integrate this pathway in full compliance with federal guidance. The vendor must process initial binding premium payments within five business days of receiving a payment invoice, excluding weekends and state holidays. Additionally, the vendor must conduct outreach to clients to communicate changes to the health insurance marketplace and federal guidelines as directed by the state. For medical claims management, the vendor must collect claim forms and supporting documentation, such as explanations of benefits, from clients, case managers, insurance companies, and healthcare providers. When encountering denied or incomplete claims, the vendor must contact healthcare providers and billing offices within five business days of receipt to assist with resolving issues and provide guidance on proper submission. The vendor must also operate a call center where inbound and outbound calls are recorded and retained in compliance with HIPAA, provided that agents obtain explicit consent from callers prior to recording. Eligibility is restricted to onshore organizations based in the United States. The selected vendor must perform all work offsite at their own office location. The agency is looking for proposals to determine the budget for this project. Bidders must submit all questions regarding this opportunity no later than June 5, 2026.