Administrative Services for Medical, Pharmacy, Stop Loss, Dental, and Vision Benefit Plans

The issuing county seeks a vendor to provide administrative services for its self-funded medical, pharmacy, stop loss, dental, and vision benefit plans. Medical plan responsibilities include claims adjudication and payment administration, claims appeals, coordination of benefits, prior authorization administration, and ACA-required external appeals.

The selected vendor must provide a dedicated toll-free member services number, escalation access for complex claims, eligibility and provider issues, call center operations, and issue resolution support. Customer service representatives must be based in the United States during standard business hours, with interactive voice response routing, average speed-to-answer standards, call abandonment reporting, and multilingual support.

The vendor will also support HIPAA, Transparency in Coverage, Mental Health Parity, the No Surprises Act, and other applicable compliance requirements. Additional responsibilities include implementation management and planning, coordination with county payroll, human resources, and benefits administration systems, utilization and case management, disease management, care coordination, population health programs, digital engagement tools, predictive analytics, care gap identification, and high-cost claimant intervention. Questions must be submitted by November 10, 2026.