The client seeks a vendor to provide third party claims administrator services, including comprehensive administrative management of eligibility loading, ID card issuance, and electronic claims processing. The selected vendor will be responsible for enrolling members prior to the contract's effective date via electronic transfer from previous TPAs, and must fully disclose the accessibility and any associated costs for claims information. Claims management will include coordination of benefits, subrogation, Medicare coordination, and addressing disputed claims, with detailed processes for litigation management and member outreach regarding additional coverage options such as Medicare or Medicaid.

Professional services required include providing a robust network of credentialed physicians, hospitals, and ancillary providers, maintaining ongoing quality assurance, and offering utilization management services to optimize care and hospital stays without compromising quality. Claims processing services are expected to cover proper claim submission instructions, electronic and manual claim handling, benefit determination, and eligibility file maintenance.

For new business installation, the vendor must collaborate with benefit partners on new products and delivery systems, participate in employee meetings, and act as a liaison between administrative, technical services, and claims departments.