Specifications include, but are not limited to: 1. Renewal for 2025 plan year delivered to Gallagher by no later than July 1, 2024. 2. Provision of provider network(s) and adjustment of claims according to network contracts, usual and customary rates, and all other applicable adjustments. 3. Prompt member notification about changes in provider network(s). 4. Provision of member/participant identification cards in a prompt and efficient manner. 5. Provision of on-line eligibility maintenance (including COB, subrogation and special notes to file). 6. Prompt notification to members/participants of changes in eligibility and provision of all member/participant notifications required by HIPAA and other applicable laws and regulations. 7. Provision of accurate and timely adjudication of claims, correction of errors, and follow-up to provider or member questions. 8. Provision of 800 number telephone customer service, including user friendly human access for claim inquiries. 9. Processing of payments to providers in a prompt and efficient manner. 10.Provision of paper and electronic EOBs for members. 11.Promptly advising members of denials and providing a prompt appeal process including rendering a decision on second level appeals and functioning as the claims fiduciary for appeals. 12.Identifying and providing for collection and/or litigation of overpayments, fraudulent claims, and subrogation; and providing reports to Monroe County Government on fraud and subrogation cases. 13.Effectively identifying and correcting improperly coded medical procedures (including upcoding and unbundling) and duplicate billings/payments. 14.Maintaining fully automated claims adjustment and information management. 15.Provision to Monroe County Government of advice of laws, and regulations (including case law) related to the provision and administration of medical plan. 16.Prompt provision of complete and accurate statistical claims reports. 17.Timely submission of all reports required by law or regulations regarding the provision and administration of group medical plan. 18.Electronically signed bid documents, will be acceptable, but they must be printed and delivered in a sealed package by the deadline to the name and address listed on the cover.
