Self-Funded Health Plan Medical Administration Services

A client seeks a qualified vendor to provide self-funded health plan medical administration services under a comprehensive administration model. The selected claims administrator must deliver accurate claims data feeds to third-party claims and eligibility warehouses, incorporating a network reimbursement strategy and managed care capabilities into new or existing programs.

Key responsibilities include timely and accurate claims payment, effective and responsive member services, and the provision of regular reporting and data feeds to client subcontractors for effective management of the health plan. The administrator should demonstrate strong plan management experience for self-funded medical programs and a robust provider network to ensure employees' access to high-quality care.

Additional requirements include maintenance of pre-admission certification, concurrent review, and case management programs for all employees, regardless of network access. The selected partner must enable freedom of choice for employees to select providers best suited for quality care and utilization controls, while maintaining effective utilization management throughout the plan. The contract period is expected to span two years.