Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-7238

Government Authority located in California; USA based organization looking for expert vendor for nurse case management, utilization review, peer review, medical bill review, and pharmaceutical benefit management services.

[*] Budget: Looking for Proposal

[*] Scope of Service:

(1) Vendor needs to provide nurse case management, utilization review, peer review, medical bill review, and pharmaceutical benefit management services.
1. Nurse Case Management (NCM):
- Doctors and Nurses assigned to the project shall be state licensed and possess a minimum of three years of experience in workers' compensation nurse case management.
- The Contractor shall provide nurse case management services to aid the injured workers in their recovery by ensuring appropriate care, treatment, and disability status (off work, modified or alternative work, etc.). The Contractor shall also facilitate the use of the most suitable treating physician and ensure the effectiveness of the medical provider's treatment plan. Furthermore, the Contractor shall identify existing and potential barriers to progress and provide specific recommendations for intervention.
2. Utilization Review (UR) / Peer Review (PR):
- the Contractor furnish UR an PR services to ensure that medical providers' treatment requests align with patients' medical conditions, comply with evidence-based guidelines, and adhere to all legal and statutory requirements and regulations as specified by the California Department of Industrial Relations, Division of workers' compensation (DWC).
- The contractor must integrate completely with other Contractors, including the in-house City systems.
- The contractor must also integrate the MBR and PBM system and the UR and PR system to identify denied and modified medical treatment for appropriate payment approvals.
3. MEDICAL BILL REVIEW (MBR):
- the Contractor to provide workers' compensation medical bill review services that encompass a range of activities
- The Contractor must identify and correct fee schedule excesses, duplicate charges, and billing infractions, as well as recognize and unbundle service codes as appropriate.
4. Pharmaceutical Benefit Management (PBM):
- The contractor is responsible for ensuring that the city's pharmacy benefit management services deliver necessary and effective drug therapies at the lowest net cost.
- Establish a network of pharmacy benefit providers.
- Utilize utilization review techniques to manage narcotics appropriately throughout the duration of a claim.
- Develop individualized medication plans that are appropriate and effective for each claimant.
- Encourage the use of cost-effective generic medications and ensure that employees use the most efficient channels for obtaining their medication.
(2) All the questions must be submitted no later than April 3, 2023.

[*] Eligibility:

- Onshore (USA Organization Only);

[*] Work Performance:

Performance of the work will be Offsite/Onsite.

Expiry Date : Friday, 28 April, 2023

Question Answer Deadline : Friday, 3 March, 2023

Category : Medical Billing and Coding

Country : USA

State : California

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