Summary

This is a specifications document for a Medicaid claim submission and management services contract issued by Salt Lake County, Utah, specifically for the Sheriff's Office Jail Health Services Division under the 1115 Medicaid Waiver program. The selected contractor will be responsible for preparing, submitting, and managing Medicaid claims for incarcerated individuals who received Medicaid-covered services or medications during the final 90 days of incarceration. The initial implementation phase will focus on approximately 90 Medication-Assisted Treatment (MAT) participants, with plans to expand to all inmates receiving Medicaid-eligible medical care as the program matures. The contractor must integrate seamlessly with the County's Saphire Health EHR system to enable secure data exchange, eligibility verification, and claim submission while complying with all County IT standards, security, and privacy policies. Additional responsibilities include providing staff training on identifying and validating Medicaid-eligible claims, designating a dedicated Account Manager to oversee billing operations, and deploying additional billing specialists as needed based on claim volume.

The contractor must meet specific measurable performance benchmarks including submission of 95 percent of clean claims within five business days and high-priority claims exceeding $10,000 or near filing deadlines within two business days; 100 percent initial follow-up on unpaid claims within 30 calendar days; denial review and appeal initiation within 10 business days; average denial resolution time of 30 calendar days or less; and 100 percent compliance with timely filing requirements to prevent loss of eligible reimbursements under the 12-month Utah Medicaid filing limit. The contractor is also required to submit monthly reports detailing claim submissions, reimbursements, denials, and resolution timelines; attend quarterly performance review meetings with Health Services representatives; and provide an annual compliance audit summary with recommendations for process improvement.