8-SHE130921 Specifications.pdf

This specifications document outlines the requirements for a Medicaid claim submission and management contractor serving Salt Lake County Sheriff's Office Jail Health Services Division under the state's 1115 Medicaid Waiver program. The contractor will be responsible for preparing, submitting, and managing Medicaid claims for incarcerated individuals who received Medicaid-covered services or medications during their final 90 days of incarceration. Initial implementation will focus on Medication-Assisted Treatment (MAT) participants, approximately 90 inmates, with planned expansion to all inmates receiving Medicaid-eligible medical care as the program matures. The selected vendor must interface 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 and security policies governing inmate health data.

The contractor must meet five measurable performance benchmarks: submit 95 percent of clean claims within five business days and high-priority claims (exceeding $10,000 or near filing deadlines) within two business days; initiate follow-up on 100 percent of unpaid claims within 30 calendar days; conduct denial review and appeal initiation within 10 business days; achieve an average denial resolution time of 30 or fewer calendar days; and maintain 100 percent timely filing compliance to prevent loss of eligible reimbursements under Utah Medicaid's 12-month filing limit. The contractor must provide training to County staff on identifying and validating Medicaid-eligible claims, assign a dedicated Account Manager to oversee billing operations with additional billing specialists added as needed based on claim volume, submit monthly reports detailing claim submissions and reimbursements, and attend quarterly performance review meetings. Salt Lake County will provide inmate demographic, booking, custody, release data, and secure access to jail medical records necessary for claims processing.