Services to Support the Adjudication and Payment of Fee-for-Service Medicaid Claims and the Enrollment and Management of Providers (ASO)

It is the intent of the South Carolina Department of Health and Human Services (SCDHHS) to solicit proposals for Services, supplies, and equipment to support the adjudication and payment of valid healthcare Claims, the enrollment and management of providers, interfacing with other components of the Medicaid Enterprise which are out of the scope of this procurement, and supporting Work.

The primary objective of this request for proposal (RFP) is to seek Claims processing via Software-as-a-Service (SaaS) and support Services for the state’s remaining fee-for-service (FFS) population and any program administered by SCDHHS pursuant to the Individuals with Disabilities Education Act Part C via an Administrative Services Organization (ASO).

A Medicaid Management Information System (MMIS) is a system that meets the intent of a “mechanized claims processing and information retrieval system” as described in 42 CFR 433.111 (2015, as amended). This solicitation addresses a subset of the MMIS; it seeks an ASO that provides the function of Claims adjudication as a commoditized service for FFS healthcare Claims. SCDHHS seeks a flexible and extensible solution that can support existing Medicaid-funded health benefit programs under the purview of SCDHHS, as well as existing health benefits programs not assigned to SCDHHS, or similar future State-funded or administered health benefit programs requiring the same or substantially similar Work. In addition to performing Claims processing functions, Contractor shall provide other Services, such as prior authorizations (PAs), provider enrollment and provider management support, provider contact center, and reference data. Third Party Liability (TPL) and Third Party Recovery (TPR) are not part of this solicitation, other than interfaces to receive recoveries information for updating Claim records.

For links to the complete solicitation, attachments and amendments, when and if posted, follow the link at 
http://webprod.cio.sc.gov/SCSolicitationWeb/contractSearch.dosolicitnumber=5400011606.

All questions must be directed to the Procurement Officer identified on the Cover Page of the solicitation.