T3110 - Medical and Pharmacy Claims Reviewer, Data Management and Technical Services

The State of New Jersey's Division of Pensions and Benefits is seeking a contractor to provide comprehensive medical and pharmacy claims review, data management, and technical services for the State Health Benefits Commission and School Employees' Health Benefits Commission. The contract, designated as T3110, aims to review approximately 15 million medical claims annually for approximately 770,000 lives, with a primary focus on ensuring billing accuracy, payment responsibility, contract compliance, and clinical appropriateness of claims. The procurement mandated by P.L. 2019, Chapter 143 and P.L. 2016, Chapter 67 requires a third-party medical and pharmacy claims reviewer to conduct real-time, electronic, line-by-line claim reviews, data aggregation, analytics, and provide comprehensive reporting and consulting services. Evaluation criteria will be based on the total contingency percent for medical claims review and the all-inclusive technology fee per script for pharmacy claims review. The contract term is five years with potential two-year extensions, with an optional pre-quote conference scheduled for October 22, 2025, and quotes due by January 15, 2026. Vendors must submit a comprehensive response including completed State-Supplied Price Sheet, mandatory forms, and comply with detailed information security requirements.

The solicitation includes small business set-aside options and requires vendors to complete an extensive Third-Party Information Security Questionnaire covering 30 distinct control areas, including information security management, compliance, personnel security, and risk management. Potential bidders must provide detailed documentation such as security plans, privacy policies, SOC2 Type II audit reports, and information about subcontractors handling state data. While specific contract award values are not explicitly stated, the pricing structure includes hourly rates for various personnel roles and potential recovery/shared savings components for claims audits. The state reserves the right to award one or more contracts and may separately procure individual requirements during the contract term. Vendors must demonstrate robust cybersecurity practices, comply with state regulations, and provide comprehensive technical capabilities for claims review and data management. The procurement emphasizes cost-effectiveness, quality deliverables, and customer satisfaction, with a strong focus on protecting the confidentiality, integrity, and availability of state information assets.