1. Medical Claims and Provider Network Administration Ensure cost sustainability through efficient claims adjudication and network contracting Improve transparency in pricing, contracting, and utilization data Maintain a comprehensive, affordable, and high-quality provider network Provide flexible plan designs and tools to support effective benefit offerings Maintain a highly accurate provider lookup tool Implement value-based contracts, including site-of-service and specialty pharmacy arrangements Support medical pharmacy oversight, including: o Custom formulary administration o Manufacturer copay assistance integration o Customized preferred infusion networks Coordinate with all vendors (e.g., advocacy, pharmacy, PCI) for seamless member navigation Provide timely and accurate implementations for new Partnership groups and detailed disruption reports Facilitate advanced provider tools (e.g., PA, benefit, and claims data sharing) Deliver detailed reporting and analytics tools for OSC oversight Working with the Health Care Advocacy Provider, provide collaborative, timely response and resolution to escalated concerns brought forth by the advocacy provider or OSC Commit to performance guarantees, including: o Pricing, utilization, and data sharing o Provider and customer satisfaction o Mid-year network stability o Cost trends o Quality improvements 2. Customer Service, Health Care Advocacy, and Health Enhancement Program (HEP) Administration Deliver a seamless, high-touch customer service experience o High NPS and client satisfaction scores o Multichannel support (portal, call center, mobile) Provide real-time assistance with benefit navigation, provider referrals, and claims resolution Administer the Health Enhancement Program (HEP), including: o Preventive and chronic care compliance tracking o Personalized outreach and support o Real-time compliance and engagement reporting Coordinate with external vendors (e.g., Flyte, Hinge, Virta, Behavioral health) o Support a single sign-on, mobile-friendly member portal with customizable messaging and tools and real-time HEP compliance status o Align financial interests and incentives with the State's goals including cost control and quality improvements o Provide timely and flexible responses to OSC's requests, adjustments and escalated concerns 3. Primary Care Initiative (PCI) Administration Align vendor incentives with provider performance on cost, quality, and satisfaction (NPS) Deliver real-time financial and quality reporting to OSC and participating providers Maintain monthly or more frequent: o Claims feeds o Pre-certification data o Attribution of high-risk and at-risk members Ensure all program reporting is fully automated and integrated into population health tools accessible by OSC (de-identified) and participating provider groups by July 1, 2026 Provide a comprehensive population health tool: o Real-time updates o Pharmacy data integration o Race, ethnicity, and SDOH stratification Maintain technical transparency, including: o Annual release of financial and quality specifications 30 days before the start of the reconciliation period o Detailed shared methodology for financial and risk adjustment Enable Connie HIE integration and foster data innovation opportunities, (Connie information may be found here: https://www.conniect.org/) OSC de-identified access to reporting platform within 3 months of go live Staff the program fully by launch; provide timely replacements with OSC approval Support structured collaboration, including: o Biannual program review meetings o Rapid project scoping and pricing o Subject matter experts for analytics, reporting and program refinement
