South Dakota Posting Board #26RFP19880

South Dakota workers’ compensation claims administration and related services

South Dakota is seeking a third-party administrator to manage its self-funded workers’ compensation program. - Government buyer: State of South Dakota, Bureau of Human Resources and Administration (BHRA); the South Dakota State Employee Health Plan is also identified in the Business Associate Agreement. Procurement contact: Peggy Canter. - Services requested: Third-party claims administration and investigation, medical case management, medical bill review, MMSEA reporting, and program reporting, analytics, and strategic support. No products, part numbers, or fixed service quantities are specified. - Claims administration: Handle claim intake, evaluation, processing and payment; investigations or defense as applicable; claimant communications; medical records; electronic claim files and payments; required Department of Labor and tax reporting; provider disputes; and coordination with the State’s subrogation services provider. Provide 24/7 injury reporting and proactive management of complex claims. - Case management and cost controls: Provide managed-care, pharmacy management, nurse triage, and return-to-work or transitional-work support. Contact the State and forward specified return-to-work and appointment updates within 24 hours of assignment or receipt. Review bills against South Dakota’s fee schedule and usual-and-customary charges, identify inappropriate or duplicate charges, and apply relevant PPO discounts or negotiate costs. - Reporting and protections: Provide required electronic MMSEA reporting to CMS, including monthly and quarterly reporting and specified Medicare Secondary Payer file types; assist with Workers’ Compensation Medicare Set-Aside proposals. Protect PHI under HIPAA requirements, including safeguards, incident and breach reporting, access and audit support, and return or destruction of PHI when the agreement ends. - OEMs and vendors: No OEMs, service vendors, or named subcontractors are identified in the solicitation materials. The State’s subrogation services provider is referenced but not named. - Term: Three consecutive 12-month periods, with up to two additional one-year extensions at the State’s discretion. Extensions are not automatic.

Description

The State of South Dakota, Bureau of Human Resources and Administration seeks a licensed and qualified business partner to provide third-party claims administration for the State’s Workers’ Compensation Program. Services must include Medical Case Management, Medical Bill Review, and Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) reporting. The work also includes timely and compliant claims administration, cost-containment, risk mitigation and workplace-safety guidance, performance reporting and analytics, and management of complex claims. The RFP describes three 12-month periods, covering fiscal years July 1, 2027 through June 30, 2030.

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