Vendor System Interface Clause Samples

Vendor System Interface. The TPA is responsible for the electronic exchange of claims, provider and eligibility files and related information to and from the Board vendors. The TPA must provide a daily comprehensive review of all vendor file transmissions performed to ensure necessary files are transmitted to trading partners as expected. This monitoring process identifies any missing file transfers and ensures files are obtained within a timely manner. Current electronic transfer requirements include, but may not be limited to, the following: Pharmacy Benefit Manager (PBM) - daily, detailed claims data by participant ID number will be transferred by PBM to the TPA for purposes of tracking benefit maximum accumulations. Eligibility data (changes, additions, terminations) will be transferred by the TPA to the PBM daily. Medical Management Vendor - each day, inpatient/outpatient pre certification review and case management data will be transferred to the TPA. Each week, eligibility and network provider data will be transferred by the TPA to the medical management vendor. Detailed claims and biometric data is transferred to the medical management vendor by the TPA on a weekly basis for purposes of administering the Plan’s medical management program. A network provider file is transferred each week from the TPA to the medical management vendor. Health and Wellness (HWM) Vendor - Eligibility data (changes, additions, and terminations), detailed claims data, and biometric data will be transferred by the TPA to the HWM daily. Additional data transfer may be required to support the Health and Wellness program. Decision Support Vendor – comprehensive claims and eligibility data will be transferred to the Decision Support Vendor each month. Public Employees’ Retirement System (PERS) – daily verification of retirement eligibility and monthly file to confirm premium deduction from retiree checks. MDFA – daily exchange of files of premium receipts and related information.