Medical Claims Adjudication System Services

Likely incumbent

EFFECTUAL PUBLIC SECTOR INC on contract 15BPCC26F00000053

Heuristic partial prefix match. Total value $21.6M. Awarded 2026-04-01. Agency: Department of Justice.

Prefix-match heuristic; treat as a strong lead, not a confirmed fact.

Solicitation description

The Federal Bureau of Prisons (Bureau) currently provides healthcare to approximately 160,000 inmates in 120 prisons (institutions) geographically dispersed throughout the contiguous United States, Hawaii, and Puerto Rico. For the contract award, all federal inmates are considered to have a single benefit plan and are members of this plan. Inmate access to healthcare benefits is applied universally throughout the Bureau’s system. There are no accumulators or capitation in the Bureau’s healthcare system. Inmates do not pay premiums, copayments (for the purpose of contract award), or deductibles. Medical services rendered to all inmates in Bureau custody are governed by federal law and Bureau policies/procedures. Primary care is provided by Bureau employees as part of a medical team (e.g., physicians, advanced practice providers, nurses, pharmacists, dentists, social workers, therapists, etc.). In addition, each institution within the Bureau solicits comprehensive medical contracts, including but not limited to the facilities referenced under Place of Service Codes in the List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (see Attachment A for the relevant excerpt) for facility and physician services, based on the prevailing: 1) Federal Operating Rate Medicare rates for the applicable area for inpatient facility services; 2) Medicare fee schedule amounts for the area for outpatient facility services; 3) Skilled nursing facilities, and 4) Medicare fee schedule amounts for the area for physician services. Healthcare providers, when negotiating rates for the Bureau are expected to propose a discount from or a premium to Medicare benchmarks. The Bureau has successfully awarded most comprehensive medical contracts based on structured Medicare rates. However, there are locations where the Bureau has been unsuccessful in awarding contracts based on Medicare rates. In those cases, contracts are typically awarded at a percentage of billed charges or the fee schedule. Only Bureau institutions with contracts that are structured using Medicare rates shall participate in claims adjudication process under this contract. The Bureau is the sole payer for all healthcare services rendered to inmates in Bureau custody. The number of claims processed each year may vary based on healthcare services provided. Most healthcare providers are using electronic billing via ANSI 837 format consistent with the industry standard. For the purpose of contract award, a claim for contracted healthcare services reimbursed using the Medicare model is defined as electronic claims that conform to Medicare and Health Insurance Portability and Accountability Act (HIPAA) electronic billing standards (see http://www.cms.hhs.gov/ElectronicbillingEDITrans/01 overview.asp) from a contracted facility, physician’s office, or other healthcare provider. In summary, each institution has separate and unique contract(s) with healthcare providers...

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Data this profile does NOT cover

• No FPDSAward rows for NAICS 541519 in the trailing 12 months; vendor concentration unavailable.