HP Enterprise Services - DHHR

More documents

Recommendations

Info

HPES Response to West Virginia MMIS Re-procurement RFP 4.1.10 Solution Alignment with BMS’ Business and Technical Needs the new policies through the online application, reducing reliance on technical staff members and accelerating the implementation time line. Multiple programs, plans, and payer features are supported in interChange through the user interface, as shown in the following figure. Reference Data Maintenance The benefit package will include rules for policy, contracts, and benefit plans. Unique delivery models will be outlined in the reimbursement rules. Within WV-iC, various business rules govern each claim processed—billing rules from policy and contracts, coverage rules from benefit plans, and reimbursement rules that determine how to price and pay the claim. The authorized user can modify the disposition of edits associated with business rules that will determine whether to pay, suspend, or deny claims, according to State policy, on how each service should be adjudicated. The WV-iC will provide the ability to pay Medicaid and non-Medicaid claims such as Limited Pharmacy (ADAP), Tiger Morton, and Juvenile Justice Services within one system. This capability enables BMS to consolidate and simplify program management and reduce administrative expenses. Our benefit plan solution will help BMS manage rate-setting and benefits more creatively and with greater specificity across the diverse spectrum of programs supported. This precise targeting of benefits and services translates into more efficient management of benefit dollars. Monitor Changes Because of New Policy (Req. 2) When states outline new policies, introduce changes to existing policies, or annual changes are made to code sets, a healthcare management system that can respond quickly and efficiently to change is essential. Accurate claims processing is one of the fundamental and critical functions performed by the proposed WV-iC. The benefit administration rules management allows trained users to identify, create, refine, and maintain business rules that effectively capture and enforce medical policy. HPES will offer recommendations on the most efficient and effective means of updating the business rules to reflect BMS policies. The reference file data for HIPAA-mandated code sets is maintained using a web-based user interface, with online editing to help maintain data integrity when applying updates. The web-based user interface also provides a view to the audit trail of updates that were made, when they were made, and by whom they were made. Our design of having claim types running through a single claims engine makes the long-term maintenance and update of reference file data easier to perform than other MMIS solutions that require multiple sets of files for processing pharmacy and other claim types through separate claims engines. If a policy changes, it is critical that the system reacts quickly to the change yet prevents illogical or inconsistent results. The WV-iC MMIS rules-authoring panels are designed to allow changes yet automatically reviews those changes against existing rules to simplify the rule or prevent overlap. Users can make and apply complex updates intuitively and simply, without unnecessary steps or complications. The WV-iC MMIS also reviews the modified rule to determine if it is inconsistent with another existing rule. For example, a user may try to load a coverage rule for a group of procedures and indicate that a medical Page 230 RFP # MED11014
HPES Response to West Virginia MMIS Re-procurement RFP 4.1.10 Solution Alignment with BMS’ Business and Technical Needs The HPES Provider Services team sets the tone for provider perceptions of the program. A positive provider experience can make even the most difficult situations acceptable. Our HPES team offers knowledgeable provider services staff members who provide the essential expertise to support and deliver an outstanding provider services business function. Operate and Maintain Provider Customer Support Services (Req. 1) Our locally based Provider Services unit will comprise well-educated representatives who have access to online resources, SMEs, and the Provider Services leadership team. Our Provider Services unit will assist providers in resolving concerns and inquiries about various topics, including provider enrollment, member eligibility and benefit packages, prior authorization, claims processing, and questions about portal registration. Call center agents will use the HPES CTMS to document contacts with providers and offers the ability to research prior contacts. CTMS is a comprehensive system that tracks inbound and outbound interactions with providers including telephone calls, email, fax, the secure provider portal, and written correspondence. To enable agents to quickly access stored content, we will use our document management system, HP TRIM. Our call center delivery model uses exceptional products that have a proven history of successful integration to deliver services for customers worldwide. The call center’s telecommunications infrastructure is supported by an Avaya ACD to deliver calls and voice mails using Voice over Internet Protocol (VoIP). The front end of our provider call center comprises an AVRS provided by Genesys that allows providers to use self-service functions 24 x 7, 365 days a year. Generate Outgoing Correspondence (Req. 2, 3) Our HPES team will generate and deliver as efficiently as possible provider-related correspondence, enrollment-related notices and requests for additional information, and notifications, as directed by BMS. To support this, providers are required to indicate during enrollment—also in re-enrollment—how they would prefer to receive communications. After correspondence is generated, the approved document is sent to providers through the media they indicated during enrollment. Unless otherwise specified by BMS, provider communication will comply with their preferred method of communication—email, postal mail, or the provider healthcare portal. We also will use telephone, fax (including “fax blast”), and other channels of communication as appropriate. Additionally, billing, forms, and other state policy information will be available to providers through the healthcare portal. HPES will generate and distribute outgoing provider-related correspondence to include enrollment applications, enrollment rejection notifications, billing instructions, relevant State policy information, request for enrollment or contracting information, mailing labels, program memorandum, referrals to appropriate licensing board, and notifications of pending expired provider eligibility. HP’s Exstream document automation tool allows for the standardization of common correspondence templates, and ondemand correspondence. Notify Date-Dependent Events (Req. 4) With the scheduling features of HP Exstream, users can use the WV-iC workflow control panel to set selected date fields to trigger notifications. For example, re-enrollment dates can be back-scheduled to trigger provider notices using the portal, email or postal mail 30, 60 or 90 days before a provider’s termination date. Perform Provider Outreach Communication and Tracking (Req. 5) Similar to our approach for the development of provider publications, our staffing model includes a provider services trainer and documentation specialist who will work with BMS on the development of provider outreach materials. Outreach materials can be distributed through the portal, email or postal mail and will contain (as a header or introductory section) the intended audience, the issue or topic, the purpose, a distribution date, and, if needed, a required response date. Communications will be stored in our communications database with feedback received about the communication. An example of feedback received about the communication may be the statement: “it was too long.” Along with our ability to create analytical reports from the provider functional area, we also will provide BMS with the ability to target enrolled providers and identify geographical regions for provider recruitment. The HPES CTMS will be used by provider services representatives to track correspondence to include target population, issue or measure addresses, purpose, date of distribution, and method of distribution. CTMS provides historical contact information and serves as the tool to escalate issues within BMS and HPES related to outreach communications. CTMS also provides reports that are used for trending contact data, such as most often asked questions and responses. For more detail, please see the “Contact Management” that follows in this section. RFP # MED11014 Page 233
Page 6 and 7:
HPES Response to West Virginia MMIS
Page 8 and 9:
Page 10 and 11:
Page 12 and 13:
Page 14 and 15:
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27: HPES Response to West Virginia MMIS
Page 82 and 83: • The National Technical Informat
Page 96 and 97: Suspended claims resolution involve
Page 106 and 107: Meet BMS and CMS Requirements (Req.
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134:
Page 152 and 153:
Page 154 and 155:
show all

HP Enterprise Services - DHHR

Create successful ePaper yourself

Delete template?

Save as template?