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Response to RFP No. MED13002 State of West Virginia ... - DHHR

Response to RFP No. MED13002 State of West Virginia ... - DHHR

Request For Proposal #

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services PRGX will ensure that each scenario or audit concept describes the complete process for identifying incorrect payments and shows BMS the proof of the improper payment and the specifics regarding the Pharmacy providers and services that the scenario or audit concept covers. Audit Phase Concept Development and approval of the Audit plan leads to the Claim selection for Audit. We anticipate that the majority of the pharmacy claims will be automated reviews with the rest of reviews being Complex review Automated Reviews PRGX utilizes an automated audit process where predetermined and BMS‐approved criteria can be applied electronically to pharmacy claims data to detect improper payments or conclude a no finding determination exists. Once the selected pharmacy claims have been loaded into the PRGX’s proprietary system, the automated review triggers a process that produces a RAC Data Warehouse (RDW) file. The data is then uploaded into the RDW and any errors or external suppressions are identified. The RDW file is then loaded into our data system where demand letters and adjustment files are generated for pharmacy claims that are not suppressed. 29

Request For Proposal # MED13002 Recovery Audit Contract – Pharmacy West Virginia Health and Human Services Complex Reviews PRGX utilizes Pharmacists and Pharmacy technicians to review prescriptions claims to review pharmacy claims that require additional documentation to make a determination. Our experienced Healthcare personnel have a thorough understanding of the unique regulations, policies, and applicable coverage guidelines that make up the review criteria for each pharmacy audit. Once the record requests are received from pharmacy providers, the records are scanned and uploaded into our audit tool. Once the audits are complete, PRGX communicates the findings to the pharmacy provider. Depending upon the agreed terms with BMS, the pharmacy providers may have an opportunity to challenge the findings through an informal process (discussions) and subsequently a formal process (appeal) with BMS should they deem necessary. 2.4.1.1 Data Transfer Processes Processes for data transfer of eligibility, provider, and claims data from the BMS § 2.4.1.1 MMIS, including (but not limited to) initial data load and mapping and subsequent, periodic data refresh activities. Our experienced team of data specialists and business professionals deploy an integrated data flow processes to receive 25+ TB of new client data, averaging 125K unique files per month. Our data enterprise has access to over 5 petabytes of data at any given moment to support our business processes. We can accept and ingest data in variety of methods both electronically and physically, although secure FTP is our preferred method for data exchange. The sheer variety of clients, data types and sources of data received and processed by PRGX has ensured that we remain proactive in growing our infrastructure as well as refreshing our tools to meet the expanding demands required to meet our client service offerings. PRGX’s preference is to provide insights by mining our client’s data in a format as close as possible to the format in which the data is hosted by our clients. PRGX can accept EBCDIC flat files (in either fixed or variable‐length formats), ASCII/Unicode flat files, database backups (from AS400‐based, Oracle, DB2 or SQL Server database management systems), EDI X12, EDIFACT, and many other formats. We will work with BMS’ technical implementation teams to arrive at a mutually satisfactory data acquisition methodology for the extraction of data tables and elements required to deliver our service offerings. 30

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