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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 TABLE OF CONTENTS EXECUTIVE SUMMARY ............................................................................................................... 2 TABLE OF CONTENTS .................................................................................................................. 8 ATTACHMENT A: VENDOR RESPONSE SHEET ............................................................................ 10 2.3 Qualifications and Experience .............................................................................................. 10 2.3.1 Experience ......................................................................................................................... 15 2.3.2 Similar Projects Summary .................................................................................................. 17 2.3.3 References ......................................................................................................................... 21 2.4 Projects and goals ................................................................................................................. 27 2.4.1.1 Data Transfer Processes ................................................................................................. 30 2.4.1.2 Policy Review Process & Data Mining Techniques ......................................................... 31 2.4.1.4 Medical Records Request Process .................................................................................. 33 2.4.1.5 Approach to Clinical and Coding Review ........................................................................ 34 2.4.1.6 Project Reporting............................................................................................................ 35 2.4.1.7 Improper Payment Prevention Plan ............................................................................... 36 2.4.2 Communication and Outreach plan .................................................................................. 37 2.4.2.1 Provider Outreach and Education .................................................................................. 37 2.4.2.2 Outreach and Education Staff ........................................................................................ 39 2.4.2.3 Provider Service Call Center ........................................................................................... 39 2.4.2.3 Compiling and Maintaining Provider Contact Information ............................................ 39 2.4.3 Project Staffing Plan .......................................................................................................... 40 2.4.4 Sample Reports ................................................................................................................. 54 2.4.5 Data Validation .................................................................................................................. 58 2.4.6 Project Closure and Transition .......................................................................................... 59 ATTACHMENT B: MANDATORY SPECIFICATION CHECKLIST....................................................... 62 2.5 Mandatory Requirements .................................................................................................... 62 2.5.1 Attachment D: Special Terms and Conditions ................................................................... 62 2.5.2 Deliverables, Reporting and Service Level Agreements .................................................... 63 2.5.3 BMS Approvals .................................................................................................................. 64 2.5.4 End to End Solutions .......................................................................................................... 65 2.5.5 Compliance ........................................................................................................................ 65 2.5.6 Contractor Medical Director ............................................................................................. 66 2.5.7 Contractor Certified Coders .............................................................................................. 66 2.5.8 Appeals Support ................................................................................................................ 67 2.5.9 Provider Abrasion Limits ................................................................................................... 68 2.5.10 Data Retention ................................................................................................................ 68 8

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