Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED130063. Operations Management (OM)OM2. Payment Management, Claims/Encounter AdjudicationYESwithoutReq #Description of RequirementcustomizationOM2.150 Ability to verify that all Providers submitting input are properly Xenrolled.OM2.151 Ability to pay for services, Members or Providers who areXnormally not paid through the MMIS (where applicable), whenrequired for exception claim processing. (Note - Provider is to beenrolled to receive payment.)OM2.152 Ability to process mathematical calculations on the current claim Xand associated claims in history to limit payments to global (i.e.,bundled, controlling) procedures.OM2.153 Ability to define date parameters to support adjudication ofXservices.OM2.154 8. Suspensions (Pends) and ExceptionsOM2.155 The Vendor is expected to perform online pended claimsXresolution.OM2.156 Ability to automatically suspend all transactions in error until Xcorrections are made.OM2.157 Ability to perform exception control (desktop procedures). XOM2.158 Ability to allow authorized users to override any edits/audits to Xmanually adjudicate a claim when required for exception claimprocessing.OM2.159 Ability to capture the identity of the user who authorizes theXexception payment.OM2.160 Ability to reprocess claims that have not been finalized forXpayment.OM2.161 Ability to reprocess claims automatically when that claim was Xdenied as a result of an unapproved PA and that PA is laterapproved.OM2.162 Ability to systematically reprocess claims that have not reached Xfinal disposition without requiring the user to intervene on a claimby-claimbasis.OM2.163 Ability to define criteria for systematic claims reprocessing, with Xthe ability to review and modify that selection of claims prior toreprocessing.OM2.164 Ability to flag and reprocess previously paid claims within the Xdesignated service date span if a rate change happened to be aretroactive rate change, and implement into production only uponauthorized staff approval.OM2.165 Ability to capture and report on reprocessed claims detail,Xincluding (but not limited to) retroactive rate changes, identify ofthe user authorizing, dates of original processing and reprocessing.OM2.166 Ability to override established pricing calculations if the claim or Xthe Provider billing the claim meets the requirements defined byBMS for pricing exceptions.OM2.167 Able to capture, display and report on encounter data. XOM2.168 9. Price Claim/Value EncounterOM2.169 The system is expected to price all claims in accordance with West XVirginia Medicaid program policy, benefits and limitations.OM2.170 The Vendor is expected to allow for manual pricing of claims. XYESwithcustomizationNOunabletoprovide14.2-34