Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED130064. Program Management (PG)YESwithoutReq #Description of RequirementcustomizationPG.1 1. Manage Rate SettingPG.2 Ability to compare encounter data claims and capitation fees vs. Xfee-for-service payment data to determine utilization and paymentanalysis.PG.3 Ability to calculate rates utilizing the designated fee schedule, Xwhile providing the ability to manipulate factors in the calculation,as defined by the user.PG.4 Ability to maintain a history of any rate that includes effective and Xtermination dates.PG.5 Ability to assign budget neutrality. XPG.6 Ability to assess the fiscal impact of updating rates by testing Xagainst previously paid claims.PG.7 Ability to use the pricing files such as Medicare Physician Fee XDatabase (MPFDB) File to update Reference data without manualintervention.PG.8 Ability to automatically update Provider rate tables through an Xelectronic means (e.g., Excel, ODBC compliant database).PG.9 Ability to accept an electronic file from a third-party entity of Xpricing information to assist in rate setting (e.g., TPL allowedamount).PG.10 Ability to associate Provider-specific reimbursement contracts Xwith the Providers. Ability to accommodate various pricing files,UCR, custom fee RBRVS, PPS. (The reference to PPSencompasses all Medicare Prospective Payment Systems that theBureau currently utilizes or may wish to utilize in the future).PG.11 System can receive an electronic update of Medicare rates for XFederally Qualified Health Centers (FQHC).PG.12 Ability to pend claims awaiting approval of fee, rate and code Xupdates.PG.13 Ability to accommodate retroactive application of rates. XPG.14 Upon any change in rates, the system can provide automaticXnotification to an appropriate distribution list.PG.15 Ability to accommodate multiple rate-setting schedules (i.e.,Xhospitals, long-term care facilities, intermediate care facilities forthe mentally retarded (ICF/MR)).PG.16 Ability to extract information that supports rate setting functions. XPG.17 System should capture and apply Member resource amount or Xspend-down amount for claims adjudication.PG.18 2. Manage 1099sPG.19 Ability to establish Provider affiliations in a way thatXaccommodates actual practicing locations and Federal and Statetax requirements (one 1099 per taxable entity).PG.20 Ability to produce and distribute 1099 files, documents and reports Xas required by the IRS. (The MMIS vendor is responsible forcreating a check file that is transferred to the auditor andtreasurer’s office for processing payments. The file is returned tothe MMIS vendor with the warrant and EFT information appendedto the original file. The State agencies do not change the paymentinformation received from the MMIS).YESwithcustomizationNOunabletoprovide14.2-53