Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED130066. Pharmacy Point-of-Sale (POS)YESwithoutReq #Description of RequirementcustomizationPOS.82 Drugs with descriptions XPOS.83 Narrative denial reasons XPOS.84 Other as identified by BMS during DDI and accepted viaXformal change controlPOS.85 Ability to limit benefits on a Member-by-Member basis (i.e., Xindividual member basis), per BMS approval, for limitations suchas therapeutic categories, optional services and others defined asBMS.POS.86 The Pharmacy POS should respond with reject codes for each Xtransaction within a transmission as defined by NCPDP standard.POS.87 Ability to deny any claim without valid eligibility information on Xfile.POS.88 Ability to verify Member eligibility using demographic data as Xdetermined by BMS.POS.89 Ability to identify Medicaid vs. Non-Medicaid Members. XPOS.90 Ability to support a pharmacy lock-in capability for each Member Xwhen necessary. Lock-in to one pharmacy Provider.POS.91 Ability to support a customizable prescriber lock-in capability for Xeach Member when necessary. Lock-in to one prescribing Providerfor certain therapeutic classes.POS.92 Ability to capture and display HMO plan information (fields for Xdisplay to be defined by BMS).POS.93 Ability to edit all FFS claims submitted for Members identified to Xhave third-party coverage, including Medicare, according to BMSpolicies.POS.94 Ability to process claims when Date of Service does not exceed 12 Xmonths from the date the prescription was written.POS.95 Ability to set a maximum day supply as defined for BMS. XPOS.96 Ability to allow exceptions to the maximum day supply. XPOS.97 Ability to support the current NCPDP standard "Reversal"Xmessage which is to effectively 'debit' the named claim.POS.98 6. Claims Processing - Edits/AuditsPOS.99 Ability to process pharmacy claims, at a minimum, using all edits Xcurrently defined by the BMS.POS.100 The Pharmacy POS should perform real-time edit/auditXprocessing.POS.101 Ability to modify edits and audits as necessary or as defined by the XBMS when policy or coverage changes are implemented.POS.102 Ability to perform adjudication of unique claims (i.e. by-pass Xedits/audits) as specified by the BMS.POS.103 Ability to deny or override claim edits and audits in accordance Xwith BMS determined guidelines.POS.104 Ability to identify and exclude from coverage certain National XDrug Code (NDC) numbers as required by the BMS.POS.105 Ability to restrict a Provider to specific drugs they can prescribe X(in accordance with BMS-specified list defined during DDI).POS.106 Ability to exclude prescriber NPIs when the OIG (Office ofXInspector General) or BMS has determined they are ineligible forparticipation.YESwithcustomizationNOunabletoprovide14.2-77