Molina Medicaid Solutions - DHHR

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Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006Req #POS.147POS.148POS.149POS.150POS.151POS.152POS.1536. Pharmacy Point-of-Sale (POS)Description of RequirementAbility to enforce early refill limits using different percentages ofsupply used across different drug categories as determined byBMS.Ability to restrict replacement lost/stolen drugs in order todisallow the pharmacy to enter override code per BMS policy.Current BMS policy requires a call to the help desk for approval.11. Drug Utilization Review (DUR)Ability to provide and support point-of-sale with prospective DURedits.Ability to use existing <strong>Medicaid</strong> Member pharmacy claim historyrecords to evaluate the current prescription for possibleinteractions between the patient’s active history prescriptions andthe drug being currently prescribed.Ability to use ProDUR communications that comply with currentspecifications used in NCPDP Version 5.1 or the most currentHIPAA compliant version.Ability to provide online access to Prospective Drug UtilizationReview (ProDUR) criteria/screening data files.YESwithoutcustomizationXPOS.154 Ability to support the following requirements for ProDUR: XPOS.155 Support an edit process that should be parameter or tabledrivenXand be flexiblePOS.156 Provide the capability to update system parameters withoutcomplex programming within one (1) business day of receiptof requestXPOS.157POS.158POS.159POS.160Provide BMS users with role-based access to DUR data (online)for the purpose of displaying module groupings(therapeutic classes), dosing, and other criteria used for editing.Other as identified by BMS during DDI and accepted viaformal change control12. Drug Utilization Review (DUR) - Claims ReviewThe DUR Clinical Modules should be configurable andcustomizable and provide edits per BMS policy. The modulesshould include (at a minimum):POS.161 Drug Drug Interaction (DD) XPOS.162 Therapeutic Duplication (TD) XPOS.163 Ingredient Duplication (ID) XPOS.164 Early Refill (ER) if applicable XPOS.165 Pregnancy Precaution (PG) XPOS.166 High Dosage (HD) XPOS.167 Maximum Duration (MX) XPOS.168 Breastfeeding Precaution (SX) XPOS.169 Low Dosage (LD) XPOS.170 Late Refill (LR) XPOS.171 Drug/Allergy alerts XPOS.172 Ingredient/therapeutic duplication crossover XPOS.173Other as identified by BMS during DDI and accepted viaformal change controlXXXXXXXXXYESwithcustomizationNOunabletoprovide14.2-80
Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006Req #POS.174POS.175POS.176POS.177POS.178POS.179POS.1806. Pharmacy Point-of-Sale (POS)Description of RequirementRxDUR should have capability to modify the ON/OFF status ofclinical modules. (BMS expects the Vendor's solution to have theflexibility to set to "ignore" status such DUR edits as late refill orpregnancy for certain therapeutic classes, but be able to applythem to other therapeutic classes. An example is to deny ACEinhibitors for members who are pregnant, but do not denyPenicillins for members who are pregnant).Ability to implement a ProDUR system using online real-timeintervention at the POS with clinical edits to detect, at a minimum,maximum/minimum daily dosages for all applicable NDCs.Ability to capture and store chronic disease states in the Memberfile.13. Drug Utilization Review (DUR) - Alerts & OverridesAbility to display multiple POS messages as a return response tothe billing Provider.Ability to user-define text of messages to be returned topharmacies.Ability to user-define business rules which allow differentmessages under different circumstances.YESwithoutcustomizationXPOS.181 Ability to apply alerts according to BMS specifications. XPOS.182 For each alert/denial, the ability to include, at a minimum, the Xfollowing information (to the Provider):POS.183 Alert conflict type (e.g., drug allergy alert) XPOS.184 Alert severity (e.g., minor, major, etc.) XPOS.185 Available data related to the alert (e.g., other drug or condition Xin conflict).POS.186 Other as identified by BMS during DDI and accepted viaXformal change controlPOS.187 Ability to support a role-based override capability for all edits. XPOS.188 Ability to support special situations where State/Federalprograms/exceptions exist with "soft edits" to allow Provideroverride.XPOS.189 Ability to support "hard edits" to prevent Provider override. XPOS.190 Ability to support a special "BMS Management Override" for Xpaper claims where normal editing is bypassed.POS.191 Ability to require the Provider to enter codes for actions taken inresponse to the drug interaction alerts/warnings and the outcomesof those actions in accordance with NCPDP response codes. Thesystem should maintain these acknowledgment codes in history, aswell as report them when requested by the BMS.XPOS.192POS.193Ability to user-define additional text to accompany standardNCPDP DUR reject codes and their associated return messages.Ability to edit against data elements in a Provider file of theprescriber identified in the prescriber ID field of a submitted claimfor the purpose of overriding or producing claim (e.g., notrequiring PA for scripts written by certain doctors, or denying aclaim within a certain drug class when written by a specificprescriber).XXXXXXXYESwithcustomizationNOunabletoprovide14.2-81
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Molina Medicaid SolutionsResponse t
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e10vkTable of ContentsItem 1:Overvi
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e10vkDepartment of Health Services
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e10vkservices, and reputation or na
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e10vkIf our government contracts ar
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e10vkIf our cost increases resultin
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e10vkour board of directors. Becaus
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e10vkFirst Quarter $ 44.94 $ 23.46S
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e10vkTable of ContentsCertain compo
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e10vkNevada 8,037 1,106.45 9,099 1,
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e10vkInvestment IncomeInvestment in
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e10vkand 2007, respectively. EBITDA
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e10vk$2.8 million, or $0.10 per dil
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e10vkREPORT OF INDEPENDENT REGISTER
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e10vk65Table of ContentsMOLINA HEAL
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e10vkDelegated Provider InsolvencyC
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e10vk2007 (see Note 11, “Long-Ter
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e10vk$ 252,380 $ 248,039Gross reali
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e10vkTable of ContentsMOLINA HEALTH
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e10vk$10.9 million, and $7.9 millio
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e10vkIn July 2008, our board of dir
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e10vkThe Registrant has an equity i
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e10vkSIGNATURESPursuant to the requ
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exv12w1EX-12.1 2 a51362exv12w1.htm
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e10vkEX-31.1EX-31.2EX-32.1EX-32.2Ta
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e10vkLeverage operational efficienc
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e10vkhealth plans. Among such facto
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e10vkMissouri and Ohio health plans
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e10vkWe are subject to various rout
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e10vkIt may be difficult for a thir
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e10vkItem 5:PART IIMarket for Regis
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e10vkstates to exclude certain bene
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e10vkMedical care ratio 86.8% 84.8%
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e10vkTable of ContentsMedical care
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e10vkare required to pay a fee for
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e10vkknown. While we believe our cu
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e10vkYear Ended December 31,2009 20
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e10vkCalifornia $ 481,717 $ 417,027
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e10vkMOLINA HEALTHCARE, INC.NOTES T
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e10vk2008, we had transitioned fewe
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e10vknot intend to sell, nor is it
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e10vkDuring 2009, 2008, and 2007, t
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e10vk$29.17 - $30.05 9,350 5.9 $ 29
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e10vk(1) The Registrant’s condens
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e10vkChanges in Internal Controls:
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e10vkSignature Title Date/s/ Joseph
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exv10w22Commitments exceed the sum
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exv10w22Loan Document. The amendmen
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exv10w22Name:Title:Fifth Amendment
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exv10w22Fifth Amendment to Credit A
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exv10w24EX-10.24 3 a55407exv10w24.h
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exv10w24Molina ECMS ref# 729 Provid
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exv10w24HSA — Hospital Services A
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exv10w243.2 Member Eligibility Dete
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exv10w245.6 Amendment. Health Plan
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exv10w24HSA — Hospital Services A
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exv10w24License No. StreetNPI (or U
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exv10w24Page 23 of 40ATTACHMENT CPr
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exv10w24• This reimbursement meth
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exv10w24(Rule 53250(e)(4))8. Provid
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exv10w241. Right to Audit. Provider
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exv10w24Treasurer G. William Hammer
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exv10w25unless the situation is one
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exv10w25Plan in identifying, proces
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exv10w25Page 9that the offset and r
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exv10w25under this Agreement.h. Hea
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exv10w25Page 16Date 6/1/06ATTACHMEN
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exv10w25that Provider is de-delegat
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exv10w25the subscriber or Member by
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exv10w25discretion, that Provider h
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exv10w252.5 Annual Disclosure of Ca
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exv10w25Initials of authorizedrepre
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exv10w25the report is true and corr
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e10vk10-K 1 a58840e10vk.htm FORM 10
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e10vkOur StrengthsWe focus on servi
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e10vkevent.CompetitionWe operate in
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e10vkat the funding for these healt
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e10vk18Table of ContentsAlso, many
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e10vkTable of Contentsalleged non-c
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e10vk(fair value of $20.4 million).
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e10vkTable of ContentsSTOCK PERFORM
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e10vkAs of December 31, 2010, our h
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e10vkYear Ended December 31,2010 20
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e10vkAcquisitionsWisconsin Health P
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e10vkspecific performance measures
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e10vkoverestimations were tied to o
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e10vkIntangible assets, net 105,500
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e10vkOur Health Plans segment compr
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e10vkSituations may arise where the
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e10vkinvestment fund. As of Decembe
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e10vk7. ReceivablesHealth Plans seg
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e10vkindebtedness under the Credit
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e10vkstatutory capital and surplus
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e10vkCash paid in business purchase
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e10vkItem 12.Security Ownership of
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exv10w27EX-10.27 2 a58840exv10w27.h
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exv10w27(f) all transferable or ass
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exv10w27and other charges have been
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exv10w27under or affecting the Prop
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exv10w27BY A GENERAL RELEASE, WHICH
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exv10w27(f) Seller’s share of the
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exv10w2710.6 Items Not to be Prorat
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exv10w27- 21 -(i) Delinquency Repor
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exv10w27executed, and delivered by
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exv10w27MATERIALS THAT PERTAIN TO T
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exv10w27Attn: General CounselTeleph
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exv10w2718.16 Authority. The indivi
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