Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006Req #POS.194POS.195POS.196POS.197POS.1986. Pharmacy Point-of-Sale (POS)Description of RequirementAbility to override PA/Electronic Prior Authorization (EPA)requirement based on submitted diagnosis code or previouslyrecorded chronic disease regardless of the claim type the diagnosiswas submitted on.Ability to produce a report, upon request, listing all ProDUR alertsencountered for specified Members, Providers, and/or prescribers.Ability to systematically by-pass or suppress Pro-DUR alertsbased on prescriber/Provider/Member/program and/or drug fileparameters as defined by the BMS.14. Drug Utilization Review (DUR) - Default ScreeningThe initial values for DUR Default Screening Parameters pageYESwithoutcustomizationXshould be set as specified by the BMS.POS.199 Capability for modification of the default Screening Parameters. XPOS.200 Ability to rank the severity of adverse events. XPOS.201 Ability to modify the ranking of Severity Events. XPOS.202 Ability to establish initial Severity Rankings as specified by the XBMS.POS.203 Ability to reject claims when certain drug combinations are used X(as defined by BMS).POS.204 Capability of posting or not posting DUR events to the Provider, Xas determined by BMS.POS.205 15. Drug Utilization Review (DUR) - ReportingPOS.206 Ability to generate the following reporting: XPOS.207 Alerts/claims denials by reason (e.g., therapeutic duplication, Xdrug/drug interaction, excessive utilization)POS.208 Cost saving and cost tracking reports (e.g., savings amounts, Xco-pays).POS.209 Drug file update reporting (e.g., therapeutic class, updateXdescriptions, low/high dose criteria)POS.210 Other as identified by BMS during DDI and accepted viaXformal change controlPOS.211 16. Prior Authorization (PA) - ProcessingPOS.212 Ability to process PAs using the NCPDP standard guidelines. (Fullsupport of processing PAs using NCPDP Standards is desired.BMS acknowledges that most PA requests currently are includedwith claims submission. However, the proposed solution shouldreach into the future and should support D.0 and any subsequentversion during the life of the contract).XPOS.213POS.214POS.215Ability to utilize prior authorization information in claimsprocessing.Ability to approve a 3-day Emergency Fill without a PriorAuthorization. This fill should not count towards the refill count ofthe prescription. (A 3-day supply of medications is allowed to bedispensed to members for drugs that require prior authorization,per Federal regulations. The current system allows a 3-day supplyto be processed using NCPDP standard codes).Ability to provide edits in the claims processing system to identifydrugs requiring prior authorization.XXXXXXYESwithcustomizationNOunabletoprovide14.2-82