Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006TERMMDSMECTMedicaidMedicaid IDMedicaid Fraud ControlUnitMedicaid InformationTechnology ArchitectureMedicaid Reform SectionMedical ReviewMedically NeedyMedicare Action CodeMedicare AdvantageMedicare Part AMedicare Part BMedicare Part CMedicare Part DMedicare Savings Program(MSP)MEDREVIEWAuthorizationMemberMinimum Data SetDEFINITIONMedicaid Enterprise Certification ToolkitThe Federal health care program as described in Title XVIII of the Social SecurityAct. Part A covers hospitalization and Part B covers medical insuranceMedicaid ID is the Client ID from the IBIS system. It is stored on the Enrollkeystable as CarrierMemID in Health PASA section under the Attorney General that investigates potential Medicaid fraudand abuseAn initiative by the Federal Centers for Medicare and Medicaid Services tomodernize Medicaid Management Information Systems operated by the States bypromoting greater interoperability with other systems, use of Commercial-Off-The-Shelf software, reusable programs and systems, and system analysis thatallows business needs to drive system development.This section is a newly formed section that ultimately will have responsibility forthe Coordinated Care Network (CCN) waiver when approved by CMS. Familiesdeserve better health. Building on years of analysis, input, and recommendationsfrom health care providers and advocacy groups statewide, and under the directionof the Legislature, the Bureau is working to transform Medicaid. The ultimategoal is a sustainable system that will provide better health coverage to residents.Coverage that allows residents to seek treatment in coordinated systems of carewill offer better management of chronic conditions, overall improved health andhigher patient satisfaction.Pre-payment review conducted by the contractor to assure accurate payment forprocedures and/or diagnosis that require review by medical professionals.Those individuals whose income and resources equal or exceed those levels ofassistance established under a State or Federal Plan but are insufficient to meettheir costs of health and medical services.A three-digit code indicating the final outcome of the claim. If the claim is paid,“PAID” will display. A list of applicable codes is provided in the remittanceadvice explanation of codes sectionMedicare Part C health plan optionsMedicare hospital insurance, covers inpatient hospital care, hospital, home healthbenefits and limited skilled nursing facility careMedicare supplemental medical insurance, covers physician services, outpatienthospital care, and other specified servicesMedicare coverage under a managed care modelMedicare prescription drug insuranceA procedure in which the State pays the monthly Medicare premium to CMS onbehalf of eligible Medicaid members, enrolling them in the Part A and/orMedicare Savings Program, formerly called Medicare Buy-InAuthorizations in a working, undecided, or pended status that will cause the ClaimManager module to prevent payment for any services on the authorization.Medreview is an alert that authorizations that have started the review process buthave not had a final decision made towards their eventual statusA person who is qualified for Medicaid and whose application has been approved,but he or she may or may not be receiving services. Member is usedinterchangeably with “enrollee” and “recipient.”14.14.2-20