Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006TERMMember Share of CostMember’s EligibilityOrganizationMemoMilestoneMinimum Data SetsMisutilizationMITAMITA SS-AMMISModalityModificationModified AuthorizationModifierModifier DiscountModuleMTS ComponentDEFINITIONA cost sharing payment, can be a member contribution or a patient liabilityThe system of record for member demographic and eligibility information inHealth PAS. All changes to member information, with a few exceptions, willcome to Health PAS via the daily interface. Whenever a member changeseligibility organizations, health plans, rate codes, or coverage types, the existingenrollment segment must be terminated and a new enrollment segment must beaddedAn indicator that a record has additional information attached that is not currentlyvisible (e.g., comments about a discussion with a health plan member about apending authorization)The measuring point used to review and approve progress, to authorizecontinuation of work, and, depending on the terms of the Contract, to pay forwork completedThe nursing home quality measures come from resident assessment data thatnursing homes routinely collect on the residents at specified intervals during theirstay. These measures assess the resident's physical and clinical conditions andabilities, as well as preferences and life care wishes. These assessment data havebeen converted to develop quality measures that give consumers another source ofinformation that shows how well nursing homes are caring for their resident'sphysical and clinical needs.Any usage of the Medicaid Program by a provider or a recipient not inconformance with State and Federal regulation (fraud, defects in level or qualityof care, etc.).Medicaid Information Technology ArchitectureMITA State Self Assessment (SS-A)Medicaid Management Information SystemA therapeutic method or agent, such as surgery, chemotherapy, or electrotherapy,that involves the physical treatment of a disorderRoutine MMIS system changes that are identified throughout the life of theContract, documented on the Customer Service Request form, and submitted tothe Contractor for design, programming, and implementationAuthorizations that are approved but will cause the Claim Manager module toevaluate each service line on the claim depending on the status of each lineA special code providers use to adjust a CPT code on a CMS-1500 claim form.Modifiers establish different payment amounts or record descriptive informationthat does not affect payment levels. Only modifiers for which the Centers forMedicare & Medicaid Services (CMS) has established a national payment policywill affect payment levels; carrier-unique local modifiers may be used but suchmodifiers have no affect on payment under MedicareThe percentage of the contract amount on a claim line that is eligible forprocessing based on a specific modifierA group of data processing and/or manual processes that work in conjunction witheach other to accomplish a specific function.MTS is a Microsoft Transaction Server which will calculate accumulator values/balances from Com+. Microsoft COM (Component Object Model) technologyenables software components to communicate. COM+ brings together COMcomponents with the application host of MTS to handle difficult programmingtasks14.14.2-21