Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006TERMPOSPost-SQL CommandPPACAPPSPQASPRCPre-SQL CommandPremium AssistancePremium BillingPremium Rate DetailPrepayment ReviewPrescription Drug CardSystemPresent on AdmissionPresumptive EligibilityPriceractivePrimary Care Provider(PCP)Primary EnrollmentPrimary KeyDEFINITIONA site serving as a guide or point of entry to the Web, may give access to a searchengine and/or a collection of links to other related sitesPoint of SaleThe SQL command defining any processes that will be applied to records afterrunning the SQL query. For example, after the specified SQL query a post-SQLcommand would use the data to generate some type of report suitable uniquebusiness needsPatient Protectiona and Affordable Care ActProspective Payment SystemPrior Quarter Adjustment StatementProvider Relations ConsultantThe SQL command defining any processes that must be applied to Health PAS-Administrator records before running the SQL queryMaximizing cost avoidance for medical services through the accuratedocumentation of other health coverage of a member and by paying healthinsurance premiums on behalf of eligible members when it is cost effective. Anindividual's enrollment in a group health plan is considered cost effective if theexpenditures in Medicaid payments are likely to be greater than the cost of payingthe premiums and cost sharing obligations under an employer group health planfor those servicesHealth PAS module with the capability to generate invoices and process cashreceipts for specific Title XIX and Title XXI Member-related programs whichcontain cost-share componentsStores the premium rate table settingsAdministrative sanction requiring review of a provider’s claims prior to paymentimposed against a medical service provider whose billing practice has been foundin non-compliance with the Department’s policies and procedures, and/or statuesand regulations. This review shall be conducted by the Contractor.Claims processing system used by the incumbent Fiscal Agent to process allpharmacy claims with nightly data passed to MMIS (Same as POS)Used to indicate diagnoses that were documented when a patient was admitted toa facility. The implication is that additional diagnoses that occurred as a result ofthe admission would not generate additional paymentAnticipated understanding that the member will be eligible for one of the State’sprograms before that eligibility has been confirmedMedicare Reimbursement ComponentA provider whose practice is devoted to Internal Medicine, Family Practice,OB/GYN, or Pediatrics. Under HMO health plans, each member has a PCP whomust be the member's first point of contact for non-emergency healthcare services.A health plan member's PCP will perform most general services for the memberand/or will refer the member to other specialists or facilities for services the PCPdoes not provide. Some health plans allow a member to chose a PCP, while otherhealth plans assign members to a PCPThe first payer responsible for claims payment. This can be an external or internalsourceThe attribute selected from a table or database as being the most importantidentifier of the body of information14.14.2-25