Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006TERMRelationshipRelative Value ScaleRemitRemittance AdviceRendering Provider IDReplacement CodeReport IdentificationReport ItemRequest for ProposalRequired DocumentsRequirementResHab AgencyResourceRestrictionsRetro-DURRetroactiveRetrospective DrugUtilization ReviewRetroterminationRevenue CodeReversed ClaimRFPDEFINITIONwill impede the proper adjudication through the automated system. Such claim isreturned to the responsible provider without entering it into the MMISDescribes how various family members are related to a primary subscriber (i.e.spouse, child). Relationships are used in the following modules: MemberAdministration, Employer, and Policy Administrator. Restrictions, holds, or limitson an enrollment can be defined in terms of relationship. For example, themaximum age for a dependent student covered under a subscriber's health plan isa relationship-based restrictionPayment pricing based on the Relative Value Scale method. Health PAS supportsseveral RVS methods, including CRVS, McGraw-Hill RVS, and RBRVS. Eachscale consists of a specified unit amount; a discount can be applied to this pricingmethodA report that details the explanation of a member’s benefits to a provider for eachclaim (and claim line) included in a paymentA summary of claim payments and denials produced by MMIS. An RA canmailed or posted to the Web portalIdentification number of the provider who actually saw the patient and providedmedical serviceCode replacement occurs when a service billed by a provider is discontinued andan alternative code is priced in place of the discontinued code. This replacementcode is supported under the subscriber's benefit plan and contract termsAn identification number of a report to identify and associate it with the programfrom which it was produced.A unit of information or data appearing on an output report.The document that describes to prospective Offerors the requirements of theFiscal Agent, MMIS, terms and conditions and technical information.Documentation necessary for provider enrollment, claim processing and paymentor the likeA functionality specified by the state as being mandated for the ReplacementMMIS.Residential Habilitation AgencyA person or a tool available to and employed by the project to achieve projectobjectivesHold or limits on an enrollment.Retrospective Drug Utilization ReviewRefers to “back dated” coverage or service date in which a person was determinedto be eligible for a period prior to the month in which the application was initiated.A review of a patient’s drug regimen designed to identify patients at risk for druginduced illness and/or interactions.A termination that occurred after a payment was processed and the check was sentor when a health plan has supplied an advance to a provider during a claimsbacklogA numeric code that identifies a specific type of charge on a UB-04 claim formA paid claim in which all amounts are reversed or backed out of all areas inQNXT, including the accumulatorRequest for Proposal14.14.2-29