Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006Table 14.2-1: Molina’s Response to RFP Appendix E, Business and Technical Requirements1. Member Management (ME)YESwithoutReq #Description of RequirementcustomizationME.1 1. Determine EligibilityME.2 Ability to provide role-based (inquiry vs. update) access to theXMember eligibility information using a variety of secure methods,including:ME.3 Web portal XME.4 By telephone to the Provider Help Desk XME.5 Automated Voice Response System (AVRS) XME.6 Electronic inquiry through a 270 transaction XME.7 Other as identified by BMS during DDI and accepted via formal Xchange controlME.8 The Vendor is expected to accept eligibility information from a Xstate-maintained sponsor system. Currently, this system receiveseligibility information from Recipient Automated Payment andInformation Data System (RAPIDS), and Families and ChildrenTracking System (FACTS).ME.9 The Vendor is required to on a daily basis, process MemberXeligibility, including Pharmacy, update information received fromeligibility sponsor systems (in the sequence in which they werecreated) for use in claims processing, and generate all applicableupdate reports according to an agreed-upon processing schedule.ME.10 The Vendor is expected to verify that Medical/Dental and Pharmacy XPOS Member eligibility data match on, at a minimum, a monthlybasis. If the two eligibility sources are not in the same database theyshould be synchronized and reconciled on a schedule that ensuresthat eligibility data used for all claims adjudication matches betweenboth systems.ME.11 The Vendor is expected to transmit an interface file to RAPIDS and XFACTS so that required Mountain Health Trust (HMO and PAAS),LTC rates, MHC (Mountain Health Choices), other insurance orThird Party Liability (TPL) and lock in information so that some ofthis information can be printed on the Medicaid ID cards.ME.12 Ability to support flexible rules-based logic (as specified by BMS Xand Federal guidelines) to determine Member benefit plans.ME.13 Ability to identify potential or actual overlaps in program eligibility Xperiods (such as when a client switches from/to Medicaid, Statefunded,or any other programs).ME.14 The system is expected to accept conflicting or overlappingXeligibility segments, and should apply a hierarchy of business rulesto determine which one takes precedence.ME.15 The MMIS is expected to accept the Medicaid ID assigned by the Xeligibility source or through the Master Data Management (MDM)solution.ME.16 Ability to accept and maintain eligibility to pay for services provided Xfor Members who are not Title XIX or Title XXI Members.ME.17 The system should allow authorized users to manually enter Member Xeligibility information.ME.18 Ability to automatically apply data validation edits during manualentry of Member eligibility information.XYESwithcustomizationNOunable toprovide14.2-2