Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006Req #3. Operations Management (OM)OM1. Service AuthorizationDescription of RequirementOM1.152 Ability to assure that, when an overall service requiring PA resultsin the submission of multiple claim types from a variety ofProvider types, the disposition of all PA requests are consistentwith one another (if the methodology requires a separate PArequest for each claim to be submitted). The system should link orbundle all related PAs so that the disposition is the same across allProviders. (For example, if gastric-bypass surgery requires PA, thedisposition for the hospital facility payment, the surgeon’spayment, and the anesthesiologist’s payment should be consistent(e.g., approved, denied, deferred, etc.).OM1.153 The system should allow users to call up PA requests with a linkedor bundled relationship as a complete service package.OM1.154 Ability to handle HCPCS codes with a minimum of four (4)modifiers. When processing prior authorized claims, the systemshould match the PA-required procedure codes submitted on theclaim against the approved PA request at the modifier, or ifapplicable, at the multiple modifier level.OM1.155 Ability to automatically link the paid claim record with the PArecord.OM1.156 Ability to update PA records based on claims processing toindicate that the authorized service has been used or partially used,including units and/or dollars, during each PA request period. Thisinformation should be captured and displayed with PA history.OM1.157 Ability to provide dual limitation (e.g., total units/year with amonthly limit) controlling the dispensing of services over a longOM1.158period of time.Ability to identify service categories that are subject to the samelimitation and accumulate the same combination of services. Usecombined services to compare to service authorization limit.YESwithoutcustomizationXOM1.159 Ability to allow for modification to the scope of servicesXauthorized and extend or limit the effective dates of authorization.OM1.160 Ability to update PA records based on claims processing to restore Xreversed units to the PA, during each PA request period.OM1.161 Ability to amend authorizations past the end date. XOM1.162 Ability to identify and review PA requests for which an appeal hasbeen submitted (including those that are approved and on appeal),indicate the outcome of such reviews, and identify PAs for whichan appeal has been filed.XOM1.163Ability to automatically identify active or pended PA records whena reference file has been updated (e.g., procedure code, ProviderID), generate a report and request an update as necessary.OM1.164 The system should provide statistical and operational reporting Xcapabilities.OM1.165 Ability to report and maintain web portal PA activity statistics. XOM1.166 Ability to automatically generate a letter to the Provider for BMS Xentered authorizations. The letter is to include the PA number.OM1.167 Ability to provide PA-related correspondence functions to includethe following:XXXXXXXXYESwithcustomizationNOunable toprovide14.2-27