Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED130063. Operations Management (OM)OM2. Payment Management, Claims/Encounter AdjudicationYESwithoutReq #Description of RequirementcustomizationOM2.37 Prior Authorization (PA) Processing XOM2.38 Refund Function at Header and Line Level (for all medical, Xdental and pharmacy claims)OM2.39 Gross payment for Med/Dent and Pharmacy POS XOM2.40 Adpay for Med/Dent and Pharmacy POS XOM2.41 Manage Member Incentive Programs XOM2.42 Produce Check Files XOM2.43 Produce Remittance Advice XOM2.44 Other as identified by BMS during DDI and accepted via Xformal change controlOM2.45 Ability to accept all HIPAA formatted electronic claimsXsubmissions.OM2.46 The system should not accept non-HIPAA compliant codes or Xcharacters into the system.OM2.47 Ability to identify Members with other insurance (including, but Xnot limited to, Medicare Part A, B, and D).OM2.48 Ability to collaborate with Medicare intermediaries, Part A, B and XD, on an ongoing basis to receive and process cross-over claimsthrough the Medicare electronic data submission system.OM2.49 Ability to identify and process pay-and-chase claims (including Xsubrogation). Capture other insurance allowed and payableamounts.OM2.50 Ability to identify TPL and assure that the Title XIX program is Xthe payer of last resort in accordance with the State plan.OM2.51 Ability to process claims for populations that are not Title XIX. XOM2.52 The claims processing component is expected to integrate with all Xother functional areas of the MMIS, including Member, Provider,Benefit Plans, Prior Authorizations, Contracts, Pharmacy,Referrals, Reference (including Correct Coding Initiative, editing),enhanced claim editing, other insurance, and Financial.OM2.53 Adjudicated claims cannot be changed outside an approvedXadjustment process. Once a claim is adjudicated and in a finalstatus, the information is to remain static while it is displayed (e.g.,users may not cut claim information from claim lines/data).OM2.54 Ability to provide a free-form text narrative (length/number of Xcharacters to be approved by BMS) on the claim record that:OM2.55 Identifies the user, date, and time entered XOM2.56 Provides the capability to display free form narrative inXchronological or reverse chronological sequenceOM2.57 Includes an associated user-defined special condition code/flag XOM2.58 Ability to report on the special condition code/flag. XOM2.59 Other as identified by BMS during DDI and accepted via Xformal change controlOM2.60OM2.612. Claims History FileAbility to maintain a full historical record, which includes edit,audit, and resolution information, from initial receipt to paidstatus.XYESwithcustomizationNOunabletoprovide14.2-30