47. BEB47 Maintain the benefit package associated with each benefit plan, including any rules that apply. 48. Maintain member data, including all designated original source data, and all other data that is necessary to manage all of the business functions of KY Medicaid. 49. BEB49 Add new groups of eligible members, as distinguished by program code or functionality, when directed by CHFS, or its designee. 50. BEB50 Support the administration of a variety of benefit packages and claims processing and program administration requirements. 51. BEB51 Support the administration of a variety of service delivery models, including, but not limited to, full-risk capitation, primary care capitation, physician case management, MCO agreements, vendor contracting arrangements, and utilization controlled FFS arrangements. 52. Receive requests from DMS for benefit package updates; validate, test, receive CHFS approval, and then implement according to CHFS specifications. 53. BEB53 Make available to CHFS, or its designee, online inquiry and update capability for access to the EPSDT data. 54. BEB54 Identify and report abnormalities found during screenings and referred for treatment, from data submitted on claim forms. 55. Identify and report (from paid, denied and pended and encounter claims) members receiving treatment under the EPSDT program. service
187. PRB87 Respond correctly to written correspondence, with at least an interim answer, within five business days of receipt of the correspondence, and provide a final response within 15 business days of receipt of the correspondence. 188. PRB88 Test and report the results of electronic billing, automated remittance, and electronic fund transfer option testing within ten business days of the provider’s written request to test. 189. PRB89 Produce and transmit a provider update (for PCP) file to KAMES/PA62 by 7:00 p.m. ET. 190. PRB90 Apply approved batch and real-time updates to the Provider Module, within 24 clock hours of receipt. 191. PRB91 Provide support and guidance via research and testimony at Dispute Resolution Meetings and in other legal forums. 192. PRB92 Support Annual Disclosure of Ownership (ADO) Electronic Process. 193. PRB93 Support multiple languages spoken by the provider. MANAGED CARE (MC) 194. MCB1 The Vendor should perform all functional requirements as needed to support capitated payment for Commonwealth managed care programs. 195. MCB2 Accept and process encounter claim data from any Commonwealth-approved Contractors, or other contractual entities. 196. MCB3 Create and publish a manual that specifies requirements for the submission of encounter claims and fee-for-service by an MCO or other Commonwealth-approved Contractors.
265. CRB11 Sort hardcopy claims, as approved by CHFS, or its designee. 266. CRB12 Assign unique claim control numbers and batches to claims and accompanying documentation. 267. CRB13 Log claim, scan/image claim, apply a Transaction Control Number (TCN), and assign the claim to a batch for processing, within 24 hours of receipt of a paper claim. 268. CRB14 Pre-screen hardcopy claims before entering into the system, and return those not meeting certain criteria (for example, no provider number) to providers; log returned claims daily. 269. CRB15 Develop and maintain screening instructions for each claim type, according to direction provided by the CHFS. 270. CRB16 Perform data entry functions and appropriate manual prescreening functions prior to entry of claims data into the system. All required fields, per the CHFS, should be completed. Claims missing any key data elements or submitted on an inappropriate claim form are to be returned to the provider and logged into a system that allows appropriate auditing. Online inquiry is to be used, as needed, for required address information to return the claim. 271. CRB17 Return claims to providers for predefined reasons. 272. Destroy hard copy claims and reports, according to HIPAA standards and the CHFS specifications. 273. CRB19 Log tapes and diskettes, upon receipt, and assign batch number. 274. CRB20 a claim into the MEMS for processing within five workdays of being logged in (received in mailroom).
282. CRB28 Verify the quality and readability of all imaged claims and documentation. 283. CRB29 Develop and implement procedures to ensure the integrity of claims submitted by providers via Direct Data Entry (DDE) on the internet or other electronic submission of claims. 284. CRB30 Maintain a dedicated EDI unit adequately staffed within Frankfort, KY to assist customers with EDI issues, the receipt of electronic remittance advices, and future technological advances in electronic data transmission. 285. CRB31 Produce claims entry statistics reports, in a format conducive to assessing performance compliance, and deliver to the CHFS. 286. CRB32 Accept original forms (red ink) or copies/faxes of a claim and be able to process it into the MEMS. 287. CRB33 Provide a data entry system that includes, but is not limited to, hardcopy claims and claim adjustment/voids, which provides for field validity edits and pre-editing for fields, such as: provider number, member ID number, procedure codes, diagnosis codes, or others, as defined by the CHFS. 288. CRB34 Perform data entry of all hardcopy claims. 289. CRB35 Maintain a 98% accuracy rate of all keyed claims and any data manually entered by the MEMS Vendor or contract data entry staff. 290. CRB36 Maintain and staff a data entry unit adequate to key hard copy claims within a maximum of five workdays from the TCN date. 291. CRB37 Provide monthly reports/information that show the overall data entry error rate, the error rate per keyer, a corrective action
313. CRB59 Provide training in the use of the Enhanced Claims Editing function of the MEMS to CHFS, and its designee’s, personnel, initially and on an ongoing basis. CLAIMS ADJUDICATION (CA) 314. CAB1 Operate and maintain the Prior Authorization function of the MEMS, in accordance with Kentucky Medicaid policy. 315. CAB2 Process prior authorization for designated services, as required by the CHFS’s policy, and carry sufficient information to adjudicate all claims. 316. CAB3 Implement policy and procedures related to prior authorization/claims/encounter processing. 317. CAB4 Require prior authorization, as required by CHFS program policy. 318. CAB5 Submit prior authorization (PA), addendums to prior authorization and update requests to CHFS, for approval or denial, within 24 hours of receipt and perform appropriate processing of the requests, following approval or denial by CHFS. 319. CAB6 Accept and all PAs, addendums, and update requests from PA contractors. 320. CAB7 Disallow entry of PA requests for dates during which a member is ineligible for services. 321. CAB8 Purge old prior authorization records, according to CHFS, or its designee, specified criteria. 322. CAB9 Provide online inquiry and access to the authorization data set.
344. CAB31 Furnish, as established by CHFS, copies of claim documents and associated TPL attachments for CHFS to utilize for adds and updates to the TPL Module Files. 345. Operate the TPL Module of the MEMS, including improvements as they are implemented, to meet the of CHFS and the requirements of Federal regulations. 346. CAB33 Work out a data exchange system with insurance carriers, the Department of Defense, Workmen's Compensation, Highway Patrol, and entities, as required by Federal regulations and by CHFS. Also, update TPL Files with data exchange info, as approved by CHFS. 347. CAB34 Generate and mail member inquiries from the claims payment process to aid in TPL identification. 348. CAB35 Handle the production and mailing of bills to appropriate third parties by way of hard copy documents or electronically, as specified by CHFS. Also, work with the third-party source, as necessary, to design and implement the billing procedures. 349. Mail billing documents containing paid claims data in an appropriate format, as determined by CHFS, to TPL sources for recovery purposes. 350. CAB37 Mail third party premium payment checks, as directed by CHFS and required by Federal regulations, when CHFS determines it is cost effective to the Medicaid program. 351. CAB38 Obtain, from Medicare carriers and intermediaries that are located in surrounding Commonwealths or designated as regional processors, the claims data, by tape or direct transmission, necessary to pay applicable Medicare
deductible and coinsurance for Medicare/Medicaid eligible members. 352. Process TPL data received from sources of eligibility and the Child Support Enforcement Agency. Also, maintain online work files for CHFS, which allows automatic updates to TPL module files. 353. CAB40 Produce and mail all appropriate party queries to potential carriers and members for CHFS's use in updating TPL Files, as a result of the claims payment process, data matches, and other events specified by CHFS. 354. CAB41 Produce and mail billing documents, to insurance carriers, comprised of paid claims data for recovery purposes. 355. CAB42 Provide CHFS with financial control numbers for TPL recovery checks received by CHFS. 356. CAB43 Print and maintain an inventory of forms, such as prior authorization forms, and send requested forms to providers within five calendar days of the receipt of the request. 357. CAB44 Print routine and special request reports/information, in a media as determined by CHFS. 358. CAB45 Produce all claims entry statistics reports/information and submit to CHFS or its designee, in agreed upon and approved format and media. 359. CAB46 Propose edit and audit criteria for claims processing. 360. Report suspected fraud and abuse, identified during audits, onsite visits, or any other communication with providers, to CHFS.
in order for CHFS not to assess the credit balance against the MEMS Vendor. 404. CAB91 In the event the MEMS Vendor initiates suit against the provider to recover its loss, CHFS, if necessary, assigns its rights to the MEMS Vendor in pursuing the collection of such loss. Deposit any such collections outside the MEMS into the MEMS Vendor’s administrative account. 405. Maintain a staffed claims adjustment unit to handle voids, credits, and debits in a timely manner. Adjustments should be completed within 15 calendar days of submission, except in those cases where CHFS has approved a longer period. 406. CAB93 Provide CHFS with monthly report of credit balance and status of each account, including reasons for or documentation explaining the credit balance. The report should include those credit balances that have been satisfied during the previous month and a report of each effort made to collect the credit balance. 407. CAB94 Pursue actively all credit balances more than 30 days old, by procedures approved by CHFS. 408. CAB95 Submit the following credit balance documentation to CHFS: The written factual determination as to how the credit balance occurred, the amount of the credit balance, and when it occurred. Copies of the claim or claims, data sheets, payment records, canceled check or checks, copies of two demand letters, responses, and any other documentation relating to the credit balance. 409. Take steps to recoup the credit balance amount from the provider, but the collection process should occur outside the
420. CAB107 Maintain procedures to accept and ensure the integrity of electronic pharmacy claim records submitted by the PBM, including adjustments and reversals. 421. CAB108 Operate and maintain the Encounter Processing function of the MEMS system. 422. CAB109 Send encounter reject notices to Managed Care Organizations (MCOs) for encounters failing 423. CAB110 Establish balancing processes to ensure control within the MEMS encounter processing cycles. 424. CAB111 Reconcile all encounter records entered into the system to batch processing cycle input and output figures. 425. CAB112 Maintain procedures to ensure the integrity of electronic encounter records submitted by MCO(s) and pharmacy encounters submitted by the PBM, including adjustments and replacements. 426. CAB113 Produce online and hardcopy balancing and control reports/information, according to CHFS, or its designee, specifications for encounter data. 427. CAB114 Perform presence and format editing on all encounter records according to CHFS, or its designee, specifications. 428. CAB115 Perform validity editing on all entered encounter records, using current information on Provider, Member eligibility, and Reference data, pursuant to CHFS, or its designee, specifications. 429. CAB116 Produce all encounter entry statistics reports/information and submit (email or hand delivery) to the CHFS, or its designee. 430. CAB117 Propose edit and audit criteria for encounter processing.
six-year post-contract period or until resolution. During the Contract period, access to these items should be provided at the MEMS Vendor's office. During the six-year post-contract period, delivery of and access to the listed items should be at no cost to CHFS, or its designee. 480. FIB46 Provide an annual SSAE16 audit performed at the Kentucky facility. 481. FIB47 Provide online access to financial information according to CHFS, or its designee, specifications. 482. FIB48 Provide CHFS with the necessary reports/information to reconcile all fund categories. 483. FIB49 Enter non-claim-specific financial transactions received from DMS. 484. FIB50 Provide training in the use of the Financial Processing function of the MEMS to CHFS, and its designee’s, personnel, initially and on an ongoing basis. 485. FIB51 Make recommendations in any area in which the MEMS Vendor feels improvements can be made. 486. Support all Financial Processing functions, reporting, and data elements necessary to meet the requirements of this RFP. REFERENCE DATA (RF) 487. RFB1 Operate and maintain the Reference Data maintenance function of the MEMS, in accordance with policy set forth by KY Medicaid.
592. DWB15 Provide exception reports/information. 593. DWB16 Provide control file reports/information. 594. DWB17 Provide management reports/information. 595. Ensure that shown on reports/information include a description, including codes for procedures, drug, and diagnosis codes, CLIA certification codes, specialty, and any other codes, and provide on all reports that display codes. 596. DWB19 Ensure that reports are available online and allow authorized users to sort, group, regroup, summarize, print, export to PC software, and perform other output management functions, including drill-down to the original claims data for a more detailed view. 597. DWB20 Ensure that reports meet the guidelines for compliance with Federal SUR requirements. 598. DWB21 Match HEDIS (Healthcare Effectiveness Data and Information Set) reports to Federal requirements. 599. DWB22 Ensure that the DSS/DW data is correct, internally consistent, and consistent with comparable data used in other MEMS functions and reports. 600. DWB23 Ensure that data in the DSS is synchronized to reflect the data in the MEMS, the Eligibility Determination module, PBM, Drug Rebate, and the web portal, including additions due to updates from other sources. The DSS/DW is to be synchronized on a weekly basis to reflect the data in the MEMS, as well as additions due to updates, unless otherwise specified by CHFS.
610. Provide continuous DSS/DW and data training, as deemed necessary by CHFS. Provide DSS/DW training workshops and scheduled trainings at a frequency specified by CHFS. 611. DWB34 Develop training materials. Materials are to include workshops, ongoing professional development user to more experienced user specific training), and others, as defined by CHFS. 612. DWB35 Provide assistance via email, online, in person, or other means, as specified by CHFS, to users to support effective use of data query, data analysis, and report formatting capabilities, in a timeframe defined by CHFS. 613. DWB36 Provide training for CHFS area office staff at the regional sites specified by CHFS. 614. DWB37 Provide comprehensive training in all areas of the data, tools, and report repository. 615. DWB38 Provide training that is focused on common day-to-day of the specific groups being trained. 616. DWB39 Provide training at an approved location by CHFS. 617. DWB40 Provide hands on training of the Business Intelligence tool functionality in multiple user level capabilities. 618. DWB41 Provide training materials that are comprehensive. 619. DWB42 Provide a training plan that includes regularly scheduled training and curriculum. 620. DWB43 Provide training when new versions of the tools and software are implemented. 621. DWB44 Provide training when a major change order is implemented.
622. DWB45 Develop and maintain menu-driven help screens, up-to-date manuals, Data Element Dictionary and instructional materials, which assist CHFS, or its designee, designated users in their use of the DSS/DW. 623. DWB46 Obtain CHFS, or its designee, approval for any changes to the DSS/DW processes, prior to implementation. 624. DWB47 Review the database structure to streamline and minimize the length of time for updates. 625. DWB48 Ensure that the system maintains the capability to perform various manipulations or calculations of data necessary to support CHFS, or its designee, requests. 626. DWB49 Provide the capability to analyze the drug usage of Medicaid members and review the dispensing patterns of pharmacies and prescribing physicians. Also, produce reports/information identifying aberrant usage or prescribing practices. 627. DWB50 Develop queries and reports/information to fulfill CHFS’s analytical needs, per a timeframe defined by CHFS. 628. DWB51 Provide for automated cost settlement functionality, including Provider Statistical and Reimbursement (PS&R) System, for nursing facilities and hospitals. 629. DWB52 Provide user-friendly way of manipulating data (i.e., wizards, more drop-down boxes). 630. DWB53 Build cost settlement spreadsheets from claims history. 631. DWB54 Generate settlement notices to the provider and apply adjustments to claim/encounter history. 632. DWB55 Provide CHFS with access to all Drug Rebate module and Supplemental data.
633. DWB56 Provide CHFS a mechanism to verify data between Drug Rebate module and DSS. 634. DWB57 Coordinate any MEMS data changes with the DSS/DW DBA. 635. DWB58 Notify CHFS, or its designee, within 24 hours of any incorrect reports. 636. DWB59 Advise CHFS of enhancements or upgrades, when newer versions of software used in the DSS/DW become available. Advise CHFS of potential benefits and pitfalls on enhancements, upgrades, or possible changes to the system. 637. DWB60 Make recommendations in any area in which the MEMS Vendor feels improvements can be made. 638. DWB61 Review outputs to determine improvements could be made in report content or format and provide recommendations to CHFS. 639. DWB62 Make MAR recommendations for improvements. 640. DWB63 Report information to assist management in fiscal planning and control. 641. DWB64 Conduct comprehensive and systematic ongoing review of Medicaid program utilization, as well as targeted or focused reviews, profiles, and specialized analyses and decision support services, as may be requested by CHFS. 642. DWB65 Provide the capability to develop, implement, and maintain a controlled query and report repository with the ability to share those objects among users. 643. DWB66 Provide a report library that can be indexed and searched and can retrieve published reports, or should recommend COTS software to meet CHFS’s requirements.
651. DWB74 Provide decision-making support, with an emphasis on and non-structured queries and reporting. Provide the ability to easily detect, analyze, and reports/information patterns in the Kentucky Medicaid Program expenditures. 652. DWB75 Ensure that the Data Warehouse is to run 24/7, with exception of scheduled maintenance downtimes. 653. DWB76 Support all DSS/DW functions, files, and data elements necessary to meet the requirements of this RFP, CMS Certification Standards, and the State Medicaid Manual. 654. DWB77 Recommend all additional fraud and abuse methods, algorithms, actions, activities, theories, tools, and techniques of which the MEMS Vendor becomes aware. 655. Design and implement activities to proficiently and proactively detect potential fraud and abuse by all providers and members. 656. Design and implement activities to proficiently and proactively detect inappropriate billings and over payments, and violations of provider instructions conveyed by applicable Medicaid handbooks and bulletins. 657. DWB80 Design and implement activities to proficiently and proactively detect significant percentage increases or decreases in a provider’s claims. 658. DWB81 Perform detection and normative benchmarking of use, cost, and treatment patterns using clinically and analytically defensible provider grouping and profiling methodologies. 659. DWB82 Perform detection and normative benchmarking of use, cost, and treatment patterns using review criteria and standards.
727. PIB54 Perform detection and normative benchmarking of use, cost, and treatment patterns using clinically and analytically defensible provider grouping and profiling methodologies. 728. PIB55 Withhold provider payments, as directed by CHFS, or its designee. 729. Refer evidence or reports/information of provider fraud or abuse to CHFS, or its designee. 730. PIB57 Respond to Commonwealth requests for general information about the reports/information, within a timeframe specified by DMS. 731. PIB58 When reporting deficiencies are identified and substantiated, correct the problem, get DMS approval, and rerun the report, within a timeframe specified by DMS. 732. PIB59 Meet Federal and Commonwealth requirements for SUR, as outlined in Program Integrity Regulations. CUSTOMER RELATIONS (CS) 733. CSB1 Operate and maintain the Automated Eligibility Verification System (AEVS) function of the MEMS, for Kentucky Medicaid providers to verify member eligibility. 734. CSB2 Provide a voice messaging system for after hour callers stating hours of operation and providing options for callers to leave messages. Full message script to be approved by CHFS, or its designee. 735. CSB3 Provide a voice messaging option, at CHFS, or its designee, designated intervals, during the queue hold time. 736. CSB4 Provide appropriate staff levels to support this function.
804. WSB9 Provide downloadable PDL for providers via the Kentucky Medicaid Website. 805. WSB10 Update the Kentucky Medicaid Website with a full PDL within ten business days after each therapeutic category has been reviewed. 806. WSB11 Produce web Drug Rebate invoices, providing the data in an electronic format for retrieval. 807. Utilize KOG to maintain system of secure access for valid web user identification and password to access the secure services. 808. WSB13 Display the most current Member eligibility information, including third party liability (TPL), managed care enrollment, program limitations and service limits exhausted by member on the Kentucky Medicaid Website. 809. WSB14 Allow providers to check on claim status. 810. WSB15 Allow providers to inquire on check-write information from the most recent payment cycle. 811. Maintain online PA creation, inquiry, and update. 812. Maintain the capability for providers to search National Drug Codes on the Kentucky Medicaid Website. 813. WSB18 The system Website response time should be within 4 seconds for 99 percent of the time. 814. WSB19 Operate and maintain the Web Services function of the MEMS, in accordance with policy set by DMS.
Security authentication. Security authorization. 822. WSB27 Maintain a web service that has the capability to expose metadata that describes all data fields which this web service is capable of providing (publishing) and should provide metadata that describes all data fields that the MEMS wishes to receive (subscribe) from other third-party systems. This metadata should be accessible to the Commonwealth's central metadata web server, which processes all data published and subscribed by third-party database-driven applications in the Commonwealth. 823. WSB28 Maintain the MEMS web services to meet the Commonwealth and CHFS’ web services interface standards for third-party database-driven applications. The web services interface standards for third-party database-driven applications are updated on a regular basis. The MEMS Vendor should be responsible for modifying, throughout the life of the Contract, the MEMS web service, to meet the most current Commonwealth and CHFS web services interface standards. 824. WSB29 Complete additions and/or updates to the web portal that do not require functionality change(s), within one calendar day from CHFS, or its designee, request. 825. WSB30 Keep and maintain electronic records, of all web portal access and usage, in an easy to retrieve format. 826. WSB31 Maintain a method for a KY Medicaid provider to enroll by downloading printable application forms from the web portal. 827. Support, at the user level, the ability to receive and respond to secure and HIPAA-compliant emails from providers, other contractors, and CHFS staff.
1023. GNB67 Notify DMS, in writing, immediately upon discovery of any overpayments, duplicate payments, or incorrect payments, regardless of the cause. 1024. Responsible for immediate reimbursement of the overpayments, duplicate payments, or incorrect payments, regardless of the based on approval of DMS. 1025. GNB69 Recoup the overpayments, duplicate payments, or incorrect payments outside the MEMS, on approval of DMS. 1026. GNB70 Perform all system maintenance to ensure the MEMS remains current and 100% functional. 1027. Confirm security access request within five minutes of receipt, per DMS’s policy. 1028. GNB72 Process reinstatement/new access/deactivation requests, within timeframe established per CHFS policy. 1029. Establish method of destruction of confidential information by shredding and/or burning, in accordance with Commonwealth and Federal requirements. 1030. GNB74 The MEMS Vendor should provide the Commonwealth staff with online access to all MEMS online screens, systems, and data, including all Web-enabled capabilities, for 99% of each month, 24 hours per day, seven days per week, with the exception of scheduled downtime. The MEMS Vendor should maintain the MEMS accessibility during other hours, subject to reasonable Commonwealth notification. Response time should be less than or equal to three seconds for access to inquiry and update screens, as measured on the Commonwealth’s equipment.