Pharmacy Point of Sale Electronic Claims Management System Artificial Intelligence Opportunities Services

The vendor is required to provide pharmacy point-of-sale electronic claims management (POSECMS) system artificial intelligence (AI) applications in areas such as call center operations and service authorization, agency is interested in forward-looking solutions across the entire portfolio of functions.
- Objectives:
•    Understand current and emerging AI capabilities applicable to MEDICAID PBM.
•    Identify opportunities for AI to improve efficiency, accuracy, program integrity, member and provider experience, and health outcomes.
•    Gather recommendations on how AI requirements should be integrated into.
•    Encourage innovative concepts for the broader application of AI within a Medicaid pharmacy solution.
- Requirement:
1. Current and emerging AI capabilities
•    Organization’s experience with AI in pharmacy processing and benefits management.
•    AI-enabled features or modules are currently available in your pharmacy point-of-sale (pos) claims solution
•    Emerging AI technologies are you developing or planning to deploy within the next 2–5 years.
2. Application of AI across key functions
•    Call center facilitation and support (e.g., operations, monitoring and reporting)
•    CRM functionality and workflow automation
•    Claims adjudication and fraud, waste and abuse detection
•    Prior authorization automation and optimization
•    Drug utilization review and clinical decision support
•    Member and provider engagement (e.g., chatbots, virtual assistants)
•    Predictive analytics for medication adherence and clinical outcomes
•    Formularies, coverage policy management, and cost containment
•    Reporting, analytics, and operational dashboards.
3. Governance, transparency, and ethics
•    Ensure transparency, explain ability, and fairness in your AI algorithms
•    Processes do you have in place to monitor and mitigate bias and ensure compliance with Medicaid and regulatory requirements
•    Guardrails and security requirements should be within the AI solution requirements
4. Integration and interoperability
•    AI capabilities integrate with other Medicaid systems, electronic health records (EHR), and third-party data sources
•    APIs do you support for interoperability
5. Implementation and change management
•    Best practices for implementing AI-driven solutions in Medicaid pharmacy operations.
•    Training, support, and change management resources do you provide for state agencies, providers, and members.
6. Recommendations for requirements
•    AI-related requirements and evaluation criteria should be included in future pharmacy POSECMS solutions.
•    There any pitfalls, risks, or considerations the state should be aware of when integrating AI into Medicaid pharmacy operations.
•    ‘Human in the loop’ be factored into solutions.
7. Additional innovative concepts
•    Any additional ideas, pilot concepts, or forward-looking applications of AI that could benefit the state Medicaid ops programs.

- Contract Period/Term: 3 years
- Questions/Inquires Deadline: November 14, 2025