Payment Integrity and Pre-Pay and Post-Pay Capabilities Services

The Vendor is required to provide Payment Integrity capabilities spanning Pre-Pay and Post-Pay domains.
- Solutions that reduce improper payments before adjudication, recover overpayments retrospectively, detect fraud, and improve overall payment accuracy across Medi-Cal, Medicare Advantage (D-SNP), and Covered state claims operations.
- Pre-Pay Capabilities
•    Claims Editing
o    Code validity (ICD/CPT/HCPCS), NCCI (MUE/PTP), bundling/unbundling logic, modifier validation, provider taxonomy, Delegation of Financial Responsibility (DOFR) routing, and APR-DRG support.
•    Data Mining / Complex Editing
o    Pattern-based detection, rules-plus-analytics, high-cost outlier identification, and utilization anomaly detection.
•    Coordination of Benefits (COB) – Pre-Pay
o    Primary/secondary payer determination, Other Health Insurance (OHI) discovery, real-time coverage validation, and EOB management.
•    Clinical Validation – Pre-Pay
o    Medical necessity review, diagnosis-procedure consistency checks, and inpatient level-of-care/length-of-stay (LOS) validation.
- Post-Pay Capabilities
•    Data Mining & Recoveries
o    Retrospective identification of payment errors, incorrect rates, Multiple Procedure Payment Reductions (MPPR), DRG validation, and duplicate payments.
•    Provider Contract Overpayment
o    Repricing of historically paid claims against provider contracts to identify and recover overpayments.
•    Coordination of Benefits (COB) – Retroactive
o    Post-pay identification of other coverage, recovery management, and provider engagement workflows.
•    Clinical Audits – Post-Pay
o    DRG review, chart audits, implant/device review, and nurse/physician-led clinical validation.
- Solution combines rules-based editing with advanced analytics to surface risks that rules alone would not catch.