The Vendor is required to provide medicaid management information system has historically been the central system within the state medicaid enterprise, functioning as the single, integrated system for claims processing and information retrieval.
- The Services include:
• Adjudicate fee-for-service (FFS) claims for medicaid reimbursement
• Process managed care encounter claims
• Support all medicaid financial activity (including managed care capitation payments).
• Manage the receipt, adjudication, editing, pricing/shadow pricing, disbursement of funds, and reporting of claims and encounters including, but not limited to, physician, hospital, outpatient, nursing home, dental, vision, transportation, disability services, behavioral health, and waiver services.
• Adjudicate FFS claims in real-time and produce x12 transaction remittance advices.
• Support a diverse set of reimbursement methodologies for FFS and managed care organizations, and apply those reimbursements based on the appropriate criteria.
• Track, display, and report on all claims and encounters processing activity throughout the adjudication process, including reimbursement.
• Be configurable and flexible to support claims and encounters processing to ensure accurate and timely processing and adjudication determinations based on benefit criteria, reimbursement rules, and associated standard reference data.
• Generate capitation payments to the health plans based on the number of recipients assigned to the plan and the correct capitation rate based on the rate cell within which the recipient resides.
• Be responsible for the file maintenance, reconciliation, storage, and retrieval of reference data including that of recipients and providers received from external partners or other module vendors to generate enrollments, process claims, encounters, and capitation payments.
• Maintain recipient eligibility, benefit plan assignment, and plan enrollment
• Process MCO enrollments and auto enrollments.
• Process and maintain centers for medicare and medicaid services’ (CMS) buy-in functions and reference data.
• EDI transactions using the x12 format with enhanced validation processing to share data with trading partners.
- Questions/Inquires Deadline: April 8, 2025