Second Pass Claims Editing System

The Vendor is required to provide second pass claims editing system solution functionalities:
•    Edit and identify prepay issues not identified by current editing system. 
•    Edit capabilities should include but not be limited to duplicates, modifiers, bundling and unbundling, national correct codding initiative (“NCCI”) and medically unlikely edit (“MUE”) alignment, diagnosis-related group (“DRG”)/ Medicare severity diagnosis related groups (“MSDRG”), outpatient and ambulatory payment classifications (“APC”) related, site-of-service, units, age/sex, and additional specialty edits. 
•    Solution edits shall include but not be limited to the following claim types: facility, professional, ancillary and lab, behavioral health (“BH”), pharmacy (“RX”), and durable medical equipment (“DME”). 
•    Edit outcomes to include deny, pend, and informational activities. 
•    Apply multiple procedure payment reduction. 
•    Provider records access and edits: edit core system provider data to ensure accurate primary and secondary provider specialty (IES), provider type, and other data identifying scope of practice. 
•    Authorization and automation: must have read authorizations, manual processes that could be automated, and evaluate prepay options (e.g., error script.). 
•    Duplicate services: in-house duplicate edit capabilities, clarification on duplication detection for provider claims. 
•    Customizability: proposer to configure and customize edits and logic. 
•    Configuration may be sourced and must have a clear and timely path to submit edits. 
•    Provider billing detection: solution shall detect excess utilization at the provider level. 
•    Clinical validation approach: quality assurance and audit processes (sampling, validation, false positive monitoring), clinical and coding credentials involved in development, appeals and reconsideration support (evidence packets, turnaround, overturn tracking). 
•    Table maintenance: solution shall provide custom edits, manage table maintenance, maintain criteria, code changes, provider id updates, and assume responsibility for ongoing maintenance. 
•    Implementation and integration with QNXT. 
•    Flow: QNXT → 1st pass provider → new service
•    Coordination of benefits (“cob”) and primary and secondary identification. 
•    Fraud, waste, and abuse functionalities. 
•    Facilitate prior authorization integration for utilization management (“um”) and prior authorization (“pa”) exchanges. 
•    Consistency with data migration for member, provider, claims history, and pa data migrations.
- Requirements
•    Edit sources: centers for Medicare and Medicaid (“CMS”) and Medicare guidance, state Medicaid policy, authority administrative rules, fee schedules, other payer actions, e.g., managing care quality, administrative processes, and financial sustainability. 
•    Operations: solution to clarify turnaround time (real-time vs. overnight vs. 24+ hours). 
•    No claim adjudication - editing only; manual intervention handled by agency. 
•    Reporting requirements: provider-reported hours, cross-payer reporting, savings and outcomes, provide sample reporting dashboard, protected health information (“phi”) breakdown. 
•    Claim pattern review: solution to evaluate provider billing patterns, time-based codes, Siu related analytics, support targeted scenario analysis. 
•    Electronic data interchange (“EDI”) compliance: support required x12 transactions: 270, 271, 276, 277, 278,820, 835, 837. 
•    Configurations of benefit setups.
•    Data security to include demonstrable health insurance portability and accountability act (“HIPAA”) compliance, soc2 or equivalent, multi-factor authentication, incident notification, data retention and return and transition support, written disaster recovery strategy. 
•    Provide a project manager for implementation:
o    Lead requirements gathering sessions. 
o    Meetings to be scheduled by the agency project manager. 
o    Validate functional and technical specifications. 
o    Facilitate communication with the agency project manager. 
o    Risk identification and mitigation planning. 
o    Manage issue tracking and resolution in partnership with agency project manager. 
o    Ensure regulatory and compliance alignment (e.g., HIPAA). 
o    Oversee proposer configuration activities at implementation 
o    Manage testing cycles - system integration testing (“SIT”), user acceptance testing (“UAT”). 
o    Coordinate training planning and materials for agency staff members.
o    Ensure deployment readiness and go-live planning. 
o    Support post go-live stabilization. 
o    Provide status reporting and documentation on a monthly cadence. 
o    Monitor and track compliance with deliverables and service level agreements (“SLA”).