Claims/Services Data Subsystem Sample Clauses

Claims/Services Data Subsystem. (A) The System implemented by CONTRACTOR must include a Claims/services Data Subsystem that collects, processes, and stores data on all services delivered for which CONTRACTOR is financially responsible, primarily for the following purposes: (i) Processing claims and tracking service utilization data; (ii) Capturing all medically related services, including medical supplies and/or equipment (using standard codes as specified by HHSC, e.g. HCPCS, ICD9-CM), rendered by service providers to an eligible member; (iii) Approving, preparing for payment, or rejecting or denying claims submitted. This subsystem may integrate manual and automated systems to validate and adjudicate claims. Refer to Section VIII of the RFP for additional information. (B) Functions and features of this subsystem are: (i) Accommodate multiple input methods -- tape, claim document, magnetic media; (ii) Support entry and capture of a minimum of two diagnosis codes for each individual encounter for a provider on a specific date of service; (iii) Edit and audit to ensure allowed services are provided to eligible clients by eligible providers; (iv) Interface with the Enrollment and Eligibility Subsystem, Provider Subsystem, and/or other CHIP-related systems specified by HHSC; (v) Edit for utilization and service criteria, medical policy, fee schedules, multiple contract periods and conditions; (vi) The ability to submit data to HHSC when requested through electronic transmission using specified formats and meeting specified edits; (vii) Support multiple fee schedule benefit packages and capitation rates for all contract periods for individual providers, groups, services, etc. A claim must be initially adjudicated and all adjustments must use the fee and policy applicable to the date of service; (viii) Provide timely, accurate, and complete data for monitoring claims processing performance; (ix) Provide claims editing capability for detecting CPT coding errors; (x) Provide timely, accurate, and complete data for reporting service utilization; (xi) Maintain and apply prepayment edits to verify accuracy and validity of claims data for proper adjudication; (xii) Maintain and apply edits and audits to verify timely, accurate, and complete data reporting; (xiii) Submit reimbursement to non-contracted providers for emergency services and medically necessary services not available in network but rendered to members in a timely and accurate manner. (xiv) Validate approval and denials of precertificat...