Common use of Processing Requirements Clause in Contracts

Processing Requirements. The Provider Data Maintenance function must have the capabilities to: 1. Transmit a provider enrollment file to the Department in a specified format; 2. Maintain current and historical provider enrollment applications from receipt to final disposition (approval only); 3. Maintain on-line access to all current and historical provider information, including Provider rates and effective dates, Provider program and status codes, and summary payment data; 4. Maintain on-line access to Provider information with inquiry by Provider name, partial name characters, provider number, NPI, SSN, FEIN, CLIA number, Provider type and specialty, County, Zip Code, and electronic billing status; 5. Edit all update data for presence, format, and consistency with other data in the update transaction; 6. Edits to prevent duplicate Provider enrollment during an update transaction; 7. Accept and maintain the National Provider Identification (NPI); 8. Provide a Geographic Information System (GIS) to identify Member populations, service utilization, and corresponding Provider coverage to support the Provider recruitment, enrollment, and participation; 9. Maintain on-line audit trail of Provider names, Provider numbers (including old and new numbers, NPI), locations, and status changes by program; 10. Identify by Provider any applicable type code, NPI/TAXONOMY code, location code, practice type code, category of service code, and medical specialty and sub-specialty code which is used in the Kentucky Medicaid program, and which affects Provider billing, claim pricing, or other processing activities; 11. Maintain effective dates for Provider membership, Enrollment status, restriction and on-review data, certification(s), specialty, sub-specialty, claim types, and other user-specified Provider status codes and indicators; 12. Accept group provider numbers, and relate individual Providers to their groups, as well as a group to its individual member Providers, with effective date ranges/spans. A single group provider record must be able to identify an unlimited number of individuals who are associated with the group; 13. Maintain multiple, provider-specific reimbursement rates, including, but not necessarily limited to, per diems, case mix, rates based on licensed levels of care, specific provider agreements, volume purchase contracts, and capitation, with beginning and ending effective dates for a minimum of sixty (60) months. 14. Maintain provider-specific rates by program, type of capitation, Member program category, specific demographic classes, Covered Services, and service area for any prepaid health plan or managed care providers; 15. Provide the capability to identify a Provider as a PCP and maintain an inventory of available enrollment slots; 16. Identify multiple practice locations for a single provider and associate all relevant data items with the location, such as address and CLIA certification; 17. Maintain multiple addresses for a Provider, including but not limited to:  Pay to;  Mailing, and  Service location(s). 18. Create, maintain and define provider enrollment status codes with associated date spans. For example, the enrollment codes must include but not be limited to:  Application pending  Limited time-span enrollment  Enrollment suspended  Terminated-voluntary/involuntary 19. Maintain a National Provider Identifier (NPI) and taxonomies; 20. Maintain specific codes for restricting the services for which Providers may xxxx to those for which they have the proper certifications (for example, CLIA certification codes); 21. Maintain summary-level accounts receivable and payable data in the provider file that is automatically updated after each payment cycle; 22. Provide the capability to calculate and maintain separate 1099 and associated payment data by FEIN number for Providers with changes of ownership, based upon effective dates entered by the Contractor; 23. Generate a file of specified providers, selected based on the Department identified parameters, in an agreed upon Department approved format and media, to be provided to the Department on an agreed upon periodic basis; and 24. Generate a file of provider 1099 information. 25. Reports – Reports for Provider functions are as described in Appendix X.

Processing Requirements. The Provider Data Maintenance function must have the capabilities to: 1. Transmit a provider enrollment file to the Department in a specified format; 2. Maintain current and historical provider enrollment applications from receipt to final disposition (approval only); 3. Maintain on-line access to all current and historical provider information, including Provider rates and effective dates, Provider program and status codes, and summary payment data; 4. Maintain on-line access to Provider information with inquiry by Provider name, partial name characters, provider number, NPI, SSN, FEIN, CLIA number, Provider type and specialty, County, Zip Code, and electronic billing status; 5. Edit all update data for presence, format, and consistency with other data in the update transaction; 6. Edits to prevent duplicate Provider enrollment during an update transaction; 7. Accept and maintain the National Provider Identification (NPI); 8. Provide a Geographic Information System (GIS) to identify Member populations, service utilization, and corresponding Provider coverage to support the Provider recruitment, enrollment, and participation; 9. Maintain on-line audit trail of Provider names, Provider numbers (including old and new numbers, NPI), locations, and status changes by program; 10. Identify by Provider any applicable type code, NPI/TAXONOMY code, location code, practice type code, category of service code, and medical specialty and sub-specialty code which is used in the Kentucky Medicaid program, and which affects Provider billing, claim pricing, or other processing activities; 11. Maintain effective dates for Provider membership, Enrollment status, restriction and on-review data, certification(s), specialty, sub-specialty, claim types, and other user-specified Provider status codes and indicators; 12. Accept group provider numbers, and relate individual Providers to their groups, as well as a group to its individual member Providers, with effective date ranges/spans. A single group provider record must be able to identify an unlimited number of individuals who are associated with the group; 13. Maintain multiple, provider-specific reimbursement rates, including, but not necessarily limited to, per diems, case mix, rates based on licensed levels of care, specific provider agreements, volume purchase contracts, and capitation, with beginning and ending effective dates for a minimum of sixty (60) months. 14. Maintain provider-specific rates by program, type of capitation, Member program category, specific demographic classes, Covered Services, and service area for any prepaid health plan or managed care providers; 15. Provide the capability to identify a Provider as a PCP and maintain an inventory of available enrollment slots; 16. Identify multiple practice locations for a single provider and associate all relevant data items with the location, such as address and CLIA certification; 17. Maintain multiple addresses for a Provider, including but not limited to:  • Pay to;  • Mailing, and  • Service location(s). 18. Create, maintain and define provider enrollment status codes with associated date spans. For example, the enrollment codes must include but not be limited to:  • Application pending  • Limited time-span enrollment  • Enrollment suspended  • Terminated-voluntary/involuntary 19. Maintain a National Provider Identifier (NPI) and taxonomies; 20. Maintain specific codes for restricting the services for which Providers may xxxx to those for which they have the proper certifications (for example, CLIA certification codes); 21. Maintain summary-level accounts receivable and payable data in the provider file that is automatically updated after each payment cycle; 22. Provide the capability to calculate and maintain separate 1099 and associated payment data by FEIN number for Providers with changes of ownership, based upon effective dates entered by the Contractor; 23. Generate a file of specified providers, selected based on the Department identified parameters, in an agreed upon Department approved format and media, to be provided to the Department on an agreed upon periodic basis; and 24. Generate a file of provider 1099 information. 25. Reports – Reports for Provider functions are as described in Appendix X.K.