System Hardware, Software and Information Systems Requirements. The CONTRACTOR is required to maintain system hardware, software, and information systems (IS) resources sufficient to provide the capacity to:
(1) accept, transmit, maintain, and store electronic data and enrollment roster files;
(2) accept, process, maintain, and report specific information necessary to CoLTS program administration and other contracted service arrangements, including but not limited to, data pertaining to providers, Members, claims, encounters, grievance and appeals, disenrollment for other than loss of Medicaid eligibility and HEDIS and other quality measures; comply with the most current federal standards for encryption of any data that is transmitted via the internet by the CONTRACTOR or its subcontractors;
(3) conduct automated claims processing in current HIPAA compliant formats;
(4) accept and maintain at least a ten (10) digit Member identification number to be used for all communication to HSD and is cross-walked to the CONTRACTOR’s assigned universal Member number, and which is used by the Member and Providers for identification, eligibility verification, and claims adjudication by the CONTRACTOR and all subcontractors;
(5) estimate the number of records to be received from providers and subcontractors; monitor and transmit electronic encounter data to HSD according to encounter data submission standards, in order to monitor the completeness of the data being received and to detect providers or subcontractors who are transmitting partial or no records;
(6) disseminate electronically enrollment information to Network Providers and subcontractors/vendors within twenty-four (24) hours of receipt of information or, at a minimum, ensure that current eligibility information is available to Network Providers for eligibility verification within twenty- four (24) hours of receiving this information, via a website, automated voice response system, or other means. Network Providers must be able to verify eligibility on weekends, holidays, and after normal business hours;
(7) maintain a website for dispersing information to Network Providers and Members, and be able to receive comments electronically and respond when appropriate, including responding to practitioner e-prescribing transactions for eligibility and formulary information;
(8) transmit data electronically over a web-based FTP server;
(9) receive data elements associated with identifying Members who are receiving ongoing Covered Services under Fee-For-Service Medicaid or from ano...
System Hardware, Software and Information Systems Requirements. The CONTRACTOR is required to maintain system hardware, software, and information systems (IS) resources sufficient to provide the capability to:
A. accept, transmit, maintain, and store electronic data and enrollment roster files;
B. accept, process, maintain, and report specific information necessary to the administration of managed care and other contracted service arrangements;
C. conduct automated claims processing in current HIPAA compliant formats;
D. accept and maintain at least a ten digit member identification number to be used for identification, eligibility verification, and claims adjudication by the CONTRACTOR and all subcontractor;
E. estimate the number of records to be received from providers and subcontractors; monitor and transmit electronic encounter data to HSD/MAD according to encounter data submission standards, in order to monitor the completeness of the data being received and to detect providers or subcontractors who are transmitting partial or no records;
F. disseminate enrollment information to providers within twenty-four (24) hours of receipt of the information;
G. maintain a website for dispersing information to providers and members, and be able to receive comments electronically and respond when appropriate;
H. receive data elements associated with identifying members who are receiving ongoing services under fee-for-service Medicaid or from another CONTRACTOR and using, where possible, the formats that HSD/MAD uses to transmit similar information to an MCO;
I. transmit to HSD/MAD or another CONTRACTOR data elements associated with its members who have been receiving ongoing services within its organization or under another contractual arrangement;
J. have an automatic access system for providers to obtain member enrollment information. Address the cross-reference capability of the system to the member’s ten-digit identification number designated by HSD/MAD to the member’s social security number, and the member’s most current category of eligibility; and
K. maintain a system backup and recovery plan.
System Hardware, Software and Information Systems Requirements. The CONTRACTOR is required to maintain system hardware, software, and information systems (IS) resources sufficient to provide the capability to:
A. Accept, transmit, maintain, and store electronic data and enrollment roster files;
B. Conduct automated claims processing;
C. Estimate the number of records to be received from providers and subcontractors, monitor, and transmit electronic encounter data to HSD according to encounter data submission standards;
D. Transmit data electronically over a Bulletin Board System and via internet;
E. Disseminate enrollment information to providers within five (5) business days of receipt of the information;
F. Maintain a website for dispersing information to providers and members, and be able to receive comments electronically;
G. Have the systems capability to receive data elements associated with identifying members who are receiving ongoing services under fee-for-service Medicaid or from another CONTRACTOR;
H. Have systems capability to transmit to HSD or another CONTRACTOR data elements associated with their members who have been receiving ongoing services within their organization; and
I. Maintain a system backup and recovery plan.
