TPR SUBSYSTEM. HMO's third party recovery system must have the following capabilities and capacities:
(1) Identify, store, and use other health coverage available to eligible Members or third party liability (TPL) including type of coverage and effective dates.
(2) Provide changes in information to TDH as specified by TDH.
(3) Receive TPL data from TDH to be used in claim and encounter processing.
TPR SUBSYSTEM. SYSTEM-WIDE FUNCTIONS --------------------- HMO MIS system must include functions and/or features which must apply across all subsystems as follows:
TPR SUBSYSTEM. 104 10.11 YEAR 2000 (Y2K) COMPLIANCE....................................... 105 ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM........... 105 11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM......................... 105 11.2 WRITTEN QIP PLAN................................................. 105 11.3 QIP SUBCONTRACTING............................................... 105 11.4 ACCREDITATION.................................................... 106 11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP........................... 106 11.6 QIP REPORTING REQUIREMENTS....................................... 106 1999 Renewal Contract Xxxxxx Service Area August 9, 1999 iv
TPR SUBSYSTEM. HMO's third party recovery system must have the following capabilities and capacities: 1999 Renewal Contract Bexar Service Area August 9, 1999
(1) Identify, store, and use other health coverage available to eligible Members or third party liability (TPL) including type of coverage and effective dates.
(2) Provide changes in information to TDH as specified by TDH.
(3) Receive TPL data from TDH to be used in claim and encounter processing.
TPR SUBSYSTEM. 126 10.12 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) COMPLIANCE.................................. 126 ARTICLE 11 QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM ................................................. 127 11.1 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM .................................................. 127 11.2 WRITTEN QIP PLAN ........................................................................................ 127 11.3 QIP SUBCONTRACTING ...................................................................................... 127 11.4 ACCREDITATION............................................................................................ 127 11.5 BEHAVIORAL HEALTH INTEGRATION INTO QIP................................................................... 128 11.6
TPR SUBSYSTEM. HMO must submit a joint interface plan (JIP) in a format specified by HHSC. The JIP will include required information on all contractor interfaces that support the Medicaid Information Systems. The submission of the JIP will be in accordance with the HMO's Readiness Review and submitted prior to any major system changes thereafter.
TPR SUBSYSTEM. HMO's third party recovery system must have the following capabilities and capacities:
(1) Identify, store, and use other health coverage available to eligible Members or third party liability (TPL) including type of coverage and effective dates.
(2) Provide changes in information to TDHS as specified by TDHS. (3) Receive TPL data from TDHS to be used in claim and encounter processing. TDHS/HMO CONTRACT August 11, 1999 86 93 10.11 YEAR 2000 COMPLIANCE
10.11.1 HMO must take all appropriate measures to make all software which will record, store, and process and present calendar dates falling on or after January 1, 2000, perform in the same manner and with the same functionality, data integrity and performance, as dates falling on or before December 31, 1999, at no added cost to TDHS. HMO must take all appropriate measures to ensure that the software will not lose, alter or destroy records containing dates falling on or after January 1, 2000. HMO will ensure that all software will interface and operate with all TDHS, or its agent s, data systems which exchange data, including but not limited to historical and archived data. In addition, HMO guarantees that the year 2000 leap year calculations will be accommodated and will not result in software, firmware or hardware failures.
10.11.2 TDHS and all subcontracted entities are required by state and federal law to meet Y2K compliance standards. Failure of TDHS or TDHS contractor other than an HMO to meet Y2K compliance standards which results in an HMOs failure to meet the Y2K requirements of this contract is a defense against a declaration of default under this contract.
TPR SUBSYSTEM. 91 10.11 YEAR 2000 COMPLIANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . 92 11.1 QUALITY IMPROVEMENT PROGRAM (QIP) SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 11.2 WRITTEN QIP PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 11.3 QIP SUBCONTRACTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 11.4 ACCREDITATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Dallas Service Area Contract 4
TPR SUBSYSTEM. 10.2 SYSTEM-WIDE FUNCTIONS HMO MIS system must include functions and/or features which must apply across all subsystems as follows:
(1) Ability to update and edit data.
(2) Maintain a history of changes and adjustments and audit trails for current and retroactive data. Audit trails will capture date, time, and reasons for the change, as well as who made the change.
(3) Allow input mechanisms through manual and electronic transmissions.
(4) Have procedures and processes for accumulating, archiving, and restoring data in the event of a system or subsystem failure.
(5) Maintain automated or manual linkages between and among all MIS subsystems and interfaces.
(6) Ability to relate Member and provider data with utilization, service, accounting data, and reporting functions.
(7) Ability to relate and extract data elements into summary and reporting formats attached as Appendices to contract.
(8) Must have written process and procedures manuals which document and describe all manual and automated system procedures and processes for all the above functions and features, and the various subsystem components.
(9) Maintain and cross-reference all Member-related information with the most current Medicaid number.
10.3 ENROLLMENT/ELIGIBILITY SUBSYSTEM The Enrollment/Eligibility Subsystem is the central processing point for the entire MIS. It must be constructed and programmed to secure all functions which require Dallas Service Area Contract 88 Membership data. It must have function and/or features which support requirements as follows:
(1) Identify other health coverage available or third party liability (TPL), including type of coverage and effective dates.
(2) Maintain historical data (files) as required by TDH.
(3) Maintain data on enrollments/disenrollments and complaint activities. This data must include reason or type of disenrollment, complaint and resolution by incidence.
(4) Receive, translate, edit and update files in accordance with TDH requirements prior to inclusion in HMO's MIS. Updates will be received from TDH's agent and processed within two working days after receipt.
(5) Provide error reports and a reconciliation process between new data and data existing in MIS.
(6) Identify enrollee changes in primary care provider and the reason(s) for those changes and effective dates.
(7) Monitor PCP capacity and limitations prior to connecting the enrollee to PCP in the system, and provide a kick-out report when capacity and limitations are exceeded.
(8) Verify...
TPR SUBSYSTEM. 96 10.11 YEAR 2000 (Y2K) COMPLIANCE........................................ 96 ARTICLE XI QUALITY ASSURANCE AND QUALITY IMPROVEMENT PROGRAM........ 97
