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Attachment E: Requirements Traceability Matrix provides a comprehensive listing of all project requirements.

The vendor should
document its approach to requirements and indicate in Attachment E the location of a response to a requirement by filling in the
column “Response Reference”.

Attachment E: Requirements Traceability Matrix
MAS Req ID

Requirement

Business Area

Business Process

Corresponding
MECT Checklist

Weight

Response Reference

The Contractor must:
BUS001

Facilitate open and timely communication with the Department, other contractors and stakeholders, as well as a strong
working relationship to achieve the overall project goals.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS002

Designate one or more persons responsible for the security of each facility.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS003

At a minimum, transfers data from Medicaid Management Information System (MMIS) claims history, recipient
enrollment, provider enrollment, and primary reference data (e.g., diagnosis, procedure, National Drug Code (NDC), and
pricing) information to the Medicaid Data Warehouse (MDW).

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS004

Provide complete segregation of State data, documents and files from that of other contractor customers.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

3

Section:
Page:

BUS005

Receive, review for completeness and process hard copy and fax applications for:
• Trading Partner and Security Agreements
• Electronic Transmitter Identification Numbers (ETIN)
• Electronic Funds Transfers (EFT)
• Web Portal Users Ids
Transaction failing the completeness review must be returned to the submitter without further processing.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS006

Review applications; make determinations and set application status to approve, pend, deny or other statuses defined by
the Department; and communicate determinations as approved by the Department. Reviewers must note application
deficiencies and send emails or letters to the applicant requesting information for:
• Trading Partner and Security Agreements
• ETINs
• EFTs
• Web Portal Users

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS007

Accept Trading Partner and Security Agreement applications via hard copy, fax, and the Web Portal.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS008

Develop and maintain all Trading Partner and Security Agreements and related instructions on the Web Portal as required
by the Department including but not limited to:
Business Relationship
• Security Packet A for real-time (Direct Connection) processing
Management
• Security Packet B for batch processing
• Trading Partner Agreements

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS009

Develop and maintain applications, instructions and related materials on the Web Portal for obtaining ETINs, enrolling in Business Relationship
EFT, and obtaining Web Portal user IDs as required by the Department.
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS010

Support, monitor and maintain a Web Portal application that allows providers, and applicants to enter applications for
Trading Partner and Security Agreements, ETINs, EFT, Provider Enrollment, Provider Maintenance/Updates and Web
Portal User IDs.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

2

Section:
Page:

BUS011

Image, edit, verify, index and route for processing hard copy and electronic applications, maintenance and termination
requests for:
• Trading Partner and Security Agreements
• Managed Care contracts
• ETIN
• Web Portal User
• EFT

Business Relationship
Management

BR01 Establish Business
Relationship

MC1.5

1

Section:
Page:

BUS012

Comply with all relevant provisions of regulations promulgated under the Health Insurance Portability and Accountability
Business Relationship
Act of 1996 (HIPAA), American Recovery and Reinvestment Act of 2009 (ARRA) and Health Information Technology
Management
for Economic and Clinical Health (HITECH) Act including privacy and security regulations.

BR01 Establish Business
Relationship

RI4.1, ME4.1

3

Section:
Page:

BUS013

Comply with provisions for Administrative Simplification under the HIPAA of 1996 to ensure the confidentiality,
integrity, and availability of PHI:
• Provide safeguards as described in the October 22, 1998 State Medicaid Director letter, Collaborations for Data Sharing Business Relationship
between State Medicaid and Health Agencies;
Management
• Perform regular audits; and
• Support incident reporting.

BR01 Establish Business
Relationship

RO5.2; RI4.2

2

Section:
Page:

BUS014

Use or disclose Protected Information (PHI) only to perform functions, activities or services specified in this RFP, for, or
Business Relationship
on behalf of the Department, provided that such use or disclosure would not violate the HIPAA, ACA, or HITECH
Management
regulations, if done by the Department.

BR01 Establish Business
Relationship

RI4.1, ME4.1,

1

Section:
Page:

BUS015

Provide a solution that prevents unauthorized access and safeguards the confidentiality of person/consumer data in
compliance with State and federal law, including but not limited to HIPAA, the NYS Personal Privacy Protection Law,
and the data breach provisions of the NYS Technology Law.

Business Relationship
Management

BR01 Establish Business
Relationship

BE1.8, ME4.1

1

Section:
Page:

BUS016

Obtain written approval from the Department prior to release of PHI to any non-Department entity. Verify with the
Department that the requesting party is authorized to receive information.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS017

Ensure PHI is rendered unusable, unreadable or indecipherable to unauthorized individuals in accordance with
Department of Health and Human Services Guidance published April 27, 2009.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

2

Section:
Page:

BUS018

Encrypt sensitive data (PHI and PII) according to the FIPS 140-2 standards to qualify for the safe harbor provisions of the Business Relationship
HITECH act.
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS019

Provide a solution that complies with the Federal Information Security Management Act (FISMA) regulations for security Business Relationship
and privacy.
Management

BR01 Establish Business
Relationship

NA

2

Section:
Page:

BUS020

Comply with all additional protections of individual privacy rights provided by NYS (NYS) and organizations with which Business Relationship
the State has Memorandums of Understanding (MOU) (e.g. Planned Parenthood).
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS021

Ensure the network architecture and all proposed network hardware and software is compliant with NYS Office of Cyber
Security and Critical Infrastructure Coordination, Cyber Security Policy P03-002, NYS Information Technology Policies, Business Relationship
Standards and Guidelines (http://www.cscic.state.ny.us/lib/policies) and maintains compliance as security policies are
Management
updated by the Department.

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS022

Ensure the network architecture and all proposed network hardware and software is compliant with NYS Information
Technology Policies, Standards and Guidelines G07-001, Identity and Access Management: Trust Model.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS023

Ensure the proposed solution, including network architecture and all proposed network hardware and software, is
compliant with security requirements for a Level 3 cryptographic module as defined in Section 5131 of the Information
Technology Reform Act of 1996, and further defined FIPS publication 140-2 issued May 25, 2001 to encrypt all PHI and
PII data at rest and in motion.

Business Relationship
Management

BR01 Establish Business
Relationship

SP2.1, SP2.2

1

Section:
Page:

BUS024

Support a role based access control that has the flexibility to provide roles to State and State approved contractors, as
defined by the Department.

Business Relationship
Management

BR01 Establish Business
Relationship

SP1.3

1

Section:
Page:

BUS025

Provide a user friendly interface for Security Administrators to grant, manage and revoke access for individuals.

Business Relationship
Management

BR01 Establish Business
Relationship

SP1.4

1

Section:
Page:

BUS026

Provide quarterly, or upon request of the Department, review of access rights and update access rights upon request of the Business Relationship
Department.
Management

BR01 Establish Business
Relationship

SP1.4

1

Section:
Page:

BUS027

Ensure applications provide detailed system audit trails on all inquiries, adds, updates or deletes to the database
completed by an authorized user. Audit trails must include user, action, time, and record changed.

Business Relationship
Management

BR01 Establish Business
Relationship

SP3.1, PR3.5

3

Section:
Page:

BUS028

In reports, provide capability to redact records in whole or in part to comply with State and/or federal privacy laws,
regulations or standards. A copy of the original record, as submitted, must be retained

Business Relationship
Management

BR01 Establish Business
Relationship

BE1.8

1

Section:
Page:

BUS029

Provide a solution that remains compliant with current and future Centers for Medicare and Medicaid Services (CMS)
regulations for security and privacy and certification requirements.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS030

Secure media and reports with appropriate controls to regulate receipt, movement, re-use, removal and disposal of data.
PHI or PII data on removable media must be encrypted according to the FIPS 140-2 standard and only authorized
personnel may store, access, decrypt, or disclose data on the removable media.

Business Relationship
Management

BR01 Establish Business
Relationship

SP2.3, SP2.4

1

Section:
Page:

BUS031

Provide a solution to enforce the principle of least privilege access e.g. limiting individual access to specific applications,
Business Relationship
screens, databases, fields and files based on a need-to-know basis. The minimum amount of access privileges are assigned
Management
to an individual to perform their assigned job duties.

BR01 Establish Business
Relationship

SP1.7

2

Section:
Page:

BUS032

Provide a network infrastructure solution that must be self-contained and in its own security perimeter. In securing the
perimeter of the contractor's network, the use of International Computer Security Association (ICSA) compliant firewalls
are required.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS033

Ensure there is never a connection to the State’s internal computer network without the prior, written consent of the State,
which the State will reasonably provide if necessary or appropriate for the contractor to provide support. As a condition of Business Relationship
connecting to the State’s computer network, the contractor must secure its own connected systems in a manner consistent Management
with the State’s then-current security policies, which the State will provide to the contractor on request.

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS034

Provide Internet security functionality to include the use of firewalls, intrusion detection/intrusion prevention (IDS/IPS),
https, encrypted network/secure socket layer (SSL), and security provisioning protocols such as secure sockets layer, and
Internet protocol security (IPSEC).

Business Relationship
Management

BR01 Establish Business
Relationship

SP2.3, SP2.4

2

Section:
Page:

BUS035

Implement mechanisms to safeguard data integrity and confidentiality of data passing over both internal and public
networks.

Business Relationship
Management

BR01 Establish Business
Relationship

SP2.3, SP2.4

1

Section:
Page:

BUS036

Put in place a firewall between the contractor's private network and the connection to the State's network.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

2

Section:
Page:

BUS037

Keep confidential any information passing through the contractor's network.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS038

Ensure that measures are in place to mitigate any new network security risks created by connecting the network to a third- Business Relationship
party network.
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS039

Establish responsibilities and procedures for remote use, as defined in the NYS Office of Cyber Security and Critical
Infrastructure Coordination, Cyber Security Policy P03-002 (http://www.cscic.state.ny.us/lib/policies) and NYS
Department of Health Security Requirements document, located in the Procurement Library.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS040

Create, maintain, change, remove and modify all user log-in accounts, profiles and passwords as needed including mass
password expirations and mass system log-outs. User accounts for contractor applications shall utilize single sign-on
verification.

Business Relationship
Management

BR01 Establish Business
Relationship

SP1.1

1

Section:
Page:

BUS041

Track user log-ons and log-offs to each proposed system by user identifiers so that a history of valid and non-valid logon
requests by user can be available for investigative purposes.

Business Relationship
Management

BR01 Establish Business
Relationship

SP1.1

1

Section:
Page:

BUS042

Provide an anti-virus and anti-malware solution to detect, report and prevent adware or spyware. Establish procedures for Business Relationship
guarding, monitoring, and detecting malicious software in accordance with polices and procedures adopted by the NYS. Management

BR01 Establish Business
Relationship

SP3.5

2

Section:
Page:

BUS043

Detect, report and prevent hacking, intrusion and other unauthorized use of contractor resources.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS044

Assign discrete security roles for creating, deleting and updating data.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS045

Assign unique user identification to identify and track each user of the system, including authorized providers or other
non-employee users.

Business Relationship
Management

BR01 Establish Business
Relationship

SP1.1

1

Section:
Page:

BUS046

Provide the ability to assign multiple roles to a user ID as well as a single password for external users (Department Staff,
Providers, Trading Partners, etc.) to all contractor applications.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS047

Maintain and generate updates and/or validation reports of authorized users and authorized level of system access on a
schedule agreed by the Department.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS048

Terminate electronic sessions after a specified time of inactivity on all systems, this time may vary by function.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS049

Log unauthorized access attempts by IP identification, user ID, date and time.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS050

Provide tools that will assist Department and contractor staff in analyzing and reporting activity on the security log files.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS051

Enforces password policies for length, character requirements, and updates and provide the ability to disable log-on
capabilities if unsuccessful password entry is attempted after five (5) unsuccessful attempts and automatically notify
security administration staff upon disabling log-on capabilities.

Business Relationship
Management

BR01 Establish Business
Relationship

SP1.2

1

Section:
Page:

BUS052

Enforce effective physical security measures for all proposed equipment, sites, network components, processing areas,
mail rooms, and storage areas used in providing Medicaid Administrative Services to the State

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

BUS053

Provide accountability control to record access, including attempts at access by non-authorized individuals.

Business Relationship
Management

BR01 Establish Business
Relationship

NA

1

Section:
Page:

etc. including but not limited to: • Trading Partner and Security Agreements • EFT agreements • ETIN agreements • Web portal user agreements Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS067 Ensure the Web Portal provides all Trading Partner and Security Agreements and related instructions as required by the Department including but not limited to: • Security Packet A for real-time (PC-to-Host. memos and e-mails. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS063 Utilize web-based technology with compatibility with all major web browsers. personal digital assistants or similar devices that are used for home working or are being transported away from the normal work location.) to the contractor's application and describe approach to minimize impact on current users. Business Relationship Management BR01 Establish Business Relationship NA 1 Section: Page: BUS055 Terminate system access for all terminated or transferred contractor employees by the end of their last business day or within one (1) workday of notification by the Department for Department staff or contractors. Firefox. The contractor must document what existing power and/or cabling is covered by this standard and must Management communicate that to the Department for appropriate protective action. Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS065 Communicate with providers regarding the Business Relationship process for Trading Partner and Security agreements. including. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: . form letters. Electronic Gateway (BBS)) processing • Trading Partner Agreements Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS068 Generate automated letters and/or electronic notifications to providers with Trading Partner and Security Agreements as directed and approved by the Department. The security provided must be equivalent to that for on-site equipment used for the same purpose. but is not limited to. security personnel. CPU-to-CPU) processing • Security Packet B for batch (FTP. taking into account the risks of working outside the contractor’s premises. BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS062 Support the transition of current business partner users (providers. Quarterly meetings must begin within ninety (90) calendar days of the Management contract start date. Business Relationship Management BR01 Establish Business Relationship NA 1 Section: Page: BUS059 Provide facility security which includes. trading partners. ETINs. Internet Explorer. agents or others working with it from outside the contractor’s premises. individual letters. Business Relationship Management BR01 Establish Business Relationship NA 1 Section: Page: BUS061 For quality improvement and system enhancement purposes. produce and distribute Business Relationship notifications via mail. and Web Portal Users including but not limited to the following types of requests: • Applications • Maintenance • Terminations Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS066 Prepare. conduct quarterly status user group meetings for each of up Business Relationship to six (6) user groups identified by the Department. This equipment may include. Security Access Reader Card System. but is not limited to.BUS054 Provide system access to all new State and contractor staff within two (2) workdays of request. labels. Business Relationship Management BR02 Manage Business Relationship Communication NA 2 Section: Page: BUS064 Provide the ability to automatically generate. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS069 Produce information packets when Trading Partner and Security Agreements are approved. including. and mobile platforms to support sharing of information with providers and members. when appropriate. but not limited to. and outside surveillance cameras with recordings archived for thirty (30) calendar days to contractor's facility. Safari. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS070 Send automated letters/notices to providers with Trading Partner and Security Agreements informing them when the Trading Partner and Security Agreement is terminated. Google Chrome. track and maintain member and provider correspondence. but not Business Relationship limited to. Business Relationship Management BR01 Establish Business Relationship NA 1 Section: Page: BUS058 Ensure that any contractor devices that will be connected to the Department network must be screened and approved by the Department prior to connection. its subcontractors. Business Relationship Management BR01 Establish Business Relationship NA 1 Section: Page: BUS060 Provide visitor logs and supervised visitor access to contractor's facility. electronic and/or Web Portal. BR01 Establish Business Relationship NA 1 Section: Page: BUS057 Obtain prior Department approval for the use of any equipment by the contractor. Business Relationship Management BR01 Establish Business Relationship NA 1 Section: Page: BUS056 Protect power and telecommunications cabling carrying information or supporting information services from interception Business Relationship or damage. EFTs. all forms of personal computers.

Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS083 Ensure that the Web Portal provides EFT applications. Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS086 Review maintenance requests. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS082 Send automated letters/notices to users informing them when their Web Portal access is terminated. make determinations. index and associate hard copy and fax Trading Partner and Security Agreement applications and route for processing. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS077 Generate automated letters and/or electronic notifications to providers with active EFT agreements as directed by the Department. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS078 Send automated letters/notices to providers whose ETIN is expiring within a time frame set by the Department informing Business Relationship them of their responsibilities. Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS079 Ensure that the Web Portal provides Web Portal user applications. instructions and related materials as required by the Department. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS076 Automatically identify ETINs that are to expire within a period specified by the Department and notify the providers based on Department defined business rules. review for completeness and process hard copy and fax maintenance requests for: • Trading Partner and Security Agreements • ETINs • EFTs • Web Portal Users Transactions failing the completeness review must be returned to the submitter without further processing. Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS088 Provide the capability to image. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS081 Produce information packets when Web Portal user access is approved. instructions and related materials as required by the Department.BUS071 Ensure the Web Portal provides ETIN applications. Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: . Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS084 Receive. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS074 Send automated letters/notices to providers with ETINs informing them when the ETIN is terminated. and update information as specified by the Department for: • Trading Partner and Security Agreements • ETINs • EFTs • Web Portal Users Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS087 Maintain Trading Partner and Security Agreement information with date specific history as required by Department business rules. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS080 Generate automated letters and/or electronic notifications to users of the Web Portal as directed and approved by the Department. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS075 Provide the capability to generate annual ETIN recertification notices as directed by the Department. Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS073 Produce information packets when ETINs are approved. review for completeness and process hard copy and fax termination requests for: • Trading Partner and Security Agreements • ETINs • EFTs • Web Portal Users Transactions failing the completeness review must be returned to the submitter without further processing. instructions and related materials as required by the Department. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS085 Receive. Business Relationship Management BR02 Manage Business Relationship Communication NA 1 Section: Page: BUS072 Generate automated letters and/or electronic notifications to providers with active ETINs as directed and approved by the Business Relationship Department. Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS089 Provide the capability for users of provider area of the Web Portal to enter Trading Partner and Security Agreement applications. Send automated letters/notices to providers informing them when the aforementioned is terminated.

change. Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS105 Provide the capability to image. Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS097 Provide the capability to perform mass updates to Trading Partner and Security Agreement information as required by the Business Relationship Department. index and associate hard copy and fax Trading Partner and Security Agreement maintenance requests Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS094 Track each Trading Partner and Security Agreement maintenance transaction through all the steps in the maintenance process Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS095 Provide the capability to review and update Trading Partner and Security Agreement maintenance requests via the webbased application based on policies established by the Department. fax. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS111 Provide the capability to image. BR03 Manage Business Relationship Information NA 1 Section: Page: BUS092 Provide the capability for applicants to check the status of Trading Partner and Security Agreement application processing Business Relationship through the provider area of the Web Portal. and the Web Portal. and terminate ETINs based on Department business rules through the webbased application. and completeness. along with the capability to review and/or print applications prior to Management and after submission. Business Relationship Management BR03 Manage Business Relationship Information NA 2 Section: Page: BUS099 Maintain New York Prescription Saver (NYPS) agreements with approximately 4. index and associate hard copy and fax ETIN termination requests Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS112 Provide the capability to automatically terminate groups of ETINs based on criteria determined by the Department. The termination of a Trading Partner and Security Agreement must result in the discontinuation of applicable services including but not limited Business Relationship to: Management • Access to the provider area of the Web Portal • Ability to submit electronic and hard copy transactions BR04 Terminate Business Relationship NA 1 Section: Page: BUS103 Provide the capability for users to enter Trading Partner and Security Agreement termination requests via the provider area of the Web Portal Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS104 Provide the capability to view. Business Relationship Management BR03 Manage Business Relationship Information NA 2 Section: Page: BUS100 Coordinate Medicaid transportation administrative function between the Department and transportation managers. change. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: . add and update Trading Partner and Security Agreement information via the web-based application as required by the Department. BR03 Manage Business Relationship Information NA 1 Section: Page: BUS091 Provide the capability through the provider area of the Web Portal to modify. index and associate hard copy and fax Trading Partner and Security Agreement termination requests Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS106 Provide the capability to automatically terminate groups of Trading Partner and Security Agreements based on criteria determined by the Department. Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS098 Support and manage the annual ETIN re-certification process. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS108 Maintain the data associated with a terminated Trading Partner and Security Agreement as specified by the Department. Errors returned must be Management clearly identified to facilitate correction by the user. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS110 Provide the capability to view. Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS093 Provide the capability to image. and terminate Trading Partner and Security Agreements based on Department Business Relationship business rules through the web-based application. validity. add. inter-field relationships. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS107 Automatically update information associated with a Trading Partner and Security Agreement termination based on Department business rules. add. save and delete Trading Partner and Security Business Relationship Agreement applications entered prior to submission. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS109 Accept ETIN termination requests via hard copy.BUS090 Edit Trading Partner and Security Agreement applications entered through the provider area of the Web Portal based on Business Relationship Department business rules for data presence. Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS101 Review termination requests and update information as specified by the Department for: • Trading Partner and Security Agreements • ETINs • EFTs • Web Portal Users Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS102 Terminate Trading Partner and Security Agreements in accordance with Department policies. Business Relationship Management BR03 Manage Business Relationship Information NA 1 Section: Page: BUS096 Provide the capability to view.000 participating pharmacies serving the NYPS Program.

at a minimum. pharmacy and behavioral health services over the last five years. health plans. fax.3 1 Section: Page: CAR006 Provide oversight reporting tools to generate individual case manager reports including all referrals and other services received by their enrollees and group case managers by contract.7 Outreach 1 Section: Page: WA3. employment or other criteria for reporting. Generate monitoring reports to determine if services approved in the plan of care are provided. CM02 Manage Case Information NA 1 Section: Page: CAR003 Describe the contractor’s experience with coordinating primary care. and the Web Portal. and make available electronically individual’s approved plan of care (POC) and identify the date a participant’s POC assessment is completed and the date of the next POC re-evaluation. Regional Health Information Organizations (RHIO) and other contractors or carveouts as well as solutions considered and implemented. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS124 Automatically update information associated with an EFT termination based on Department business rules.4 1 Section: Page: CAR002 Provide specific examples of comprehensive care management programs that the contractor has implemented over the last Care Management five years and how the contractor ensured a person-centered approach. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS118 Update information associated with a Web Portal User termination automatically based on Department business rules.2. by member.3 . and reporting for the EPSDT services covered under Medicaid. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS117 Provide the capability to automatically terminate groups of Web Portal Users based on criteria determined by the Department. management.1. (EPSDT). index and associate hard copy and fax EFT termination requests Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS123 Provide the capability to automatically terminate groups of EFTs based on criteria determined by the Department. add. and Treatment. Care Management CM01 Establish Case WA1. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS121 Provide the capability to review and approve EFT termination requests received from providers via the web-based application. and terminate Web Portal Users based on Department business rules through the web-based application. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS125 Maintain the data associated with a terminated EFT as specified by the Department. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS116 Provide the capability to view. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS120 Accept EFT termination requests via hard copy. Care Management CM02 Manage Case Information CA4.BUS113 Automatically update information associated with an ETIN termination based on Department business rules. CM02 Manage Case Information NA 1 Section: Page: CAR007 Receive. government health programs. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS122 Provide the capability to image. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: CAR001 Identify the date a member is assessed to meet a waiver level of care (LOC) and the date of the LOC reevaluation. challenges the organization has encountered in collaborating with providers. WA3. the screening and related diagnosis and treatment services the member receives for Early and Periodic Screening Diagnosis. change. store. Care Management CM03 Manage Population Health BE1. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS114 Maintain the data associated with a terminated ETIN as specified by the Department. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS115 Accept Web Portal User Termination requests via the Web Portal. Include in this description. Care Management CM02 Manage Case Information 1 Section: Page: CAR008 Capture and provide member data to support case identification. dental. specialty medical. Care Management managerial oversight. WA3. Care Management CM02 Manage Case Information NA 3 Section: Page: CAR004 Allow Care Manager system access with defined security roles to retrieve member information including but not limited to: • Associate System User IDs with specific Care Management Agencies • Member service utilization reporting • Member health home enrollment information Care Management CM02 Manage Case Information NA 3 Section: Page: CAR005 Identify. tracking. Business Relationship Management BR04 Terminate Business Relationship NA 1 Section: Page: BUS119 Maintain the data associated with a terminated Web Portal User as specified by the Department.

electronic and/or Web Portal when appropriate including but not limited to: • Personal care • Transportation rosters CAR017 Enter. indicating: • Single Beneficiary or Beneficiaries • Status of the request • Services authorized • Number of units approved • Service date range approved • Date specific history • Requested amount • Cost approved / Authorized amount • Provider approved (unless approved as non-provider specific) Care Management CM08 Authorize Service CA5. CR2.4 1 Section: Page: CAR015 Image.e. regular and irregular updates) to the Prior Approval / Authorization records. Care Management CM08 Authorize Service CA5. Care Management American Indian Health Program) .g. Care Management CM08 Authorize Service NA 1 Section: Page: CAR020 Provide a physician review process for prior approval/prior authorization requests that must be completed within 24 hours Care Management of escalation based on Department guidelines. CM08 Authorize Service NA 1 Section: Page: CAR019 Support and monitor individual or mass updates (i. VeriFone) Care Management CM08 Authorize Service NA 3 Section: Page: .9.6 1 Section: Page: CAR012 Provide the capability to change the services authorized and to extend or limit the effective dates of the authorization. DiRAD & ARU) • Batch transmission (e. when required.13.12 2 Section: Page: CAR013 Receive.g.g. edit. CM08 Authorize Service NA 3 Section: Page: CAR021 Provide an emergency process so that members can obtain an initial supply of medication in the event that a prior approval/prior authorization decision cannot be made and/or applied to the for claims processing within the required timeframe. VPN or leased line) • Interactive Voice Response (IVR) (e. Transactions failing the completeness review must be returned to the submitter without further processing. • Surgical/anesthesia reports • Medical records • X-rays/images • Orthodontic study models • LTC Prior Authorization • Certain prescription drugs as required • Other items required by State or federal rules Care Management CM08 Authorize Service CA5. and index prior approvals/prior authorizations and associated materials Care Management CM08 Authorize Service CA5.g. CM08 Authorize Service CA5. Care Management CM08 Authorize Service NA 3 Section: Page: CAR018 Perform the initial telephone prior approval/prior authorization request determinations with trained. policies and procedures within specified timeframe.4 1 Section: Page: CAR011 Support retroactive entry of prior authorization requests.e. review for completeness and process for determination hard copy and electronic prior approvals/prior authorizations and supporting materials under Medicaid or other NYS medical assistance and public health programs (i. Maintain the original and the change data in the prior authorization record.CAR009 Establish and maintain an adjudicated prior authorization record. verify. and make prior approval/prior authorization determinations in real time based on Department approved regulations. FTP and Secure FTP) • Point of Service (POS) Device (e.11 2 Section: Page: CAR010 Enable prior authorization staff to send requests for additional information on paper or electronically. Care Management CM08 Authorize Service CA5.. CA5.1 2 Section: Page: CAR014 Receive. review for completeness and process prior authorization attachments. OCR and/or data enter. clinical professionals Care Management available for consultation with the prescriber. Care Management CM08 Authorize Service CA5.. Care Management CM08 Authorize Service NA 3 Section: Page: CAR022 Support all channels approved by the Department for Authorizations including: • Paper • Fax • Web-based application • Provider area of the Web Portal • Direct connection (e.14 1 Section: Page: Care Management CM08 Authorize Service NA 1 Section: Page: CAR016 Produce and distribute rosters via mail. review.

completeness.8 1 Section: Page: CAR033 Provide the capability to modify.7 1 Section: Page: CAR029 Provide the capability to establish a prior approval/prior authorization that will override one type of service restriction and a combination of service restrictions. Care Management CM08 Authorize Service NA 1 Section: Page: CAR028 Assign to each prior approval/prior authorization a unique prior approval/prior authorization number for tracking and monitoring purposes. Drug Contractor Management Rebate/ Pharmacy Pricing and MDW) staff to ensure the success of the project. CO07 Manage Contract NA 3 Section: Page: CON003 Receive. contract start and end dates.CAR023 Accept. UR edits. and to establish multiple prior approvals/prior authorizations for the same service to Care Management override multiple service restrictions separately.5 3 Section: Page: CAR037 Implement and enforce service limits to each transaction based on Department business rules. and all prior approval/prior authorization edits. enter. MC7.g.10.0. dispensing provider qualifications or other criteria established by the Department. capture. submitting and ordering provider. and 1. and performance of all Subcontractors. capitation rates. prior approval/prior authorization requests and resulting determinations. inactions. CO07 Manage Contract ME2. D. CA5. Care Management CM08 Authorize Service NA 3 Section: Page: CON001 Where Department policy guidance is not readily available in writing. The contractor will incorporate such guidance in the appropriate Manual and/or database Contractor Management CO02 Manage Contractor Communication NA 1 Section: Page: CON002 Serve as the Prime Contractor and be solely responsible for integration of all work to be performed. covered services. process and respond to Authorizations based upon industry standards and support the transition from the Department's current business rules allowing the following formats: • HIPAA X12 278 standard format (version 5010) • NCPDP (version 5. regardless of whether Subcontractors are used. Care Management CM08 Authorize Service CA5.2. capitation effective date. organization name.8 1 Section: Page: CAR035 Provide the capability to modify. All changes to edits must be reviewed and approved by Care Management NYS.1. As Prime Contractor. inquire on. Clinical Drug Review Program or other pharmacy prior authorization programs as determined by the Department Care Management CM08 Authorize Service POS3. the MAS Contractor shall also be the System Integrator and ensure that Core MMIS and Supporting Services Contractor staff work cooperatively with key interfacing contractors (e. CM08 Authorize Service NA 1 Section: Page: CAR030 Provide the capability to override prior approval/prior authorization requirements based on prescriber specialty. claims history.1 . members per month.1. and re-insurance threshold. the contractor will contact the Department to seek policy guidance and will return the provider’s call. add and delete criteria used for the determination of prior approval/prior authorization requests in a flexible manner that allows for rapid change while maintaining a date specific history of criteria. Care Management CM08 Authorize Service CA5. Care Management CM08 Authorize Service NA 1 Section: Page: CAR036 Provide the capability to search. CM08 Authorize Service NA 1 Section: Page: CAR034 Provide the functionality to automatically enforce Department defined business rules to make a determination on prior approval/prior authorization requests. organization type. eligibility. timeliness for change requests. along with the capability to review and/or print prior approvals/prior authorizations and supporting materials Care Management both prior to and after submission. Further.batch) • NYS proprietary format • Other Industry Standard paper and electronic formats Care Management CM08 Authorize Service NA 3 Section: Page: CAR024 Enforce Authorization edits based on Department business rules. save and delete prior approvals/prior authorizations and supporting materials prior to submission. Care Management CM08 Authorize Service CA5. interfield relationships. contract period/year.. validity. and provide the capability to view Managed Care Organization (MCO) contract and administrative information electronically including but not limited to geographic locations. prior approval/prior authorization history including duplication. enrollee count. Care Management CM08 Authorize Service CA5. State and contract staff must have the capability to enter criteria via the web-based application that will be used to perform these updates. the contractor is the Department’s single point of contact for all services to be performed under this contract including services performed by Subcontractors and is solely accountable for the actions. Care Management CM08 Authorize Service NA 1 Section: Page: CAR026 Accept and process real time pharmacy prior approval/prior authorization transactions received from the Preferred Drug Program. maximum enrollment threshold. Care Management CM08 Authorize Service NA 3 Section: Page: CAR032 Edit prior approval/prior authorization information based on Department business rules for data presence. MC1.1 2 Section: Page: Contractor Management . CM08 Authorize Service NA 3 Section: Page: CAR025 Enable administrative updates of authorizations in the Authorization Registry. Care Management CM08 Authorize Service NA 1 Section: Page: CAR031 Notify the provider per Department guidelines of specific prior approval/prior authorization types.1 3 Section: Page: CAR027 Track each prior approval/prior authorization through all the steps in the authorization process as defined by the Department. and update all information related to prior approvals/prior authorizations via the web-based application.

Contractor Management CO07 Manage Contract BE1. CO07 Manage Contract RO6. design artifacts and narrative description.7 1 Section: Page: CON005 Ensure any design or business process model documents required for MMIS certification present the design in an understandable fashion. that is based upon industry best practices and standards. providers.11 1 Section: Page: CON010 Support and monitor real time inbound/outbound transactions. resources. WMS/HIX. with cross referenced requirements. Contractor Management CO07 Manage Contract BE1. including but not limited to: • Common Benefit Identification Card (CBIC) transactions • POS transactions as specified by the Department • HIPAA and proprietary transactions as specified by the Department Contractor Management CO07 Manage Contract POS4. The work plan shall adhere to industry best practices and standards for project management.g. claim transaction. Contractor Management CO07 Manage Contract NA 3 Section: Page: CON018 Submit the initial work plan to the Department within 30 days of contract award for review and approval. and task dependencies.. MCO. CO07 Manage Contract NA 1 Section: Page: CON019 Establish and staff a Program Management Office (PMO) that manages the PMP and reports directly to the Department Project Management group. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON020 Take responsibility for ensuring that the contractor's application is updated to reflect application changes made to the eMedNY and MDW systems during the Planning and Implementation Phases. Work plan must Contractor Management be continually updated/maintained on at least a weekly basis throughout the duration of the contract.g.7. Contractor Management CO07 Manage Contract ME2.11 1 Section: Page: CON007 Support and monitor the receipt and processing of files received from all sources (e. eligibility verification transactions. PI3. managing and resolving issues that may result in affecting the project.10 1 Section: Page: CON009 Support and monitor transactions received in files.CON004 Perform periodic reconciliations of State member records with Enrollment Broker. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON006 Support the receipt. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON013 Facilitate a project kickoff meeting with contractor and Department team members that clearly articulates topics including. and perform notification processes based on Department business rules. MDW. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON012 Develop materials for the project kickoff meeting and submit to the Department for approval at least two weeks prior to the date of the kickoff meeting. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON016 Develop and execute a Project Management Plan (PMP) within the first 30 calendar days of contract award.. tracking. and be broken down into Work Breakdown Structures (WBS). prior approval/prior authorizations transactions). processing and response to HIPAA and NYS proprietary transactions. Contractor Management CO07 Manage Contract NA 1 Section: Page: . providers. approved by the Department.2 1 Section: Page: CON008 Develop.3 2 Section: Page: CON011 Support and monitor all channels applicable to the specific transaction (e. and monitor the generation of files to be distributed to all sources (e. and Primary Care Physician enrollment records. transmit. Contractor Management CO07 Manage Contract MC2. milestones. CMS) as specified by the Department. identify transaction discrepancies including errors and pends. The PMO shall also integrate with other relevant state contractors and entities.. CMS. The PMP shall include: • Quality Management • Scope Management • Requirements Management • Issue Management • Risk Management • Change Management • Configuration Management • Performance Management • Communication Management Contractor Management CO07 Manage Contract NA 2 Section: Page: CON017 Develop and maintain a project work plan in Microsoft Project that includes each phase of the project that is resource loaded and includes both contractor and Department activities. OIG) Contractor Management as specified by the Department. including key tasks. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON015 Disclose any risks found by the contractor within one (1) business day to the Department.g. deliverables. but not limited to the following: • Project organization • Project communication • Team member responsibilities • Key project processes • Project work plan Contractor Management CO07 Manage Contract NA 1 Section: Page: CON014 Take a proactive approach to identification.

including. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON027 Identify the contractor staff that will be involved in the risk management process. in addition to the contractor's team. The contractor shall evaluate and set the risk priority for each risk based on the likelihood the risk will occur and the potential impact of the risk. status report. and availability of PHI within the first 90 days of the project and then annually thereafter. and create a risk management strategy. assign risk management responsibility. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON028 Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality. CO07 Manage Contract SP2. The findings must be issued to the Contractor Management Department. Use a project management tool accessible by State staff. that includes the following capabilities: • Issue and Risk Management • Scope Management • Configuration Management • Change Management • Action Item Management Contractor Management CO07 Manage Contract NA 1 Section: Page: Contractor Management CO07 Manage Contract NA 1 Section: Page: This tool must maintain project information for the full lifecycle of the project. integrity.5 1 Section: Page: CON029 Implement a Configuration Management System and use proven promotion and version control procedures for the implementation of modified: • System modules • COTS products • System software • Network • Files • Databases • Hardware Contractor Management CO07 Manage Contract NA 3 Section: Page: CON021 Discuss in the Communication management section of the PMP: • Each category of stakeholders and their communication needs • The method and frequency of communicating in order to meet those needs • The allocation of appropriate resources to meet the communication schedule Contractor Management CO07 Manage Contract NA 1 Section: Page: CON030 Be available to the Department at the Department's offices as requested for any meetings that may arise as a result of the project tasks associated with this RFP. CON024 Make all project management documentation available online to Department and contractor staff. the contractor shall produce and distribute an updated status report at least 24 hours before the meeting. work plan. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON026 Describe the approach and methodology that will be used for timing for risk identification and tracking and monitoring risks. For this meeting.CON022 CON023 Participate in a weekly status meeting with Department personnel. and include a mitigation strategy for all potential risks and vulnerabilities. The tool shall be updated with the requirements in Attachment E within 30 days of contract award. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON025 Maintain a Requirements repository that will be used throughout the life of the contract. but not limited to the PMP. The Requirements repository must: • Map each requirement to all milestones and project phases in which they occur • Be continuously updated by the contractor throughout the life of the contract • Link Functional Requirements to the appropriate artifacts during all System Development Lifecycle (SDLC) phases • Have the capability for both forwards and backwards traceability The contractor must provide State staff with training and access to the tool. The tool must be maintained throughout the project and updated regularly. Contractor Management CO07 Manage Contract NA 1 Section: Page: . and status meeting agenda and minutes.

CO07 Manage Contract NA 1 Section: Page: CON036 Manage the process to assemble and maintain current version of Certification Review Package contents and provide access to Certification Review Package contents to authorized Department and contractor staff. reports required for the certification process. Implementation. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON042 Participate in federal MMIS certification activities as requested by the Department and work with the Department to resolve any deficiencies identified during the review. modify the certification review documentation as necessary and support the re-review by CMS. training and preparation. CO07 Manage Contract NA 1 Section: Page: CON034 Develop the Certification Review Package that includes: • Confirmation that system operations meet requirements and performance standards as specified by CMS for certification • Complete Certification Readiness Checklists • Copy of system acceptance letter to the contractor from the Department Contractor Management • System documentation including: Source Code Library. Substantive and representative sample of reports and information retrieval screens • Documentation for onsite review: reports and all documentation that may be requested by CMS following the Preliminary Review CO07 Manage Contract NA 1 Section: Page: CON035 In conjunction with the State Quality Assurance contractor. and supporting documentation throughout Contractor Management the Planning. User Manual. identify and collect the documentation and outputs of the targeted MMIS processes required to support the CMS certification review. processes and procedures that will be used to create the certification documents and assist during the CMS visit. The certification team must work with the Department's Certification Team to plan and review certification schedules. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON037 Prepare draft Certification Review Package materials for review and approval of the State. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON039 Archive first-run test claims and reports until receipt of certification. Acceptance Test Results Deliverable. in conjunction with the State Quality Assurance contractor. and. It must describe the processes and procedures that will be used to manage Certification requirements throughout the Planning and Implementation Phase.CON031 Develop. and maintain a Certification plan that defines the contractor’s approach to federal MMIS certification. and updates to related communication vehicles. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON033 Develop the Certification Checklist Traceability Deliverable. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON043 Develop a Corrective Action Plan to address any issues impacting the certification process. and other documents as requested by the Department during the certification Contractor Management preparation process. which must trace Certification Checklist requirements to functionality. The plan must define the contractor’s approach and plan for preparing for certification and performing activities including but not limited to: • Completing the initial update of the Certification Checklists in Attachment F of this RFP • Completing Certification Phase Deliverables • Validating MMIS functionality against the Certification Checklists. creating the Certification Checklist Traceability Deliverable. MITA Assessment. and how these activities are integrated with the contractor’s project management system. testing. Contractor Management CO07 Manage Contract NA 1 Section: Page: . report printouts. Operating Procedures. and Operations Phases. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON038 Conduct walk-through of certification review deliverables. The contractor will ensure all other documentation required by CMS is provided in the Certification Review Package. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON041 Assist the Department in preparing for and conducting the CMS certification site-visit. produce. and maintaining the Certification Checklists • Developing and assembling documents that will be used to support the certification process and review • Performing a Certification Readiness Test • Assisting the Department in preparing for and conducting the CMS certification site-visit • Responding to CMS inquiries during and after the site-visit Contractor Management CO07 Manage Contract NA 2 Section: Page: CON032 Establish and staff a Certification Team to participate in all certification activities including the creation of the Certification Plan. make the required changes. This includes documentation. Certification. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON040 Archive first-run of federally required reports to be included in certification documentation. and responding to CMS inquiries during and after the site-visit. Acceptance Test Plan. manage the certification activities.

which shall not be unreasonably withheld. j. and seek approval for any revisions to the plan. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON052 Ensure that all direct work is performed in the United States. where the staff is located and how communication is handled between remote sites and the project site. Account Executive (Available Onsite at Project Facility upon request). Quality Assurance Manager (Onsite at Project Facility 4 Days Per week). b. and to keep contractor and State management apprised of such in a timely manner. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON045 Be responsible for any applicable damages pursuant to the contract terms relative to the delivery of a federally certified MMIS. Operations Manager (Onsite at Project Facility 4 Days Per week). description. The contractor pharmacy staff is also required to be current on the latest industry standards and developments. support and assist in outreach activities. transfer or reassignment of Key Staff such personnel will remain assigned to the performance of duties under this contract until replacement personnel. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON050 Provide a dedicated EPIC outreach manager to direct. The Matrix which is included in Attachment J summarizes relevant experience of the proposed staff • Provide accommodation for identified staff in the project facility as specified per position CON048 Key staff include: a. h. PBM Manager (pharmacy prior approval) (Available Onsite at Project Facility upon request). c. d. The plan must include but is not limited to: • A detailed organizational chart for each phase of the Contract • Type and number of personnel proposed for each operational unit • Summary job descriptions and qualifications for all labor categories identified in the proposed organizational chart. to proactively analyze the impact on the Program. Medical Director (Available Onsite at Project Facility upon request). l. g. MEIPASS Operations Manager (available Onsite at Project Facility 4 Days per week) CON049 Maintain pharmacy clinical staff to provide pharmaceutical expertise throughout operations and to support the Prospective Drug Utilization Review and formulary maintenance functions in coordination with State personnel. to include liquidated damages as specified in this RFP. including at a minimum title. their respective roles. are in place performing the Key Staff functions • Replace staff only with staff of comparable experience. including responsibility descriptions. Information Security Officer (Available Onsite at Project Facility upon request). Contractor Management CO07 Manage Contract NA 1 Section: Page: CON051 Provide an annual Staffing and Organization Plan detailing how the project staff is actually organized. Contractor Management CO07 Manage Contract NA 1 Section: Page: Contractor Management CO07 Manage Contract NA 1 Section: Page: The contractor must: • Not alter the number of Key Staff as proposed without the written approval of the Department. Contractor Management CO07 Manage Contract NA 1 Section: Page: . and rationale for filling that role with a subcontractor • A description of the contractor’s staffing plans for managing the staff to ensure that project deadlines are met • A depiction of staff loading by project phase CO07 Manage Contract NA 2 Section: Page: CON047 Obtain Department approval for the Staffing and Organization Plan within 30 days of contract award. Compliance Manager (Onsite at Project Facility 4 Days Per week).CON044 Establish ongoing process to be used throughout the contract to assess system changes and operational changes that may impact the ability to meet any federal MMIS certification requirements. Customer Service Manager (Available Onsite at Project Facility upon request). Data Conversion Manager (Onsite at Project Facility 4 Days Per week). i. approved by the Department. Transition Manager (Onsite at Project Facility 4 Days Per week). If the Department gives written approval of the termination. on-site/off-site designation and specific skills/knowledge Contractor Management • Designation of all positions considered by the contractor or defined by the Department in this RFP as a required key position and detailed resumes for the individuals proposed for these positions • A description of each organizational unit required in this RFP or needed by the contractor. required education/training/certification. training and ability to the incumbent in the position • Will submit a Staff Skills Matrix for each person filling a Key Staff position. Account Manager (Onsite at Project Facility 4 Days Per week). to carry out the requirements herein • An identification of all subcontractors. m. f. required experience. Clinical Manager (medical prior approval) (Available Onsite at Project Facility upon request) n. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON046 Provide detailed Staffing and Organization Plan for each phase of the project. k. DDI/Configuration Manager (Onsite at Project Facility 4 Days Per week). e.

analysis. scope management. The Training Plan shall demonstrate the commitment of the contractor staff to meet the learning needs of the system required for contractor staff. SP1. in conjunction with and approved by the Department. on the contractor's processes to be used to complete the scope of work. EFT.6 1 Section: Page: CON055 Deliver detailed training during the project initiation task. Contractor Management CO07 Manage Contract PI3. and Department staff.16 1 Section: Page: CON057 Develop and maintain a Course Curriculum that represents the complete set of courses required to instruct all of the user groups on how the system works and how it supports their respective job functions. related documentation and materials. risk management. of the contractor’s Project Management Methodologies in order to participate in creating and reviewing required deliverables and orient Department technical staff and Department contractor staff in configuration management. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON062 Provide on-line access to training schedule and meeting information through the Web Portal for Department staff. subject to Department approval of course structure and contents and provide the Department with hard and electronic copies of all the training materials in the document repository.Develop. and execute.16 1 Section: Page: CON058 Create Instructor Guides and Trainee Guides for the initial “train-the-trainers” training performed as part of the MAS Project. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON063 Provide an online training manual and operational guide and Computer Based Training (CBT) for reconciling discrepancies in the contractor's application and the source files. and location of quarterly provider training seminars. CO07 Manage Contract PI3. and an evaluation component for users from the State. an Annual Training Plan. and other supporting contractors. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON060 Develop a training plan and training materials for contractor provider support staff and provide at regular intervals.6 1 Section: Page: CON054 Conduct an annual training needs assessment with the State’s staff to ensure that the development of the Training Plan addresses the training needs of Department and stakeholders using the contractor's system(s). to Department Contractor Management staff. For each course contained in the curriculum. in-house provider bi-weekly training sessions. The training must include topics representing all levels of complexity encountered by contractor staff and broken out by organization structure. This training must be specific to the proposed technical architecture. schedule. workflow management and the contractor's Contractor Management SDLC processes and deliverables so that they can productively participate in the deliverable production and review process. This training must transfer knowledge. CO07 Manage Contract NA 1 Section: Page: CON059 Develop all training materials for seminar and Web-based delivery. CO07 Manage Contract NA 1 Section: Page: CON056 Deliver detailed technical training during the project initiation task for Department technical staff on the contractor's processes to be used to complete the scope of work. curriculum.16. quizzes. intermediate and advanced training courses to be conducted • Define training modules. provider association meeting workshops. CON053 The Annual Training Plan must: • Identify inputs. as well as the training exercises. These guides shall be continuously updated and placed in the document repository so that they can be re-used in the future by additional trainers and trainees. requirements management. as required by the Department • Define roles and responsibilities and expectations for Department input and participation • Define contractor analysis criteria to be used to identify providers who require on-site training and billing assistance for Department approval CO07 Manage Contract SP1. LDSS. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON061 Provide comprehensive training. and methods to be used to define training requirements • Define training topics. project management and SDLC methodologies proposed by the contractor. The Trainee Guide will contain actual course content that Contractor Management is pertinent to the trainee. Provide a recommended training course list to support each user's security role as an output of the training needs assessment. and tools to be used to delivery training • Include annual POS. The contractor Annual Training Plan shall be reviewed and approved at least 60 days prior to the beginning of the contract year. the contractor. The Instructor Guide will provide all of the material necessary to conduct the class. Contractor Management CO07 Manage Contract NA 1 Section: Page: . so that future trainers have a step-by-step procedure to follow to deliver training to new staff. maintain. Regional Local Departments of Social Services (LDSS) Contractor Management meetings and provider site training • Define beginner. configuration management. a course outline. or syllabus must be developed and stored in the document repository. Contractor Management CO07 Manage Contract PI3. requirements management and overall design and development programs so that they can productively participate in the deliverable production and review process. This training must be specific to the quality management. content management. and electronic claims submission marketing plans • Include plans for Department staff training. Providers. and reference material associated with the specific course.

Contractor Management CO07 Manage Contract NA 1 Section: Page: CON072 Conduct quarterly training in central locations throughout the state. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON071 Perform quarterly provider training seminars. as needed.g. PM2. CO07 Manage Contract NA 1 Section: Page: CON065 Educate providers across the State. and process for referrals based on Department-approved criteria to identify providers who require training and on-site assistance. collect the evaluations at the conclusion of the training and provide the Department with a summary of provider responses as well as copies of completed evaluations within five (5) days of each training session. and Contractor Management distribution of Provider manuals. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON068 Log. CO07 Manage Contract NA 1 Section: Page: Contractor Management . the claims processing system. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON070 Perform training for newly enrolled providers that includes but is not limited to providing for initial training to be performed online and through Webinars with follow-up on-site training by a provider representative. track. Department staff. Onsite training shall be provided at contractor site or other locations approved by the Department. and individual training. approved by the Department for new hires in the Department or refresher training to Department staff. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON078 Present mock training sessions for Department approval and update training materials as necessary prior to delivering training. and stakeholders. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON080 Distribute provider training questionnaires at all training sessions to solicit questions from providers that are not addressed during the session. as needed or as required by the Department. proper billing. provider association meeting workshops. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON073 Provide specialized training related to policy changes affecting specific provider prior to implementing new policies and services.12. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON074 Track and report when newly enrolled providers complete the initial training tutorial. staff performing visit. individual training as needed. CO07 Manage Contract NA 1 Section: Page: CON085 Train all Department staff and providers on all major system changes that occur during the life of this contract. reason for visit. fraudulent and excessive billing). and date visit made.1 2 Section: Page: CON067 Conduct provider visits as needed to train providers in program billing procedures and to provide claim resolution assistance. and prior approval/prior authorizations procedures through workshops. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON076 Offer training to office staff or third-party billers or authorized submitters who submit claims on behalf of providers. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON075 Provide in-depth user training for the New York Medicaid Program operations and policy staff to use the system to perform their day-to-day functions. presentations at professional association meetings. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON079 Provide on-line access to training schedule and meeting information through the provider Web Portal for authorized providers. and Contractor Management assisting providers in the installation and maintenance of the electronic claims submission tools. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON066 Perform analysis of provider inquiry. Contractor Management CO07 Manage Contract CR1.CON064 Offer Provider training through a variety of presentation methods (as approved by the Department). presentations at professional association meetings. For example: webbased. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON082 Prepare a Department-approved Training Evaluation Forms for distribution at training sessions. provider advisory groups. follow-up action required. developing training materials. conducting training seminars. and report provider on-site visits via the Contact Management System that includes but is not limited to: date visit requested. about the NYS health insurance programs supported by the MAS. number(s). who made the request. billing patterns (e. training sessions. visit content and outcomes. training sessions. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON084 The contractor will be responsible for provider outreach. at no charge to the providers. inhouse provider bi-weekly training sessions. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON077 Conduct in-service training for the contractor’s provider services team and Department staff. and on-site provider training. workshops. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON083 Define contractor analysis criteria to be used to identify providers who require on-site training and billing assistance for Department approval. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON081 Maintain and submit to the Department the Provider Training Sign-In Sheets for all providers (by provider type) who participate in training sessions. provider name.

Contractor Management CO07 Manage Contract NA 1 Section: Page: CON097 Provide courier service to the Department. Provide and maintain adequate workspace. OHIP Data Mart. CO07 Manage Contract NA 1 Section: Page: CON091 Ensure that the Training Environment supports users' security roles mirroring production and support user access to all users of the system(s). This space must be available throughout the entire contract period and at no additional cost to the State. LAN connections. environmental impact and fire code requirements. The contractor must have the Contractor Management ability to restore the environment within twelve (12) hours if necessary. OIG. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON088 Ensure the training environment contains a separate but complete set of database tables. including the Department. memory and hard drive space to operate and support the current release of Microsoft’s operating system and Office Suite software. Contractor Management CO07 Manage Contract NA 1 Section: Page: Contractor Management CO07 Manage Contract NA 1 Section: Page: CO07 Manage Contract NA 2 Section: Page: CON092 Maintain a project facility for this contract within a ten (10) mile radius of the NYS Capitol building. and implementation leads. CO07 Manage Contract NA 2 Section: Page: CON087 Ensure the training environment contains no PHI of individuals eligible for medical benefits under Medicaid or other NYS medical assistance and public health programs. digital telephones. In addition. development. Access to the project facility shall be available twenty-four (24) hours per day. and member relations staff as well as designated state staff. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON090 Perform periodic backups on the information stored in the training environment’s databases. handicap parking must meet all local. Office of Medicaid Inspector General (OMIG). call center and IT facilities used by the contractor for this Contract by authorized Department staff. the internet and e-mail. provider relations. and the internet CO07 Manage Contract NA 1 Section: Page: CON096 Absorb all costs related to securing and maintaining the contractor’s project and computer facilities and any other of its locations for the life of the project. and authorized consultant staff must be provided a two-network drop at the contractor's project facility to allow Contractor Management the desktop to be connected to the contractor's LAN. that allows training data to be created specifically to support the Training Materials independent of the development and testing databases. OSC staff. OIG staff and authorized consultant staff during business hours without prior notice. and all office supplies for no less than 100 Medicaid program staff. The PCs must be refreshed every three (3) years. Contractor Management CO07 Manage Contract NA 1 Section: Page: . The facility shall provide adequate workspace for contractor project management. computers. individual phone numbers. Office of State Comptroller (OSC). and OMIG office buildings with pickup and delivery service two (2) times each business day. design. OSC. CON093 Computers must adhere to Transaction Processing Performance Council (TPC) benchmarks and have suitable. A schedule of migration frequency must be developed to avoid training session interruptions. escort or other requirements. The Training Environment must mirror the production environment allowing users Contractor Management to enter and process data exactly as they will when they enter the same data into production. as well as any additional equipment and software necessary to access and utilize MMIS functions as well as associated State systems including the MDW. building codes and all handicapped accessibility regulations. The PCs must have at a minimum 21" flat-screen monitor and be sized to reflect "power-user" status. NYS parking will be within easy access to the facility mentioned above.CON086 Create and maintain a separate Training Environment that is dedicated totally to the development and delivery of training to users of the contractor's system(s). One (1) run shall be in the morning and one (1) run in the afternoon. Parking for State will be designated and reserved. departmental liaison. including Department. while maintaining privacy. State and Federal requirements for number and design. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON095 Medicaid program staff. admission. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON098 Provide accessibility to the project. and authorized consultant staff. CON094 Maintain a minimum of one-hundred-ten (110) reserved parking spaces for State use at the project facility. including ninety (90) State employee and twenty (20) visitor spaces. sufficient Contractor Management processor speed. OSC. the Department's LAN or OSC'S LAN. escort or other requirements. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON089 Implement Configuration Management procedures to ensure migration of program code and data to the Training Environment is properly managed and executed. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON100 Provide and maintain all necessary telecommunications circuits between the Department offices and the contractor's facilities. seven (7) days per week without prior notice. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON099 Observe all Occupational Safety and Health Administration (OSHA).

white boards. and hardware and network back-up. LCD projectors). Contractor Management CO07 Manage Contract NA 2 Section: Page: CON105 Provide a training room within the contractor's project facility with the capacity to handle up to fifteen (15) students at a time. CO07 Manage Contract NA 3 Section: Page: CON113 Back up all data files that reside on the multiple environments on a daily basis. as well as to allow for maintenance of the production environment. Contractor Management CO07 Manage Contract BE1. The plan shall address backup and Contractor Management recovery. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON117 Develop and maintain an automated scheduling system for running the back-up processes for all environments. Secure backups include database data. Backups must be executed so that any data set can be restored from the backup medium after the discovery and notification that a restoration is needed.. operating system and RDBMS software. errors. CO07 Manage Contract NA 1 Section: Page: CON119 Support restoration and recovery of lost or corrupted data or software. speed. checkpoint/restart capabilities. disaster recovery and business continuity. This back-up site must be at a separate location and must meet the requirements of a TIER III data center as defined by Uptime Institute. as well as other system and Department services deemed necessary by the Department. CO07 Manage Contract SP1. Contractor Management CO07 Manage Contract NA 2 Section: Page: . Contractor Management CO07 Manage Contract NA 1 Section: Page: CON116 Store and assume responsibility of the cost for all back-up copies to be in a Department approved back-up storage location for five (5) years. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON106 Receive Department approval for all proposed off-site procedures. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON111 Notify the Department within one (1) hour of any disruption in service. stuffing and mailing process. files. failed file transmissions. Contractor Management CO07 Manage Contract NA 3 Section: Page: CON114 Provide a backup/recovery component comprised of a high capacity backup and recovery infrastructure for all data.5 1 Section: Page: CON109 Notify the Department of all discrepancies. retention and storage of back up files and software.CON101 Ensure physical security of checks during matching. On a weekly basis the contractor will back up all databases and other data and store the backups at a secure off-site location.11 1 Section: Page: CON110 Inform the Department immediately of any incidents that cause the failure of any component of the MAS. and flexibility provides the capacity needed to meet the Department's service levels and Disaster Recovery requirements detailed in this RFP. locations. available to the Department. support computer based training. can continue Contractor Management in the event of a disaster or major hardware problem at the primary site(s). Contractor Management CO07 Manage Contract NA 1 Section: Page: CON102 Maintain a Department-approved secure check vault storage area for checks prior to release to providers. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON104 Maintain multi-purpose meeting room(s) at the contractor’s facilities used for this project. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON121 Maintain or otherwise arrange for a disaster recovery site at a separate location in the event of a disaster that renders the production site inoperable.g. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON112 Provide for a back-up processing capability at remote site(s) from the contractor's primary site(s) such that normal payment processing. provide each student with desk space and his/her own PC. Contractor Management CO07 Manage Contract NA 3 Section: Page: CON115 Ensure the frequency. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON107 Develop and maintain operational policy and procedure manuals for all MAS business processes. failover. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON103 Provide secure storage for physical and electronic historical records. All back-ups must be transferred to the successor contractor as described in the Department approved Transition Plan. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON118 Develop and maintain a process to verify that all back-up and restoration processes were run appropriately and stored in a Contractor Management proper location. and protocols. and program code. with all necessary equipment to support program meetings with State Staff (e. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON108 Submit a Business Continuity Plan to the Department for approval within thirty (30) calendar days of contract signing that is based upon the contractor’s business continuity and disaster recovery methodology. and access the training environment. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON120 Design the capability to switch operations from the production environment to the failover environment in the event technical problems incapacitate the production server(s). or abnormal interactions with external interfaces during any file transfer process.

after the implementation of the Operations Phase. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON135 Provide call center services to providers and members from 8:30 AM (ET) to 5:30 PM (ET) weekdays and from 9:00 AM (ET) to 1:00 PM on the Saturdays and State approved/designated holidays. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON130 Produce a report summarizing the hot site processing test results to the Department within thirty (30) calendar days of the Contractor Management completion of the test. callers must be able to leave messages that are returned within twenty-four (24) hours. and a Web Portal. a hierarchy of critical services and infrastructure to determine the order that services must be restored. When the call center is not operating. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON137 Provide and execute quality assurance procedures to ensure that the financial management system disburses. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON124 Ensure the Business Continuity Plan contains a section for a Disaster Recovery Plan that addresses recovery of all MAS functions. maintained. and accounts for Medicaid payments accurately. Call center services to pharmacies must be available from 7:00 AM (ET) to 10:00 PM (ET) weekdays and from 9:00 AM (ET) to 1:00 PM on the Saturdays and State Contractor Management approved/designated holidays. and must satisfy all requirements for federal MMIS certification. The DRP must be available and present at the Department's Contractor Management site and at an offsite location approved by the Department.CON122 Provide the ability to convert to the back-up site within twenty-four (24) hours in the event the primary site becomes unavailable and/or the failover procedures cannot be successfully executed. CO07 Manage Contract NA 2 Section: Page: CON136 Produce and maintain State-approved comprehensive and accurate written procedures documenting all major aspects of financial management and ensure strict adherence to the procedures unless otherwise directed by the Department. CO07 Manage Contract NA 1 Section: Page: . The DRP test must be included as a part of Acceptance Testing and be executed annually. CO07 Manage Contract BE1. at which time the contractor will have thirty (30) days to secure and make operational a New back-up site. the Department may at its sole discretion declare the back-up site the Contractor Management New primary site. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON128 Provide the Department with up-to-date copies of the DRP in an electronic and printed version on the first business day of each calendar quarter during the term of the contract and after any substantive change to the DRP. CO07 Manage Contract NA 3 Section: Page: CON123 Ability to operate the Call Center if the primary site becomes unusable or unsafe. CO07 Manage Contract NA 1 Section: Page: CON129 Execute the DRP test annually (at no cost to the Department. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON127 Modify the DRP. The Department reserves the right to inspect the disaster recovery back-up site and procedures at any time with twentyfour (24)-hour notification. along with the Department. at the anniversary date of the contract. Correspondence. maintain and submit to the Department.11 1 Section: Page: CON131 Perform an annual review of the disaster recovery back-up site. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON132 Establish. human resources and the technology infrastructure. all proposed off-site procedures. tracks. The contractor must Contractor Management also provide a walk-through of its DRP during the first calendar quarter of each year for the life of the contract. and until satisfactory results are approved by the Department) to demonstrate the capability of the DRP to restore processing capability for all critical system components at the back-up site. disaster recovery software and operational procedures to reflect the changes implemented with any new system functionality if the system changes or any enhancements will impact the disaster recovery capability. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON133 Provide Customer Service Center functions for providers and members via a Call Center. The test at the remote site must be performed for all input. and accessible for audit purposes. Department overrides of procedures must be documented. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON134 Provide dedicated toll-free call center telephone number(s) within the continental United States. CO07 Manage Contract NA 1 Section: Page: CON126 Ensure that each aspect of the DRP is detailed as to both contractor and Department responsibilities. In the event the contractor cannot return to the original MMIS site within seven (7) calendar days. locations and protocols for review and Contractor Management approval prior to implementation. Contractor Management Release to the Provider community and OSC as required by the Department. CO07 Manage Contract NA 1 Section: Page: CON125 Develop. A report of the back-up site review must be submitted within thirty (30) calendar days of the review. processing and output procedures functions. This report must include remediation steps taken to resolve any issues discovered during the test. Modifications to the DRP must be submitted to the Department for review and approval. and provide sufficient office space within twenty-four (24) hours of notification by the Department to continue all activities previously being conducted at the primary site. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON138 Submit the annual payment cycle schedule by the last State business day in September each year for Department approval. procedures for all off-site storage and validation of security procedures.

located in the Procurement Library. on the anniversary date of the contract. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON158 Revise the Security. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON155 Include a description of all security tools.gov/ocs) and NYS Department of Health Security Requirements document. member registry. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON157 Deliver an initial Security. rules. attachments. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON153 Ensure the Security. and detail design) • Use of facilities and the right to photocopy any and all documentation Contractor Management CO07 Manage Contract NA 3 Section: Page: CON145 Notify the State of any changes made to the contractor's application and adjustments to edits. Office of Attorney General (OAG). Contractor Management CO07 Manage Contract NA 2 Section: Page: CON140 Produce and make available the check register and EFT register to the Department and OSC and independent auditors at the end of each claims payment cycle. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON141 Monitor. OSC. and other entities as specified by the Department. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON144 Provide the audit staff with support. memos.. documentation (e. Privacy.CON139 Perform monthly bank account reconciliation and submit Department-approved reports within ten (10) workdays of the end of each reporting month. Privacy. CO07 Manage Contract NA 1 Section: Page: . the federal Department of Health and Human Services (DHHS). based on an annual Contractor Management risk assessment and submit for Department review and approval. and Confidentiality Plan is aligned with the NYS Office of Cyber Security and Critical Infrastructure Coordination. triage and route for resolution all returned undeliverable mail sent to providers. Privacy and Confidentiality Plan annually. located in the Procurement Library. internal reports. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON150 Develop and implement a Security. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON151 Ensure the Security. The approved plan will be integrated into the Contractor's Standard Operating Procedure. Contractor Management CO07 Manage Contract PI3. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON146 Support and monitor the preparation and production and distribution of reports as specified by the State. and Confidentiality Plan aligns with National Institute of Standards and Technology SP 800Contractor Management 63 Electronic Authentication Guidance. including but not limited to: • Access to all contractor personnel and facilities • Access to all information (e. regulations. and OMIG. Privacy and Confidentiality Plan during the first thirty (30) calendar days of the project for Department review and approval in accordance with the NYS Department of Health Security Requirements document. provider registry. Privacy. OSC. hardware and software the contractor is using and how they integrate to form a comprehensive security architecture. Resolution must occur within 30 days of receipt of the undeliverable mail. and other documents in accordance with State retention requirements and dispose of in accordance with Department-approved procedures. Standards and Guidelines (http://www. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON148 Support periodic archiving of program information based upon agreed criteria and schedules with the Department. Cyber Security Policy P03-002. Standards and Guidelines G07-001. and Confidentiality Plan is aligned with NYS Information Technology Policies. Contractor Management CO07 Manage Contract PI3.7 1 Section: Page: CON147 Distribute reports via hard copy. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON152 Ensure the Security. NYS Information Technology Policies. members. CO07 Manage Contract NA 1 Section: Page: CON154 Ensure the Security. and Office of Medicaid Inspector General (OMIG) or other authorized personnel who perform audits relating to the NYS Medicaid program.dhses. including job accounting/software • Access to all documentation including but is not limited to: software and operating manuals.g. Privacy..g. Contractor Management CO07 Manage Contract NA 3 Section: Page: CON156 Include a description of the approach to monitoring potential security violations and the actions that will be taken if violations are detected.ny. as directed by the Department. transaction information. Identity and Access Management: Trust Model. Privacy and Confidentiality Plan approved by the Department for all projects and all major system enhancements.14 2 Section: Page: CON143 Assist Department staff in responding to audit findings or requests for information. electronic. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON149 Maintain all hard-copy forms. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON142 Assist audit staff from the Department. reporting repository and/or the web-portal as specified by the Department. and Confidentiality Plan is aligned with the Certification Commission for Healthcare Information Technology Security Criteria for 2007 Certification of Inpatient EHRs. and reference information and pricing information) • All application programs and libraries • All systems programs and libraries • Access to the operating system.

but not be limited to. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON168 Prepare a detailed Requirements Validation Document that will be managed as a baseline to guide work to be performed in subsequent Project tasks. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON160 Facilitate. and output of the joint development sessions • Describe how the joint development sessions will be conducted • Define how demonstrations of functionality will occur (Describe templates and tools that will be used) • Describe how the requirements will be documented (Provide templates and samples) • Define the methodology and analytical tools used to complete the requirement validation tasks (Provide samples and templates) • Describe how the Department's business processes will be integrated into the Requirements Validation sessions • Describe how the proposed methodology and tools will be supported by experienced staff Contractor Management CO07 Manage Contract NA 3 Section: Page: CON165 Provide Department project staff with a structured. interactive overview of the Proposed System including all its components and functions to orient the team to the contractor’s system in advance of the joint development sessions. CO07 Manage Contract NA 1 Section: Page: . document.. the following items: • Definition and documentation of the proposed business process model of New processes (referred to as "To Be") • Documentation showing that the “To Be” processes are aligned with the MITA framework Contractor Management CO07 Manage Contract NA 1 Section: Page: CON164 Develop and implement an approved Requirements Validation Plan and methodology. At a minimum this matrix must identify where each of the approved requirements will be addressed in subsequent design. CON167 Collect documentation and requirements from the joint development sessions (i. as appropriate. identifying changes needed to support use of the new system. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON161 The contractor must implement a governance process over the initial configuration. in conjunction with the State Quality Assurance contractor. The Analysis must employ Value-Added Chain (VACD) and Event-driven Process Chain (EPC) diagrams. the purpose of which is to: • Confirm a common understanding of each requirement to ensure that the proposed solution includes all required functionality • Validate the “To Be” Business Processes • Identify any new requirements and explore these requirements in sufficient detail to adequately support system design activities Where commercial software (already designed and developed) is proposed. This Contractor Management overview must be held periodically for new staff. as directed by the Department CO07 Manage Contract NA 1 Section: Page: Contractor Management CO07 Manage Contract NA 1 Section: Page: CON162 CON166 Provide the following deliverables during the implementation phase: • Business Design Document • Requirements Validation • Test Plans Conduct a series of joint development sessions with Department staff and other stakeholders. development and testing deliverables. Office of State Comptroller (OSC). integration and testing of the MAS Contractor Management CO07 Manage Contract NA 1 Section: Page: Contractor Management CO07 Manage Contract NA 1 Section: Page: CON163 Develop a Business Process Analysis. and deliver outcomes for state approval of configuration sessions with the Department. sessions to review functional expectations and establish configuration will take place in lieu of joint development sessions. approved notes and updated requirements) and store it in an online repository accessible to all joint development session participants and others as directed by the Department. The Business Process Analysis shall include. expectations. At a minimum the plan must: • Define the goals. Privacy and Confidentiality Plan to the Department for review and approval thirty (30) business days prior to the start of operations. beginning within 15 business days of the project kick-off meeting.CON159 Submit an updated Security.e. and Office of Medicaid Inspector General (OMIG) participants. At a minimum the Requirements Validation Document will: • Include an evaluation of all requirements identified in Technical and System Architecture Requirements • Include all New requirements defined in the joint development sessions Contractor Management CO07 Manage Contract NA 1 Section: Page: CON169 Develop and maintain a Requirements Traceability Matrix to associate finalized requirements with the work products that Contractor Management satisfy them.

stress test) • Validate the accuracy of the data Contractor Management CO07 Manage Contract NA 1 Section: Page: CON179 During System Integration Testing the contractor must validate the accuracy of the data being passed to the MDW at volumes illustrative of operations and confirm the accuracy of all data submitted. with all data elements on the screens identified by number. At a minimum the Logical Design Document shall: Contractor Management • Identify general flow of functions in a flow diagram. and all calculated or generated fields on the screens described clearly • Include instructions for requesting reports or other outputs with examples of input documents and/or screens • Include instructions for file maintenance. procedures and tools for problem identification and resolution • Describe how it will maintain accurate test data while protecting privacy • Describe how regression testing will be done at all levels when errors are corrected Contractor Management CO07 Manage Contract NA 2 Section: Page: CON176 Conduct Integration Testing to test business functionality as well as related technical functionality and provide a report of Contractor Management test results. provider types and claims types). Contractor Management CO07 Manage Contract NA 1 Section: Page: . test cases. and test results. the flow diagram must identify all major processes • Include sample layouts for all outputs. fixing errors and troubleshooting • Be available and maintained on-line via the R-MMIS • Have instructions for sequential functions (for example. and the steps necessary to correct such errors Contractor Management • Include tables of valid values for data fields (for example. including screen layouts and print report layouts. creating reports. which must provide details on how any new business processes are supported. their location within the organization and the purpose (outcome) of the process or procedure CO07 Manage Contract NA 1 Section: Page: CON174 Develop Business Operating Procedures. test cases and test results will be traced to requirements • Describe the processes. abbreviations. its conceptual architecture. Define the business rules structures and how they will be incorporated into the process flow CO07 Manage Contract NA 1 Section: Page: CON171 Develop the System Architecture and Infrastructure Plan to describe how external system interfaces will be implemented Contractor Management CO07 Manage Contract NA 1 Section: Page: CON172 Describe and execute on the standards for software products. • Assure that system conforms to requirements and specifications • Validate links between programs and subsystems or functions • Validate the operating environment of the system • Validate the accuracy of the adjudicated claim billing logic • Confirm operating performance • Verify that on-line response times meet Department-specified requirements under load (full production volume. presented on screens and reports • Include illustrations of screens used in the subsystem. The Plan must be updated at least annually. with descriptions of code values and data element numbers for reference to the data dictionary • Include for each process and procedure the user. and creation of data. approved by the Department. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON175 Develop. balancing instructions must follow the actual flow of the process) • Include consistent definitions of codes and terms. CO07 Manage Contract NA 1 Section: Page: CON177 Specify the criteria the contractor will use in determining the completion of each System Test activity. CO07 Manage Contract NA 1 Section: Page: CON173 Provide a User Manual for any State staff reviewers and users.CON170 Develop a Logical Design Document detailing how and where each requirement is met by the new system. and identify output frequencies • Document all applicable policy and business rules. maintain and implement a Comprehensive Test Plan. This is to be a description of the standards to be followed for Contractor Management representing requirements. including codes and descriptions in English. At a minimum the Plan must: • Describe each type of testing and detail the contractor's approach to each • Describe how test scenarios. etc. At a minimum the User Manual must: • Provide a software user step-by-step instructions for accomplishing tasks and work processes. for testing the MAS. and field names throughout various sections of Manual • Include error message descriptions for all fields incurring edits. design. test procedures. code. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON178 During System Integration Testing the contractor must: • Verify all edits. audits. and a Logical Data Model demonstrating how data flows through the business model.

CON180 Develop the Systems Integration Testing (SIT) Test Results Report. and record Parallel Test testing results and discrepancies reported by the Department. and resolution of problem. and business rules. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON191 Provide the following support for the technical coordination effort with Stakeholders: • Provide technical support to Department users on proposed technologies • Build on the current Department effort to achieve a higher MITA standing in conjunction with the State Quality Assurance contractor • Provide technical support to Department users in the identification and documentation of their functional requirements • Confirm interface requirements with Department system business stakeholders Contractor Management CO07 Manage Contract NA 1 Section: Page: . including the status of defect resolution as of the date of the report and implications from the testing for system implementation Contractor Management CO07 Manage Contract NA 1 Section: Page: CON186 Detail the steps that were taken if the software or hardware experienced performance issues Contractor Management CO07 Manage Contract NA 1 Section: Page: CON187 Complete comprehensive Parallel Testing. proper functioning of edits. At a minimum the deliverable must: • Provide an overview of the testing effort • Document the disposition of all test cases. test scenarios. including expected and actual results • Identify and classify all defects. etc. in which users test all functions in a production-like controlled and stable environment. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON189 Update the Business Process Analysis that was developed during Requirements Validation. and the format and content of all system outputs. assist with test data. to demonstrate the ability to process expected workloads accurately within prescribed time frames. corrective steps taken. which include: • Demonstration of successful execution of all test scripts • Demonstration that the system test is stable within the test environment • Demonstration that the appropriate level of configuration management has been applied to all affected configurable items Contractor Management CO07 Manage Contract NA 1 Section: Page: CON181 The contractor must support the user community during User Acceptance Testing (UAT). Assist the users in the preparation of testing material • Provide access to authorized Department staff and contractors to the UAT environment. audits. type of problem. This will include issues such as security. test cases and test scripts CO07 Manage Contract NA 1 Section: Page: CON182 Perform volume and stress tests as directed by the Department. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON183 Report the results of the Stress and Performance Test. converted files. but not be limited to. At a minimum the contractor must: • Provide an overview of the testing activities that will be performed by the users and the environment in which this work will be completed. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON190 Report business change management status as part of the Monthly Project Status Report and weekly project status meetings. privacy. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON188 Monitor. Parallel Testing results must be documented. Demonstrate in the report that the Stress and Performance Test met Contractor Management testing completion criteria identified in the Stress and Performance Test Plan. navigating the UAT environment and reviewing the test results. including the status of defect resolution as of the date of the report and implications from the testing for system construction and UAT • Demonstrate in the report that the SIT met testing completion criteria. test scripts. including expected and actual results Contractor Management CO07 Manage Contract NA 1 Section: Page: CON185 Identify and classify all defects that were found. process and tools that will be used to execute the UAT and training on the operation of the technical environment to support user validation Contractor Management • Describe the system changes that were made and the methods that will be used to test these changes • Provide training to Department and other designated contractors on preparing test cases using the automated test generator. description of problem. problems identified. • Provide training on the system. the accuracy of claim records payment and file maintenance. tracked and analyzed to determine if corrective action is required and the reason for the discrepancy and contractor must provide reports during Parallel Testing to include. identifying changes the Department agrees to make to its business processes in order to support the use of the system. track. CO07 Manage Contract NA 1 Section: Page: CON184 Document the disposition of all test cases. including but not limited to.

Include discussion as to whether the conversion process will be implemented in phases. The final ORR report must contain the completed checklists. The ORR Plan must include extensive checklists for each functional area containing items related to the preparedness of that function for a successful implementation. This shall address the following: Contractor Management • Define the sources of all data to be converted • Describe the plan for normalization of data to be converted • Description of tools and processes used to report and identify potential data issues • Data conversion execution plan and schedule for completing the conversion processes • Plans for necessary manual conversion and data cleanup activities • Testing methodology and approach to ensure the accuracy of the converted data CO07 Manage Contract NA 2 Section: Page: CON193 Develop the Data Conversion Specifications and Mapping document. At a minimum the plan must: • Define the processes. methodology and tools to be used to complete the conversion effort • Describe the general approach that will be used to complete the data conversion processes • Define the boundaries of the data conversion effort. which identifies the strategy and procedures. These new elements must be incorporated into the system design and be reflected in the logical and physical data model • Document rules for populating data not found in the current system Contractor Management CO07 Manage Contract NA 1 Section: Page: CON194 Develop a Data Conversion Test Plan. roles and responsibilities for all activities in the review effort. report and respond to all problem conditions reported during the review and prepare an ORR corrective action plan Contractor Management for problem correction and resolution. CO07 Manage Contract NA 1 Section: Page: CON197 Prepare and review with the Department a final ORR report that demonstrates the contractor is ready to begin operations in the production environment and assume all MAS / fiscal agent functions using the new system. signed off by key state stakeholders during the review process and the status and results of the ORR corrective action plan activities.CON192 Develop and implement a Data Conversion Plan to convert data files from the prior MMIS to the contractor’s data system. CO07 Manage Contract NA 1 Section: Page: Contractor Management . At a minimum the Test Plan must: • Describe the approach to Data Conversion testing • Describe how manual conversion of data will be tested • Document how the contractor will demonstrate that the data conversion process functions as designed • Include record count integrity and data integrity in the approach to testing the conversion processes Contractor Management CO07 Manage Contract NA 1 Section: Page: CON195 Develop a comprehensive Operational Readiness Review (ORR) Plan approved by the Department. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON196 Track. procedures. At a minimum the Deliverable must: • Document the mapping of all current system source data to the new system • Document any elements that do not exist in the new system and the justification for not including • Document any new elements.

This will include regular audits by OMIG.. CO07 Manage Contract NA 1 Section: Page: CON203 Provide full cooperation with the State. any other authorized State agency. OSC. and validation of the timeliness and accuracy of all payments for services under the state plan. The plan must also contain the criteria for determining if each activity is successful and the triggering mechanism for implementing the contingency plan. and litigation of possible fraud and abuse cases or any other possible misconduct which may affect the Program.CON198 Develop ORR checklists focusing on the additions. The System Implementation Strategy must clearly address implementation and contingency planning and define the contractor's approach to implementation assurance support including how the system will be measured against the required thresholds and how outstanding issues will be addressed. efficiently. verification. The contractor must respond in a timely fashion to all State audit requests for information and/or clarification. The Implementation Contingency Plan sets forth detailed descriptions of activity integration and resources to accommodate backup activities should the implementation Contractor Management results not come out as anticipated. as well as an independent auditor. While many of the following functional areas may not be exposed to any change from the transition to the MAS. consistent with the requirements of Appendix A: Standard Clauses for New Contractor Management York State Contracts including provisions of access to protected health information and all other confidential information when required for audit purposes as determined by the State as appropriate.11 1 Section: Page: CON204 Allow for the monitoring. describing its approach to ensuring that the system is ready to be implemented and that Department approvals have been obtained to initiate operations. and in a timely manner) and smoothly transition system operation and maintenance from the contractor system develop staff to operations staff. approved by the Department. CO07 Manage Contract NA 1 Section: Page: CON200 Work in conjunction with Department staff to complete implementation activities in a manner that does not disrupt recipient and provider services (e. the application must satisfy all requirements specified in the RFP and documented during Contractor Management the requirements validation and systems design activities. The plan must clearly define each implementation outcome and the backup activities that will occur for each if problems occur. initiated. CO07 Manage Contract PI3. Contractor Management CO07 Manage Contract NA 3 Section: Page: CON201 Develop an Implementation Contingency Plan as a companion plan to the Implementation Plan. CO07 Manage Contract NA 3 Section: Page: Contractor Management . Examples of check list functional areas include but are not limited to the following: • Facility • Hardware operation • Telecommunications • Interfaces with external State agencies and outside business partners • Contractor staff hiring and training • User staff training • Provider training • Department staff training • User training • All system user and operations documentation including procedure manuals • Toll free and other phone lines • Claim forms distribution • Mail room operations • Imaging operations • System security • System access • Building security • Confidentiality of data • Report generation and distribution processes • System backup and recovery procedures • Hardware and software installation • System testing and user acceptance testing Contractor Management CO07 Manage Contract NA 1 Section: Page: CON199 Update the System Implementation Strategy deliverable.g. findings. they must be included in the ORR process to verify this fact. completed. To be ready for implementation. all functions must work correctly. changes and omissions resulting during the transition from the eMedNY system to the MAS. and an extension of the Implementation Strategy required with the contractor's proposal. and any law enforcement authorities with audits and in the investigation. in progress. documentation. CO07 Manage Contract NA 1 Section: Page: CON202 Provide comprehensive reports to the State detailing audits planned. recoveries Contractor Management based on actual findings (no projections).

In addition. Each reconciliation must provide an exact accounting of all transactions recorded on the financial records of both the contractor and the bank during the previous month. The contractor must provide separate banking Contractor Management services and fiscal accountability necessary to maintain payment and refund functions of each program (e. at a minimum. the contractor must audit a sample of checks meeting the criteria specified Contractor Management by the State in the prepayment audit procedures.CON205 Provide the Office of the State Comptroller. a monthly reconciliation of the State’s escrow account utilized exclusively for funding the disbursement account.g. Elderly Pharmaceutical Insurance Coverage (EPIC). made during the previous month for each account. at a minimum. CO07 Manage Contract NA 1 Section: Page: CON211 The contractor must additionally complete. maintenance. Confirmation of claim information directly with the pharmacy or member is expected when needed to ensure the accuracy of payments. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON217 Support online entry. upon State request. CO07 Manage Contract NA 1 Section: Page: CON212 Collateral to secure deposits must be pledged as required by the NYSOSC and NYS Finance Law. ensuring the cumulative accuracy and agreement of the financial records of the Contractor Management contractor and the bank. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON209 Provide separate banking services and fiscal accountability for deposits to the following account owned by NYS Refunds and recoveries account. and reporting of system and operational change requests. be in accordance with generally accepted accounting standards. The contractor will retain prepay audit work papers and related documentation for future reference and make these available to the State upon request. All account reconciliations must be in a State approved format and. The contractor. and provide to the State. Accordingly. The contractor may not establish any EPIC. an accounting of all banking transactions. be in accordance with generally accepted financial accounting standards. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON213 Provide internal audit function to ensure the integrity of the EPIC Program. MEIPASS or Medicaid related bank account unless such account and the depository bank is expressly approved by the NYSOSC. The reconciliations must be in a state approved format and. also ensure the cumulative accuracy and agreement of the financial records of the State Contractor Management and the bank. NYPS. transfers. The refund and recoveries receipt account is for the deposit of Medicare Part D plan Contractor Management recoveries.). CO07 Manage Contract NA 2 Section: Page: CON214 Maintain fully separate accounting information for each program administered under the contract. be in accordance with generally accepted accounting standards. charges and credits. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON216 Document current system data to new system data and provide status reports identifying conversion issues and mitigation. all banking proposals and procedures will be subject to prior review and approval by the NYSOSC. for all disbursement accounts: the pharmacy provider EFT and checking accounts. detailed reviews of several system generated exception reports are required to confirm the accuracy of payments. including payments. CMS. and copying. and fee refund account. etc. at a minimum. It is the contractor responsibility to open and maintain the bank accounts for the Program. The reconciliation must provide an exact accounting of all transactions recorded on the financial records of the State (which the State will furnish to the contractor) and the bank during the previous month. prior to the release of any reimbursement. CO07 Manage Contract NA 1 Section: Page: CON210 The contractor must complete and provide to the State reconciliations for the revenue and disbursement account. Each month-end balance in the escrow account must be reconciled to the specific member refunds and pharmacy provider EFT disbursements that have not cleared the bank by month-end. CO07 Manage Contract NA 1 Section: Page: CON208 Provide the State. The NYS OSC will periodically transfer funds from this account to a separate NYS account managed by the State. may be required to perform internal audits of selected operations within the contactor. the Inspector General of the United States. As part of this function. Contractor Management CO07 Manage Contract NA 3 Section: Page: CON206 The contractor may not establish any State of New York Medicaid Program related bank account unless such account and Contractor Management the depository bank is expressly approved by the NYS OSC CO07 Manage Contract NA 1 Section: Page: CON207 Utilize a State approved bank located in NYS to provide banking services. member excess co-pay refund account. to ensure accuracy. NYPS. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON215 Implement a paper pricing data-entry verification process or alternate process acceptable to the State. the contractor will be responsible for conducting a semi-monthly prepayment audit. audit. The accounting must be in a State approved format and. For the prepayment audit. State settlements and pharmacy refunds. Contractor Management CO07 Manage Contract NA 1 Section: Page: . by the fifteenth day of each month. All bank charges are the liability of the contractor and must be built into the applicable claims administrative fee. and their authorized representatives with access to all records relating to contractor performance under this contract for the purposes of examination. Any remaining differences between the uncleared items and the State escrow account balance must be fully researched and documented by the contractor.

and resolve any erroneous data from external interface data sources Contractor Management CO07 Manage Contract NA 1 Section: Page: CON226 Preserve and make available all other pertinent books. documents.CON218 Provide online reporting of operational performance metrics accessible by NYS staff. all banking proposals and procedures will be subject to prior review and approval by the NYSOSC. an annual SSAE 16 audit review for review and approval by the Department (SSAE-16 SOC 1 for the first two contract years and SSAE-16 SOC type II for subsequent years). the accuracy of claim records payment and file maintenance. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON219 Document how workflow-related data is to be processed. and maintain all necessary production reports to be produced by the contractor necessary for State oversight of the contractor’s administration of the Medicaid Program Contractor Management CO07 Manage Contract NA 1 Section: Page: CON225 Identify. CSV. and business rules. routed. CO07 Manage Contract NA 1 Section: Page: CON231 Perform Member & Provider Satisfaction surveys through an independent contractor and methodology. audits or litigation that have been initiated and not resolved at the end of seven years. Excel) • After conversion. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON220 Identify. which relate to appeals. quarterly and annual Management and Administrative Reporting System (MARS) reporting cycles. if necessary. will be retained until resolution of the findings. and controlled. audits. It is the contractor responsibility to open and maintain the bank accounts for the Program. CO07 Manage Contract NA 1 Section: Page: Contractor Management . at no additional cost to the State. PDF. CO07 Manage Contract NA 1 Section: Page: CON233 Maintain parallel MMIS operations to future contractors during the turnover phase to ensure proper functioning of edits. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON224 Identify the requirements. The contractor must respond to each audit with a proposed Corrective Action Plan within 30 calendar days of the audit. prior authorization. non-PHI reports need to be remotely accessible on demand by designated MARS users through a Contractor Management secure portal. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON228 Provide online access to thirty six (36) months of history related to claims. monthly. produce. and records (including electronic storage media) of the contractor involving transactions related to the contract for a period of seven years from the date of expiration or termination of the contract. The contractor may not establish any Preferred Diabetic Supply related bank account unless such account and the depository bank is expressly Contractor Management approved by the NYSOSC. • NYS requires historical MARS reports converted from their current Open text Alchemy format into more usable formats for users (ex. All bank charges are the liability of the contractor and must be built into the applicable claims administrative fee. All PHI and Non-PHI reports must be read only • PHI MARS reports must be reviewed for potential deletion in favor of only providing PHI data through the MDW. If PHI reports are still deemed necessary by the Department. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON229 Online inquiry is available for 36 months of adjudicated claims history and any claims still in process.12 1 Section: Page: CON232 Collateral to secure deposits must be pledged as required by the NYSOSC and NYS Finance Law. tracked. Contractor Management CO07 Manage Contract MC4. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON227 Records. and maintain throughout the life of the contract all NYS Medicaid policies and business rules supported by the contractor's solution. and the format and content of all system outputs. papers. Accordingly. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON230 Define report specifications and online screens to be provided by the contractor that will allow the State to monitor status Contractor Management of Health Insurance Premium Payment (HIPP) cases. document. they must be securely archived and only made accessible to the appropriate users through the portal CON223 Provide. TXT. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON221 Perform internal auditing of all aspects of the program Contractor Management CO07 Manage Contract NA 1 Section: Page: CO07 Manage Contract NA 2 Section: Page: CON222 Support weekly. research. approved by NYS. and point of sale data.

45 requires prepayment and post-payment claim reviews to ensure the accuracy of Medicaid payments.127 supporting the NYS Medicaid Program. allow providers to submit claims up to 12 months from the date of Contractor Management service. and exceptions criteria and identifying exceptions so the agency can correct inappropriate practices or “misutilization” of recipients and providers. annual contract performance evaluations. must be proposed that describe oversight activities that allow for the assessment of the fiscal agent’s quality of performance and adherence to federal regulations related to claims processing timeliness. This must include read. such as type of illness. CMS and OIG]) will have full access at all times (both prior to and after certification) to all contractor systems (whether remotely or on-site) and records in accordance with 42 CFR 433. accuracy. . and oversee all aspects of the contractor. CO07 Manage Contract NA 1 Section: Page: The State shall include the Department. reviews of the fiscal agent’s internal quality assurance audit findings and oversight of the fiscal agent’s surveillance and utilization reviews of potential overpayments to providers or beneficiaries. • Verification that the claim does not duplicate or conflict with one reviewed previously or currently being reviewed. CON237 Please note: Federal regulation 42 CFR 447. service location. to include procedures. monitor. coding errors. processes and systems.CON234 The State (and thereby HHS [i. and system logic. This includes an annual SSAE 16 audit (SSAE-16 SOC 1 for the first two contract years and SSAE-16 SOC type II for subsequent years) of the fiscal agent’s controls. Federal regulations address timely filing requirements by providers and timely processing by the Contractor Management fiscal agent. as defined respectively in 10 NYCRR § 98. • Checking that the number of visits and services delivered are logically consistent with the recipient’s characteristics and circumstances. processes and systems. duplication. • Checking for third party liability. pricing. CO07 Manage Contract NA 1 Section: Page: CON239 In accordance with Federal regulation 42 CFR 447. write. Describe in detail the internal control structure that will be used by the contractor and its subcontractors to meet and adhere to federal regulations related to claim processing timeliness. control. CO07 Manage Contract NA 1 Section: Page: Propose internal controls.21 (a) (1) and (a) (2). several controls are required to ensure effective oversight of claims processing. in particular. Medicaid providers are required by federal law to submit claims for services rendered in a timely manner. gender. These activities include prepayment and post-payment reviews which ensure claims processing accuracy. documentation. All requests for access to systems and records by CMS will be read-only and will come through the State agency in writing. Office of State Comptroller (OSC). data entry errors. and Office of Medicaid Inspector General (OMIG). including all aspects of Medicaid services delivery. on-going monitoring of the fiscal agent’s claims processing and system test plan to detect errors in and outside the MAS. and payment for services. Contractor Management • Verification that a payment does not exceed any reimbursement rates or limits in the State plan.45. provider service profiles. medical necessity. Post-payment claim reviews consist of developing and reviewing recipient utilization profiles. and describe oversight activities to assess the fiscal agent’s quality of performance and adhere to federally mandated claims processing accuracy requirements. to include procedures.e. Federal accuracy standards consider risk factors associated with beneficiary eligibility. third-party liability. and override permissions within the MMIS necessary to manage. age. In addition to implementing federally required prepayment and post-payment reviews. Prepayment reviews consist of the following: • Verification that the recipient was included in the eligibility file and the provider was authorized to furnish the service. all costs associated with production and reproduction shall be the Contractor Management responsibility of the contractor. policy violations. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON236 Notwithstanding the foregoing. CO07 Manage Contract NA 1 Section: Page: CO07 Manage Contract NA 1 Section: Page: CON238 Internal controls.1. CON235 Request approval by designated NYS authorized representatives for any changes made to program business rules and adjustments to edits. limitations. member Contractor Management and provider management. when records are sought in connection with a “fraud” or “abuse” investigation.

Contractor Management CO07 Manage Contract NA 1 Section: Page: CO08 Close out Contract NA 1 Section: Page: CO08 Close out Contract NA 1 Section: Page: CON240 CON241 CON249 CON250 Contractor Management The contractor must complete all services within scope of this RFP in accordance with the requirements and applicable federal regulations in an accurate and error-free manner. and make any modifications necessary to prevent similar errors in the future. and recommendations for continued processing in the event the transition is not completed by the transition date. and reporting responsibilities. CO07 Manage Contract NA 1 Section: Page: CON243 The contractor must be fully bonded and insured to cover actual damages to the State in the event of a failure to meet the performance requirements as specified in the RFP. bear the financial burden to fix the error and its downstream impacts. Contractor Management charter. including the Department and/or OMIG and OSC. and survey samples of providers to assess their perception of the timeliness of the fiscal agent’s claims processing. review of the fiscal agent’s timely filing business practice manual and the provider general billing manual. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON244 Describe the contractor oversight activities that will be used to monitor the internal controls and adhere to federally mandated claims processing accuracy requirements. Additionally. and gathering of other required data. the contractor shall issue an error report to the Department within five (5) business days that includes: • Description of the error • Identification of the source of the error • Cause of the error Contractor Management • Impact of the error to all impacted stakeholders. policies related to timely filing.The contractor must propose procedures. Schedule for the transition. Any time an error is identified by the contractor or identified by another party. in order to complete a controlled transition to the Department or successor contractor(s). Contractor Management CO07 Manage Contract NA 1 Section: Page: CON247 Describe how the internal audit function supports the development and implementation of internal controls processes. involvement of the MAS Contractor / fiscal agent’s quality assurance staff. The contractor's staff shall assist Department staff in responding to CMS inquiries. risks associated with the transition and proposed mitigation strategies for each risk identified. The contractor must provide support to the Department during the PERM review process. standards and criteria for solutions and approaches included in this response. files and user and operations documentation. Contractor Management . processes and systems that will be used to test that the internal controls are working effectively. Contractor Management including selection of samples. Provide technical support and assistance with Transition at the end of this contract. This Plan must include: Proposed approach to the transition to a successor contractor. The contractor must provide a means to audit and track for accuracy. Contractor Management CO07 Manage Contract NA 1 Section: Page: CON248 Please provide a copy of your most current SSAE16 SOC 1 report. including at a high level the function’s size. and communicated to the contractor. the contractor will be responsible for any financial damages to the Department that results from such errors. all Department data. production of hard-copy documents. including the date of the function’s last Quality Assurance Review. the contractor will assume the risk. CO07 Manage Contract NA 1 Section: Page: CO07 Manage Contract NA 1 Section: Page: CON242 The contractor is responsible for maintaining its systems as well as the contract operations to the standards required to pass the periodic Payment Error Rate Measurement (PERM) reviews conducted by CMS or any subsequent review process established by CMS. Tasks and sub-tasks for the transition. internal capabilities to produce and review audit reports related to claims processing timeliness. including financial (if applicable) • Strategy to fix the error • Plan to prevent similar errors for happening again in the future If the error is deemed to be a result of the contractor’s system and/or services. Provide a Transition Plan to the Department within one year before the start of the Operations Phase and update annually prior to the start of the next year of operations. Contractor Management CO07 Manage Contract NA 2 Section: Page: CON245 Describe the current internal audit function and overall governance structure. This level of support shall also be provided to all other State audit agencies or their designees. This may include having an auditor test a sample of claims to calculate timeliness of claims processing and to identify aged claims. A statement of resource requirements that would be required by the Department or a successor Contractor Management contractor(s) to take over the MAS. CO07 Manage Contract NA 1 Section: Page: CON246 Describe the internal audit function’s processes and practices for complying with the institute of Internal Auditors’ International Standards for the Professional Practice of Internal Auditing.

Final settlement of all contractor invoices. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON265 Coordinate MMIS certification activities with the MDW. QA contractor and any other applicable contractors throughout the remaining period of the incumbent MMIS Contractor Management contract and ongoing meetings after implementation. This will include meeting with the incumbent and devising work schedules that are agreeable for both the Department and incumbent MMIS contractor. CO08 Close out Contract NA 1 Section: Page: CON263 Cooperate with the eMedNY contractor during turnover activities and meet all requirements specified for the successor MMIS contractor in the eMedNY Turnover Plan. An independent audit by an entity with no contact or relationship with the contractor. and the Social Security Administration Management (SSA)TPQ process. Eligibility and Enrollment Management EE01 Determine Medicaid Eligibility NA 2 Section: Page: ELG003 Determine income eligibility and eligibility for premium assistance for all new EPIC members and renewals based on Eligibility and Enrollment online information exchanges with the NYS Department of Taxation and Finance. and all related documentation when requested by the Department.1 3 Section: Page: ELG002 Receive and process member eligibility information and generate acknowledgement and notification when member information is received from external sources. package. the contractor must work closely with the eMedNY contractor to ensure that all maintenance and development projects in progress within the legacy eMedNY environment are coordinated with the implementation plan and schedule for the MAS. Contractor Management CO08 Close out Contract NA 1 Section: Page: ELG001 Integrates with NYS Eligibility systems to support the assignment of members to Medicaid benefits/benefit packages based on Federal and/or State-specific eligibility criteria. Eligibility and Enrollment Management EE01 Determine Medicaid Eligibility BE2. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON266 All program data used to facilitate and administer the NYS’s Medicaid program under this contract. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON260 Perform the following closeout services including: Final reconciliation. patches. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON252 Maintain financial management responsibilities through the effective date of the transfer of responsibility and through the Contractor Management completion of the reconciliation of final cycle processing including cycle data and report output. located in the Procurement Library. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON256 Inventory and transfer all work-in-progress in accordance with the Department-approved Transition Plan. This will include meeting with the successor and devising work schedules that are agreeable for both the Department. the contractor. desk level procedures. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON255 Transfer all source non-proprietary program code. Health Insurance Exchange. with exclusion only to proprietary code of the contractor. deficiencies. Upon close out of the resulting contract of this procurement or upon request of the NYS Department of Health.CON251 Cooperate with the successor contractor(s). Contractor Management CO08 Close out Contract NA 1 Section: Page: CON258 Include the Department and successor contractor staff in the design of any program changes underway during the transition period. the contractor must clearly identify each change and provide all updated user documentation that may result from system changes. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON261 Develop and gain Department approval on the Incumbent Transition Support Strategy that details the contractor's approach to supporting transition activities with the incumbent MMIS. the contractor must prepare. and implement any remaining system modifications. schedule. Final assessment of any liquidated damages. the incumbent MMIS contractor. MDW contractor. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON259 Provide operations and technical applications walk-throughs with Department and successor contractor staff. Final reconciliation of all accounts receivable. manuals. while providing all required transition services. Final settlement of all outstanding financial transactions. MDW.1 1 Section: Page: . Contractor Management CO08 Close out Contract NA 1 Section: Page: CON262 Participate in scheduled contract coordination meetings between the Department. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON257 Identify. In fulfilling this requirement. and other systems as necessary. and turnover all program data to the department. and the successor contractor(s). eligibility system and QA contractors. CO08 Close out Contract NA 1 Section: Page: CON253 Provide access to employees by the Department or the new contractor and actively encourages transfer of system and operations knowledge. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON264 During the planning and implementation phase. Contractor Management CO08 Close out Contract NA 1 Section: Page: CON254 Provide a written commitment to work with the Department and successor contractor(s) in planning and performing Transition Phase activities. that must be in place prior to a system freeze. is the sole property of the NYS Department of Health. or fixes. EE01 Determine Member Eligibility BE2.

respond to. Eligibility and Enrollment Management EE02 Enroll Member NA 1 Section: Page: ELG010 Safeguard members from a terminated MCO from loss of services through automatic placement to fee-for-service (FFS) status until enrollment to a new MCO can be established. BE4. process and respond to real time CBIC transaction functions including but not limited to: • Add card • Update (post void date) to an existing card • Delete card • Delete all cards • Inquiry for three most recent cards Eligibility and Enrollment Management EE02 Enroll Member NA 2 Section: Page: ELG005 Identify CBIC cards which have been swiped for the first time and transmit a transaction to the OTDA CBIC IT unit to assist with voiding previous ID cards used by the member. Management EE03 Disenroll Member ME1.1. Eligibility and Enrollment Management EE02 Enroll Member NA 1 Section: Page: ELG007 Identify and resolve invalid or incomplete EPIC application information Eligibility and Enrollment Management EE02 Enroll Member NA 1 Section: Page: ELG008 Perform quarterly assignment of members to Lead Health Homes based on the following: • Acuity/Risk score above a Department assigned threshold • Member service utilization in the Loyalty analysis closely matches providers within a Lead Health Home’s provider network • Lead Health Home has capacity to serve member Eligibility and Enrollment Management EE02 Enroll Member NA 1 Section: Page: ELG009 Produce and distribute ANSI X12N 820 and X12N 834 transaction.1 and D.2.2. that includes but is not limited to: • Selecting groups of providers based on criteria determined by the Department • Generating recertification notices • Tracking recertification responses • Terminating unresponsive providers Eligibility and Enrollment Management EE05 Determine Provider Eligibility WA2.2. ME2.. BE3. on entities or individuals meeting the qualifications contained in the provider Management agreement including geographic locations and capitation or FFS rates EE05 Determine Provider Eligibility WA2.1 3 Section: Page: ELG016 Support.g. generate. process.7 1 Section: Page: ELG012 Receive and process Health Home member eligibility exceptions received from the Welfare Management System (WMS) Eligibility and Enrollment and disenroll non-members from Health Home rosters Management EE03 Disenroll Member NA 1 Section: Page: ELG013 Provide a means to accept. including applications and supporting Eligibility and Enrollment materials via hard copy. BE3. coverage or benefit inquiry (version 5010) • HIPAA X12 271 eligibility.0 Eligibility and Enrollment Management EE04 Inquire Member Eligibility BE4.5 1 Section: Page: ELG014 Support all channels approved by the Department for eligibility verification transactions. BE3.3. Eligibility and Enrollment Management EE02 Enroll Member NA 3 Section: Page: ELG011 System has capability to disenroll a member from an MCO within the first 90 days and/or after 12 months if requested by Eligibility and Enrollment the member. and respond to electronic eligibility inquiry transactions received in HIPAA standard formats including: • HIPAA X12 270 eligibility.1. and state 18NYCRR 502/504. and track member eligibility inquiries and responses with data including but not limited to: • Member identification • Eligibility status including managed care and TPL (Commercial and Medicare) • Utilization threshold limits • County of fiscal responsibility • Co-pay information • Member restrictions/exceptions Eligibility and Enrollment Management EE04 Inquire Member Eligibility BE3.1. Eligibility and Enrollment Management EE04 Inquire Member Eligibility BE1. contractor maintains historical reference of discrepancies and their solution within fields in the System that are usable for both eligibility and claims payment.5 2 Section: Page: ELG015 Accept. Eligibility and Enrollment Management EE04 Inquire Member Eligibility NA 2 Section: Page: ELG018 Develop and manage a provider enrollment and recertification process per regulations 42 CFR 455. MC1. BE3.ELG004 Accept. coverage or benefit response (version 5010) • NCPDP 5. Eligibility and Enrollment Management EE02 Enroll Member NA 1 Section: Page: ELG006 Provide the capability to view member CBIC information via the web-based application.8 1 Section: Page: . or Web Portal.4. capture. fax. MC1.8 3 Section: Page: ELG019 Accept and capture traditional and nontraditional provider enrollment information. and distribute scheduled client eligibility maintenance and discrepancy reports (e. Eligibility and Enrollment Management EE04 Inquire Member Eligibility NA 1 Section: Page: ELG017 Establish and maintain a process to allow pharmacies to verify member eligibility during call center hours. presumptive eligibility and death reports).

Management listed in Abuse Registries. partners. or Web Portal. EE05 Determine Provider Eligibility PR2. Part 504. Enrollment application information requirements are dependent upon the category of service (COS) for which the provider is enrolling.11. Eligibility and Enrollment Management EE05 Determine Provider Eligibility NA 1 Section: Page: ELG023 Accept ETIN applications via hard copy. and JPG). EE05 Determine Provider Eligibility PR1. affiliates and Eligibility and Enrollment subcontractors for sanctions..7 1 Section: Page: ELG036 Schedule. and completeness.5. Web-based application must have the ability to pend enrollments for State review based on criteria defined by the State. WA2. Eligibility and Enrollment Management EE05 Determine Provider Eligibility PR1. Microsoft Word. Eligibility and Enrollment Management EE05 Determine Provider Eligibility PR2. and maintain an appeals process for provider enrollment rejections. and the Web Portal.11 1 Section: Page: ELG025 Provide the ability to obtain and to process provider fingerprints.g. BE1. Vendors should describe within their response how they propose to complete provider re-certification operations for all Medicaid participating providers by July. PR1. Eligibility and Enrollment Management EE05 Determine Provider Eligibility NA 3 Section: Page: Eligibility and Enrollment Management EE06 Enroll Provider PR1. Eligibility and Enrollment Management EE05 Determine Provider Eligibility MC1.8 1 Section: Page: ELG021 Edit enrollment application information based on Department business rules for data presence. pursuant to 18NYCRR. Eligibility and Enrollment Management EE05 Determine Provider Eligibility WA2.ELG020 Provide the capability for User to enter enrollment application information and upload supporting materials in industry standard formats (including. review and process: • Hard copy provider enrollment applications and supporting documentation • Hard copy and fax disenrollment requests • Hard copy and fax maintenance requests Incomplete applications must be returned to the submitter without further processing.5. Eligibility and Enrollment Management EE05 Determine Provider Eligibility NA 1 Section: Page: ELG024 Allow Web Portal users to register online for access to the secure areas of the portal based on security rules defined Eligibility and Enrollment Management EE05 Determine Provider Eligibility BE1. approval. pending status. and Eligibility and Enrollment changes to program participation eligibility effective dates in accordance with and State guidelines and federal guidelines Management contained in CFR 431.2 1 Section: Page: ELG033 Ensure all provider information is available in the Provider registry upon completed enrollment. . Eligibility and Enrollment Management EE05 Determine Provider Eligibility NA 2 Section: Page: ELG028 Accept and capture provider recertification applications and supporting materials via hard copy.105.10. terminations.2 3 Section: Page: ELG031 Track each provider enrollment application through all the steps in the enrollment process. application rejections. validity. Eligibility and Enrollment Management EE05 Determine Provider Eligibility PR1. affiliation with individuals debarred by State or Federal Agencies. It is the Department's intent to launch the provider re-certification process as soon as possible after contract signing.g. fax. administer and complete recertification in conjunction with Medicare recertification (within 12 months of Medicare) in order to minimize duplicative credentialing and site visits. provider maintenance and provider termination activity.3 1 Section: Page: ELG034 Produce monthly statistical reports which outline provider enrollment.5 2 Section: Page: ELG027 Conduct background checks and third party validation on all information submitted by providers to identify any disqualifying events. inter-field relationships. Generate automated letters and/or electronic notifications to providers based on the status of the application for enrollment (e.2 1 Section: Page: ELG022 Provide notice to the user via the Web Portal upon submission and require that they accept the terms and conditions established by the Department and record information related to that acceptance as required by the Department.3 3 Section: Page: ELG030 Enable State access to web-based application to approve and deny enrollments as well as process specific enrollment terminations (e. Web-based application must have the flexibility to change the pend criteria as directed by the State. directors. Eligibility and Enrollment Management EE05 Determine Provider Eligibility BE1. PR1. or rejection of their applications).2. but not necessarily limited to.3. 2015.9 1 Section: Page: ELG032 Maintain all information related to approved and denied applications for a period specified by the Department. managing employees.2 1 Section: Page: ELG035 Support. PR1.7(a) and OMIG terminations). ownership and ownership exclusions are to be screened as directed under PPACA). criminal background and fingerprinting for higher risk providers as defined by CMS and the Department. agents. PR2. Terms and conditions must be available for user review. exclusions.2. document. Eligibility and Enrollment Management EE05 Determine Provider Eligibility NA 2 Section: Page: ELG026 Conduct background checks on providers’ owners. manage. Eligibility and Enrollment Management EE05 Determine Provider Eligibility PR1. Eligibility and Enrollment Management EE05 Determine Provider Eligibility NA 1 Section: Page: ELG029 Conduct provider enrollment/screening in compliance with the Patient Protection and Affordable Care Act (PPACA) rules Eligibility and Enrollment and regulations (e.2 1 Section: Page: ELG037 Receive. officers. or otherwise unqualified to provide service. fax. Errors returned must be clearly identified to facilitate correction by the user. Management EE05 Determine Provider Eligibility WA2. terminations.g. PR1. PDF. denials.

ELG038 Perform pre-enrollment credentialing and screening activities for Title XIX pursuant to State and federal requirements found at 42 CFR. or Web Portal. Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG040 Electronically associate enrollment applications and all supporting materials (including any supporting materials not received with the original application). Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG047 Process provider enrollment and contracting which supports multiple provider enrollment “roles”. Eligibility and Enrollment Management EE07 Disenroll Provider NA 1 Section: Page: ELG054 Inactivate or suspend all providers not responding to recertification or relicensure requirements in accordance with guidelines from the Department. Mail-order non-NYS resident pharmacies registered in New York may be enrolled Management to process claims as secondary when such enrollment is certified by EPIC (see Section 249 of the NYS Elder Law). provider maintenance and provider termination activity. and the Web Portal. Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG045 Create alerts/extracts for Health Home user accounts communicating changes in member Medicaid eligibility or Manage Care enrollment Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG046 Provide the capability to mass enroll Managed Care network providers based on files received from Managed Care Plans or other sources as designated by the Department.g.2 3 Section: Page: ELG039 Image.6 1 Section: Page: ELG057 Provide the capability through the web-based application to retrieve and batch individual provider enrollment files (including the enrollment application. edit and verify hard copy or fax enrollment applications and supporting materials received as directed by Department. Eligibility and Enrollment Management EE07 Disenroll Provider NA 1 Section: Page: ELG056 Provide the capability for portal users to inquire through the provider area of the Web Portal on the status of transactions submitted for processing. application rejections. save and delete EFT applications entered prior to submission. Providing pharmacy providers written notification. including but not limited to: • FFS provider • Billing • Service Bureau/Biller • Rendering • Limited Pay • Primary Care Provider • Managed Care Organization • Health Home • Client as a payee • In-home caregivers Eligibility and Enrollment Management EE06 Enroll Provider ME2. EE06 Enroll Provider NA 1 Section: Page: ELG049 Receive and process pharmacy provider enrollment forms and signed agreements. Eligibility and Enrollment Management EE08 Inquire Provider Information NA 1 Section: Page: . notifying pharmacy providers of Eligibility and Enrollment enrollment determinations. along with the capability to review and/or print applications prior to and after submission. Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG041 Accept and process Electronic Funds Transfer (EFT) applications via hard copy. EE06 Enroll Provider NA 1 Section: Page: ELG050 Produce monthly statistical reports which outline provider enrollment. stating reasons for denial and outlining rights to appeal. Section 455 as well as 18NYCRR. fax. Eligibility and Enrollment Management EE07 Disenroll Provider NA 1 Section: Page: ELG052 Provide the capability to review and process disenrollment requests received from a provider for selected or all enrolled Categories of Service (COS) via the web-based application. Parts 502 and 504. Eligibility and Enrollment Management EE08 Inquire Provider Information PM2. PDF) accessible. Provider relations shall be required by the contractor to educate participating providers on the NYPS as needed. Optimal Character Recognition (OCR) and/or data enter. Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG044 Allow online Health Homes enrollment and disenrollment. Eligibility and Enrollment Management EE06 Enroll Provider WA2. Eligibility and Enrollment Management EE07 Disenroll Provider NA 1 Section: Page: ELG053 Terminate providers based on information received from external agencies and Department defined rules. Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG042 Provide the capability through the Web Portal to modify. Eligibility and Enrollment Management EE07 Disenroll Provider NA 1 Section: Page: ELG055 Track each provider disenrollment request through all the steps in the disenrollment process. of determinations to deny Management enrollment. Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG043 Be responsible for the pharmacy enrollment function of NYPS. per EPIC policy. as required by the Department. Eligibility and Enrollment Management EE06 Enroll Provider NA 1 Section: Page: ELG051 Accept and capture providers' disenrollment requests and supporting materials via hard copy. fax. all supporting materials and correspondence) in an industry standard file format (e.3 1 Section: Page: ELG048 Enroll pharmacies registered in a contiguous state when such enrollment is certified as necessary by EPIC (see Section Eligibility and Enrollment 253 of Title 3 of the NYS Elder Law).

TP2. amount.6 1 Section: Page: FIN010 Identify claims with trauma diagnosis codes.7. including but not limited to: • Third Party Recovery (TPR) • Fraud and abuse recoveries • Provider payments Financial Management FM02 Manage TPL Recovery TP2. • Preparation of retroactive reports (reverse crossover) to Medicare Part B or the provider. Financial Management FM02 Manage TPL Recovery NA 1 Section: Page: FIN009 Generate automated TPL billing information to providers for members with third party coverage.14. TP2. TP2. possible need for individual consideration. court orders.4 1 Section: Page: FIN011 Monitor TPL third party avoidance and collections per State Plan.3 1 Section: Page: FIN012 Provide the capability to process files in Department specified proprietary formats as special inputs for adjustments and voids to claims identified by the Third Party contractor. Provide the ability to produce TPL data and cost avoidance reporting as required by federal and State rules and regulations.15. Financial Management FM02 Manage TPL Recovery TP2. Financial Management FM01 Manage Provider Recoupment CA2.8. negative claim balances) • Payment history (e. Contractor must either confirm accuracy of plan discrepant Financial Management amount or calculate a revised discrepant amount. as appropriate.3 1 Section: Page: FIN005 Provide the capability via the web-based application to process funds received transactions that may create history only voids/adjustments for payments sent in by a provider to refund amounts for claims. stakeholders.10. audit trail of payment source. audits. for all claims paid by Medicaid that should have been paid by Medicare part B. negative retroactive rate adjustments.g. TP2. Financial Management FM02 Manage TPL Recovery PM2..2. Financial Management FM02 Manage TPL Recovery TP1. Eligibility and Enrollment Management EE08 Inquire Provider Information PM4. FM08 Prepare Member Premium NA Invoice 1 Section: Page: FIN007 Verify billed amounts are within reasonable and acceptable limits or if it differs from the allowable fee schedule amount by more than a certain percentage (either above or below)..9 1 Section: Page: FIN001 Support maximum cost avoidance and reimbursement for Medicaid members through: • Designation of claim amounts collected to reimburse CMS and the State with any remainder paid to the member. and date) • Current recoupment balance due • Recoupment balance paid Financial Management FM01 Manage Provider Recoupment NA 1 Section: Page: FIN003 Provide the capability to process payments sent in by a provider to refund amounts for claims that should not have been paid and create void/adjustment claims without affecting provider payment. TP2.4 1 Section: Page: . Financial Management FM01 Manage Provider Recoupment NA 1 Section: Page: FIN004 Accept and process files from the Department's Financial Management Group (FMG) to establish recoupment accounts receivable as specified by the Department. Financial Management FM01 Manage Provider Recoupment NA 2 Section: Page: Financial Management FM01 Manage Provider Recoupment FI4.ELG058 Respond to requests for provider enrollment status and other provider information from providers. identify and resolve premium payment discrepancies. • Identification of members for referral to the Lock-in program • Accumulating claims up to a specified threshold amount and seeking TPL recovery when the threshold is reached • Seeking recovery of claims previously paid when TPL coverage is identified by billing the third parties using the X12N 837 Coordination of Benefits transaction or a proprietary format • Automatically re-billing insurance companies if a response (payment or denial) is not received within NYS guidelines • Supporting recovery from an estate or designated trust • Screening verified TPL resources against paid claims history retroactively for three years to identify recoverable funds Financial Management FM01 Manage Provider Recoupment TP2. TP2. TP2.13. TP2.9 1 Section: Page: FIN002 Maintain all data required to support recoupments. or business associates via the provider area of the Web Portal and the Customer Service Center. FIN006 Review. tax liens. then the claim is flagged and routed for manual review for: ? Possible incorrect procedure ? Possible incorrect billed amount When too high.16 1 Section: Page: FIN008 Provide efficient and timely identification of Third Party Liability (TPL) information from all sources and initiate follow up for purpose of maintaining most up to date TPL information.11. including the following: • Recoupment amount • Recoupment payment schedule or percentage • Reason for recoupment (e. Financial Management FM02 Manage TPL Recovery NA 1 Section: Page: FIN013 Track and associate to individual claims all financial transactions by source. accident codes and indicators and routes verification against TPL coverage.g.

but not limited to.10 1 Section: Page: FIN030 Maintain Accounts Receivables information. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN024 Review and take appropriate action on notices received through the Workflow Management System regarding accounts receivable balances. as follows: • Period of time covered • NDC number • Total units paid • Product names • Number of prescriptions paid • Rebate amount per unit based on the CMS approved formula Financial Management FM04 Manage Drug Rebate POS6. containing each account the beginning balance. Financial Management FM06 Manage Accounts Receivable Information FI2. law. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN018 Manage accounts receivable and collection activities as directed by the Department. Financial Management FM06 Manage Accounts Receivable Information PM3. Financial Management FM06 Manage Accounts Receivable Information ME3. pending credit. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN028 Conform to Generally Accepted Accounting Principles (GAAP) and to the State of New York and federal policy. PM2.10 1 Section: Page: FIN025 Provide capability to support premium collection inquiries and produce premium collection reports. prepare extracts of pharmacy claims history required by drug manufacturer rebate process.12 1 Section: Page: FIN031 Maintain garnishments and tax levies and assignment information to be used in directing or splitting payments to the provider and garnishor.14 1 Section: Page: FIN023 Image and index recoupment payments and associated documents (including correspondence) received from providers. Financial Management FM06 Manage Accounts Receivable Information TP2. Financial Management FM06 Manage Accounts Receivable Information FI2. report weekly as directed by the Department. and Provider level. including the handling of and accounting for liens. ME3. weekly.13 1 Section: Page: FIN033 Maintain lien information for recoupments. FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN020 Establish accounts receivable balances at the Taxpayer.. Financial Management FM06 Manage Accounts Receivable Information FI3. and totals. or other time period payments.FIN014 At request of the Drug Rebate/Pharmacy Pricing Administrator.9 1 Section: Page: FIN016 Monitor payment processes and perform analysis which: • Identifies payments by type such as. Financial Management FM04 Manage Drug Rebate NA 3 Section: Page: Financial Management FM06 Manage Accounts Receivable Information PM2.5 1 Section: Page: . Financial Management FM06 Manage Accounts Receivable Information PM2. and Financial Management regulation. FIN017 Process accounts payable transactions to resolve outstanding credit balances as required by the Department.4 1 Section: Page: FIN026 Withhold the federal share of payments to Medicaid providers to recover Medicare overpayments. activity for the period.2 1 Section: Page: FIN032 Maintain capability to identify providers with accounts receivable balances and no claim activity by program during a Department-specified number of months.2 3 Section: Page: FIN015 Maintain current NCPDP standards. Financial Management FM06 Manage Accounts Receivable Information PM2. Entity. FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN029 Maintain an accounts detail and summary section. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN021 Establish accounts receivable balances via the web-based application including but not limited to: • Recoupment amount • Recoupment payment schedule or percentage • Reason for recoupment Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN022 Generate automated letters and/or electronic notifications to providers when a credit balance or accounts receivable has been established. ending balance.9 1 Section: Page: FIN027 Identify payer issues and develop and implement action plans to improve collections. abortions and sterilizations • Monitors accumulated liability for deficit payments • Alerts administration when significant change occurs in daily.3. recoupments and emergency provider payments. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN019 Develop an Accounts Receivable Management Plan including the management of delinquent accounts for approval by the Financial Management Department.7. the recoupment schedule. Claims must include all NDC and other data needed to support the rebate process. Financial Management FM06 Manage Accounts Receivable Information FI3.

Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN054 Provide the capability to log. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN041 Provide the capability to search. dispute resolution agreements received.g. negative retro rate adjustments. FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN045 Apply payments received to accounts receivable balances. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN053 Provide the capability to maintain the final dispute resolution agreement on unit quantity amounts. electronically associate checks received and reconcile those payments by TCN/Claim Financial Management line.10 1 Section: Page: FIN051 Maintain a process to calculate and apply interest (simple and compound) to accounts receivable balances based on Department business rules.5 1 Section: Page: FIN042 Provide the capability to reconcile accounts with the designated Financial Institution based on the exchange of files. FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN040 Allow providers to view accounts receivable information through the provider area of the Web Portal. all supporting materials and correspondence) in an industry standard file Financial Management format (e. audits. FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN048 Provide the capability to retrieve and review claims included on the invoice for the NDC/HCPCS/UPN code being disputed via the web-based application based on Department rules. PDF). Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN046 Provide the capability to automatically balance quarterly invoicing and payments.10 1 Section: Page: FIN036 Collect principal and interest owed by providers on accounts receivable as directed by the Department. Financial Management FM06 Manage Accounts Receivable Information ME3. image. tax liens. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN052 Provide the capability to analyze utilization data to assist in the dispute resolution process. negative claim balances) • Payment history • Current recoupment balance due • Recoupment balance paid • Recoupment write-off Financial Management FM06 Manage Accounts Receivable Information PM3. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN044 Provide the capability to log. inquire on and update all information related to recoupments via the web-based application including but not limited to: • Recoupment amount • Recoupment payment schedule or percentage • Reason for recoupment (e. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: . image. PM2.. FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN039 Calculate simple or compound interest with different interest rates based on Department business rules with the flexibility Financial Management to waive interest on a case by case basis. provides Financial Management reporting to Department on same. quarterly. payment information.g. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN037 Track dispute resolution contacts including but not limited to: • Pharmacies • Other billing providers Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN038 Log receipt data of each withholding or penalty request including the completion date of withholding or penalty. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN050 Provide the capability to automatically generate notices regarding accounts receivable balances based on Department business rules taking into account dispute status. court orders. as required. manage and report on accounts receivable activity as directed by the Department. and on request to the Department in aggregate and/or on individual accounts.FIN034 Monitor. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN055 Provide the capability to track dispute resolution contacts including: pharmacies and other billing providers. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN049 Provide the capability to enter information related to the write-off of accounts receivable via the web-based application. Financial Management FM06 Manage Accounts Receivable Information PM2.1. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN043 Provide the capability to receive EFT for accounts receivable and reconcile those payments to accounts receivable by TCN/Claim line. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN035 Report monthly. electronically associate. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN047 Provide the capability through the web-based application to retrieve and batch accounts receivable information (including the original invoice.

Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN064 Process Cash Advance transactions that support and monitor the generation of both an accounts payable and accounts receivable transaction for the payment to be recouped as required by the Department.3 2 Section: Page: FIN058 Provide the capability on recoupment transactions to set the percentage to recoup each payment cycle or use the system defaults via the web-based application. collection and accounting for enrollment fees and enrollment fee refunds.FIN056 Provide dashboard reporting for monitoring. Financial Management FM07 Manage Accounts Receivable Funds FI3. FI3. process and track payments received from providers for outstanding accounts receivable balances. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN069 Provide the capability to enter payment information received including but not limited to payment amount. Provide the ability. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN068 Provide the capability to electronically associate payments and other documents with the appropriate recoupment.12 1 Section: Page: FIN066 Provide the capability to accept and process provider payments based on Department business rules. FM07 Manage Accounts Receivable Funds FI3. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN057 Provide the capability to process accounts receivable transactions including but not limited to: • Negative claim adjustments/voids • Negative retroactive adjustments • Recoupment transactions as required by the Department Financial Management FM06 Manage Accounts Receivable Information TP2. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN065 Provide support for identification and application of recovery funds and lump-sum payments. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN074 Support and monitor the production of stop payment orders for checks that have not cleared within a period established by Financial Management the Department.8 1 Section: Page: FIN063 Process Lump Sum Payment transaction for payments to a provider that are not related to a specific claim as required by the Department. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN067 Provide the capability to image and index recoupment payments and associated documents (including correspondence) received from providers. check information. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN070 Provide the capability to enter and maintain text notes associated with recoupment payments via the web-based application.9 1 Section: Page: FIN075 Assign a unique control number to each recoupment and payment. log. subject to audit or recovery down to the line detail level. FI4. Financial Management FM06 Manage Accounts Receivable Information NA 2 Section: Page: FIN060 Provide the capability to create and execute financial transactions via the web-based application based on Department business rules including but not limited to: • Recoupment (including setting the percentage to recoup) • Funds Received • Lump Sum Payment • Cash Advance Financial Management FM07 Manage Accounts Receivable Funds FI4. & Offset Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN062 Process funds received transactions that may create history only voids/adjustments for payments sent in by a provider to refund amounts for claims as required by the Department. repayments. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN071 Ensure that returned or refund checks received by the contractor are logged each business day with tracking information including but not limited to: • Disposition • Date and time • The identity of the contractor staff that processed the check Financial Management FM07 Manage Accounts Receivable Funds FI2. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN073 Support and monitor the production of letters to providers for checks that have not cleared within a period established by the Department.12. in the System. tracking and reporting on dispute resolution activity. and previously. to identify claims currently.8 1 Section: Page: FIN072 Receive. Financial Management FM06 Manage Accounts Receivable Information NA 1 Section: Page: FIN059 Complete EPIC billing.8.1 1 Section: Page: FIN061 Process accounts receivable transactions as required by the Department including but not limited to: • Negative claim adjustments/voids • Negative retroactive adjustments • Recoupment transactions • Advancements. FM07 Manage Accounts Receivable Funds NA 1 Section: Page: Financial Management . and date received. Financial Management FM07 Manage Accounts Receivable Funds FI3.

and premium payment transactions monthly for each member enrolled in MCOs on the first of the month automatically. Identifying the monthly premium amount for the applicable Part D plan. copayments. Identify and track errors Financial Management or discrepancies between NYS and Federal Buy-In member information.2 Invoice 1 Section: Page: FIN080 Provide the capability to process member cost sharing (e. The system must be capable of locking a few select members to specific pharmacies as identified by the State. Financial Management FM10 Manage Member Financial BE5. Financial Management FM10 Manage Member Financial NA Participation 1 Section: Page: FIN087 Identify members who are enrolled in Medicare Part D. Identifying EPIC seniors and their corresponding Medicare Part D plan coverage dates (retroactive payments may be necessary).g. but no more than the low-income benchmark amount established by CMS. BE2.9 . iv. during claims payment. the current monthly payment amount may include adjustments (credits/payments) for prior months for the member based on retroactive EPIC or Part D plan enrollment dates or LIS effective/terminated dates. FIN083 Maintain all records and reports of administrative expenses and supply information necessary to claim Federal Financial Participation (FFP) on the contractor fees at the appropriate rate. and Buy-In payments received. In addition. BE5. maintain. MC2. This file must contain distinct summary records of monthly Medicare Buy-In debits and credits obtained from CMS. Determining if EPIC member is eligible to have premiums paid based on their incomes. (Payment for a health home claim is based on the base rate for the Health Home provider multiplied by the acuity score for the recipient) Financial Management FM10 Manage Member Financial NA Participation 1 Section: Page: FIN090 Monitor published pricing sources to identify market fluctuations and then accurately apply necessary price changes at the Financial Management NDC level.8 Invoice 1 Section: Page: FIN081 Track Medicare deductibles and coinsurance paid by Medicaid for all crossover claims. ME2. There must be systematic ability to override a denial. Financial Management FM07 Manage Accounts Receivable Funds FI3. ME3. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN079 Process premium. Determining whether low income subsidy exists for current month or past months for EPIC member. Processes change transactions to update Buy-In member information.FIN076 Apply claims payment amounts to outstanding accounts receivable balances based on the Department's business rules automatically. Track exceptions where outstanding account receivables have not been paid by eligible members Financial Management FM08 Prepare Member Premium BE5.4 Participation 1 Section: Page: FIN086 Produce and transmit a Medicare Buy-In Premium Billing file to the Department's FMG.3.7. Low Income Subsidy (LIS). vi. including sending messages to the pharmacy regarding the need to bill the other payer first. Calculating monthly amount owed by EPIC to the Medicare Part D plan for each member. dual eligible.8. and apply member cost sharing including but not limited to: • Patient liability amounts • Medicaid Co-Payments • Medicaid Premiums Financial Management FM10 Manage Member Financial BE2. Health Home enrollment and pay to information to ensure correct payment disbursement Financial Management FM10 Manage Member Financial NA Participation 1 Section: Page: FIN089 Support Health Home acuity score payment methodology. FM10 Manage Member Financial NA Participation 1 Section: Page: FIN091 Generate enrollment records. LTC patient liability) on any service specified by Financial Management the state using a fixed amount or percent of charges. Spend-down.2. Payments via EFT or check will be produced and reported on the X12 820 (5010 and future versions). Identifying monthly premium amount covered by CMS if low income subsidy is in effect.6. POS5. FM08 Prepare Member Premium CA4. Financial Management FM07 Manage Accounts Receivable Funds NA 1 Section: Page: FIN077 Apply payments received from providers to the outstanding accounts receivable balances based on the Department's business rules. iii. FM11 Manage Capitation Payment 3 Section: Page: Financial Management NA ME2. subsequent to any subsidy payment. If necessary. The contractor’s system must be capable of denying claims for those with other insurance.4.1 Participation 1 Section: Page: FIN088 Verify. Financial Management v.6 Participation 1 Section: Page: FIN085 Transmits member Buy-In information to and accepts Buy-In response information from CMS-specified Federal Medicare Beneficiary database(s). ii. capitation payments. per-member per-month (PMPM).. FM10 Manage Member Financial BE5. Financial Management FM09 Manage Contractor Payment FIN084 Calculate.5. the processing must include the ability to process the remaining balance to the Program after payment by a primary payer. by member and program type. BE5.5. FM08 Prepare Member Premium FI3.1 Invoice 1 Section: Page: FM08 Prepare Member Premium NA Invoice 2 Section: Page: 1 Section: Page: FIN082 Financial Management Calculate monthly EPIC payments including but not limited to: i. MC2. and other insurance programs if applicable for the purpose of cost avoiding their claims at the POS (EPIC is the payer of last resort).7 1 Section: Page: FIN078 Support multiple payment adjustments for a given provider including a prioritization of accounts receivables to satisfy outstanding balances and controls to prevent duplicate recoveries. ME2.6. Co-Pay.

Financial Management FM11 Manage Capitation Payment MC2.2.5. Cash Advance transactions must contain at a minimum preassigned shares percentages.10 Information 1 Section: Page: FIN097 Maintain and make available to the Department such records and reports concerning the contractor internal administrative Financial Management process as is necessary to permit the Department to verify the validity and accuracy of all bills for service. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN105 Update claim history and financial files with the check number.. or are deceased from the monthly MCO capitation payment. and amount paid after the claims payment cycle. sex. MC2. and other. EFT number. Financial Management FM11 Manage Capitation Payment NA 1 Section: Page: FIN095 Maintain accounting information and complete audit trail including but not limited to: • Accounts payable information • Accounts receivable information • General ledger information Financial Management FM13 Manage Accounts Payable FI2.1 Information 1 Section: Page: FIN106 Transmit records of recoupment identifying the claim affected and amounts to the MDW. mass adjustment to rates according to State policy. a valid County Code and Category of Service.3 2 Section: Page: FIN094 Provide the capability to add premium. Financial Management FM13 Manage Accounts Payable FI2.5. MC2. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN108 Assign a general ledger code to every claim. health status. A Lump Sum Payment transaction must contain at a minimum the appropriate shares percentages. MC2. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: . bonus and incentive payments based on Department business rules. Exclude enrollees who have terminated enrollment.8 2 Section: Page: FIN093 Calculate PMPM capitation payment for the actual number of days of eligibility in a month (i.1. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN100 Support and monitor the process to generate a check to the provider when the payment received exceeds the accounts receivable balance. FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN098 Notify the Department of the following: • Payment cycle information as specified by the Department by 9:30 am on the first day following the cycle • Confirmation from the Comptroller’s Office that funds are in place for check and EFT release • Delays in the completion of the payment process by 8:00 am on the day following the scheduled completion day of the cycle • Immediately upon discovery of any erroneous payments. FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN107 Maintain lien information to be used in directing or splitting payments to the provider and lien holder. Provider Type and additional criteria required by the Department. General Ledger Codes are assigned based on Major Program Code. or other. a County Code. Provide capabilities to perform Financial Management "what-if" analysis for proposed recoupments.5. category of eligibility. MC2. warrant number. and for each member whose enrollment in a Managed Care Organization was retroactively modified or enrolls in another plan. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN104 Provide the capability to process Cash Advance transactions that generate both an accounts payable and accounts receivable transaction for the payment to be recouped. and a Category of Service. Claim Type. FM11 Manage Capitation Payment ME2. enrollee may not be enrolled for a full month) based on State-defined rate factors such as age. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN102 Provide the capability to process accounts payable transactions including but not limited to: • Claims • Adjustments/voids • Retroactive adjustments • Lump sum payments • Cash advance transactions as required by the Department Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN103 Provide the capability to process Lump Sum Payment transactions for payments to a provider that are not related to a specific claim. rate changes or other proposed payment or eligibility changes.5 Information 1 Section: Page: FIN096 Provide the capability to view and export all accounting information and complete audit trail via the web-based application including but not limited to: • Accounts payable information • Accounts receivable information • General ledger information Financial Management FM13 Manage Accounts Payable FI2. Financial Management geographic location.6.e. MC2. irrespective of cause Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN099 Provide the capability to transmit test EFT transactions to the designated Financial Institution and verify that the EFT transaction was processed in accordance with Department policies and procedures.FIN092 Automatically generate capitation payment adjustment and void transactions for reconciliation of errors or corrections. date of payment. FI3. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN101 Provide the capability to process accounts payable transactions to resolve outstanding credit balances as required by the Department. disenrolled.

Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN119 Manually pull and void provider check(s) and associated remittance advice(s) after printing at the Department’s request. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN115 Administer direct reimbursement to the American Indian Health Program (AIHP) providers and patients for deductibles and copays.FIN109 Provide the capability to view and update general ledger codes via the web-based application based on Major Program Code. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN121 With written notice from the State. pharmacy provider cycle claims for NYSP are within two days from claim adjudication. and payment effective dates. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN111 Reconcile accounts with the designated financial institution based on the exchange of files containing information related Financial Management to the status of checks and EFTs. The contractor must arrange to have manual checks delivered via expedited (twenty-four hour) delivery upon request by the State. the contractor shall develop and submit to NYS for review and approval a Disbursement Reporting Plan that shall include account information for all New York Medicaid Program related bank accounts. and pull/remove associated remittance advices at the Department's request. FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN112 Manage all aspects of the EFT process including the capability to reprocess failed EFTs. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN126 Upon initial establishment of State of New York Medicaid Program related bank accounts. FIN122 Exert controls and counts to prove that every check produced was actually mailed. FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN118 Provide the capability to generate a check to the provider when the payment received exceeds the accounts receivable balance based on Department business rules. in a human readable format. Financial Management FM14 Manage Accounts Payable FI3. and confirmation of NYS OSC and FMG access to such accounts. payment amounts. Provider Type and additional criteria required by the Department. NOTE: Special processing requests for manual checks are infrequent. and unrestricted access to the NYS OSC and FMG to all accounts established under the contract used to administer NYS payments to Medicaid providers incusing the ability to deposit and withdraw funds as necessary. uncleared checks. uninterrupted. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN128 Maintain all bank account established and administered under the contract as Zero Balance Accounts Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: . all supporting claim information pertaining to a payment including all raw claim data received through the claim transaction. reissued checks and payment errors and also perform monthly bank reconciliation and other money management tasks. and refunding excess member co-payments Financial Management FM14 Manage Accounts Payable BE2. reporting timeframes and for cleared payments and payment confirmation. account number. ownership.3 Disbursement 1 Section: Page: FIN113 Support and monitor the production of EFT/checks by provider and ETIN. An example would be a member request for a refund in an emergency situation.3 Disbursement 1 Section: Page: FIN117 Produce hard-copy checks for the payment cycle (for providers requesting that option) and maintain control of all hard Financial Management copy checks until distributed to providers. issue manual checks on an as-needed basis for any special payments as directed.5 Disbursement 3 Section: Page: FIN124 Provide the capability to view and export. Financial Management FM13 Manage Accounts Payable NA Information 1 Section: Page: FIN110 Process EFT reimbursements to providers for EFT returns. as submitted. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN116 Manage all aspects of the warrants process. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN120 Adjust (void) any claims associated with the payments (check or EFT) when the Department instructs the voiding of a check/EFT. stop payment orders. Pharmacy providers are reimbursed via EFT. Monitor security of checks during the matching. cleared checks. and process claim data. Claim Type. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN123 Facilitate and disburse payment of pharmacy provider claims. multiple provider specific reimbursement rates with begin and end dates. financial institution. stuffing and mailing process. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN127 Provide full. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN125 Enable State access to web-based application to provider data to support oversight of financial management pre-payment and post payment review functions. Provider data shall include but is not limited to National Provider Identifier (NPI). Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN114 Remove EFT payments from the banking file prepared for EFT transfers. Financial Management FM14 Manage Accounts Payable FI3.

Lump Sum.2 1 Section: Page: FIN144 Verify all banking transactions via online bank access to ensure timeliness and accuracy of the transaction. FM15 Manage 1099 FI2. family planning. add and update date specific shares funding (Federal. PM1.4. FI2. This may include involvement of the MAS Contractor / fiscal agent’s quality assurance staff to review payment amounts. and issuance of special forms such as “B” notices to providers for purposes of correcting Financial Management mismatched employer identification numbers. Financial Management FM15 Manage 1099 NA 1 Section: Page: FIN139 Track all requests for replacement or corrected 1099s. FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN132 Generate Medicaid transportation payment transactions to providers monthly for the costs of the dispensed MetroCards. Financial Management FM15 Manage 1099 NA 1 Section: Page: FIN141 Maintain a cumulative pharmacy-specific accounting file after each payment cycle. check information. Financial Management FM18 Manage Fund NA 1 Section: Page: FIN149 Provide the capability to view. FM18 Manage Fund NA 1 Section: Page: FIN150 Provide the capability to assign weekly payment cycle funding information by various State agency appropriation pursuant to Department accounting rules. Financial Management FM18 Manage Fund FI2.7 1 Section: Page: FIN143 Collect and maintain the data necessary to support the budget neutrality reporting requirements as specified in the NYS’s 1115 Waiver. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN131 Generate Medicaid transportation payment transactions (EFT and paper check) to individual members for travel expenses Financial Management incurred. Provide tax data following each pharmacy-specific accounting file after each payment cycle for IRS reporting purposes. and long term care) as required by the Department via the web-based application.5. FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN133 Maintain full responsibility for all federal form 1099 processing. with approval from the Department. Financial Management FM15 Manage 1099 NA 1 Section: Page: FIN137 Generate 1099 forms for the AIHP Financial Management FM15 Manage 1099 NA 1 Section: Page: FIN138 Respond to and resolve all 1099 inquiries and issues regarding correct reporting of tax information based on the federal 1099 and NYS policies (including incorrect FEINs). Financial Management FM18 Manage Fund NA 1 Section: Page: FIN148 Provide files and reports with information necessary to compute the weekly funding as required by the Department.4 1 Section: Page: FIN134 Produce and mail hard copy 1099 forms to providers as specified by the Department. FI2. sterilization. charge indicator. NYS Department of Taxation and Finance. and other entities specified by the Department. MC8. FM18 Manage Fund NA 1 Section: Page: Financial Management Financial Management .3. Financial Management FM18 Manage Fund NA 1 Section: Page: FIN145 Accept any responsibilities for overdraft penalties on checking accounts including but not limited to: • Depository • Disbursing • Special payment Financial Management FM18 Manage Fund NA 1 Section: Page: FIN146 Maintain sufficient controls to track each financial transaction (e. Financial Management FM14 Manage Accounts Payable NA Disbursement 1 Section: Page: FIN130 Provide separate banking services and fiscal accountability for facilitating NYS Medicaid transportation payment. and maintain appropriate audit trails on the claim and payment history files.g. Financial Management FM17 Manage Budget Information MC8. etc. State and Local Governmental Unit) Financial Management information based on member aid category. including the ability to distinguish the “1115 expansion eligibles” from other groups of Medicaid-eligibles and identify who would be ineligible for Medicaid in the absence of the 1115 Waiver. or contractor review.FIN129 Allow access to OSC and support random sampling reviews of manual checks and EFT transaction. PM1.3. Financial Management FM15 Manage 1099 NA 1 Section: Page: FIN136 Produce replacement / corrected 1099s based on provider request. submission of data to federal and State tax authorities.1.3. PM1.6. Financial Management FM15 Manage 1099 NA 3 Section: Page: FIN142 Provide capability to support the production of information and or reports to support the preparation of budget allocations Financial Management by fiscal years FM17 Manage Budget Information PM1. balance batches. Financial Management FM15 Manage 1099 NA 1 Section: Page: FIN140 Update the status of entities exempt from the 1099 reporting process.). State. services indicator (e. including issuance to providers. Advance Payments. abortion.g.5 1 Section: Page: FIN147 Generate a Financial Control Number (FCN) for every approved fiscal transaction. and date received. Financial Management FM15 Manage 1099 NA 1 Section: Page: FIN135 Produce and distribute 1099 files to the Internal Revenue Service (IRS). PM1.

decide whether further Financial Management research and analysis is required before correction of the problem. recoveries and adjustments.1 1 Section: Page: FIN156 Provide State access to all financial information such as. outstanding amounts and adjustment amounts and perform analysis of timely reimbursement. whether the inappropriate payment represents an incorrect payment. and establish a correction date. and transportation managers. name. and distribute Medicaid transportation expense reports including but not limited to recipient ID. Financial Management address. PM5 1 Section: Page: FIN159 Produce basic NYPS management reports. FM19 Generate Financial Report NA 1 Section: Page: FIN164 Develop. produce.15 1 Section: Page: FIN153 Provide any fiscal agent operations support necessary for the MDW to complete CMS37 and CMS64 reporting. date of service.g.5 1 Section: Page: FIN157 Perform analysis of billing habits and TPL payments to determine and propose where program cost reductions might be achieved. by eligibility group. enrollment. Financial Management FM19 Generate Financial Report MC4.6 1 Section: Page: FIN163 Provide a monthly report listing all contractor or State identified inappropriate payments. processing of payments. rate cell. Financial Management FM19 Generate Financial Report NA 2 Section: Page: FIN154 Matches capitation summary data and FFS claims data to verify that the MCO payments do not exceed FFS upper limits. Financial Management FM19 Generate Financial Report PM2. Financial Management FM18 Manage Fund NA 1 Section: Page: FIN152 Maintain separate bank accounts for benefits programs and special payments. these reports must be comparable to the reports found in the Procurement Library. and an estimate of the dollar amount of any incorrect payment. FM18 Manage Fund POS2.6 1 Section: Page: FIN162 Provide program reporting on provider participation and fiscal activities including but not limited to: • Payments • Services • Types of services • Member eligibility categories Financial Management FM19 Generate Financial Report PM3. Transfer special payment account funds to the Department designated bank account at the direction of the Department. for claims made by PTAR facilities.7 1 Section: Page: FIN155 Generate reports of capitation payment with flexibility to sort/filter for various categories (e. FM19 Generate Financial Report NA 1 Section: Page: . Any interest earned on this account shall accrue to the Department. but not limited to.). etc. Financial Management FM19 Generate Financial Report PM2. and paid amount. FM19 Generate Financial Report PM1.1. Financial Management FM19 Generate Financial Report MC6. At a minimum. approve the plan for correction. units used. paid amounts. for NYPS. Reconcile Financial Management accounts with the designated Financial Institution based on the exchange of files containing information related to the status of checks and EFTs . costs. Ad-hoc reporting requests may be made from time to time. Reimbursement from accounts shall be under the direction of the Department.8 1 Section: Page: FIN158 Produce financial and program analysis reports as required by the Department using the Commercial Off-the-Shelf Financial Management (COTS) reporting tool. The Contract Administrator shall review the report. MMTPs. and reconciliations. addressing utilization. Financial Management FM19 Generate Financial Report NA 1 Section: Page: FIN161 Provide automated processes for performing periodic bank account or fund allocation reconciliations to include management of bank accounts. Financial Management FM19 Generate Financial Report FI2.FIN151 Provide the capability via the web-based application to view and update a Public Goods Pool file which contains percentages and fixed dollar amounts used to calculate the Medicaid Program’s contribution to the Public Goods Pool. units approved. etc. Financial Management FM19 Generate Financial Report NA 1 Section: Page: FIN160 Generate NYPS reports of any rebate rate changes and/or utilization adjustments. The reports must be produced for each quarter associated with the changes.. This report will describe the cause of the inappropriate payment.

e. reinstated eligible members and changes to existing member data. Upstate WMS. Co-Pay accumulated amount and Co-Pay met date • TPL information • Member Offender information • Restricted Transportation information • Service Utilization Limits/Thresholds • CBIC information • Early Intervention • Spend down information • MCO association Member Management ME01 Manage Member Information BE1. BE2. ME01 Manage Member Information BE1.5. • RRE Transaction files which contain member restriction. First Name. BE1. required to support transaction processing and reporting including but not limited to: • Minimum data set described by Part 11 of the State Medicaid Manual 11375 Data Requirements • Eligibility Information (Case. and HBE (when available) including but not limited to.6. Program and Effective Dates) including Managed Care and Scope of Benefits • Family Health Plus (FHP) • Restriction/ Exception/Exemption (RRE) • Principal Provider/Net Available Monthly Income (NAMI) • Prepaid Capitation Plan • Co-Pay Information including Co-Pay begin and end dates. and controls and accounts for transactions with errors.1 1 Section: Page: MEM003 Provide via the web-based application the capability to search online and retrieve member data based on member data fields and combinations of data fields including but not limited to: • Member ID • Social Security Number • Last Name. TP1. Member Management disease management. and HBE (when available) at least daily.3. ME1. Archive and maintain member data and update transactions Member Management ME01 Manage Member Information BE1.5.5 2 Section: Page: MEM006 Processes all transactions that update the member data set (as defined in ME001) and benefit assignments. BE1. Eligibility Category.9. ME1. ME1. age plus or minus five years • Gender • HBE account number Member Management ME01 Manage Member Information NA 1 Section: Page: MEM004 Accept and process updates of member eligibility information from NYC WMS. outcomes.Maintain current and historical information for all individuals eligible for medical benefits under Medicaid or other NYS medical assistance and public health programs (i. Member Management ME01 Manage Member Information BE1.2. Edit data received from eligibility systems for reasonableness. BE1. ME2.5. PM4. Cystic Fibrosis) as determined appropriate for such programs.1. special needs status for such programs as lock-in. in accordance with Department business rules. Demographics. BE1. These eligibility updates must include processing for New eligible members.5.1 2 Section: Page: MEM005 Accept and process files received from NYC WMS. Middle Initial • Case Number • Date of Birth (DOB). BE2. ME01 Manage Member Information BE1. exception and exemption data additions and updates • Principal Provider files which contain Principal Provider Information additions and updates • WMS PCP files which contains additions and updates to PCP data • Pay-In /Excess Bill transaction files Member Management ME01 Manage Member Information BE1.6.2. Eligibility information must be displayed both as eligibility segments and by the Member Management eligibility status that would be in effect on any given period. Upstate WMS. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM008 Maintain clinical.8.9 1 Section: Page: MEM001 .1. ME2.5 3 Section: Page: MEM002 Maintain eligibility information so that it represents a complete history of every eligibility period and can reflect retroactive coverage downgrades. utilization and other indicators of special population.3. American Indian Health Program. TP1. and high dollar case management files.2 2 Section: Page: MEM007 Maintain current and historical records of benefit assignment(s) for members. The overlapping stacked eligibility is a representation of the eligibility data which is stored on the WMS/Health Benefits Exchange (HBE) Database.

12 1 Section: Page: MEM022 Initialize member Co-Pay amounts annually. Member Management ME01 Manage Member Information BE2.14 2 Section: Page: MEM012 Develop and maintain cross-references files of health insurance carriers to employers. These are individuals who have been in an OMH/OMR facility for a period of five years or more and have subsequently been Member Management enrolled in Medicaid. Generate and maintain an audit trail of all updates to the member insurance data. The processing must include applying corrective actions and establishing the relationship between the original and current member IDs.12.13.1 1 Section: Page: MEM015 Collect and manage member information necessary to produce all utilization reports for monitoring cost neutrality of waiver services to a target population. inquire on and update member data Member Management ME01 Manage Member Information BE1.13.1 2 Section: Page: MEM017 Accept and process the "member 621 eligible" file from the Department and apply updates to the Member registry.MEM009 Maintain utilization threshold information for each member in each category including but not limited to: • Member's benefit year begin and end dates • Override limit and effective date • Actual use units.8. the reconciliation process must compare member data from the contractor's application with the WMS/HIX systems member data and identify discrepancies.15 1 Section: Page: MEM013 Maintain and provide the capability to review through the web-based application casualty-related information (e. Member Management ME01 Manage Member Information WA5. motor Member Management vehicle accident and workers’ compensation information). TP1.9 2 Section: Page: .4 1 Section: Page: MEM010 Profile all services provided to a member during a single episode of care.5 1 Section: Page: MEM018 Accept and process the member offender file from the Department of Criminal Justice Services (DCJS). TP1. including those updates that were not applied due to errors. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM025 Accept and process data reconciliation files at least quarterly from the WMS/HBE systems (NYC and Upstate). ME1.2 1 Section: Page: MEM014 Collect and manage member information necessary to produce all reports to facilitate cost reporting and financial monitoring of waiver programs.5 1 Section: Page: MEM023 Identify members who have reached their annual Co-Pay limit or who are exempt from Co-Pays. ME01 Manage Member Information BE1.2 1 Section: Page: MEM016 Produce and transmit files to the Third Party Contractor (TPC) responsible for TPL recovery at a frequency specified by the Department with information including but not limited to: • Case information • Member demographics • Member eligibility information Member Management ME01 Manage Member Information BE2.1.13.13 2 Section: Page: MEM021 Provide the capability via the web-based application to search. warning date and status • Overuse date • Status Member Management ME01 Manage Member Information BE2. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM024 Initialize service utilization limits for each member within general service categories specified by the Department including but not limited to: Physician.13. PI2. ME1.6 1 Section: Page: MEM020 Maintain a process that automatically identifies members who are suspected of having multiple member IDs for further processing at a frequency specified by the Department. Member Management ME01 Manage Member Information BE1.2. ME01 Manage Member Information TP1. Laboratory. Pharmacy.7 1 Section: Page: MEM011 Maintain and update current TPL information. Member Management ME01 Manage Member Information BE1. ME1. PI2. ME01 Manage Member Information NA 1 Section: Page: MEM019 Accept and process the Multiple ID file received from WMS/HBE which contains resolution information on members with multiple member IDs. and Dental Clinic. Member Management ME01 Manage Member Information BE1. Medical Clinic. Mental Health Clinic. for a time period specified by the State. TP1. ME01 Manage Member Information ME1.6.g. Member Management ME01 Manage Member Information WA5. this file contains Member Management members who are restricted from receiving services from Medicaid.. Member Management ME01 Manage Member Information BE1. ME1. Reconciliation files to be received and processed include but are not limited to: • Member Eligibility • Restriction/Exception/Exemption • Principal Provider • Prepaid Capitation Plan (PCP) • Pay-In Member Management ME01 Manage Member Information NA 1 Section: Page: MEM026 Apply Managed Care enrollment/disenrollment information received through automated interfaces to the Member registry Member Management as defined by the Department. Member Management ME01 Manage Member Information BE1.

Specified Low Income Medicare Beneficiary (SLIMB) individuals and Qualifying Individuals 1 (QI-1) Member Management ME01 Manage Member Information BE5. Qualified Disabled Working Individual (QDWI). Part C and Part D) • Medicare coverage dates • Medicare Buy-In eligibility (Buy-In Part A and Buy-In Part B) • Medicare Buy-In coverage dates • Member Original Buy-In Program eligibility status • Transactions processed • Errors identified • Error correction status • Medicare premiums to be paid • Member Medicare Savings Program status for the following programs.5 3 Section: Page: MEM032 Accept and process the monthly TPL Contractor Resource Update Files which contain new records. and Part B information • Ensure that all Medicare eligibility information received via external interfaces is: • Associated with the most current active Member ID • Maintain integrity of Medicare eligibility information based on a hierarchy established by the Department (e. Buy In and Medicare Savings Program information.1. ME01 Manage Member Information NA 1 Section: Page: MEM030 Provide the capability via the web-based application to view.1. Qualified Medicare Beneficiary (QMB). modified or removed at a frequency specified by the Department. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM034 Process Medicare Information including but not limited to: • Identify potential errors with data exchange files and reject files pursuant to Department guidelines • Edit and post member Medicare eligibility information received from Department approved sources • Maintain separate data fields as necessary to distinguish Part A. change and delete Managed Care benefit plan information including but not limited to: • Managed Care benefit plan header information • Managed Care benefit plan coverage information • Managed Care benefit plan claim type information • Managed Care benefit plan referring and specialty provider information Member Management ME01 Manage Member Information NA 1 Section: Page: MEM031 Maintain member Medicare.g. TP1. add.1.MEM027 Maintain all current and historical information for all members enrolled in Managed Care including but not limited to: • Managed Care Prepaid Capitation Plan (Name and Provider Identification Number) • Managed Care Scope of Benefits (Coverage Information) • Prepaid Capitation Plan Code • Prepaid Capitation Plan Package Code • Member Prepaid Capitation Plan begin and end enrollment dates Member Management ME01 Manage Member Information MC1. TP1. including but not limited to: • Health Insurance Claim Number (HIC) • Medicare eligibility information (Part A. to assist contractor and Department staff in resolving discrepancies Member Management ME01 Manage Member Information NA 2 Section: Page: .11. Part B. ME01 Manage Member Information BE2. PM1. BE5.12 2 Section: Page: MEM033 Provide the capability to enter. inquire on and update Medicare and Managed Long Term Care information via the webbased application. additions and changes Member Management to existing Medicaid/Medicare records. inquire on. Railroad Retirement) • Maintain source identifiers of Medicare related information for Audit trail • Create views into source files. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM029 Produce and transmit a file to the WMS/HBE containing updates made to the Manage Care Scope of Benefits information Member Management at a frequency specified by the Department.8 2 Section: Page: MEM028 Produce and transmit a file for the Manage Care Broker of Manage Care members whose eligibility has been added.

Managed Long Term Care. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM040 Provide the capability to enter. PM4. and Medicare Savings Program information via the web-based application. credit. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM046 Process and maintain Medicare data from the MMA file including: • Medicare Part A and Part B: verify accuracy of current Medicare data and update data • Medicare Part C: using the MMA return data and the plan information create commercial insurance • Medicare Part D: must maintain member Medicare Part D information. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM044 Produce and transmit the Medicare Modernization Act (MMA) file to CMS on a schedule to be defined by the Department. Member Management ME01 Manage Member Information TP1.1.MEM035 Automatically perform Buy-In functions for Medicare Part A and Medicare Part B in accordance with CMS and Department specifications including but not limited to: • Identify potential errors with data exchange files and reject files pursuant to Department guidelines • Edit and post member Medicare Buy-In eligibility information received from Department approved sources • Support utilization of all CMS Buy-In transaction codes • Maintain source identifiers of Buy-In related information for Audit trail • Use alternate demographic information from CMS to override system member demographic data • Identify instances where the Member ID associated with the HIC/SSN on the CMS Billing File is not the most current eligible NYS Member ID • Provide a real time interface to enter exception records for inclusion in the daily CMS interface process • Post date of death according to Department rules • Process credit transactions in accordance with State and federal rules • Process Medicare Buy-In closings based on Department rules • Process Medicare Buy-In creations based on Department rules • Create views into source files.10 1 Section: Page: MEM043 Maintain and validate AIHP member enrollment based on data provided for member with each tribal nation.10. and action transactions for Parts A and B. including but not limited to: • Carrier Name • Carrier Plan Code • Enrollment period • Benefit Package • Low Income Subsidy (LIS) • Employer Retirement Drug Subsidy (must maintain member Employer Retirement Drug Subsidy status) Member Management ME01 Manage Member Information NA 2 Section: Page: MEM047 Obtain and process all Medicare Part C Advantage Plan and the Medicare Part D Prescription Plan information from CMS. Member Management ME01 Manage Member Information NA 2 Section: Page: MEM038 Accept and process the Buy-In CMS monthly billing file from CMS which includes debit. including but not limited to: • Contract ID • Plan Description Name • Plan Type Member Management ME01 Manage Member Information NA 1 Section: Page: . to assist contractor and Department staff in resolving discrepancies Member Management ME01 Manage Member Information NA 3 Section: Page: MEM036 Accept and process the daily Buy-In CMS response file that contains Buy-In maintenance transactions. inquire on and update Buy-In. date and reason for all changes • Maintain a complete transaction history • Maintain the complete State buy-in history for each member Member Management ME01 Manage Member Information NA 1 Section: Page: MEM042 Identify all current and prospective dual eligible members (dual eligible members are eligible for Medicare and Medicaid Member Management concurrently). TP1.10 1 Section: Page: MEM045 Accept and process the MMA response file received from CMS. This file represents the NYS dual eligible and prospective dual eligible population. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM041 Track and audit all transactions related to Buy-In including but not limited to: • Indicate the source and date of key identifiers from source files • Indicate the user ID. Member Management ME01 Manage Member Information NA 2 Section: Page: MEM037 Produce and transmit a daily TPL Buy-In Part A and a TPL Buy In Part B file for CMS which contains transactions that request CMS to enroll members on the Buy-In program or request changes to on-going member Buy-In information. ME01 Manage Member Information PM4. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM039 Accept and process the monthly SDX input file received from WMS/HBE which contains information about benefits received by Supplemental Security Income (SSI) applicants/members.

Member Management ME01 Manage Member Information NA 1 Section: Page: MEM050 Provide the capability via the web-based application to inquire on Medicare Part D and Medicare Part C Contract ID and Benefit Plan ID information. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM061 Provide the capability to update the member's Utilization Threshold information upon final adjudication of the claim Member Management ME01 Manage Member Information NA 1 Section: Page: MEM062 Provide the capability to update the member's Co-Pay information upon final adjudication of the claim based upon business rules defined by the Department including recording any Co-Pay amount credited by a void or adjustment. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM051 Provide the capability to inquire on Medicare Part D information via the web-based application.g. including but not limited to: • Source of TPL information (e. insurance company) • Policy Number • Policy Coverage dates • Group Number • Carrier Code • Policy Sequence Number • Policy Holder SSN • Policy Holder Last Name and Policy Holder First Name • Employer ID • Coverage Codes (Scope of Benefits) • Medicare Part C Indicator • Name of insurance company • Address of insurance company • Relationship to Medicaid Beneficiary • Services covered • Multiple resources under one Beneficiary • Group health plan participants • Health Insurance Premium Payment (HIPP) participant Member Management ME01 Manage Member Information TP1. Carrier data and Employer data for all applicable members. Verification data includes the ‘type of insurance coverage” for each policy (e. BE2.7 1 Section: Page: MEM056 Accept and process the Personal Injury Clearing House information file from OFT which contains information on members who have filed liability claims with insurance carriers in NYS. X12N 270 eligibility determination. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM054 Maintain all current and historical TPL Commercial Insurance information (Commercial and Medicare Part C).9 2 Section: Page: MEM055 Accept and process TPL contractor resource update files containing additions. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM052 Automatically terminate Medicare Part D entitlement when all Medicare eligibility has ended. Carrier data and Employer data via the web-based application.MEM048 Create and maintain registries with Medicare Part C Advantage Plan and the Medicare Part D Plan information that include Contract ID. physician. Member Management ME01 Manage Member Information NA 2 Section: Page: MEM053 Produce and transmit a file to WMS/HBE to support the generation of the "Reduction In Benefit" notification letter. Member Management ME01 Manage Member Information BE2. TP1. outpatient. insurance companies. and Benefit Plan. inpatient. A history of "Good Cause" eligibility spans must be maintained. inquire on. update and void Commercial Insurance information (Commercial and Medicare Part C).5. TP1. Carrier Name. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM049 Maintain crosswalk between Contract IDs. Member Management ME01 Manage Member Information BE2.12. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM058 Provide the capability to enter. TP1. Carrier Name and current Carrier Code for both Medicare Parts C and D Plan information. and attorneys verification data. closings and changes to commercial insurance information... dental). providers.8. member. and employers. Plan Type. pharmacy.1. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM059 Provide the capability via the web-based application to perform mass changes to Carrier data including but not limited to: • Voiding TPL data previously updated in error Member Management • Terminating carrier policy and coverage information • Creating policy information for new carrier based on existing carrier ME01 Manage Member Information NA 1 Section: Page: MEM060 Provide the capability via a web-based application to indicate "Good Cause" on individual member records in order to bypass health insurance on claims and exclude from recovery projects.g. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM057 Accept and process the SSI Referral file from SSA which contains Commercial Insurance information.6 1 Section: Page: .

produce and distribute member labels as specified by the Department. of the number of letters generated and actions taken..5 1 Section: Page: . no longer active in EPIC). Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM082 Generate Third Party letters and track original and follow-up letters to employers. ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM081 Generate letters to inform members who have reached their Co-Pay maximum amount for the current fiscal year. insurers. electronic and/or Web Portal. as well as drug expenditures. Member Management ME02 Manage Applicant and Member Communication NA 2 Section: Page: MEM078 Generate automated casualty-related letters and/or electronic notifications to members. motor vehicle department. produce and distribute member notifications via mail. but were later removed from the Medicare Part D plan enrollment due to a legitimate reason (i. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM073 Process premium assistance updates received daily for recipients that are eligible for Medicare Buy-In and HIPP. as well as the percentage of letters generated to the number of new members/renewals transmitted to the NYS Department of Taxation and Finance. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM065 Track individual EPIC member personal data. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM080 Prepare. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM066 Provide monthly reports stating the counts of EPIC members who received Plan Reassignment letters – generated by plan Member Management and by letter type. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM071 Execute Health Home member loyalty algorithms and assign members corresponding member loyalty codes. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM076 Prepare. and Part D status. monthly and annual reports. ME01 Manage Member Information NA 1 Section: Page: MEM067 Provide monthly reports of counts of EPIC members by Medicare Part D plan submitted on the enrollment files. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM074 Provide for the employee share of HIPP to be reimbursed to the employee or paid to the employer or insurance carrier.MEM063 Provide the capability to update prior approval/prior authorization upon final adjudication of the claim based upon business rules defined by the Department. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM072 Create and disseminate member assignment and loyalty data to Managed Care Plans and Lead Health Homes online.6 1 Section: Page: MEM079 Prepare. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM075 Verify HIPP recipient premium amounts. ME01 Manage Member Information NA 1 Section: Page: MEM064 Track and maintain an audit trail for all transactions related to Commercial Insurance. Member Management ME02 Manage Applicant and Member Communication TP1. attorneys. in a State approved format. including the capability to record both service units used and those returned by Member Management a void or adjustment. produce and distribute Explanation of Benefit (EOB) notifications to selected members on a schedule determined Member Management by the Department. members and others to verify health coverage and status changes. according to State-specified criteria. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM070 Provide Lead Health Homes export capability to download network member data in specified file formats or search for information by Member ID. electronic and/or Web Portal when appropriate including but not limited to: • Co-Pay Maximum • Utilization Threshold Letters • Member Inquiries • TPL Medicare Warning Letter Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM077 Distribute notifications to members. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM068 Provide monthly bypass report of all members who received a Plan Reassignment letter. providers and other stakeholders as specified by the Department via mail. etc.e. Member Management ME02 Manage Applicant and Member Communication TP1. Member Management ME01 Manage Member Information NA 1 Section: Page: MEM069 Produce weekly.

MEM083 Develop and maintain member information materials on the Web Portal including but not limited to: • Pharmacy Benefit information • Medical. electronic and/or Web Portal when appropriate to inform both members and providers regarding prior approvals/prior authorizations. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM093 Prepare. including but not limited to: • Prior approvals/prior authorizations with pended and missing information • Prior approvals/prior authorizations decisions Member Management ME02 Manage Applicant and Member Communication NA 2 Section: Page: MEM087 Prepare. based on the user’s security profile in accordance with technology policies. It shall be searchable Member Management by distance from a location and ideally would have links and/or interfaces to the Non-Emergency Medical Transportation (NEMT) contractor’s online transportation scheduling site. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM096 Provide members with individual benefit summary and detail reports on request. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM097 Maintain inventory of standard written communications and notifications for members. when operational. produce and distribute service request determinations to the provider and member or appropriate designee. providing relevant information such as EPIC Part D premium payments. personal care. ME02 Manage Applicant and Member Communication NA 2 Section: Page: MEM100 Require a real-time (or near real-time) client portal to view provider directory information and (recommended) scheduling module to include the ability to send notice to the practice of a cancelation prior to the appointment.5. produce and distribute written notice of pharmacy prior approval/prior authorization to affected providers and members as directed by the Department. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM085 Reconcile Medicaid and Children's Health Insurance Program (CHIP) eligibility and enrollment with the New York Health Benefit Exchange. and Member Management other communications. copayments. Member Management ME02 Manage Applicant and Member Communication POS3. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM090 Prepare. Explanation of Medicare Benefits (EOMB). produce and distribute notifications to inform providers/submitters when prior approval/prior authorization is required/missing. Member Management ME02 Manage Applicant and Member Communication NA 2 Section: Page: MEM091 Produce notifications to inform both providers and members regarding the decisions made about prior approval/prior authorization requests when they are finalized as specified by the Department. Notices must be written in English and other required languages in accordance with Department-approved procedures and content. ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM088 Prepare.9 1 Section: Page: MEM084 Conduct periodic reviews of all member support materials on the Web Portal based on a schedule approved by the Department. produce and distribute notifications via mail. transportation & waiver services benefit information • Utilization Threshold information • FAQs • Other information specified by the Department • Prior approval/prior authorization information • Participating provider list by provider type/specialty • EOB information Member Management ME02 Manage Applicant and Member Communication PM4. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM089 Prepare. through the web. and prescription purchases. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM095 Maintain updated Department letterhead and electronic facsimiles of signatures of Department officials who sign computer generated notifications. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM098 Distribute State-approved plan notification letters to members that are selected for Plan Reassignment. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM086 Prepare. produce and distribute written notices to members and prescribers regarding their hearing rights following a pharmacy prior approval/prior authorization request denial as directed by the Department. These letters will be specific to the EPIC member and provide the Medicare Part D plan selected and whether the member will receive premium assistance or not. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM092 Produce notifications to inform both members and providers (including providers that are part of the treatment team) according to Department business rules on prior approval/prior authorization status changes. produce and distribute notifications and attachments to inform members and/or providers on prior approval/prior Member Management authorization determinations. ME02 Manage Applicant and Member Communication NA 1 Section: Page: . and other State eligibility and enrollment sources. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM099 Support secure online client access to MMIS data. and distribute all member communications as required. 1 Section: Page: MEM094 Provide the capability to produce on demand notifications and attachments to inform members and/or providers (including providers that are part of the treatment team) on prior approval/prior authorization information. including claims data.

paper and fax submissions to override limits with clinical or administrative review as directed by the Department.10 1 Section: Page: OPS014 Provide the capability to automatically verify that numeric items with definitive upper and/or lower bounds are within the Operations Management proper range. pharmacy.1.8 1 Section: Page: OPS016 Provide capability and controls to allow payment for treatment obtained by an enrollee for an emergency medical condition without prior authorization. allow payment to FFS providers for services rendered in reenrollment periods or other periods of transition.6 2 Section: Page: OPS012 Provide and maintain a unique submitter number for each billing service or submitter that transmits electronic or paper claims to the NYS MMIS for a single provider or multiple providers. fax. Operations Management OM04 Submit Electronic Attachment NA 1 Section: Page: OPS005 Accept claim attachments via hard copy. and adjudicate mass adjustments for all paid and denied claims. POS2..g. Retroactive rate adjustments can affect claims from 1978 forward. Operations Management OM07 Process Claims CA2. verify.g.14 1 Section: Page: OPS004 Provide the capability to image. Operations Management OM04 Submit Electronic Attachment NA 1 Section: Page: OPS008 Identify. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM102 Empower members by providing access to information and tools that can be used to improve their health. OCR and/or data enter. and ensure accuracy of captured claims to validate that all claims received are processed. including exceptions to limits.3.6.13 1 Section: Page: OPS013 Provide the capability to automatically verify that any data item that contains self-checking digits (e. Operations Management OM05 Apply Mass Adjustment NA 1 Section: Page: OPS011 Provide a retroactive rate adjustment process to automatically generate adjustment transactions when provider rate modifications result in a change to the reimbursement amounts for previously adjudicated claims. or Web Portal. MC5.g. mental health and dental clinic. Operations Management OM07 Process Claims CR1. Operations Management OM07 Process Claims MC5. Operations Management OM04 Submit Electronic Attachment NA 1 Section: Page: OPS006 Accept electronic attachments in Industry Standard format or as mandated by HIPAA (e. with the exceptions stated per the State Plan. edit and verify hard copy or fax claim attachments received as directed by Department. electronic. capitation payments. at and over threshold services and web. Operations Management OM04 Submit Electronic Attachment NA 1 Section: Page: OPS007 Generate electronic transaction acknowledgment in Industry Standard format or as mandated by HIPAA (e. X12 275). digital and other electronic media supporting materials received. directions and policy guidance. or voided using flexible criteria to select batch. MC5. Operations Management OM05 Apply Mass Adjustment MC2.7.5 1 Section: Page: OPS015 Provide and maintain system data entry procedures and ability to systematically conduct field validity edits and preediting for hardcopy claims and claim adjustment/voids on: • Provider number • Member ID number • Procedure codes • Diagnosis codes Operations Management OM07 Process Claims CR1.. X12 275). physician office. track. incorrect loaded rate).MEM101 Provide the ability for the client to track the progress of their hearing request for appeals online. OM05 Apply Mass Adjustment NA 3 Section: Page: OPS010 Provide the capability to select previously adjudicated claim(s) to be reprocessed. adjusted. trace to the source. Operations Management OM04 Submit Electronic Attachment NA 1 Section: Page: OPS002 Provide the capability to convert x-rays and other radiological films to digital images of quality usable by the contractor for medical review and Departmental oversight. OM07 Process Claims CA2. OM04 Submit Electronic Attachment CR1. Operations Management OM04 Submit Electronic Attachment NA 1 Section: Page: OPS003 Provide the capability to electronically associate claim and prior approval/prior authorization attachments received by any Operations Management media to the appropriate claim and/or prior approval/prior authorization with prompt retrieval of attachments. and report to the Department. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: MEM103 Provide solution to limit and review high utilization of medical. and laboratory services on a beneficiary specific level based on medical condition under Department regulation.g. Operations Management and zero pays. Member Management ME02 Manage Applicant and Member Communication NA 1 Section: Page: OPS001 Provide the capability to electronically associate the prior approval/prior authorizations to hard copy. and block payment to FFS providers for services included in the MCO benefit package. analyze. and correct errors that have resulted in improper claims processing (e. Operations Management OM07 Process Claims CR1.. reprocess as needed.2.D. member I. POS2.4 2 Section: Page: OPS017 Utilize quality and validation procedures to control. Provide real time response to providers regarding nearing. This process must be executed based on a schedule approved by the Department. Operations Management OM05 Apply Mass Adjustment NA 3 Section: Page: OPS009 Provide the ability to process.6 1 Section: Page: . Number) passes the specified check-digit test. if final edit dispositions are incorrect.. allow FFS payment to providers for services carved out of the MCO benefit package. MC5.

33.22 1 Section: Page: OPS033 Verify that the provider is eligible to render the specific service covered by the claim..1 1 Section: Page: OPS036 Flag for review claims.6 1 Section: Page: OPS021 Identify and track all edits and audits posted to claims. assign unique control Operations Management numbers and batch hardcopy claim forms and attachments. Operations Management OM07 Process Claims CA4.g.2 1 Section: Page: OPS037 Identify any incomplete claim batches that fail to balance to control counts. Operations Management OM07 Process Claims NA 1 Section: Page: OPS042 Provide the capability to edit claims for beneficiaries in LTC facilities to ensure that services included in the LTC payment Operations Management rate are not billed separately by individual practitioners or other providers. Operations Management OM07 Process Claims CA1. date-stamp. adjustment/void forms. OM07 Process Claims CA4. OM07 Process Claims CR1. at the local rate. Operations Management OM07 Process Claims CA2.26 1 Section: Page: OPS030 Price claims according to pricing data and reimbursement methodologies applicable on the date(s) of service on the claim. Operations Management OM07 Process Claims POS3.3 1 Section: Page: OPS019 Verify that suspended transactions have valid error/exception codes. Operations Management OM07 Process Claims NA 1 Section: Page: OPS031 Price Medicare coinsurance or deductible for crossover claims. Operations Management OM07 Process Claims POS2. Operations Management OM07 Process Claims CA2. rejecting only individual bad claims and accepting all others. RF1.7 1 Section: Page: .17. OM07 Process Claims CA2. at the lower of the Medicaid or Operations Management Medicare allowed amount.6 1 Section: Page: OPS040 Facilitate provider enrollment and claims processing for AIHP claims by providers not enrolled in Title XIX Medicaid including character and competence review of those providers Operations Management OM07 Process Claims NA 1 Section: Page: OPS041 Provide ongoing assistance related to member and provider enrollment and claims processing for the AIHP. with a diagnosis and procedure which indicate an emergency that occurs within one day of a similar claim from the same provider. Operations Management OM07 Process Claims CA3. Julian date.e. and updated turnaround documents. Operations Management OM07 Process Claims CA3. overrides or manual intervention) information by the individual user. POS2. Operations Management OM07 Process Claims CA4.24 1 Section: Page: OPS027 Provide the capability to pay claims per capita.3 1 Section: Page: OPS035 Verify that the member was eligible for the particular category of service at the time it was rendered. Operations Management OM07 Process Claims CA4.4 1 Section: Page: OPS026 Flag and routes for manual intervention claims that fail State-defined service limitations including once-in-a-lifetime procedures and other frequency.10 1 Section: Page: OPS024 Utilize data elements and algorithms to compute claim reimbursement for claims that is consistent with 42 CFR 447.2 1 Section: Page: OPS038 Routes and reports on claims that are processed that indicate the member’s date of death for follow-up by the member eligibility or TPL personnel. POS3.13 1 Section: Page: OPS022 Maintain claim resolution (e. at the other State’s rate or flags and routes for manual pricing). Operations Management OM07 Process Claims CA4.25 1 Section: Page: OPS028 Price services billed with procedure codes with multiple modifiers.. periodicity. Operations Management OM07 Process Claims CA2. Operations Management OM07 Process Claims CA2. and dollar limitations.3 1 Section: Page: OPS020 Verify all claims for services approved or disallowed are properly flagged as paid or denied. Operations Management OM07 Process Claims CA1. Operations Management OM07 Process Claims CA2. based upon the State Plan.2 1 Section: Page: OPS023 Perform quality control procedures to screen and capture electronic images. Operations Management OM07 Process Claims CA1. Operations Management OM07 Process Claims CR3. depending on State policy. Operations Management OM07 Process Claims CA2.31 1 Section: Page: OPS032 Edit claims for consistency and payment limitations using the Medicare Correct Coding Initiative or similar editing criteria. Operations Management OM07 Process Claims CR1.2 1 Section: Page: OPS034 Verify that the provider is eligible to provide the specific service covered by the plan to the specific member. for the same member.OPS018 Processes batch 837 claims.4 1 Section: Page: OPS039 Provide the capability to pend or deny claims for members assigned to the member lock-in program based on state guidelines.23.32 1 Section: Page: OPS029 Price out-of-state claims according to NYS policy (i.15 2 Section: Page: OPS025 Flag and route for manual intervention claims that do not contain prior authorization if the services require prior authorization or require prior authorization after State-defined thresholds are met. from FFS.

) OM07 Process Claims TP1.1. Operations Management OM07 Process Claims CA4. store. Operations Management OM07 Process Claims CA5.5 1 Section: Page: .4 1 Section: Page: OPS057 Limit payment for services provided to waiver program participants to those described within the member’s approved plan of care and deny claims exceeding dollar or utilization limits approved in waiver or exceeding the approved individual waiver budget cap. Operations Management OM07 Process Claims WA1.e.3 2 Section: Page: OPS048 Accept. POS2. spenddown) ? Non claim-specific financial transactions such as fraud and abuse settlements. OM033. Operations Management OM07 Process Claims CR1. Operations Management OM07 Process Claims CA2.1. request for review. record. abortion. process. physical.2 1 Section: Page: OPS046 Provide and maintain the capability to process standard financial transactions including recoupments and payouts which cover more than one claim/service. have been received and maintained for audit purposes. and warranty data ? Manufacture’s tracking data for implants ? Waivers and demonstration specific requirements These documents may be freeform or in HIPAA attachment format.. per the reference records or edits.g. and response transactions required by 45 CFR Part 162. insurance recoveries. OM07 Process Claims WA4. identifies services provided to children who are under a medical child support order. Notify the provider of claims denied because of TPL coverage. Operations Management OM07 Process Claims WA4.9 1 Section: Page: OPS044 Limit benefits payable by beneficiary eligibility category or other beneficiary groupings. OM07 Process Claims WA4.. POS2. such as: ? Operative reports ? Occupational. Operations Management OM07 Process Claims TP2. including but not limited to: ? Sterilization.3 1 Section: Page: OPS053 Identify and track claims designated as “mandatory pay and chase”. and hysterectomy consent forms ? Manual or automated medical expenditure transactions which have been processed outside of the MMIS (e. and retrieve documents submitted with or in reference to claim submission activity.5 1 Section: Page: OPS050 Record and identify that all required claim attachments. Transactions failing the completeness review must be returned to the submitter without further Operations Management processing. Operations Management OM07 Process Claims CA4.19 1 Section: Page: OPS051 Generates notices or alerts to agency if number of unduplicated participants enrolled in the wavier program exceeds the number of participants approved in the waiver application. and flags Operations Management diagnosis information to identify prenatal care services provided to pregnant women and preventive pediatric services provided to children. OM07 Process Claims WA5. nursing facility or Intermediate Care Facilities for individuals with Mental Retardation (ICF/MR) and sends Operations Management notice to the provider of the admission. review for completeness.OPS043 Edit claims for newborns’ eligibility based upon NYS defined newborn enrollment policies and procedures. Operations Management OM07 Process Claims WA4. Operations Management OM07 Process Claims CR2. WA4.17.5 1 Section: Page: OPS058 Deny claims based on claims processing edits that are for products or services that are covered under TPL but allow for payment of claims that would have been rejected due to TPL coverage if provider includes override codes that indicates that benefits are not available.g. and speech therapy reports ? Durable Medical Equipment (DME) serial number. process and send electronic health care service review. and apply program specific edits for claim transactions and claim attachments for NYS waiver programs.11 2 Section: Page: OPS045 Maintain claim resolution (e. cost.18 1 Section: Page: OPS047 Provide the capability to receive.2 1 Section: Page: OPS054 Receive. makes appropriate payments and flags such claims for future recovery (i.23 1 Section: Page: OPS049 Accepts other claim related inputs to the MMIS.3 1 Section: Page: OPS056 Provide the capability to prevent or suspend payments for waiver services furnished to individuals who are inpatients of a hospital. and cash receipts ? Electronic cost reports ? Disproportionate share reports ? Drug rebate ? Any other inputs required for services under the State’s approved plan Operations Management OM07 Process Claims CR2.2 1 Section: Page: OPS055 Provide the capability to prevent or suspend waiver payments for members who have become ineligible for Medicaid. overrides or manual intervention) information by the individual user. professional and institutional referral certification and authorization (ASC X12N 278) • Internet submissions or prior authorization requests Operations Management OM07 Process Claims CA5. as follows: • Retail pharmacy drug referral certification and authorization • Dental. POS5.27.3 1 Section: Page: OPS052 Accesses individual beneficiary claims histories to extract data needed to produce annual report to CMS on cost neutrality Operations Management and amount of services.

non-covered charges.g. procedure codes. the correct reimbursement amount is derived based on the lowest payment amount for that rate code.. adjudication codes. Operations Management OM07 Process Claims NA 1 Section: Page: OPS068 Adjust pricing based upon Department business rules including but not limited to discount rates or markup rates. revenue code. OM07 Process Claims CR1. Operations Management OM07 Process Claims NA 1 Section: Page: OPS061 Support distribution of broadcast messages on remittances. attending.. item/service not available in the area for the maximum price on file. UB04.g. ordering. dates of service. American Indian Health Plan Claims. address. OCR and/or data enter. pricing. edit information. date of birth) • Service information (e. Perform quality control procedures to verify that the electronic image is legible and meets quality standards. review for completeness and process paper and electronic media claim transactions and claim attachments and auto-archives or forwards to appropriate operational area for processing..g. supervising. total charges.g. or there is prior approval/prior authorization required Operations Management and the procedure file does not have a price) for claims routed through the Workflow Management System based on business rules defined by the Department via the web-based application. edit. an excess pay situation. gender.g. eMedNY 150003. OM07 Process Claims NA 1 Section: Page: OPS071 Use pricing methodologies (with required “lesser of” logic) based on Department business rules including but not limited to: • Federal Maximum Allowable Cost (FMAC) pricing • State Maximum Allowable Cost (SMAC) pricing Operations Management • Federal Upper Limit (FUL) pricing • Average Wholesale Price (AWP) pricing • Wholesale Acquisition Cost (WAC) pricing • Average Actual Acquisition Cost (AAC) pricing OM07 Process Claims NA 1 Section: Page: OPS063 The contractor's application must support all channels approved by the Department for claim transactions including but not limited to: • Paper Claims • POS (Point of Service) devices • Direct connection (e. admission/discharge dates. operating) • Member information (e. service Operations Management units. VPN or leased line) • Batch transmission (e. prescribing.2 1 Section: Page: OPS060 Perform manual review and resolution of pended claims and refer claims requiring policy decisions to the Department. third party payment) • NYS prescription serial number on all pharmacy claims • Adjudication information (e.9 1 Section: Page: Operations Management OM07 Process Claims CR1. Operations Management OM07 Process Claims NA 1 Section: Page: OPS062 Image. verify. member ID.g. Pharmacy claim form. Transactions failing the completeness review must be returned to the submitter without further processing. pay to. Operations Management OM07 Process Claims NA 2 Section: Page: OPS066 Derive the correct reimbursement amount using the rate code and zip plus 4 information from the claim.g.. In cases where the rate code and zip plus 4 combination is not found. servicing/rendering. Cystic Operations Management Fibrosis Program claims) and claim attachments as directed by Department. Co-Pay. name. FTP and Secure FTP) • Provider area of the Web Portal .OPS059 Receive. Operations Management OM07 Process Claims NA 1 Section: Page: OPS070 Provide the capability to price the claim from a prior approval/prior authorization (e. diagnosis. NY CMS 1500 &15002..15 1 Section: Page: OPS064 Maintain all information related to claims adjudication including but not limited to: • Provider information (e. rate codes. Claim form A (Dental & Transportation). billing. pend tracking information) • Adjustment and void transaction information OM07 Process Claims BE2.g.6 2 Section: Page: OPS065 Process ordered ambulatory claims submitted in the 837I Institutional claim format as a Professional claims. Operations Management OM07 Process Claims CR2. and index paper claims (e. Operations Management OM07 Process Claims NA 1 Section: Page: OPS067 Use the Net Available Monthly Income (NAMI) amount to reduce the payment based on Department business rules for Inpatient and Nursing Home pricing. Operations Management OM07 Process Claims NA 1 Section: Page: OPS069 Use and apply pricing methodologies for Over the Counter (OTC) drugs based on Department business rules.

POS2. Operations Management OM07 Process Claims NA 1 Section: Page: OPS084 Transmit records of adjustments. Operations Management OM07 Process Claims NA 1 Section: Page: OPS079 Accept and process all paper and electronic Medicare crossovers for Medicare Part A.OPS072 Use a variety of pricing factors within Department approved pricing methodologies. Operations Management OM07 Process Claims CR2. These pricing factors include but are not limited to: Price claims using a variety of pricing factors within Department approved pricing methodologies applicable on the date(s) of service on the claim. recycle. NDC or other code sets determined by the Department • Pharmacy Program (e. Operations Management OM07 Process Claims PM3. Operations Management OM07 Process Claims NA 1 Section: Page: OPS078 Generate electronic receipt notifications that contain claim attachment information as specified by the Department. and immunization administration Operations Management • Brand and generic indicators • Drugs grouped by generic code. including claim-specific and non-claim-specific recoveries. recoupment.15 2 Section: Page: OPS087 Provide the capability to assign a unique control number to each claim for tracking and monitoring purposes. PM1.11. to suspend to a specific location.2 1 Section: Page: . Operations Management OM07 Process Claims NA 1 Section: Page: OPS074 Price claims based on pricing information and reimbursement methodologies applicable for the claim's date of service. therapeutic class. Operations Management OM07 Process Claims NA 1 Section: Page: OPS075 Apply a variety of claims pricing methodologies for pharmacy supply claims. Operations Management OM07 Process Claims NA 1 Section: Page: OPS077 Provide the capability to promptly retrieve.6. B.28. Operations Management OM07 Process Claims CR1. suspend to the provider/state staff for correction.15 1 Section: Page: OPS073 Determine the price for pharmacy supply claims based on the procedure code and the General Fee schedule as specified by Department business rules. HIV) • Program type or plan type • Provider attributes • Member attributes • Other pricing factors as determined by the Department OM07 Process Claims CA2. deny.8 2 Section: Page: OPS083 Support transition to allow electronic claim submission by providers and tribal nations for the AIHP and the Cystic Fibrosis Program.7. view. Pricing factors and methodology shall be reviewed and approved by the Department Operations Management OM07 Process Claims NA 1 Section: Page: OPS076 Accept or reject claim attachments based on standards established by the Department. Operations Management OM07 Process Claims BE1.3 1 Section: Page: OPS080 Perform adjustments to original and adjusted claims and maintain records of all previous processing.g. and print claim attachments. Operations Management OM07 Process Claims NA 1 Section: Page: OPS081 Update provider payment history and recipient claims history with all appropriate financial records and reflect adjustments in subsequent reporting.7 1 Section: Page: OPS082 Allow the disposition of edits to be easily changed to pay. POS2. POS2. Operations Management OM07 Process Claims ME1. All changes to edits must be reviewed and approved by NYS. AHIP. and report on the Remittance Advice/835 with a remittance remark and or adjustment reason code. and reprocessing to the MDW identifying the claim effected and changes including recoupment amounts Operations Management OM07 Process Claims NA 2 Section: Page: OPS085 Provide across program standard editing and maintain separate edits specific to the Cystic Fibrosis Program. and Medicaid Program Operations Management OM07 Process Claims NA 1 Section: Page: OPS086 Accept and transmit 834 transactions with the New York Health Benefit Exchange when operational. These pricing factors include but are not limited to: • Ingredient cost • Administrative Fees • Dispensing fees • HCPCS procedure code fees for products and services such as MTM services. C and D services in accordance with State and HIPAA requirements.

3. POS2. if date of service fall within coverage period.13. CA2. PM2.2. number of refills. CA1.3 2 Section: Page: OPS099 Provide the capability to electronically associate images of paper claims with electronic claim information. A rated generics not requiring substitution including but not limited to NTI drugs and non-A rated generic drugs.2. WA4. TP2. Operations Management OM07 Process Claims CR3. Suspend claims with exceptions/errors and routes for correction to the organizational entity that will resolve the exception/error. Operations Management OM07 Process Claims NA 1 Section: Page: OPS100 Process adjustments to reflect all claim information including but not limited to: • Document claims header • Line • Procedures • Diagnoses Operations Management OM07 Process Claims NA 1 Section: Page: OPS101 Provide document level processing with a disposition determination for every line.4. DUR overrides. CR1. and completeness.10.6.OPS088 Accept. Operations Management OM07 Process Claims NA 3 Section: Page: OPS093 Provide pharmacies with the ability to override rejected claims per NCPDP transaction standard(s) including but not limited to Utilization Threshold service limit overrides.5 1 Section: Page: OPS090 Provide the capability to process and respond to all electronic claim transactions in real time using HIPAA standard formats based on industry standards and Department requirements. (Overrides allow a previously rejected claim to be approved for payment via POS submission) OM07 Process Claims NA 2 Section: Page: OPS094 Provide the option of issuing rejections or warnings for conflicts detected by Prospective Drug Utilization Review (ProDUR) edits.6 2 Section: Page: OPS098 Apply program specific edits to claim information for all NYS benefit programs based on Department business rules for data presence. CA2.1. Operations Management OM07 Process Claims NA 3 Section: Page: OPS095 Support consistent and accurate application of the program’s mandatory generic provisions.1. CA2. Operations Management OM07 Process Claims NA 1 Section: Page: OPS097 Provide the capability for providers to enter and submit claims and supporting materials. CA1.e. Operations Management OM07 Process Claims NA 2 Section: Page: OPS092 Reject pharmacy claims exceeding limits (i.11.5.9.12. CA1.2. For Professional and Dental claims. enforce data validity standards. Operations Management OM07 Process Claims NA 2 Section: Page: OPS096 Distinguish between A-rated generic drugs and authorized generic drugs requiring generic substitution. validity (including for prior authorization..1 1 Section: Page: OPS089 Accept and process paper claim forms (Both NYS proprietary and standardized claim forms) including but not limited to: • Claim Form A (Dental and Transportation) • eMedNY 150002 (Fee For Service) • Pharmacy Claim Form Operations Management • CMS 1500 • ADA Dental Claim Form • CMS UB-04 Capture information contained on those forms based on Department business rules. OM07 Process Claims BE1. POS2. CA2. days from date written) established by the Department.4. CA2. CA2. WA4. CR1. Hierarchically assigns status and disposition of claims that fail edits. process. Combinations of lines which pay or deny do not affect the disposition of the document.2 2 Section: Page: OPS091 Process NCPDP claims from providers participating in NYS medication coverage programs where the providers are enrolled only with a proprietary Provider Identifier. cost share of premium or enrollment fees. excess income/spenddown override. CA2. OM07 Process Claims CR1. Operations Management inter-field relationships. if service is covered. if Operations Management any line on a claim pends. the entire document must be pended. POS5. TPL coverage prior to payment. and respond to electronic claims transactions received in HIPAA standard formats including: • Retail pharmacy drug claims (NCPDP) • Dental health care claims (X12N 837D) Operations Management • Professional health care claims (X12N 837P) • Institutional health care claims (X12N 837I) • Coordination of benefits data. Operations Management OM07 Process Claims PR4. and skilled Operations Management nursing facility override based on Department business rules.11. Errors returned must be clearly identified to facilitate correction by user. CA2.8. if alternate pricing prior to payment) . WA4. when applicable • Future claims attachments OM07 Process Claims CR3.12. track claim status and review claims adjudication information.7. depending on the conflict and/or its severity based on Department business rules.8.3. OM07 Process Claims NA 2 Section: Page: .

Operations Management OM07 Process Claims NA 1 Section: Page: OPS106 Edit claim transactions and perform alternate pricing based on Department business rules for TPL information..30. POS2. medical and member data. breast cancer surgery) Operations Management OM07 Process Claims NA 1 Section: Page: OPS109 Edit claim transactions based on Department business rules for ordering.34 1 Section: Page: . POS2. Operations Management OM07 Process Claims NA 3 Section: Page: OPS111 Perform ProDUR edits and identify contra-indications and potential adverse events that may be associated with dispensing the drug prescribed. Operations Management OM07 Process Claims NA 2 Section: Page: OPS112 Perform ProDUR edits on compound drug ingredients according to Department business rules. must easily adapt to changing edit requirements and be designed to enforce edits based Operations Management on a variety of combinations of parameters including but not limited to: frequency. prescribing.3. TP2. Operations Management OM07 Process Claims NA 1 Section: Page: OPS118 Adjust payments based on pricing factors including but not limited to: • Patient liability amounts • Medicaid Co-Payments • TPL amounts • Medicare paid amounts Operations Management OM07 Process Claims BE2.g. Operations Management OM07 Process Claims NA 1 Section: Page: OPS107 Edit claim transactions based on Department business rules for the association between the billing and the servicing providers. media Operations Management type and Department business rules. Operations Management OM07 Process Claims CA2. OM07 Process Claims NA 2 Section: Page: OPS114 Reject transactions that do not meet minimum standards based upon Department business rules. quantity and duration of therapy for selected drugs or drug classes.5.g. number of refills. and/or referring provider Operations Management information. edits for concurrent program enrollment and provider specific data.20. TP2. billing provider NPI Operations Management unknown) OM07 Process Claims NA 1 Section: Page: OPS115 Resolve and/or make pricing determinations. waiver program) • Claim transaction • Media type • Claim type • Entity or provider level Operations Management OM07 Process Claims CA4. deny/reject. Operations Management OM07 Process Claims NA 1 Section: Page: OPS117 Provide the capability to price claims at both the document and line levels. (e. for claims pended for edit Operations Management failures for adjudication in accordance with Department business rules and procedures.10 1 Section: Page: OPS103 Provide the capability to use the prescriber specialty for pharmacy edits. (e.OPS102 Provide the capability to selectively apply edits based on Department business rules including but not limited to: • Major program code (e. The solution. rendering.29. OM07 Process Claims NA 1 Section: Page: OPS110 Edit pharmacy claim transactions based on Department business rules (e. Operations Management OM07 Process Claims NA 3 Section: Page: OPS113 Provide medical limit and step therapy editing for pharmacy claims with prescriptions falling outside the approved parameters automatically identified as requiring prior approval/prior authorization. Operations Management OM07 Process Claims NA 3 Section: Page: OPS104 Derive the edit payment status (pay. days from date written).. CA2. including the use of commercially available packages. CA2. pend) for each edit failure based on the date of service claim type. and diagnostic. OM07 Process Claims NA 1 Section: Page: OPS116 Reprocess resolved pended claims through all edits for adjudication. as well as clinical and administrative resolutions.g. Operations Management OM07 Process Claims NA 1 Section: Page: OPS108 Edit claim transactions based on Department business rules for limiting services by procedure to specific providers.21 1 Section: Page: OPS119 Determine pricing based on Department business rules using the rate code submitted on the claim and accounting for: • Medicaid copayment reductions • Third Party reductions • Medicare/Medicaid maximization rules • Patient responsibility minimization rules Operations Management OM07 Process Claims NA 1 Section: Page: OPS120 Accommodate variable pricing methodologies for identical procedure codes based on the benefit plan the member is enrolled in at the time of service.12. OM07 Process Claims NA 1 Section: Page: OPS105 Edit claim transactions based on Department business rules for member restrictions.g. This includes the ability to pay for lines determined to be payable and not paying for lines that have been denied. exceptions and exemptions.

Operations Management OM07 Process Claims NA 1 Section: Page: OPS122 Provide the capability to pay only the designated federal share for specific claims based on Department business rules. Operations Management OM07 Process Claims NA 1 Section: Page: OPS123 Provide the capability to manually price pended claims..1 2 Section: Page: OPS133 Edit claim transactions based on Department business rules for valid reference information including but not limited to: • Diagnosis (including age/sex parameters) • Procedures (including modifiers. Operations Management OM07 Process Claims NA 1 Section: Page: OPS136 Edit claim transactions based on Department business rules for combinations of procedure codes..11 1 Section: Page: OPS135 Edit claim transactions based on the payable status for the procedure and/or diagnosis as specified by the Department.12 1 Section: Page: OPS134 Edit claim transactions based on Department business rules for the relationship between diagnosis and procedures or drug Operations Management formulary.12. member eligible on date of service). CA2.OPS121 Provide the capability to adjust pricing based on Department business rules for the grouping of procedures performed (e. Operations Management OM07 Process Claims NA 1 Section: Page: OPS129 Derive the claim type and assign the appropriate claim type. Operations Management OM07 Process Claims NA 1 Section: Page: OPS132 Edit claim transactions based on Department business rules for provider enrollment status and eligibility to provide claimed services during the period covered by the claim Operations Management OM07 Process Claims CA2. OM07 Process Claims NA 1 Section: Page: OPS127 Determine the price for professional and dental claims based on the procedure code and the General Fee. multiple surgery reimbursement cutbacks). Operations Management OM07 Process Claims NA 1 Section: Page: OPS126 Provide the capability to perform adjustments or voids on previously adjudicated claims (including those processed within the same pay cycle) using the edit and pricing rules applicable to the original claim’s dates of service and associate them Operations Management with the original claim.g. units and age/sex parameters) • Drug Formulary (NDC for rebates) • Revenue Codes • Rate Codes Operations Management OM07 Process Claims CA2. category of service and specialty code (where appropriate) based upon Department business rules. POS2.g. OM07 Process Claims CA2.9. or exempt from. Operations Management OM07 Process Claims NA 1 Section: Page: OPS124 Provide the capability to price the claim from a prior approval/prior authorization (e. CA2. Operations Management OM07 Process Claims NA 2 Section: Page: OPS131 Edit claim transactions based on Department business rules for member eligibility (e. surgical procedures subject to.g. Operations Management OM07 Process Claims NA 1 Section: Page: OPS130 Process a claim transaction which meets the minimum standards through all applicable edits. Operations Management OM07 Process Claims CA2.14 1 Section: Page: . or when a prior approval/prior authorization is required and the procedure file does not have a price) based on business rules defined by the Department. Alternate Fee schedule or the Resource Based Relative Value Scale (RBRVS) Fee schedule with the capability to adjust the price as specified by Department business rules based on information including but not limited to: • Provider/Major Program • Provider ID • Major Program • RBRVS (Resource Based Relative Value Scale) • Procedure Code/COS/Specialty/Place of Service (Visit Matrix) • HIPAA recognized modifiers and any local modifiers (including multiple modifiers on the same claim line) • Category of Service (COS) • Provider Type • Specialty Code • County Code • Medicare/Medicaid Maximization rules Operations Management OM07 Process Claims CA2.10. CA3. an excess pay situation.. All edit failures must be recorded and included in the response transactions to the limit allowed by the transaction. item/service not available in the area for the maximum price on file. frequency.22. Adjustments or voids can be submitted by the provider or Department.32 1 Section: Page: OPS128 Adjust the claim document including all line items. Operations Management OM07 Process Claims NA 1 Section: Page: OPS125 Provide the capability to adjust the claim payment during the Utilization Review (UR) process via the web-based application.

identified by the Department. for review for program integrity and quality assurance purposes. and provide capability to identify duplicate claims (originals. Operations Management OM07 Process Claims POS2. Operations Management OM07 Process Claims NA 1 Section: Page: . pending.OPS137 Edit claim transactions to identify those requiring manual review and/or pricing to be done by the contractor based on Department business rules. Operations Management OM07 Process Claims NA 1 Section: Page: OPS151 Provide capability to pend claims in real-time based on specific criteria.22 1 Section: Page: OPS140 Provide a mechanized claims processing system for NYPS capable of applying pre-loaded rebate amounts per NDC to individual claims at the point of sale. updated rebate amount is applied at the point of sale as an added discount for the NYPS Operations Management member (in addition to the Program’s brand/generic drug discount). the contractor must develop a process that assures the applicable. Examples include: • Outpatient claim submitted for a date of service which was previously covered under an inpatient claim. pending or denied). must have the rebate amount subtracted from the member amount due at the point of service.15 1 Section: Page: OPS138 Edit claim transactions at the entity and provider group level based on Department business rules for utilization review. CA2. A unique feature of NYPS is the requirement that any drug covered by the NYPS Program that has an NYPS contracted manufacturer discount (rebate).1. Operations Management OM07 Process Claims NA 1 Section: Page: OPS150 Provide oversight capabilities to State staff to review claim submission and claim history information. • Dates of service for a practitioner claim do not overlap with the dates of service for another claim from the same practitioner for a single Beneficiary unless the additional services are appropriate for the same date of service • A single provider for multiple visits on the same day to a single Beneficiary Operations Management OM07 Process Claims CA2. OM07 Process Claims NA 2 Section: Page: OPS142 In accordance with NYS Public Health Law § 280. Operations Management OM07 Process Claims NA 1 Section: Page: OPS152 Track provider bills. Operations Management OM07 Process Claims NA 1 Section: Page: OPS141 Facilitate NYPS electronic claims processing. assign claim status (paid. In order to accomplish this. Send monthly notification to recipients of bills used to offset spenddown. POS2.19.15 1 Section: Page: OPS143 Perform a pre-payment audit of NYPS claims before making payments. apply amount of an individual's bills toward the spenddown of other individuals in the household. This number must be made part of the adjudicated claim. OM07 Process Claims NA 1 Section: Page: OPS148 Track all claims. Operations Management OM07 Process Claims CA1. suspended. Operations Management OM07 Process Claims NA 1 Section: Page: OPS144 Provide the capability to execute claim edits and deny claims based on State approved utilization threshold business rules Operations Management OM07 Process Claims NA 1 Section: Page: OPS145 Provide manual override capabilities to State approved utilization threshold business rules Operations Management OM07 Process Claims NA 1 Section: Page: OPS146 Provide the capability of linking a claim to a prior approval/prior authorization number and calculate the number of unused occurrences remaining on that prior approval/prior authorization number. Modify response to providers when eligibility is checked. CA2. All other covered prescription drug claims submitted to NYPS regardless of whether they have a rebate contract are covered subject to Program benefits and limitations (see procurement library. pending or denied). reimbursement to the provider pharmacy under the New York Prescription Saver Program shall be adjudicated and paid within two business days for any rebates. CA2. dispensing fees and drug costs not paid by the resident eligible for such program at the point of sale. suspended. comparing cumulative bill amounts to the spenddown amount and process claims once the spenddown has been met. resubmitted claims. Pharmacy Claims Processing –Plan Administration Manual for what is covered under NYPS).17 2 Section: Page: OPS149 Provide the capability to electronically associate original claims (paid.21. Operations Management OM07 Process Claims CA2. Operations Management OM07 Process Claims NA 1 Section: Page: OPS147 Provide functionality where claims adjusted or voided through audit cannot be re-adjusted or re-processed by the provider Operations Management without Department approval. For households with more than one individual.3.18. and/or adjudicating) and reject duplicates. and duplicate claims received by any media. duplicate or near duplicate services. Manual checks are issued to a very limited number of pharmacy providers in emergency or unusual situations.14 1 Section: Page: OPS139 Edit claim transactions at the entity and provider group level based on Department business rules for Utilization Review including but not limited to: • Services that Conflict with Previous Services • Services that Conflict In Combination with Prior Services • Services that Conflict with National Correct Coding Initiative (NCCI) procedure to procedure edits Operations Management OM07 Process Claims BE2. The member is responsible to the pharmacy after all applicable discounts. Pay bills retroactively if the spenddown amount is adjusted. CA2.

messaging capability in the most recent NCPDP format.4 1 Section: Page: OPS169 Generate remittance advices (RA) and transmit to providers in either electronic or hard copy form as requested by the provider. coordination of benefits with other payers. FI3. Operations Management OM07 Process Claims NA 1 Section: Page: OPS166 Accept and process updates from claims processing that “draw down” or decrement authorized prior authorization services.4. editing on Medicare Part D and other insurance edits. reprocess as needed. review for completeness and process pharmacy paper claim transactions and claim attachments. The claims processing system must be flexible and capable of integrating and enforcing the various utilization review. Operations Management OM07 Process Claims NA 1 Section: Page: OPS159 Process all pharmacy claims. and store Medicaid transportation prior authorizations for member travel expenses for Nonemergency ambulance.OPS153 Screen and address calls regarding claim adjudication. CR1. process. Full claims history must be made available to the State for use by Program Management and Program Integrity. OM07 Process Claims NA 2 Section: Page: OPS160 Identify.11 2 Section: Page: OPS161 The POS shall accept ASC X12N NCPDP claims required by 45 CFR Part 162. Operations Management OM07 Process Claims BE1. Compound claims must be reimbursed according to the applicable plan logic and benefit design. CR1.9. 1 Section: Page: OPS162 Compares the claim against member history and benefit rules to determine if the claim complies with State standards. Hard copy RA's must be produced in a proprietary format specified by the Department. CA1. HIPAA compliant RA codes and messages must be used for denied and paid claims. Operations Management OM07 Process Claims NA 1 Section: Page: OPS156 Develop and execute an iterative process to adjudicate and pay up to twenty four (24) months of claims in the contractor’s Operations Management application that were previously adjudicated and paid by the current MMIS. iii. tracking and covering drugs that are covered first by the Medicare Part D plan after any Medicare Part D deductible is met. Operations Management ii. Operations Management OM07 Process Claims NA 1 Section: Page: OPS164 Receive. Operations Management Include the ability to validate all claims received are processed. Operations Management OM07 Process Claims NA 1 Section: Page: OPS165 Receive. and to retrospectively analyze the effect of new or modified edits and audits after they are implemented. and v. and report to the Department. analyze. Transactions failing the completeness review must be returned to the submitter without further processing. Operations Management OM14 Generate Remittance Advice FI3. process. ambulette. and store NYC Medicaid transportation claims from the Public Transportation Automatic Reimbursement System (PTAR) for NYC enrollees travel expenses.g.5 3 Section: Page: OPS155 Provide online capability to test and estimate the effect of new or modified edits and audits prior to their use in claims processing. OM07 Process Claims CA1. benefit design features and cost containment components of the current and future Program including but not limited to: i. EPIC may also cover Medicare Part D excluded drugs.5. a concurrent DUR program to aid the pharmacist at the POS. Operations Management OM08 Authorize Service NA 1 Section: Page: OPS168 Generate a remittance statement for each provider with activity in a payment cycle even if no EFT/check is generated. Other offline Payments billed by PTAR facilities and MMTPs do not provide prior authorization to the MAS Contractor. as adjudicated. FI3.1. and of all mass or individual adjustments impacting the claim. trace to the source.15.0 or any newer NCPDP versions implemented by the contractor.5 1 Section: Page: .7. FI2. if final edit dispositions are incorrect. and apply specific edits for e-visit and tele-health claim transactions.6. review for completeness. iv. OM07 Process Claims NA 1 Section: Page: OPS157 Process compound claims that are submitted to EPIC through the paper Universal Claim Form (UCF) or via POS using NCPDP Version D. including no payment claims (zero pay) through the claims processing system subject to the EPIC and NYPS Program’s pricing logic and various business rules. process. incorrect loaded rate). Operations Management OM07 Process Claims NA 1 Section: Page: OPS163 Provide the capability to receive. taxi and livery services. Electronic RA's must meet HIPAA standards for the X12 835 (version 5010) standard transaction for paid and denied claims with the ability to split the RA based on standard transaction size limitations. Operations Management OM07 Process Claims NA 1 Section: Page: OPS158 Receive. Operations Management OM14 Generate Remittance Advice FI3. Operations Management OM07 Process Claims POS2. including ambulatory patient groups (APG) claims based on information in the appropriate policy manual Operations Management OM07 Process Claims NA 1 Section: Page: OPS154 Maintain claims history and an audit trail of all New York Medicaid claims as submitted (including identifying claims input medium for control and balancing).. process. and store Medicaid transportation claims from 2-4 NYS DOH contracted Transportation managers and NYC Methadone Maintenance Treatment Programs (MMTPs) for NYS enrollees travel expenses incurred by the enrollee. Operations Management OM08 Authorize Service NA 1 Section: Page: OPS167 Receive. and correct errors that have resulted in improper claims processing (e.

FTP and Secure FTP) • Provider area of the Web Portal • Hard copy Operations Management OM14 Generate Remittance Advice NA 1 Section: Page: OPS174 Provide prompt response to inquires regarding the status of any claim through a variety of appropriate technologies. dates.g. FTP and Secure FTP) • Provider Area of the Web Portal Operations Management OM18 Inquire Payment Status NA 1 Section: Page: OPS179 Accept and process X12 276 Claim Status Request (version 5010) responding with the X12 277 Claim Status Response (version 5010). VeriFone) • Direct Connection including (e. referring provider) • Reference information • Claim information • Member information • TPL Payment Information Operations Management OM18 Inquire Payment Status NA 1 Section: Page: OPS176 Provide the capability to retrieve claims information (including all supporting materials and correspondence) and produce Operations Management it in an industry standard file format (e. this will generate multiple remittance advice statements. PM2. ordering provider. and tracks and monitors responses to the inquiries. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS182 Calculate the payment amount for the provider by accumulating reimbursement amounts during the cycle to determine the Operations Management net payment amount. OM18 Inquire Payment Status NA 1 Section: Page: OPS177 Provide the capability to confirm that a prior approval/prior authorization for claimed services exists when required by Department business rules. PDF) accessible through the web-based application. OM27 Prepare Provider Payment NA 1 Section: Page: . VPN or leased line) • Batch Transmission (e. Operations Management OM18 Inquire Payment Status NA 1 Section: Page: OPS178 Support all channels approved by the Department for claims inquiry transactions including but not limited to: • Call Center Services using IVR Technology and Automated Response Technology • POS (Point of Service) Device including (e. For providers with multiple ETINs. Operations Management OM14 Generate Remittance Advice NA 1 Section: Page: OPS172 Generate X12 277 Health Care Claim Status Notification (version5010) transactions for all pended claims.8 2 Section: Page: OPS175 Provide the capability via the web-based application to review all information (including historical) related to a claim including but not limited to: • Claim and adjudication information (including images for paper claims and attachments) • Adjustment and void information • Provider information (e.g. billing provider.7 1 Section: Page: OPS180 Provide the capability to view payment information via the web-based application including but not limited to: • Adjudicated claims information • Payment amounts. Operations Management OM14 Generate Remittance Advice NA 1 Section: Page: OPS173 Support the transmission of (RA) and Health Care Claim Status Notification transactions via the following channels: • Direct Connection (e.g. Processes electronic claim status request and response transactions (ASC X12N 276/277) required by 45 CFR Part 162 Operations Management OM18 Inquire Payment Status CA1.OPS170 Generate remittance advices by provider and Electronic Transmitter Identification Number (ETIN). Operations Management OM18 Inquire Payment Status NA 1 Section: Page: Operations Management OM18 Inquire Payment Status FI3.g.11. cycle.g. If the provider has an outstanding accounts receivable balance.g.g. the amount will be applied to that balance based on Department business rules. OPS181 Provide the ability for authorized system users to withhold or suspend provider payments after adjudication. VPN or leased line) • Batch Transmission (e. servicing provider. Operations Management OM14 Generate Remittance Advice NA 1 Section: Page: OPS171 Generate a monthly member level detailed premium remittance advice file by Carrier even if no EFT/check is generated. method • Remittance Advice information • Imaged copies of all paper claims or RA's • Capitation payments • Other payment information identified by the Department.

for each payment cycle and transmit payment authorizations to the designated Financial Institution for payment processing. Manual checks are issued for a variety of reasons including accelerated payments and replacement of damaged or misplaced system checks. The payments must meet the following conditions: • Covers all or specific providers • Are based on payment history as specified by the Department • Are only available to participating providers as defined by the Department • Are based on a payment percentage determined by the Department Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS191 Provide the capability to review check/EFT balancing information (including shares information) for the payment period via the web-based application. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS199 Maintain all data required to support premium payment processing. OM27 Prepare Provider Payment NA 1 Section: Page: OPS197 Provide the capability to create the following transactions via the web-based application based on Department business rules: • Hold / Release EFT Transactions • Stop EFT Transactions • Debit EFT Transactions Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS198 Provide the capability to track and correct any unsuccessful or incorrect EFT payments. adjust or suspend claims payments for all categories of providers or members within specified categories on a run-to-run basis. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS192 Provide the capability through the web-based application to retrieve payment information.OPS183 Maintain payment data as required by Department business rules including but not limited to: • Adjudicated claims information • Provider information • Payment amounts • Check/EFT information • Payment cycle • Payment and release dates • Timing of claims filing by provider to ensure good fiscal controls and statistical data.6 1 Section: Page: OPS186 Provide the capability to pay specific exempt providers as a separate payment cycle when normal payments are suspended Operations Management or otherwise not processed. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS190 Provide an automated payment calculation process capable of determining and creating interim or emergency payments. are scheduled in-between transmission of EFT payment files and EFT disbursement of funds. In the event holidays. Operations Management OM27 Prepare Provider Payment FI3.3 1 Section: Page: OPS184 Produce at least one payment cycle per week with the capability to process extra payment cycles Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS185 Generate EFT/checks by provider and Electronic Transmitter Identification Number (ETIN). Operations Management OM27 Prepare Provider Payment PM3. EFT payment files shall be produced one day earlier to eliminate delay of Medicaid payments. where Financial Operations Management Institution are closed for business to the public. or all claims for a particular provider Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS188 Provide the capability to pay. Operations Management OM27 Prepare Provider Payment PI3. based on approved provider EFT agreements. all claims processed. including Medicare and Managed Care data.2 1 Section: Page: OPS194 Provide the capability to create the following transactions via the web-based application based on Department business rules: • Stop Check Transaction • Void Check Transaction • Stop & Reissue Check Transaction • Void & Reissue Check Transaction Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS195 Provide the capability to reconcile accounts with the designated Financial Institution based on the exchange of files containing information related to the status of checks. OM27 Prepare Provider Payment NA 1 Section: Page: OPS187 Provide the capability to hold payment for individual claims. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS193 Provide the capability to generate manual checks or split existing checks and EFTs via the web-based application based on Department business rules while retaining all data required for fund source determination. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: .6 1 Section: Page: OPS189 Balance the RA payment amount to the check/EFT amount and reflect any and all adjustments. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS196 Produce an EFT payment file. Operations Management OM27 Prepare Provider Payment FI4.

Operations Management OM28 Manage Data SP2. OM28 Manage Data PI2. RF1.7 2 Section: Page: OPS212 Log each batch into an automated batch control system and coordinate with other contractors to provide batch control. Operations Management OM27 Prepare Provider Payment NA 1 Section: Page: OPS201 Maintain all current and historical reference data related to claims processing and provide capability to retrieve. WA1.2 2 Section: Page: OPS218 Provide the capability to produce claim detail and special reports by provider-type and Beneficiary classification (e. as needed. which is defined by the Average Wholesale Price (AWP) less 15% to 20 % plus a dispensing fee (ranging anywhere from 0. and report unduplicated participants enrolled in 1915C programs. Operations Management OM28 Manage Data NA 1 Section: Page: OPS207 Provide data governance activities that support the Department Data Governance organization in meeting its goals. Operations Management OM28 Manage Data NA 1 Section: Page: OPS208 Generate FFS claims reporting for services furnished outside of a capitation agreement (i. process updates. paying the lesser of these fees.4.). showing increases/decreases and cumulative year-to-date figures after each claims processing cycle. the State defined Estimated Acquisition Cost (EAC). Operations Management OM28 Manage Data PI3. Operations Management OM28 Manage Data CR3. and/or plus a provider specific dispensing fee. flagging or otherwise noting clean claims (error free) Operations Management that are delayed over 30 days.. financial payment processing). PI2.1. eligibility files.g. for services “carved-out” of the managed care program). ? Reimbursement for prescription drugs are usually processed by either a) Federal Upper Limit (FUL) or Maximum Allowable Cost (MAC) with some drugs. Operations Management OM28 Manage Data PI2. other waiver programs. RF1. balancing and scheduling of data load cycles (e.6. Case.7 1 Section: Page: OPS211 Document and produce reports on the time lapse of claims payment. respond to queries and report requests. Operations Management OM28 Manage Data RF1. category of service—COS) and other key variables (e. the rate established by the State. Operations Management OM28 Manage Data NA 1 Section: Page: OPS206 Collaborate with and take direction from the State on all issues surrounding data.. Operations Management OM28 Manage Data CR1. track. OM28 Manage Data RF1. archived reference data for processing of outdated claims or for duplicate claims detection.11 1 Section: Page: OPS213 Provide the capability through the web-based application to review information on each provider's payments to monitor trends in accounts payable such as.2.2 1 Section: Page: OPS209 Employ an electronic tracking mechanism to locate archived source documents or to purge source documents in accordance with HIPAA security provisions.4 1 Section: Page: OPS214 Provide the ability to identify.g. Indian Health Services (IHS) and hospital inpatient and outpatient reimbursement is to be the lower of the provider’s “usual and customary” charge. (See 447. and metadata.8 1 Section: Page: OPS202 Maintain. and ensure the integrity of all data. POS2. Operations Management OM28 Manage Data PI3. and archive all reasonable and customary charge information for Medicaid and Medicare to support claims processing: ? Reimbursement under the Medicaid program for other than outpatient drugs. store.g.. Operations Management OM28 Manage Data PM3. Rural Health Clinic (RHC). etc.1 1 Section: Page: OPS217 Provides ability to perform analyses and produce reports responsive to requests from NYS .4 1 Section: Page: . but not limited to.4 1 Section: Page: OPS210 Provide the ability to identify claims input for control and balancing (hardcopy and electronic media). Federally Qualified Health Center (FQHC).) OM28 Manage Data CA1.45 CFR for timely claims payment requirements. data definitions.5 1 Section: Page: OPS203 Capture.5 1 Section: Page: OPS216 Produce automated reports providing information that reveals potential defects in level of care and quality of service. “Usual and customary” charges are calculated from the actual charges submitted on Operations Management provider claims for Medicaid payment.2 1 Section: Page: OPS215 Provide flexible reporting identifying services received by members who are enrolled in selected program(s) or who have Operations Management specified diagnoses. models. and other long-term care services.e. WA1.50 to several dollars).5. protect. Operations Management OM28 Manage Data PI3. Submitter. or b) the provider’s usual and customary charge. Operations Management OM28 Manage Data NA 1 Section: Page: OPS205 Manage information consistently across the program. or the amount which is allowed under the Medicaid program. Operations Management OM28 Manage Data CR1.OPS200 Automatically generate letters to providers for checks that have not cleared within a period established by the Department.1. Federally-assisted program participants.23 2 Section: Page: OPS204 Continually improve the quality of data and information. including data governance. Operations Management OM28 Manage Data MC6.. Group Practice.

procedure codes. BE2. Produce reports of members who exceed program norms. Operations Management OM28 Manage Data NA 1 Section: Page: OPS223 Maintain all information related to payments including but not limited to: • Provider information (e. • Enrollment/Disenrollment spans and benefit package enrollment. ranked in order of severity. Performance Management PE01 Identify Utilization Anomalies PI1..8 1 Section: Page: OPS224 Provide the capability to view. Operations Management PE03 Manage Compliance Incident Information PI4. abuse and excessive billing. all necessary data to support the MDW. at a minimum daily.3 2 Section: Page: PFM005 Apply clinically approved guidelines against episodes of care to identify instances of treatment inconsistent with guidelines. billing. total charges. including prescribed drugs. This includes: • Eligibility. rate codes. Performance Management PE01 Identify Utilization Anomalies PI4. PM2. revenue code. all necessary data to support the Department metadata repository. Performance Management PE01 Identify Utilization Anomalies PI2. and formulary codes (42 CFR 447)). diagnosis.. Performance Management PE01 Identify Utilization Anomalies PI1.9 2 Section: Page: PFM006 Generate early warning reports of high cost services and service misutilization based on current payment data to quickly identify high volume practices.g. non-covered charges. name. and reason for notice) • Requests for copies of personal records (including time/date. adjudication codes.g. physician. pend tracking information) • Adjustment and void transaction information OM28 Manage Data BE2. and QI-1 premium payments) Operations Management OM28 Manage Data NA 1 Section: Page: OPS226 Provide the capability to produce the Methadone Maintenance Treatment Program Claims extract file for the Human Resources Administration (HRA) in NYC based on specific rate and procedure codes. POS6. edit information.g. OM28 Manage Data NA 1 Section: Page: OPS225 Provide the capability to monitor spending against the QI-1 program allotment for each federal fiscal year via the webbased application. including but not limited to: • Total amount allocated. address. third party payment) • Reference information (e. at a minimum daily. current and historical Part B premiums. and status of request) Operations Management OM28 Manage Data BE1.. pricing. service Operations Management units. operating) • Member information (e. and member profiles sufficient to provide specific information as to the use of covered types of services.. type. prescribing. gender. Co-Pay. and associated spans. diagnostic.1 2 Section: Page: PFM004 Perform analysis of rendering.OPS219 Provide reporting flexibility to vary time periods for reporting purposes and to produce reports on daily. Operations Management OM28 Manage Data NA 1 Section: Page: OPS222 Deliver. and current Operations Management and historical Part A premiums.10. Operations Management OM28 Manage Data PI3.4 1 Section: Page: OPS221 Deliver.1. servicing/rendering.12 2 Section: Page: PFM003 Analyze program trends to investigate and identify misutilization of NYS’ Medicaid program services by individual members and provider and promote corrective action. including notice of benefits to members (including time/date. Operations Management OM28 Manage Data NA 1 Section: Page: OPS227 Maintain audit trail of all actions performed on a client record. ordering. Performance Management PE01 Identify Utilization Anomalies PI1. total amount spent and the total amount unspent • Total encumbered and total unencumbered for fiscal year • Current and historical Part B premiums • Current and historical Part A premiums • Monthly QI-1 activity information (e. ineligibility and retro eligibility. supervising.7 3 Section: Page: OPS228 Develops provider.8. and billing practices to generate reports of aberrant utilization and/or billing patterns. BE1.3 1 Section: Page: PFM002 Provide capability to support pattern recognition and automated fraud and abuse profiling system for the ongoing monitoring of provider and beneficiary claims to detect patterns of potential fraud. limitations and changes • Communication and notification.3. • Adjudication information (e. quarterly basis. enter and update information related to the federal allotment for the QI-1 program for each federal fiscal year including but not limited to: total amount allocated. member ID. admission/discharge dates.6.10 2 Section: Page: PFM007 Describe how the MMIS will initialize utilization limits annually for each member. date of birth) • Service information (e.. source. ordering.4. Performance Management PE01 Identify Utilization Anomalies PI3. FI4. procedure. dates of service. monthly. number of QI-1 beneficiaries. or other frequency specified by NYS. user/source.g..2 1 Section: Page: PFM001 Identify exceptions to norms of utilization or quality of care standards established by NYS for any type of member covered by the State Plan. attending. Performance Management NA 1 Section: Page: PE01 Identify Utilization Anomalies . pay to.14 1 Section: Page: OPS220 Collects and stores data needed to produce reports to assess quality and appropriateness of care furnished to participants of the waiver program Operations Management OM28 Manage Data WA5. PI2.g.g.

Chinese-Cantonese. Over the last five years of program operation there have been less than five fair hearings. Performance Management PE03 Manage Compliance Incident Information PI3.5 1 Section: Page: PFM018 Supports capability to perform focused program integrity reviews and to generate reports of all reviews undertaken. Performance Management PE05 Prepare REOMB NA 1 Section: Page: PFM022 Provide the capability to produce EOBs and instructions in multiple language options (at a minimum. upcoding. and Beneficiaries for prior authorizations. FI3. Contractor staff familiar with the facts of the Performance Management case must attend the fair hearings. Performance Management PE02 Establish Compliance Incident NA 2 Section: Page: PFM014 Participate in all fair hearings involving members or pharmacy providers. Participate in these activities upon request. Denial notices to beneficiaries include the reason for the denial and notification of the beneficiary’s right to a fair hearing. and Russian) Performance Management PE05 Prepare REOMB NA 1 Section: Page: PFM023 Produce EOBs. unnecessary services and other irregular billing or service practices.15 1 Section: Page: Provide research and documentation to support administrative hearings. to all or a sample group of the members who received services under the plan as described in §11210. appeals. The contractor may have to provide assistance at more than one trial or grand jury in a day. produce and distribute EOBs. PFM011 . Performance Management PE05 Prepare REOMB NA 1 Section: Page: PFM021 Provide the capability to inquire on. Performance Management PE02 Establish Compliance Incident NA 2 Section: Page: PFM013 Provide support to the Special Prosecutor and testify at grand juries or trials. case managers.5 1 Section: Page: PFM019 Maintains a process to apply weighting and ranking of program integrity exception report items to facilitate identification Performance Management of the highest deviators.17 Objectives 1 Section: Page: PLN002 Provide all necessary support to the Department in conducting ongoing change management sessions for all organizational units affected by the replacement system.4 1 Section: Page: PFM017 Provide the capability to monitor services for suspected abusers using a “pay and report”. Performance Management PE02 Establish Compliance Incident NA 1 Section: Page: PFM016 Track and investigate claims flagged for follow-up because of third party discrepancies. Performance Management PE05 Prepare REOMB NA 1 Section: Page: PLN001 Analyze Medicaid program costs and trends including break-even point between Medicare and Medicaid payments to predict impact of policy changes on programs. within 45 days of the payment of claims. State prosecutors frequently require expert testimony about the operation of the contractor's application and the validity of the data.1 1 Section: Page: PFM024 Produce a file containing EOB information for the Department. waste. Performance Management PE02 Establish Compliance Incident NA 2 Section: Page: PFM012 Provide expert testimony to support the pursuit of indictments and convictions of providers for Medicaid fraud. add and change EOB text by EOB code. Spanish.17 2 Section: Page: Performance Management PE02 Establish Compliance Incident CA5. Performance Management PE03 Manage Compliance Incident Information CA4. The contractor must ensure that copies of evidence and documents related to the hearing are distributed to the administrative law judge and to the member and/or pharmacy provider prior to the hearing in accordance with State regulations. Plan Management PL01 Develop Agency Goals and NA Objectives 2 Section: Page: PFM008 Describe how the MMIS will maintain UT information for members Performance Management PFM009 Provide the ability to conduct pre-payment program integrity reviews to identify fraud. Chinese-Mandarin. Performance Management PE03 Manage Compliance Incident Information CA1. lock-in. PFM010 Generates automatic approval and denial notices to requesting and assigned providers.16. or some equivalent system function that will provide reports of the claim activity for these members as scheduled or requested. PE02 Establish Compliance Incident NA 1 Section: Page: PFM015 Cooperate and participate in the resolution of State Fair Hearings and Provider Disputes at the request of the State.15 1 Section: Page: PFM020 Prepare. abuse.PE01 Identify Utilization Anomalies NA 1 Section: Page: PE02 Establish Compliance Incident FI3. Allow for withholding of payments in cases of fraud Performance Management or willful misrepresentation and supports refunding of federal share of provider overpayments within 60 days from discovery of an overpayment for Medicaid services. and court cases. PE03 Manage Compliance Incident Information PI3. include English. Plan Management PL01 Develop Agency Goals and PM1. based on criteria specified via the web-based application by the Department including but not limited to: • Random sample of members who received services • Specific members • Members who received services from a specified provider • Members who received specific services • Members who received specific services from a specified Provider • Members receiving services related to a specified procedure or formulary code • Members based on specific demographic information Performance Management PE05 Prepare REOMB FI1.

PL02 Maintain Program Policy NA 1 Section: Page: PLN014 Complete a series of enhancements designed to attain target Medicaid Information Technology Architecture (MITA) maturity levels identified in the MITA State Self Assessment (SS-A) provided in the Procurement Library.23 1 Section: Page: PLN007 Ensure that the contractor's application is CMS certifiable. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN018 Provide a solution that complies with the MITA 3. including CMS certification checklists. identifier standards. produce. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN017 Support all electronic transactions covered under HIPAA in the approved electronic format using HIPAA standard codes and messages. PL02 Maintain Program Policy NA 1 Section: Page: PLN012 Complete System and Operational maintenance activities throughout the life of the contract to modify any contractor proprietary applications in accordance with State and federal mandates. and maintain all reporting functions. The contractor must modify the MMIS to remain in compliance with HIPAA requirements related to supported transaction sets as they are promulgated. All requests for access to systems and records by CMS will be read only and will come through the State agency in writing. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN010 Ensure that the contractor's application captures and maintains all data necessary. from requirements definition through implementation and operational support.8. These Plan Management enhancements will include execution of a full SDLC methodology. POS2. Changes to business rules effecting claim adjudication shall be reviewed and approved by NYS. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN009 Ensure that the contractor's application adjudicates claims. 104-191. PL02 Maintain Program Policy NA 2 Section: Page: PLN015 Maintain and operate the contractor's application in full compliance with the 45 CFR Part 164. 95-142. State and federal rules and regulations. Plan Management PL01 Develop Agency Goals and NA Objectives 1 Section: Page: PLN004 Adhere to all MECT Checklist requirements. and Part 11 of the State Medicaid Manual. throughout the contract.gov/Research-Statistics-Data-andSystems/Computer-Data-and-Systems/MMIS/MECT.e. The application must meet federal requirements for certification and licensure as Plan Management prescribed in 42 and 45 CFR throughout the contract. Certification Checklists. privacy and security standards.PLN003 Accommodate development of Medicare integration strategies. PM2. files and data elements to meet current and future federal reporting requirements. Refer to: https://www. and routinely generates data files containing up-to-date and accurate T-MSIS reporting data in accordance with the Delivery Schedules contained in CMS’ MSIS Specifications and Data Dictionary (Balanced Budget Act of 1997 [Public Law 105-33. which have been allocated Plan Management to the MDW for fulfillment. This requirement shall not Plan Management include non-proprietary discretionary maintenance activities requested by the NYS’s Medicaid program and deviate from industry standards. industry standards.1. transaction and code set standards. and to take advantage of new or emerging technologies identified by the contractor at no cost to the State. federal MMIS certification requirements. program growth. PL02 Maintain Program Policy NA 1 Section: Page: PLN016 Provide technical support to assist providers with issues and problems processing HIPAA and proprietary transaction sets. Plan Management PL02 Maintain Program Policy NA 2 Section: Page: PLN006 Develop. Plan Management PL02 Maintain Program Policy NA 2 Section: Page: Plan Management PL02 Maintain Program Policy FR1. provides the State and HHS (i. which amends section 1903(a)(3) of the Social Security Act. based on the State’s evaluation using the checklists in the CMS Toolkit as of the first day of operations.html Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN005 Develop. FR1.0 Security Framework. prior authorizations. Plan Management PL02 Maintain Program Policy PI3.L. . and c. PL02 Maintain Program Policy NA 2 Section: Page: PLN013 Provide cost and schedule estimates based upon quantitative measures to complete System and Operational enhancement Plan Management activities requested by the State. maintain and execute a proactive approach to managing all aspects of CMS Certification. and 1902(a)(7) of the Social Security Act as further interpreted in regulations at 42 CFR 431. Plan Management b.cms. PL02 Maintain Program Policy NA 2 Section: Page: PLN008 Ensure that the contractor's application issues EOBs in accordance with the provisions of Section 10 of P. and information required for payment of services in accordance with all provisions of 42 CFR 447 and the approved State Medicaid Plan. CMS and OIG) full access to.6 1 Section: Page: PLN011 Ensure that the contractor's application provides complete and accurate data to enable MDW to perform functions necessary to meet certification requirements defined in Attachment F.4.300 to 307 including but not limited to: a. P. section 4753]) (DW) or upon request of the State (and thereby CMS). HIPAA.L.

e. the core set of children’s health care quality measures. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN023 The contractor must provide necessary resources to the State for certification as per the approved Federal Certification Plan.5 1 Section: Page: PLN027 Audit compound pharmacy claims to ensure compliance with the Program’s pricing logic. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN024 The contractor must expeditiously correct any item that CMS will not certify on a schedule to be approved by CMS and the State. PL04 Manage Health Plan Information NA 3 Section: Page: PLN033 Make available to the Department one or more members of the clinical or account management team to discuss the implications of these new trends and developments. PM1.) Plan Management PL04 Manage Health Plan Information NA 3 Section: Page: PLN032 Provide information and recommendations to the Department on new generic and biological therapies prior to release into Plan Management the marketplace to the extent such information is available in the public realm. etc.20 1 Section: Page: Plan Management . upon direction by the Department. (Pub. or within the statutory discretion of the Department. PL02 Maintain Program Policy NA 1 Section: Page: PLN028 Support the assessment of health outcomes through collection. 422 “Medicare and Medicaid Programs. 413. and data extractions from medical records. Final Rule” Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN026 Provide flexibility to alter program requirements in member eligibility. and reporting on evolving health care quality measures including: health home core quality measures. 111-5) and 42 CFR Parts 412. PL02 Maintain Program Policy NA 1 Section: Page: PLN020 Apply the current Department program methodology for distinguishing between brand and generic drug product allowed to pharmacy claims adjudication.2. The health Plan Management home core set will require reporting at the health home provider level. and the anticipated impact of proposed program modifications and contemplated benefit design changes on members. aggregation. Electronic Health Record Incentive Program. a clinical evaluation. prior approval/prior authorization and utilization management immediately during a State of Emergency to meet urgent needs of providers and Plan Management members. The Department is not under any obligation to act on such advice or recommendation. The current contractor utilizes NCPDP Plan Management standard Version 5. to the extent possible. The contractor is required to transition to newer versions as they become available at no additional cost to the State. PL04 Manage Health Plan Information PM1. L. and the core set of health care quality measures for Medicaid-eligible adults as specifications are released by CMS. prescription drug mandates. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN021 Facilitate administration of the NYPS Program and EPIC Program in accordance with program policy. CMS defined measures will be determined through analysis of claims data. PL02 Maintain Program Policy SP1. Plan Management Recommendations must include a preliminary analysis of all associated costs.0 effective 1/1/12. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN034 Assist with recommendations and evaluation of proposed benefit design changes and implement any changes necessary to accommodate program modifications resulting from legislation.. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN025 Support the Medicaid Electronic Health Record Incentive Program federal initiative created by the HITECH) through ARRA.1 D.PLN019 The POS shall comply with the latest NCPDP standards and HIPAA requirements. Medicare. while the full Medicaid-eligible adult core set of health care quality measures will be reported in the aggregate at the state level. PL04 Manage Health Plan Information NA 1 Section: Page: PLN029 Provide advice and recommendations regarding the Medicaid Pharmacy program. provider enrollment. Plan Management PL02 Maintain Program Policy NA 1 Section: Page: PLN022 Document electronically and maintain knowledge of all applicable federal and State provider enrollment and certification/licensure regulations. claims. Plan Management PL04 Manage Health Plan Information NA 2 Section: Page: PLN030 Provide a semi-annual Pharmacy Benefit Management Plan that includes but is not limited to: • Analysis and report of program goals and objectives as compared to actual financial and operational performance • Recommendations for future improvements and enhancements to the programs • Analysis of changes to the pharmacy industry best practices and technical innovation that would enhance program performance and provide cost savings Plan Management PL04 Manage Health Plan Information NA 3 Section: Page: PLN031 Inform the Department in a timely manner concerning matters that may affect the Pharmacy program including but not limited to: • Cost containment • New drugs • Conversion from brand name drugs to generic drugs and how it will impact cost • Preferred Drug List configuration • Technological improvements • e-prescribing • Pharmacy innovations • Litigation • State/Federal legislation (i.

Federal Medicaid requirements and the pharmacy program benefit structure and obtain Department approval before activating the Plan Management new drugs. PL04 Manage Health Plan Information NA 1 Section: Page: PLN055 Conduct a review and evaluation of the availability and net cost of generic drugs and make recommendations for program Plan Management inclusion/exclusion at a minimum monthly. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN048 Develop educational materials to be used to encourage PDP compliance by providers.PLN035 Analyze and report on utilization of services and prescribing patterns by various member and program categories to determine the extent of participation and related cost. the Mandatory Generic Program and the Clinical Drug Review Program. POS4. and members. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN054 Monitor the pharmaceutical industry to identify generic drugs expected to enter the market. PL04 Manage Health Plan Information NA 2 Section: Page: PLN047 Administer the Clinical Drug Review Program (CDRP) that defines prior approval/prior authorization requirements for specific drug products for a specific patient based on the clinical requirements and established guidelines for the drug's appropriate use. Plan Management PL04 Manage Health Plan Information PM4. including operation of a prior approval/prior authorization function for drugs. including but not limited to: mailings. the contractor must inform the Department of anticipated shipping dates of the Plan Management first generic drug introduced into the market for one or more strengths of a particular brand name drug. as defined by the Department. Coverage parameters include but are not limited to quantity. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN052 Design and implement targeted educational interventions aimed at changing prescribing patterns of outlier prescribers. frequency and duration limits and age/gender restrictions. electronic messages. and other conditions established by the Department such as regional shortages. including but not limited to: mailings. Plan Management PL04 Manage Health Plan Information NA 3 Section: Page: PLN044 Develop clinical evaluations of relative clinical effectiveness based on thorough evidence-based pharmaceutical reviews of current literature. Plan Management PL04 Manage Health Plan Information NA 2 Section: Page: PLN039 Analyze and report actual cost savings that result from SMAC pricing periodically.3 1 Section: Page: PLN037 Establish preliminary formulary coverage parameters for new drugs based on FDA approved indications. Prior to the actual introduction of the generic drug to market. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN050 Recommend and advise on the management of drugs/classes that meet legislative criteria for the CDRP. PL04 Manage Health Plan Information NA 1 Section: Page: PLN038 Maintain a SMAC list on a schedule as determined by the Department that reflects changing market conditions including market availability of drugs. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN042 Manage and regularly review the formulary to ensure its accuracy. Plan Management PL04 Manage Health Plan Information NA 2 Section: Page: PLN046 Present reviews of all drug/classes and make recommendations for program controls and improvements to reflect updated Plan Management clinical and financial information at least quarterly.2. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN049 Design and implement targeted educational interventions aimed at changing prescribing patterns of outlier prescribers. face to face meetings with prescribers and other direct interaction with prescribers. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN041 Develop letters and educational materials in order to promote the acceptance of the Preferred Drug Program. providers. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN040 Develop information to assist providers and members in understanding all Pharmacy Management Programs. face to face meetings with prescribers and other direct interaction with prescribers. Prepare data extracts of pharmacy claims history as requested by NYS for review. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN053 Administer the Mandatory Generic Drug Program (MGDP) which identifies brand name drugs that require prior approval/prior authorization based on the availability of an A-rated generic equivalent and Department business rules. prescribers. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN045 Recommend and advise on the management of drugs/classes based on market analysis. and members. fluctuating drug prices. electronic messages. PL04 Manage Health Plan Information NA 1 Section: Page: . The Department must determine how the program's mandatory generic substitution provisions will be applied. Plan Management PL04 Manage Health Plan Information PM4.1.3 1 Section: Page: PLN036 Analyze and report to the Department aberrant utilization and prescribing patterns for prescribers. POS6. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN051 Prepare and present recommendations regarding selected drugs/classes based on clinical evaluations and utilization/market analysis to ensure the highest overall effectiveness of the CDRP program. Plan Management PL04 Manage Health Plan Information NA 2 Section: Page: PLN043 Administer the Preferred Drug Program (PDP) aimed at selected therapeutic classes or new product introductions.

) • System downtime and the reasons for said downtime and the appropriate remediation steps taken • Accuracy of system reports • General research completed at the request of Management and/or State personnel • Performance against SLAs defined in this RFP • Data delivery performance • Data quality Plan Management PL05 Manage Performance Measures NA 2 Section: Page: PLN066 Develop and implement corrective action plans. and the QA contractor. reference. clerical.PLN056 Notify the Department regarding drugs that will result in a lower net cost to the program by enforcing mandatory generic substitution. approved by the Department. Plan Management PL05 Manage Performance Measures PM5.e. including but not limited to: mailings. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN068 Review manual. the contractor must survey retail pharmacies to identify the pharmacies that are unable to obtain the new generic drug within 21 days after the first date of shipment. may determine that enforcement is contrary to the best financial interests of the program and shall inform the contractor whether mandatory substitution shall be applied. along with other pricing rules (such as lesser of logic). and operating procedures annually for setting accuracy and error levels and for monitoring compliance. provider. OSC. The Department. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN064 Perform regular and ongoing State-approved Quality Assurance (QA) reviews of operations. The Department. begin enforcement as soon as practicable but in no event later than 14 calendar days after the first date of shipment provided that the network pharmacies are able to obtain the generic drug. client eligibility for dates of service. • System edits and audits for posting accuracy • Service authorizations for appropriateness and accuracy • Database and file updates to ensure timeliness and accuracy (i. as determined by the Department. face to face meetings with prescribers and other direct interaction with prescribers. The contractor will not consider and shall not act on availability information provided by 3rd party sources. in its sole discretion. The Quality Management Plan shall be updated annually thereafter. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: . PL04 Manage Health Plan Information NA 1 Section: Page: PLN059 Design and implement targeted educational interventions aimed at changing prescribing patterns of outlier prescribers. including but not limited to Medi-Span and First Data Bank. etc. Plan Management PL05 Manage Performance Measures NA 2 Section: Page: PLN063 Submit a Quality Management Plan to the Department for approval within at least thirty (30) days of contract execution. at a minimum. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN061 Perform administration of the Preferred Diabetic Supply Program (PDSP).. on a monthly basis. and with Department approval. eligibility. in its sole discretion. and shall be submitted each year to the Department for approval. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN057 Notify the Department regarding drugs that could potentially result in a higher net cost to the Program by enforcing mandatory generic substitution. etc. based upon the findings made by the Department. Plan Management PL04 Manage Health Plan Information NA 2 Section: Page: PLN062 Internally track performance and continuously investigate and present ways to improve contractor performance under the contract. These procedures shall be conducted. In Plan Management the event the Department decides to exercise its discretion not to enforce mandatory generic substitution. PL04 Manage Health Plan Information NA 1 Section: Page: PLN058 Assist the Department in determining whether or not mandatory generic substitution should be enforced. electronic messages. shall determine based on such evidence how the program’s mandatory generic substitution provisions will be applied.1 1 Section: Page: PLN065 Report monthly on its continuous review. and evaluation of: • Monthly samples of both hard-copy and electronically submitted Medicaid claims to evaluate system integrity through accuracy of claims payment. CMS. Plan Management PL04 Manage Health Plan Information NA 1 Section: Page: PLN060 Review Medicaid program and financial results and make recommendations for program improvements. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN067 Provide State staff access to the quality management tool(s) used by contractor staff and the ability to produce reports. the contractor shall apply SMAC pricing to the generic drug when dispensed. Report the findings from this review to the Department. The contractor must submit this information to the Department and provide any additional Plan Management information as required by the Department to reach a determination.

PM5. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: .9 1 Section: Page: PLN078 Provide a tool-based repository and managed workflow approach that supports data extraction and distribution of data maintained within the contractor's application and secure access to the data delivery functionality.5 2 Section: Page: PLN070 Measure and report monthly performance against the Service Level Agreements (SLA) in this RFP. CA2.4. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN074 On an ongoing basis. POS2. conformity. integrity. process improvements and the COTS business rules engine • System ease of use • Training programs • Data quality • Testing processes and procedures Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN075 Produce all reports necessary to oversee the MAS contract. charts. CA2. and a list of users of each standard PM report. CSV and XML) to generate MDW report distribution and/or other data archiving.3. and a summary of project risks and issues.8 3 Section: Page: PLN071 Measure and report monthly performance against the PMP. and monitor contractor compliance with service level agreements Plan Management PL05 Manage Performance Measures PM5. activities by work stream. This template shall be submitted to the State within 30 calendar days of contract award. summarize errors/defects in the data residing in the MAS Plan Management • Include error/exception handling processes that will identify/isolate the errant data • Include audit and control processes that will prove that the contractor's application was populated accurately and completely • Test and validate data quality requirements • Evaluate data quality service levels • Manage data quality issues and validate manipulated data items agree with the results of that manipulation • Clean and correct data quality defects • Design and Implement Data Quality Management Operational Procedures • Monitor Data Quality Management Operational Procedures • Monitor Data Quality on all outbound data delivery tasks PL05 Manage Performance Measures CA2. PM5.PLN069 Provide Data Quality Management activities that meet the following requirements: • Develop and promote data quality awareness • Develop comprehensive data quality requirements • Define specific Data Quality metrics and business rules • Provide a tool that supplies data profiling capabilities that will obtain comprehensive and accurate information about the content. Plan Management PL05 Manage Performance Measures POS2. and structure of data in the source systems as an on-going process • Provide the data profiling metrics such as completeness. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN073 Provide monthly status reports which provide a brief summary of weekly reports and SLA performance metrics. PL05 Manage Performance Measures PM5 1 Section: Page: PLN077 Perform data extracts (at a minimum daily) from the contractor's application for the MDW and other external systems as specified by the Department including but not limited to: • Provider data • Member data • Claims data • Prior approval/prior authorization data • Financial data • Reference data Plan Management PL05 Manage Performance Measures PM1. POS2. • Continually measure and monitor the data quality within the MAS • Include audit and control processes that will identify.g. report. their intended use.6. and accuracy in easy-to-understand reports. quality. maintain comprehensive list of standard PM reports. Plan Management PL05 Manage Performance Measures NA 2 Section: Page: PLN072 Develop a weekly status report to provide the State with an update on the progress towards achieving goals stated in the work plan.7. consistency. user and programmer training. graphs. duplication. etc.3 1 Section: Page: PLN076 Generate data for federally mandated reports for review of the State including data extract formats required for the MDW Plan Management (e.2. monitor and improve: • System performance • Database performance • Network performance • Development time through the use of tools. CA2.2.

Maintain and display an audit trail of all information changes. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN080 Research and respond to questions or issues raised by the Department or external organizations related to information in any data extract. Plan Management PL07 Manage Reference Information CA1. The contractor shall submit a plan to the Department for establishment of these committees within 90 days of contract award. table unloads). monthly and quarterly operating statistics reports to the State which provide summary information on all aspects of the contractor operations. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN083 Provide the capability to identify.2 1 Section: Page: PLN092 Receive.10. flat files.45) enrollment.g. timely payment (timely processing of provider claims 42 CFR 447.g. Gender. participation metrics and projection. trending. biweekly.14 1 Section: Page: . incorrect values. including errors in changes and suspended changes. Provide the Department with ad hoc reporting capability. forced.g. PL05 Manage Performance Measures NA 1 Section: Page: PLN094 Provide online access to all reference tables with inquiry by the appropriate code. and operational statistics. as appropriate. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN098 Provide and maintain.PLN079 Provide the capability to extract and distribute full and/or incremental datasets from the contractor's application in an industry standard format (e. Plan Management PL07 Manage Reference Information RF2. RF1. Diagnoses. Additional documentation and related materials requested by the Department shall be provided no later than twenty-four (24) hours after the request.g. The reports must summarize the Plan Management significant outcomes of each of the functional areas of responsibility such as claims processing. missing values. ICD-9..11 1 Section: Page: PLN087 Provide monthly and annual AIHP and Cystic Fibrosis Program reporting to the department (and to each tribe) for services and members served including but not limited to monthly or annual claim totals. This documentation must show the results of each test and will be submitted to the Department no later than one (1) week after the test. and utilization. Plan Management PL07 Manage Reference Information RF1. and the date that the error was resolved. etc. overall Expenditures and expenditures by service type. irrespective of other requirements in Attachment E. error/exception handling. balancing. force or deny indicator. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN081 Provide the capability to publish (“push”) the data to a destination where the data consumer can then retrieve (“pull”) the data. XML. which might enhance the efficiencies. PL05 Manage Performance Measures NA NA Unscored Section: Page: PLN090 Establish committees with consumer and provider representation to provide advice and guidance to the Department and contractor regarding the ongoing services provided under this RFP. Plan Management PL05 Manage Performance Measures NA 2 Section: Page: PLN091 The contractor may be required to submit weekly. and inconsistent values of the data sources and to continually monitor the quality of the data extracted. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN086 Conduct walkthroughs and document results from the contractor executed System Testing. quality and process measures from Lead Health Homes Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN093 Produce all reports necessary to oversee the New York State Medicaid EHR Incentive Program For Eligible Professionals Plan Management (EPs) and Eligible Hospitals (EHs) including. Plan Management PL05 Manage Performance Measures NA 3 Section: Page: PLN089 Describe innovations that can be provided by the contractor’s system. for each error code. PL05 Manage Performance Measures PM2. Plan Management PL05 Manage Performance Measures BE1. and report data quality/defect issues including data redundancy. an override. or denied. cost savings and quality improvements of the State Medicaid program. but not limited to. diagnosis and drug reference files prior to each payment cycle when required. process and submit to the MDW for analysis. and/or access for State of NY Medicaid population at no additional administrative cost. (e. call center. RF2.14 2 Section: Page: PLN097 Update all procedure. waiver services). a resolution code.9 1 Section: Page: PLN095 Manages and Maintains all data sets defined by the HIPAA Implementation Guides to support all transactions required under HIPAA Administrative Simplification Rule (e. Reason Code) and HIPAA-required external data sets (e. These must Plan Management be available at no additional cost should the Department choose to take advantage of them.1.11 1 Section: Page: PLN084 Maintain extract files and summary of history file transfers online for a minimum of 6 months with the ability to archive extract files and summary of history file transfer for a period of 5 years. Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN082 Provide the capability to trace and monitor the batch processes by including audit and control.. medical cost. Plan Management PL07 Manage Reference Information RF1. CSV. Plan Management PL05 Manage Performance Measures RF1. These provisions will be evaluated by the Department and included. NDC). Plan Management PL05 Manage Performance Measures NA 1 Section: Page: PLN088 Propose any best practices from other “clients” or existing operations to improve the quality. Plan Management PL05 Manage Performance Measures BE1.7 3 Section: Page: PLN085 Disclose all deficiencies found by the contractor within no more than one (1) business day to the Department. tax match. fiscal activities.2 1 Section: Page: PLN096 Supports code sets for the payment of Medicaid-covered non-health care services. in the final contract. The contractor must seek state staff input for required data and format these reports in a State approved format. correct.

RF1.8. OTC items. and respond to queries and report requests for all current and historical reference information including but not limited to: • Procedure Code • Claim Edit Status and Disposition • Prior approval/prior authorization Edit Status and Disposition • Procedure Pricing • Revenue Code • Products of Ambulatory Care (PAC)/Products of Ambulatory Surgery (PAS) Grouper • Diagnosis Code • Drug (NDC) • Formulary code • DRG • E-APG • Per diem rates.9 1 Section: Page: PLN107 Resolve provider appeals related to SMAC pricing directly with the pharmacy in accordance with procedures developed by the contractor and approved by the Department. RF1. RF1. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN101 Support the receipt and processing of Medicare physician fees for Primary Care Payment Bump. For example.4.3.18. Plan Management PL07 Manage Reference Information NA 1 Section: Page: Plan Management PL07 Manage Reference Information RF1. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN100 Support the receipt and processing of DRG Code Interface. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN102 Support the receipt and processing of Health Professional Shortage Areas files. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN105 Update and maintain all current and historical variations of lists for drugs that apply to specific Pharmacy Management programs including but not limited to: • Preferred and non-preferred drugs • CDRP drugs • MGDP and brand less generic Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN106 Update the SMAC list and make corresponding updates to the drug formulary for pricing claims on a schedule determined by the Department. CMS HCPCS update files following the state's process and other procedure code files and the Mandate Lab Update file. RF1. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN103 Support the receipt and processing of revenue code information from the National Uniform Billing Committee (NUBC) files. archive. add and change ICD-9 & ICD-10 Procedure Code information on the reference registry via the web-based application. and changes to previously Plan Management determined SMAC prices for drugs that have been reclassified (changed GSNs) or otherwise modified to cause a different SMAC price to apply. RF1. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN110 Provide the capability to inquire on. and injection codes • Drug-pricing file • Trauma indicators to identify potential TPL cases • Diagnosis and procedure code narrative descriptions of each code • Date parameters for all Reference Data PLN109 Provide the capability to inquire on. update.9 3 Section: Page: PLN108 Maintain.17.12. RF1.13. PM2. • Resource Utilization Groups (RUG) • Remittance Text • Drug Group Plan • Provider Rate Code and Price • Coverage status and pricing information on legend drugs.PLN099 Support the receipt and processing of ICD-9 & ICD-10 Diagnosis and Procedure files from CMS and show how ICD-10 will be integrated into claims payment. these updates would include SMAC prices for new products. RF1. Also will need to process update requests from the state as needed. PL07 Manage Reference Information POS2. E-APG grouper and other grouper files. Plan Management PL07 Manage Reference Information NA 1 Section: Page: . Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN104 Support the receipt and processing of all other benefit/reference files.15. process. add and change Diagnosis Code information via the web-based application.16. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN111 Support Medicaid provider and partners throughout the ICD-10 transition including testing of files making the transition to ICD-10. RF1.

Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN121 Provide the capability to inquire on. add. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN120 Accept and process the Health Professional Shortage Areas (HPSA) file. PL07 Manage Reference Information NA 1 Section: Page: PLN119 Provide capability to inquire on. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN122 Accept and process revenue code information from the National Uniform Billing Committee (NUBC). add and change via the web-based application date specific medical limit and step therapy edit information within the Reference registry. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN125 Provide the capability to inquire on. add. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN114 Accept and process the Bureau of Narcotics Enforcement (BNE) Prescription Serial Number Interface File.g. delete and change via the web-based application Procedure Code information as Plan Management specified by the Department. add and change via the web-based application revenue code information including: (a) Coverage information (b) Restrictions (c) Service limitations (d) Automatic error codes (e) Pricing data (f) Effective dates for all items Plan Management PL07 Manage Reference Information RF1. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN130 Provide the capability to develop new medical limit and step therapy edits and modify existing system or contractorsupplied edits based on user-defined configurable criteria. PL07 Manage Reference Information NA 3 Section: Page: PLN128 Provide the capability to develop new ProDUR edits and modify existing contractor-supplied ProDUR edits based on user-defined configurable criteria. add and change Prescription Serial Number information via the web-based application. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN123 Provide the capability to inquire on. including but not limited to revenue code pricing. add and change via the web-based application date specific Claim Edit information within the Reference registry including but not limited to: • Claims Edit Status • Claim Edit Status HIPAA Codes • Claim Edit Disposition • Claim Edit Status Resolution Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN126 Provide the capability to enter and maintain text notes associated with claim edit status information. add. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN115 Provide the capability to inquire on. excel spreadsheets) as specified by the Department. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN129 Maintain all current and historical reference information related to medical limit and step therapy editing for pharmacy claims.15 1 Section: Page: PLN117 Accept and process the CMS Mandate Lab Update File.11 1 Section: Page: PLN124 Provide capability to inquire on. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN132 Provide the capability to inquire on. delete and change price information via the web-based application. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN118 Provide the capability to inquire on. Plan Management PL07 Manage Reference Information NA 1 Section: Page: . Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN127 Update ProDUR with the most current parameters used in patient drug therapy safety edits (ProDUR edits) as updates for Plan Management these parameters become available. including but not limited to procedure pricing. Plan Management PL07 Manage Reference Information PM1. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN116 Accept and process the quarterly and annual Healthcare Common Procedure Coding System (HCPCS) Update files received from CMS. add and change HPSA information via the web-based application. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN131 Update medical limit and step therapy edits with the most current parameters as updates for these parameters become available.PLN112 Maintain grouper processes to support claims processing and pricing including but not limited to: • AP-DRG • APR-DRG • E-APG Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN113 Accept and process at a frequency specified by the Department proprietary formats and industry standard formats (e. delete and change price information via the web-based application.

NDC. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN138 Maintain a drug formulary. dollar amount. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN137 Provide the capability to specify the reasons that a prior approval/prior authorization is required for a particular drug including but not limited to program association (Preferred Drug Program... Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN141 Provide the capability to inquire on and change Drug information including but not limited to: • Drug Mass Change • DUR Filter Plan Management PL07 Manage Reference Information NA 3 Section: Page: PLN142 Maintain historical and date/time-sensitive drug formulary information to support claims processing and research including all historical formulary information for fields defined by the Department. Plan Management PL07 Manage Reference Information NA 3 Section: Page: PLN139 Accept and process files to update drug formulary information in the Reference registry as required by the Department. Drug coverage and limitations include. pricing and other MMIS functions. i. in accordance with Department business rules. (i. dollar amount. begin date and SMAC price amount. add. days’ supply.e. GSN.e. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN136 Provide the capability to establish prior approvals/prior authorizations at all levels contained in the drug formulary file including but not limited to GCN.PLN133 Provide the capability to inquire on. units. i. delete and change via the web-based application date specific prior approval/prior authorization edit information within the Reference registry including but not limited: • Prior approval/prior authorization Edit Status information • Prior approval/prior authorization Edit Disposition/Resolution • Prior approval/prior authorization Status Routing information PLN134 PL07 Manage Reference Information NA 1 Section: Page: Incorporate prior approval/prior authorization review criteria and written guidelines for prior approval/prior authorization Plan Management request processing as approved by the Department. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN140 Process the SMAC update file containing drug Generic Code Number Sequence Numbers. Plan Management PL07 Manage Reference Information NA 3 Section: Page: PLN143 Provide the capability via the web-based application to search and inquire on historical and date/time-sensitive drug formulary information. PL04 Manage Health Plan Information NA 1 Section: Page: PLN135 Provide the capability to enter and maintain text notes associated with prior approval/prior authorization edit status information. and GPI. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN145 Identify brand and generic drugs consistent with the Department's methodology. characteristics and pricing.. days’ supply • Limits over time. Plan Management PL07 Manage Reference Information NA 3 Section: Page: PLN144 Maintain drug formulary data necessary to identify reused NDCs and provide historical access to their former formulas. and Mandatory Generic Program) or age/gender edit override. therapeutic class) that may vary by population or plan and their effective dates. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN146 Provide the capability to apply and maintain indicators and their effective dates to identify drug attributes that include but are not limited to the following: • preferred drug status • NYS therapeutic code • HIV indicator Plan Management • Medicare indicator • Family planning indicator • Prior approval/prior authorization requirements • Other indicators defined by the Department PL07 Manage Reference Information NA 3 Section: Page: PLN147 Maintain drug coverage and/or limitations specified at various levels. NDC. but are not limited to: • Coverage/non-coverage • Prior approval/prior authorization requirements • Minimum and maximum days' supply limits • Member age and/or sex • Claim level limits. refills • Less than effective drugs (per Drug Efficacy Study Implementation or DESI) indicator • Nursing Home carve out status • Child Health Status • Co-Pay exempt status • Diagnosis • Unbreakable package indicator PL07 Manage Reference Information NA 3 Section: Page: Plan Management Plan Management .e. CDRP. units. to support pharmacy drug claim adjudication.

including participating in any pilot or demonstration programs for the FFS population. on a timetable determined by the Department.PLN148 Update the drug formulary on a Department approved schedule that ensures pharmacy claims are paid according to the most current drug data available. Medi-Span. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN154 Maintain the benefit package associated with each program and recommend changes due to the release of New codes or services. if drug pricing source stores 10 occurrences of AWP price. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN149 Provide the capability to accept and process drug data from multiple contractors. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN161 Support all channels approved by the Department for provider rate setting transactions including. Plan Management PL08 Manage Rate Setting NA 1 Section: Page: PLN162 Accept and process provider rate setting transactions in industry standard formats Plan Management PL08 Manage Rate Setting NA 1 Section: Page: . including but not limited to: • Preferred Drug Program • Specialty Pharmacy • CDRP • Mandatory Generic Programs Make lists available to the public via the Web Portal in formats approved by the Department.) must be utilized for formulary maintenance. and Micromedex. and ensure that pharmacy claims are reimbursed according to the most current drug data available Plan Management PL07 Manage Reference Information NA 3 Section: Page: PLN159 A nationally recognized drug database source. while other contractors may be the source of specialized or proprietary drug data. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN158 Maintain and update. or other significant changes occur affecting reimbursement. PL07 Manage Reference Information NA 1 Section: Page: PLN151 Maintain listings of drugs that are specific to pharmacy management programs. Read only on-line access to the formulary file data must be made available to staff at the State designated location. including but not limited to First Data Bank. Medispan. etc. unavailable and/or NYS legislation changes the basis of reimbursement from AWP to an alternative benchmark. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN150 Maintain unlimited historical pricing segments. a drug formulary file to support pharmacy drug claim adjudication and the Program’s defined pricing. unrestricted by the limitations of the pricing data source (i. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN153 Maintain a record of the related benefit package for each claim. but not limited to. in a timeframe negotiated and approved by the Department.g. (e. based on a Department approved schedule. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN155 Create benefit packages for programs under the contract as specified by the State. In the event the statutorily mandated methodology of reimbursement changes during the term of the agreement. weekly to disallow coverage for drugs excluded due to changes in Drug Efficacy Study Implementation (DESI) status. An update of the drug formulary file must be performed at a minimum. via the Web Portal in formats approved by the Department. Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN160 Maintain drug pricing data necessary to support Program pricing methodology. the contractor's drug pricing is not limited to 10 occurrences but must Plan Management maintain historical price spans that drop off the contractor's source file).. the Department reserves the right to require the contractor to adjust the fixed discounts and/or utilize alternative pricing benchmark(s) in order to maintain an equivalent level of discount to the Program at no additional cost to the State. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN152 Provide the capability to publish current formulary information. One drug data contractor may be the primary source of drug data within the MAS. process claims with the State-defined brand/generic classification and subject the claims to pass through pricing. The Program will continue to utilize AWP as the basis of pricing until such time as it is determined by the Department to be obsolete. Plan Management PL07 Manage Reference Information NA 2 Section: Page: PLN156 Accept claims for recipients determined eligible by the Tribal nations approved to submit AIHP claims Plan Management PL07 Manage Reference Information NA 1 Section: Page: PLN157 Successfully implement program changes passed by the State.e. emailing an excel file.

Provider Management PM01 Manage Provider Information PR4. and update provider rate information via the web-based application.2 1 Section: Page: PRV009 Requires (when appropriate). Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV002 Produce comprehensive statistical profiles of provider health care practices by peer groups for all categories of service(s) authorized under the Medicaid program. Provider Management PM01 Manage Provider Information PI1. and maintains the 10-digit National Provider Identifier.PLN163 PLN164 Maintain provider rate setting data with date specific history as required by Department business rules including but not limited to: • Rate codes • Location codes • Effective dates • Rate amount • Rate type code • Rate status code • Retroactive rate status • Inclusion code • Rate setting agency Provide the capability to manage various rate based reimbursement methodologies. Plan Management PL08 Manage Rate Setting NA 1 Section: Page: PLN166 Review batches and delete. including but not limited to: • Inpatient (DRG/Day) • Outpatient & Clinics (APG/Visit) • Nursing Homes • Managed Care Plans • Location-based reimbursement (institution/region) Plan Management PL08 Manage Rate Setting NA 1 Section: Page: Plan Management PL08 Manage Rate Setting POS2.2 1 Section: Page: PRV010 Interfaces with the National Plan and Provider Enumerator System (NPPES) to verify the NPI of provider applicants and map NPI identifiers to internal assigned numbers.5 1 Section: Page: PRV007 Displays all data by NPI or by a subset of the provider’s practice.15 3 Section: Page: PLN165 Process provider rate transactions batches received from rate setting agencies. PR4. Provider Management PM01 Manage Provider Information PI1.4.5. Provider Management PM01 Manage Provider Information WA5. Assign and maintain unique provider numbers for providers not Provider Management required to obtain an NPI number that shall not duplicate any number assigned by the NPPES. Batches must be approved to be added to the provider rate registry. The transactions must be edited based on business rules and held for review and final approval through the web-based application. Plan Management PL08 Manage Rate Setting NA 1 Section: Page: PRV001 Support the State assess of adequacy of the NYS FFS provider network. New and Plan Management updated transactions must be edited based on Department business rules. PR4.1 1 Section: Page: PRV003 Identifies deficiencies and generates reports on levels of care and quality of care by provider type.4 1 Section: Page: . accepts the NPI in all standard electronic transactions mandated under HIPAA. PR1. PM01 Manage Provider Information PR1. Flags and routes for action if multiple internal State assigned provider numbers are assigned to a single provider. Provider Management PM01 Manage Provider Information PI1. PM3. enter.3 1 Section: Page: PRV005 Provide the capability to profile provider groups and individual providers within group practices.2 1 Section: Page: PRV004 Analyze and produce reports on the details of the practice of providers identified as exceptions or outliers. PL08 Manage Rate Setting NA 1 Section: Page: PLN168 Provide the capability to produce hard copy and/or electronic notice of rate code changes for providers as required by the Department including but not limited to: • New rate codes added • Existing rate codes closed • Rate amounts changed Plan Management PL08 Manage Rate Setting NA 1 Section: Page: PLN169 Provide the capability for users of the provider area of the Web Portal to view provider rate information related only to their provider identification number.4 1 Section: Page: PRV006 Automatically identify exceptions to norms of practice established by the agency for any type of provider covered by the State plan. modify.1. Provider Management PM01 Manage Provider Information PI1. This includes identifying and collecting data on the number and types of providers and provider locations. Provider Management PM01 Manage Provider Information PI1. approve or reject individual records via the web-based application. Provider Management PM01 Manage Provider Information PI1. PR4. view.3.5. Plan Management PL08 Manage Rate Setting NA 1 Section: Page: PLN167 Provide the capability to search.6 1 Section: Page: PRV008 Provide ongoing monitoring of Medicaid and waiver programs provider capacity and capability to provide services to enrolled participants in terms of member access to health care.

6 2 Section: Page: PRV023 Maintain facility data with date specific history as required by Department business rules. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV024 Maintain Public Goods Pool data with date specific history as required by Department business rules. and adjustment transactions. middle name. numbers used before the NPI was established. PR3. authorized submitter. PR2. Provider Management PM01 Manage Provider Information PR3. and supporting documents • Hard copy and fax disenrollment requests • Hard copy and fax provider information maintenance requests Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV020 Provide imaging services for all existing hard copy provider enrollment files within 24 months of the implementation. certification numbers (e. Provider Management PM01 Manage Provider Information PR1. Provider Management PM01 Manage Provider Information NA 2 Section: Page: PRV018 Provide technical support for providers using the provider area of the Web Portal to: • View provider related information • Process provider enrollment applications and maintenance transactions • Process member eligibility verification transactions • Process prior approval/prior authorization transactions and TOAs • Process claims transactions • Process ETIN.4. PR3. multiple provider specific reimbursement rates with begin and end dates.. and other State health care program participants. OCR and/or data enter. FI3.3 1 Section: Page: PRV022 Maintain provider data with date specific history as required by Department business rules including but not limited to : NPI. initial. last names. etc. and business or corporate names and to allow flexible searches based on the provider name. and data exchange agreement transactions • Other transactions identified by the Department Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV019 Image. EFT. as determined by Department business rules. Provider Management PM01 Manage Provider Information PR3. history of claim recovery. PR2. with a searchable reason and explanation. Drug Enforcement Provider Management Administration (DEA) numbers. Provider Management PM01 Manage Provider Information FI2. index and route for processing: • Hard copy enrollment applications. ownership. PR3. waivers. multiple provider roles. send email or letter requesting information to the applicant. multiple NPIs for different subparts).1 1 Section: Page: .5 2 Section: Page: PRV012 Maintain indicators to identify providers that are FFS. and specific procedures each provider is authorized to cover. first name. PM01 Manage Provider Information PR1.2 1 Section: Page: PRV016 Produce annual hospice reports showing a comparison of hospice days versus inpatient days for each enrolled hospice members and for all hospice providers. and degrees (for example) to be divided into separate fields. Web Portal user. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV021 Accept and capture provider maintenance updates and supporting materials via hard copy. MCO network only. Provider Management PM01 Manage Provider Information PR4.PRV011 Provide the ability to manage relationships to other Medicaid provider IDs for the same provider (e. and update information based on policies established by the Department via the web-based application. fax. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV025 Provide the capability to review provider information maintenance requests and all supporting materials. members. edit. or Web Portal.4. Facilitate distribution / collection to or from the appropriate parties. allowing last name. member and/or transaction. verify credentials available through electronic interfaces or using information available from the MAS.g.10 1 Section: Page: PRV013 Use consistent provider naming conventions to differentiate between first names. Provider Management PM01 Manage Provider Information PM1.12 1 Section: Page: PRV014 Record the provider termination and/or denial reason/explanation. Captures/crosswalks subpart NPIs used by Medicare (but not Medicaid) to facilitate coordination of claims processing. Provider Management PM01 Manage Provider Information PR3.g. credentials.1. or insurers. Contractor staff must provide on-site assistance to a provider whenever requested.7.). current and historical multiple address capabilities for providers. erroneously issued prior numbers.16 1 Section: Page: PRV017 Conduct provider training sessions each year and tailor these sessions to the needs of the new provider as well as providers that are experienced in billing for Medicaid services. verify. Clinical Laboratory Improvement Amendments (CLIA) certification. Imaging services include the electronic association of the document to the appropriate provider. Track and control reconciliation of errors in transactions that are intended to update provider information. Sessions must also be tailored to provider type. Provider Management PM01 Manage Provider Information WA2.7. demographic data.4 1 Section: Page: PRV015 Process and maintain all data from provider credit.8. including providers.

note application deficiencies. pend. Notify Department as specified by the Department.8 2 Section: Page: PRV027 Provide the capability to associate (affiliate) an enrolled provider with practices (enrolled and unenrolled) for any of the following relationships that apply via the web-based application: • Hospital-based practitioner to hospital • Clinic-based practitioner to clinic • Resident or intern to hospital • Other associations Maintain information including but not limited to the effective date spans for the relationship and practice locations. Errors returned must be clearly identified to facilitate correction by the user. validity. validity. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV035 Provide the capability for applicants to check the status of ETIN application processing through the provider area of the Web Portal. CLIA. Provider Management PM01 Manage Provider Information PR3. and imaging centers • Other institutional or clinic-based locations • Service bureaus • Pharmacy Chain • Supervising Pharmacists • Practice Types • State Agency • Program Area • MCO • Ownership • Other associations • Health Home Maintain information including but not limited to the effective date spans for the relationship and practice locations. process and maintain information received from external sources (e. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV032 Provide the capability to image.g. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV034 Provide the capability through the provider area of the Web Portal to modify. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV038 Process Web Portal users registration for access to the secure areas of the portal based on security rules defined by the Department. and completeness. and completeness. send email or letter requesting information to the applicant. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV036 Review ETIN applications. inter-field relationships. PM01 Manage Provider Information NA 1 Section: Page: PRV029 Produce and transmit extract files to external entities containing provider information in a format and at a frequency specified by the Department. save and delete ETIN applications entered prior to submission. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV031 Maintain ETIN information with date specific history as required by Department business rules. along with the capability to review and/or print applications prior to and after submission. Errors returned must be clearly identified to facilitate correction by the user. NYS Education Department. deny PM01 Manage Provider Information NA 1 Section: Page: PRV037 Maintain Web Portal user information with date specific history as required by Department business rules. Provider Management PM01 Manage Provider Information PR3. Provider Management PM01 Manage Provider Information NA 1 Section: Page: .2 1 Section: Page: PRV030 Edit provider maintenance information based on Department business rules for data presence.. x-ray-facilities. CMS Provider Management and NPPES) related to both enrolled and unenrolled providers. inter-field relationships. Provider Management PM01 Manage Provider Information NA 2 Section: Page: PRV028 Receive.PRV026 Provide the capability to associate (affiliate) an enrolled provider with another enrolled provider via the web-based application for any of the following relationships including. but not limited to: • Entity number • Group practice • Emergency room physician group • Clinic • Partnership • School-based association • Mental health or other case management team • Independent laboratories. and Provider Management set application status to approve. index and associate hard copy and fax ETIN applications Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV033 Edit ETIN applications entered through the provider area of the Web Portal based on Department business rules for data presence.

inter-field relationships. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV044 Maintain EFT information with date specific history Provider Management PM01 Manage Provider Information PR3. note application deficiencies. or deny.PRV039 Edit Web Portal user applications entered on the Web Portal for data presence. Provider Management PM01 Manage Provider Information PR3. Errors returned must be clearly identified to facilitate correction by the user. and completeness.11 1 Section: Page: PRV045 Provide the capability to image. inter-field relationships. along with the capability to review and/or print maintenance requests prior to and after submission. PM01 Manage Provider Information NA 1 Section: Page: PRV041 Track each Web Portal user application through all the steps in the application process Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV042 Provide the capability for applicants to check the status of Web Portal user application Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV043 Review Web Portal user applications. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV040 Provide the capability to modify. and the Web Portal. send email or letter requesting information to the applicant. Errors returned must be clearly identified to facilitate correction by user. validity. and completeness. save and delete Web Portal user applications entered prior to submission. fax. save and delete ETIN maintenance requests entered prior to submission. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV056 Review and update ETIN maintenance requests based on policies established by the Department via the web-based application. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV050 Review EFT applications. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV058 Perform mass updates to ETIN information as requested by the Department. send email or letter requesting information to the applicant. index and associate hard copy and fax EFT applications Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV046 Edit EFT applications entered through the Web Portal for data presence. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV062 Image.9 1 Section: Page: PRV059 Support the annual ETIN re-certification process in accordance with Department business rules. validity. and completeness. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV055 Provide the capability through the provider area of the Web Portal to modify. index and associate hard copy and fax Web Portal user maintenance requests and route for processing via the Workflow Management System. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV060 Automatically grant a grace period as specified by the Department before terminating an ETIN when it reaches the expiration date. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV051 Provide the capability to transmit a test EFT to the designated Financial Institution and verify that the EFT transaction was processed in accordance with Department policies and procedures. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV061 Accept Web Portal user maintenance requests via hard copy. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV053 Image. and set application status to approve. add and update ETIN information as required by the Department via the web-based application. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV047 Provide the capability for applicants to check the status of EFT application processing through the provider area of the Web Portal. inter-field relationships. along with the Provider Management capability to review and/or print applications prior to and after submission. validity. index and associate hard copy and fax ETIN maintenance requests Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV054 Edit ETIN maintenance requests entered through the provider area of the Web Portal based on Department business rules for data presence. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV048 Provide the capability to review and update EFT applications based on policies established by the Department via the web-based application. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV052 Accept ETIN maintenance requests via hard copy. pend. Provider Management PM01 Manage Provider Information NA 1 Section: Page: . Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV049 Provide the capability to view. and the Web Portal. or deny via the web-based application. note application deficiencies. fax. add and update EFT information as required by the Department via the web-based application. and set application status to approve. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV057 View. pend. Errors returned must be clearly identified to facilitate correction by user.

index and associate hard copy and fax EFT maintenance requests . and completeness. validity.2 1 Section: Page: . Provider Management PM01 Manage Provider Information PR3.11 1 Section: Page: PRV074 Review and update EFT maintenance requests based on policies established by the Department via the web-based application. and managed care plan rosters containing all of the providers and members in their network. Specialty Board certification as appropriate. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV065 Review and update Web Portal user maintenance requests based on policies established by the Department via the webbased application. WA2. Provider Management PM01 Manage Provider Information ME2.4. along with the capability to review and/or print maintenance requests prior to and after submission.3. and any other State and/or federal requirement. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV066 View. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV075 View. along with the capability to review and/or print maintenance requests prior to and after submission. and completeness.11 1 Section: Page: PRV070 Image. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV073 Maintains a flag for providers who are eligible to use EFT and generate an electronic receipt notification for EFT maintenance requests entered through the provider area of the Web Portal that contains provider information as specified by the Department. and the Web Portal.1. save and delete EFT maintenance requests entered prior to submission. Provider Management PM01 Manage Provider Information PR3. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV071 Edit EFT maintenance requests entered through the provider area of the Web Portal based on Department business rules for data presence. inter-field relationships. State licenses. Provider Management PM01 Manage Provider Information WA2. PR2. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV067 Perform mass updates to Web Portal user information as requested by the Department. member and/or transaction.9 1 Section: Page: PRV077 Provide imaging services for all transactions including but not limited to: • Forms • Correspondence • Other documents Imaging services include the electronic association of the document to the appropriate provider. group or by zip code as instructed by the Department. Errors returned must be clearly identified to facilitate correction by user. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV069 Maintain EFT information with date specific history as required by Department business rules. Notify providers.1 2 Section: Page: PRV080 Provide the capability to restrict prior approvals/prior authorizations for a specific provider. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV081 Receive and process Lead Health Homes. Provider Management PM01 Manage Provider Information PR3. MC1. that are due for recertification prior to the end date of the current license. geographic locations. inter-field relationships. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV076 Perform mass updates to EFT information as requested by the Department. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV072 Provide the capability through the provider area of the Web Portal to modify. Errors returned must be clearly identified to facilitate correction by the user. add and update Web Portal user information as required by the Department via the web-based application. Provider Management PM01 Manage Provider Information PR2. capitation or FFS rates. in writing. Primary Care Physician. add and update EFT information as required by the Department via the web-based application. according to business rules. on entity or individual meeting the qualifications contained in the provider agreement. or provider agreement.PRV063 Edit Web Portal user maintenance requests entered through the provider area of the Web Portal based on Department business rules for data presence. fax. review team visits when necessary. certification/ licensure.2 2 Section: Page: PRV079 Track and support provider enrollment and ongoing provider updates for NPIs.9 1 Section: Page: PRV068 Accept and process Electronic Funds Transfer (EFT) maintenance requests via hard copy. save and delete Web Portal user maintenance requests entered prior to submission. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV078 Track and support any established provider review schedule to ensure providers continue to meet program eligibility requirements. validity. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV064 Provide the capability through the Web Portal to modify. Provider Management PM01 Manage Provider Information PR3.

correction and payment issues • Pharmacy Benefits Management programs • Use of various access channels such as the provider Web Portal and IVR Provider Management PM02 Manage Provider Communication NA 2 Section: Page: PRV091 Receive. provider type. PM01 Manage Provider Information NA 1 Section: Page: PRV086 Provide and maintain a toll free telephone number for providers to request prior authorizations. etc. prior approval. Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV085 Receive and process managed care plan rosters containing eligible members for determining capitation payment amounts. transportation & waiver services benefit information • Utilization Threshold information • Other information specified by the Department Provider Management PM02 Manage Provider Communication NA 1 Section: Page: . Provider Management Managed Care enrollment includes Medicaid and CHIP through Medicaid Managed Care (approximately 3.PRV082 Provide online search capability of Managed Care.000 members). At a minimum. correction and payment • Medicaid Coverage and Payment Policy • Pharmacy Benefits Management programs • Use of various access channels. prior authorizations.000 members). track and resolve provider inquiries and complaints based on the following topics including but not limited to: • General program • Provider enrollment and re-enrollment • Member eligibility • MEIPASS • Prior approval/prior authorization • Claims billing. provider Web Portal and IVR) • Transaction including but not limited to claims.8 2 Section: Page: PRV089 Receive.1. managed care enrollment. track and resolve member inquiries guidelines including but not limited to: • Medicaid Coverage and Payment Policy • Pharmacy benefit information • Medical. (e.. eligibility inquires.g. PM02 Manage Provider Communication PM3. and Child Health Plus (340. personal care. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV087 Generate responses to requests/inquiries on the availability of Medicaid services and adequacy of the Medicaid provider network based on provider/member ratios by geographic service area. Provider Management PM02 Manage Provider Communication PR1.3 million members) .11 2 Section: Page: PRV088 Provide the capability to analyze provider performance including monitoring individual provider payments to show extent Provider Management of participation and service delivery. and network provider information • Region • County • Service Level Designation • Organization Name • Health Home Organization City • Health Home Organization State • Health Home Organization Zip Code • Health Home Program Name • NPI Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV083 Allow Health Homes online single record modification of members and providers within their network Provider Management PM01 Manage Provider Information NA 1 Section: Page: PRV084 Validate all member and provider Health Home rosters received and transmit error report response transactions to Lead Health Homes and managed care plans. PM3. service authorizations. Family Health Plus (430. provider status. and Threshold Override Applications (TOAs) Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV090 Receive and respond to inquiries regarding the Pharmacy Benefit Management programs including but not limited to: • General program inquiries • Provider enrollment and re-enrollment • Member eligibility information • Prior approval/prior authorization • Claims billing. validation shall include member eligibility. Health Home.

labelers. at the request of the provider. produce and distribute provider notifications via mail. track and respond to all written inquiries from providers. produce and distribute notifications to providers of stop payment orders for checks that have not cleared within a Provider Management period established by the Department. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV104 Prepare. specific information related to the requesting provider (e. list of affiliated practitioners. PM02 Manage Provider Communication NA 1 Section: Page: PRV103 Prepare.g. electronic and/or Web Portal. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV096 Produce and transmit. Provider Management PM02 Manage Provider Communication PR1. and active rates). and other stakeholders. Provide a "knowledge database" for use by call center staff with Department review and approval. Provider Management PM02 Manage Provider Communication NA 2 Section: Page: PRV100 Conduct annual reviews of all provider support materials on the Web Portal based on Department rules. claims.10.6 1 Section: Page: PRV094 Prepare and maintain standard response templates or scripts for routine provider. and other questions for use by call center staff. Provider Management PM02 Manage Provider Communication PR1.6 1 Section: Page: PRV099 Develop and maintain provider support materials on the Web Portal based on Department approval. prior approval/prior authorization and other NYS forms • Provider bulletins • Quick reference information • FAQs • Training schedules • Tutorials and view lets • Links • Help guides • Medicaid updates / Newsletter(s) Archived and historic provider support information must be maintained and accessible as required by the Department. electronic and/or Web Portal when appropriate. index and route correspondence Provider Management PM02 Manage Provider Communication PR1. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV105 Prepare. electronic and/or Web Portal when appropriate including but not limited to: • Enrollment determination • Enrollment application • Recertification • Disenrollment • Termination • Provider inquires • Maintenance requests • Enrollment status change Provider Management PM02 Manage Provider Communication NA 2 Section: Page: PRV102 Prepare. image. produce and distribute notifications to inform providers and members of the outcome of TOA processing via mail. and member inquiries regarding eligibility..6 1 Section: Page: PRV098 Review. produce and distribute account receivable notifications to providers via mail. members. Provider Management PM02 Manage Provider Communication PR1. addresses. PR1. including but not limited to: • Provider manuals • Companion guides • Provider enrollment. invoices. members. and billing provider. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV095 Provide on-going training for call center personnel to ensure that they are knowledgeable about the functional and technical aspects of the contractor's application and Medicaid policy. acknowledge. produce and distribute personal care and transportation rosters to ordering providers. when Provider Management appropriate.6 1 Section: Page: PRV097 Receive. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV101 Prepare. service limits. billing. stakeholders or business associates as specified by the Department.PRV092 Utilize IVR and other Call Center technologies to provide: • Customer Relationship Management (CRM) • Facilitate Call Center operations • Improve customer service • Limit menu selection • Reduce wait times Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV093 Receive and respond to provider and member inquiries from providers. enrollment. Templates require prior Department approval for content and use. PM02 Manage Provider Communication NA 1 Section: Page: .

PR3. produce and distribute publications in electronic. Provider Management PM02 Manage Provider Communication PR2.PRV106 Prepare. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV110 Design. This will include tracking the order from receipt through fulfillment. formats.5. and American Indian Health Program) PRV112 Provide data entry services for all transactions and forms that require processing and cannot be accommodated using OCR services. and as required hard-copy.7 1 Section: Page: PRV107 Prepare. prepare. produce and distribute notifications regarding 1099/W2 reporting to providers via mail. PM02 Manage Provider Communication NA 1 Section: Page: PRV115 Produce the enrollment packet for newly enrolled or reenrolled providers: • Enrollment determination letters when enrollment is denied • Disenrollment letters Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV116 Provide the ability for providers to order Department forms via the provider area of the Web Portal. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV108 Notify affected providers of changes to their provider manual via email. Update and maintain current and prior years 1099/W2 reporting including adjustments to Provider Management reflect changes in funding sources and other accounting actions that do not impact provider payment amounts or 1099/W2 reporting. Cystic Fibrosis. PM02 Manage Provider Communication NA 1 Section: Page: PRV118 Send letters/notices automatically to providers whose license or certification is expiring within a time frame set by the Department informing them of responsibilities.4.6 1 Section: Page: PRV119 Provide the capability to easily change or tailor standard letters and electronic messages. Terms and conditions must be Provider Management available for user review. PM02 Manage Provider Communication FI4. produce and distribute NYS proprietary forms including but not limited to: • Claim Form A (Dental and Transportation) • eMedNY 150003 (Fee For Service) • Pharmacy Claim Form • TOAs Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV111 Prepare. The order status must be available to the requestor through the provider area of the Web Portal. and AIHP) PRV109 Distribute Medicaid and other health program updates via email and/or the web portal as specified by the Department (including but not limited to Child Health Plus. electronic and/or Web Portal as specified by the Department including but not limited to: • Provider enrollment • EFT • ETIN • Web Portal User Access • Trading Partner and Security Agreements Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PM02 Manage Provider Communication NA 1 Section: Page: Distribute Medicaid and other health program updates via email and/or the Web Portal as specified by the Department (including but not limited to CHIP. including but not limited to: • FAQs • Quick reference information • Training schedules • Help guides • Packets • Supplemental Companion Guides • Provider manuals • Provider bulletins Maintain all current and historical publications. produce and distribute provider packets via mail. These include but are not limited to: • Provider enrollment forms Provider Management • Provider Paper claim forms • Participant Claim forms (paper & electronic) • Paper prior approval/prior authorization forms PRV113 Provide notice to the user and require that they accept the terms and conditions established by the Department and record information related to that acceptance as required by the Department upon submission. the Web Portal or other electronic communication. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV117 Send letters/notices automatically to providers and their affiliates informing them of enrollment status changes and appeal Provider Management rights when the Department suspends or terminates the provider. PM02 Manage Provider Communication NA 1 Section: Page: PRV114 Generate letters and/or electronic notifications automatically to provider applicants and enrollees as directed and approved Provider Management by the Department. electronic and/or Web Portal. Cystic Fibrosis. FI4. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: . when appropriate.

and submit practice rosters for lead Health Home approval. and reimbursement amounts) • Forms • Provider Bulletins • Quick Reference Information Provider Management • FAQs • Training Schedules • Tutorials • Links • Help Guides • Newsletter(s) • Medicaid Updates PM03 Perform Provider Outreach NA 1 Section: Page: PRV129 Perform at least four (4) surveys.g. numbers of people enrolled and cost effectiveness. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV132 Provide the capability to alert stakeholders to important messages on the provider area of the Web Portal. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV131 Prepare and maintain control of incoming and outgoing NYS Medicaid program mail. each calendar year that the contractor's application is operational to obtain feedback from the provider community and report results. edit. Producing (with Department review and approval) outreach and marketing materials. recommendations for improvement to address provider concerns. PM03 Perform Provider Outreach NA 1 Section: Page: PRV134 Develop. and procedures. provider type. procedure codes. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV123 Generate an electronic receipt notification for EFT applications entered through the provider area of the Web Portal that contains provider information as specified by the Department. including information such as outreach activities that took place. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV133 Provide the ability to send providers email and electronic alert messages by provider COS. member loyalty and provider networks. diagnosis codes. Provider Management PM02 Manage Provider Communication NA 2 Section: Page: PRV126 Provide functionality for Health Home providers to enter. implement and monitor a detailed comprehensive cost effective outreach plan for the EPIC and New York Prescription Saver Programs. including but not limited to: • Provider Manuals (e. PM02 Manage Provider Communication NA 1 Section: Page: PRV128 Maintain provider support materials on the provider area of the Web Portal without requiring authentication. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV135 Organizing and holding sessions around the State to train partners to provide assistance and information about EPIC to eligible seniors and caregivers in their areas. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: Provider Management PM02 Manage Provider Communication NA 2 Section: Page: PRV124 Perform outreach activities to encourage participation in the program and provide training and other hands-on assistance PRV125 Any calls referred to the Department Medicaid Policy are accompanied by the steps the Call Center staff member has taken to try to resolve the call. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV137 Provide monthly reports and analyses of outreach and enrollment figures. and other stakeholders regarding program guidelines. or other criteria Provider Management as determined by the Department. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV122 Generate an electronic receipt notification for all Web Portal user applications which contains applicant/provider information as specified by the Department. service limits. members. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV138 Document the process flows and scripts for reaching out to pharmacies Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: Provider Management . policies. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV130 Produce and distribute notifications. developed by the contractor and approved by the Department. publications and related materials to educate providers.PRV120 Provide the capability to generate recertification notices as directed by the Department. and the contractor must implement improvements approved by the Department. Provider Management PM02 Manage Provider Communication NA 1 Section: Page: PRV121 Generate notices to providers for accounts receivable amounts due based on Department business rules. Provider Management PM02 Manage Provider Communication NA 2 Section: Page: PRV127 Accept files of Health Home eligible members. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV136 Implement and monitor effective strategies for educating community-based partners and other partners to assist in recruiting and enrolling new members.

gov/tables/technologypolicyindex. Prescription drugs. XX NA 2 Section: Page: TEC012 Capture and provide online access by the Department all data required for the MDW to produce CMS-416 EPSDT reports. print.10 1 Section: Page: TEC004 Provide a “Blue Button” solution based on federal/CMS open source standards that allows Medicaid members to view.g. banking information.1.htm). and so that users are not able to view sensitive information or other information which they have no business need to view. Technical Architecture XX NA 1 Section: Page: TEC002 Follow the State’s strategic information architecture plans as documented in P04-001 Principles Governing the NYS Information Technology Enterprise Architecture (http://www. CMS-64. Long term institutional care. CMS-21.ny. such as suspension and termination from the EPIC network Provider Management PM08 Terminate Provider NA 1 Section: Page: TEC001 Follow the State’s guidelines and constraints for information technology architecture as documented in P04-001 Principles Governing The NYS Information Technology Enterprise Architecture (http://www.ny. Inpatient hospital. and CMS-21b. as follows: • Retail pharmacy drug claims (NCPDP) • Dental health care claims (X12N 837D) • Professional health care claims (X12N 837P) • Institutional health care claims (X12N 837I) • Coordination of benefits data. both quarterly and annually.6 2 Section: Page: TEC010 Capture and provide to the MDW all data required for the MDW to report on quality performance measures for the production of the CMS-372 and CMS-372S annual reports. Provider Management PM07 Manage Provider Grievance and Appeal NA 1 Section: Page: PRV141 Provide recommended actions to the State as a result of pharmacy review and audit. COFRS.4. participating provider agreements and disclosure of ownership statements. federal MMIS certification requirements. Technical Architecture XX NA 1 Section: Page: TEC006 Ensure that all Systems data from the MMIS are delivered to the MDW in order to support reporting and analysis.PRV139 Maintain and update appropriate forms and instructional material for provider enrollment. FR1.g. • Merge outside data sources into T-MSIS data if required. that contain client demographics and program participation.gov/tables/technologypolicyindex. for any calendar year or fiscal year and for all current and future HCBS Waivers or waiver related programs. Modifications to federal and State reporting requirements made after System implementation will be applied using the approved Change Management Process.3. Technical Architecture XX NA 1 Section: Page: TEC007 Provide the data to the MDW to develop. and Part 11 of the State Medicaid Manual. FR1. Technical Architecture XX BE1. containing valid codes. produce. cash collections.).. Technical Architecture XX NA 1 Section: Page: TEC009 Capture and provide to the MDW all data that will be required to produce for submission to CMS the federally required TMSIS files. Technical Architecture XX NA 1 Section: Page: TEC011 Capture and provide to the MDW all data required (e. and detail and summary Technical Architecture data to meet federal and State reporting requirements. • Meet T-MSIS submission and timeline reporting XX FR1.) for the MDW to produce financial reporting based on Department-defined criteria and produce quarterly estimates and expenditure reports Technical Architecture for federal CMS-37.htm). etc. Technical Architecture XX NA 1 Section: Page: TEC008 Participate in MDW design sessions with MDW personnel for the implementation of system changes to the MDW and data needs of the MDW. FR1. etc. FR1. generation of documents. and maintain all reporting functions. FR2. files and data elements to meet current and future federal and State reporting requirements. claims payment.7.2. research submitted issues and take appropriate action as approved by the Department. in accordance with CMS requirements.its. This includes but is not limited to the following functionality: • Maintain data sets required for T-MSIS reporting.5. Technical Architecture • Provide and maintain T-MSIS data for adjudicated claims (e. • Conform to and maintain reporting requirements from T-MSIS File Specifications and Data Dictionary document. when applicable • Future claims attachments required under HIPAA Technical Architecture XX NA 1 Section: Page: .its. Technical Architecture XX NA 1 Section: Page: TEC005 Ensure that all MAS operational data from the System is delivered to the MDW in order to support reporting and analysis. Provider Management PM03 Perform Provider Outreach NA 1 Section: Page: PRV140 Develop a pricing appeal process. Technical Architecture XX NA 1 Section: Page: TEC003 Implement system controls to ensure data integrity during software program changes and promotion to production Technical Architecture XX SP1. State and federal rules and regulations.1 1 Section: Page: TEC013 Provide technical controls and indicators to suppress beneficiary identification for confidential services. download or share their health information with the click of a mouse on a blue-button icon. XX BE1.8 1 Section: Page: TEC014 Provide system support for the sending and receiving of electronic claims transactions. FR1. required by 45 CFR Parts 160 and 162.

TEC015

Provide ability for authorized System users to perform claim and capitation corrections in the System prior to final
payment. Verify that claim correction activities have entered only valid override code(s) or manual prices.

Technical Architecture

XX

CA1.11

1

Section:
Page:

TEC016

Provide the ability to view online and transmit in response inquires and report requests the data dictionary information for
Technical Architecture
any given System field while viewing the actual data in the System.

XX

SP1.9

1

Section:
Page:

TEC017

Provide and maintain data layout documentation, data dictionary, data mapping crosswalk, inbound/outbound capability,
and frequency for all interfaces. Data dictionary shall be developed using industry best practices identified and cited by
the contractor and approved by the Department. At a minimum, the data dictionary shall contain for each field:
• Human readable/"plain English" field name.
• A field description.
• Database field name.
• Database table.
• Field Type and length.
• Codes associated with the field.
• Descriptions of each code.
• Original field source (e.g., CBMS, 837, practitioner claim).

Technical Architecture

XX

NA

1

Section:
Page:

TEC018

Provide and store all reports in the medium designated by the State.

Technical Architecture

XX

PI3.13

1

Section:
Page:

TEC019

Require authentication of the receiving entity prior to a system initiated session, such as transmitting responses to
eligibility inquiries

Technical Architecture

xx

SP1.1

1

Section:
Page:

TEC020

Provide the capability to send electronic alert messages to State staff on potential violations of privacy safeguards, such as
Technical Architecture
inappropriate access to confidential information, and generates alerts for conditions that violate security rules.

XX

SP1.8, SP3.2

1

Section:
Page:

TEC021

Establish indicators that can be set to restrict distribution of PHI in situations where it would normally be distributed, and
Technical Architecture
tracks disclosures of PHI, and provide authorized users access to and report on the PHI disclosures.

XX

SP4.2, SP4.3

1

Section:
Page:

TEC022

Generate security incident reporting and mitigation mechanisms, including but not limited to:
? Generate warning or report on system activity based on security parameters
? Terminate access and/or generate report when potential security violation detected
? Preserve and report specified audit data when potential security violation detected

Technical Architecture

XX

SP3.4

1

Section:
Page:

TEC023

As acceptable under HIPAA privacy regulations, enable providers to receive information on clients they serve (e.g.,
eligibility, prior authorizations, service history, accumulators of service history, TPL, primary care providers, benefits and Technical Architecture
restrictions, copayments) in the Web Portal.

XX

SP4.1, SP4.4

1

Section:
Page:

TEC024

Provide the ability to allow a client to enter and view appeals and grievances, including the ability to check status and
receive related notifications and alerts via the Web Portal.

Technical Architecture

XX

NA

1

Section:
Page:

TEC025

Provide and support a data interface/data exchange with the enrollment broker contractor and other Department-defined
entities, and provide direct, update access to the enrollment and disenrollment functionality of the System.

Technical Architecture

XX

NA

1

Section:
Page:

TEC026

Ensure that the contractor's application architecture is a system based on a standards-based service oriented architecture
Technical Architecture
(SOA); employ an n-tier, component-based, application-computing architecture with an integrated enterprise service bus.

XX

NA

1

Section:
Page:

TEC027

Ensure that the contractor's application architecture can integrate Best of Breed, COTS products into its solution to meet
the needs across business functions.

Technical Architecture

XX

NA

1

Section:
Page:

TEC028

Provide a technical architecture which can advance the Department's goal of achieving a higher MITA maturity level.

Technical Architecture

XX

NA

2

Section:
Page:

TEC029

Ensure that the contractor's application architecture allows for remote data access.

Technical Architecture

XX

NA

1

Section:
Page:

TEC030

Ensure that the contractor's application architecture is configured in such a way and robust enough to implement the SLAs
Technical Architecture
defined in this RFP.

XX

NA

1

Section:
Page:

TEC031

Ensure that the contractor's application architecture can support geocoding for all transactions processed.

Technical Architecture

XX

NA

1

Section:
Page:

TEC032

Assume responsibility for the provision and maintenance of all hardware, computer network, personal computer-based
workstations, laptops, printers, supporting modems, and software needed for the MAS.

Technical Architecture

XX

NA

1

Section:
Page:

TEC033

Have the production system available twenty-four (24) hours a day, seven (7) days a week three hundred sixty-five (365)
days a year.

Technical Architecture

XX

NA

1

Section:
Page:

TEC034

Notify the Department within one (1) hour for any unexpected system outage or detected breach.

Technical Architecture

XX

NA

1

Section:
Page:

TEC035

Maintain seven (7) independent environments, including Production, System Testing, Development, User Acceptance
Testing (UAT), Regression Testing, Provider Test, and Training, that meet the SLAs defined in this RFP.

Technical Architecture

XX

NA

1

Section:
Page:

TEC036

Ensure the system supports a variable workload (i.e., routinely exhibits “peaks” or “spikes” due to retro claims
processing, large batch updates etc.).

Technical Architecture

XX

NA

1

Section:
Page:

TEC037

Install, configure, enhance, operate and maintain data lines for any required access to the Department network from the
contractor’s project site. These lines will terminate at the point of demarcation on the Department network to be
determined by the Department network services staff.

Technical Architecture

XX

NA

1

Section:
Page:

TEC038

Install, configure, enhance, operate and maintain a high speed, extensible provider network for any required transactions
and inbound or outbound files that must be processed by the contractor's application including but not limited to
transaction processing, eligibility verification, claim submission, etc.

Technical Architecture

XX

NA

1

Section:
Page:

TEC039

Provide an adequate number of dedicated POTS lines at each facility for dial-up access into the network from Albany,
New York.

Technical Architecture

XX

NA

1

Section:
Page:

TEC040

Have the capacity to support at least nine thousand (9,000) State active users, fifty thousand (50,000) active providers and
one hundred fifty thousand (150,000) total registered users (State and provider). The network also must be able to allow Technical Architecture
for ten (10) percent growth per year in the total number of users.

XX

NA

1

Section:
Page:

TEC041

Submit to the Department, prior to installation, plans for all connections to the State network.

Technical Architecture

XX

NA

1

Section:
Page:

TEC042

Ensure that the Department or any third-party authorized by the Department is able to directly access over the network,
without contractor intervention, any of the Department equipment located in the contractor’s data center.

Technical Architecture

XX

NA

1

Section:
Page:

TEC043

Ensure that authorized staff have access to the appropriate environments (i.e. UAT, Training, Production).

Technical Architecture

XX

NA

1

Section:
Page:

TEC044

Put in place a firewall and proxies between its private network and the connection to the State's network.

Technical Architecture

XX

NA

1

Section:
Page:

TEC045

Provide access to the contractor's application for remote users, through a variety of communication channels and
protocols.

Technical Architecture

XX

NA

1

Section:
Page:

TEC046

Provide access to the contractor's application for external computer systems, through a variety of communication channels
Technical Architecture
and protocols.

XX

NA

1

Section:
Page:

TEC047

Support the VeriFone terminals custom software.

Technical Architecture

XX

NA

1

Section:
Page:

TEC048

Support providers in the connectivity to the provider network, ensuring open standards, high speed connectivity and
maximizing provider participation.

Technical Architecture

XX

NA

1

Section:
Page:

TEC049

Provide software necessary to utilize the contractor's solution by State users at no cost to the State.

Technical Architecture

XX

NA

1

Section:
Page:

TEC050

Ensure the Web Portal is compatible with standard browser technology.

Technical Architecture

XX

NA

1

Section:
Page:

TEC051

Ensure the Web Portal is accessible using TCP/IP protocol through various connection methods including but not limited
to, broadband, DSL, point-to-point, mobile devices, satellite, cable, and dial-up.

Technical Architecture

XX

NA

1

Section:
Page:

TEC052

Ensure the Web Portal is operational and accessible 24/7, except for Department approved scheduled downtime.

Technical Architecture

XX

NA

1

Section:
Page:

TEC053

Provide navigation that users can easily understand, including easy navigation between screens through help menus and
other user documentation.

Technical Architecture

XX

NA

2

Section:
Page:

TEC054

Provide role-based security but not require multiple sign-in steps, recognizing that some information on the Web Portal
will be of a public nature and not require a sign-on.

Technical Architecture

XX

NA

1

Section:
Page:

TEC055

Allow users to view and copy information including but not limited to, provider manuals, instructions, bulletins, program
Technical Architecture
descriptions, eligibility criteria, Medicaid Updates and forms

XX

NA

1

Section:
Page:

TEC056

Provide links to other State and federal websites and external entities, including but not limited to certifying agencies, SSA, public health care and nutritional programs, and other programs determined by the Department to be appropriate for
Technical Architecture
portal access.

XX

NA

1

Section:
Page:

TEC057

Allow providers, members, trading partners, the State and the State’s designees to register online for access to the secure
areas of the portal.

Technical Architecture

XX

PR1.1

1

Section:
Page:

TEC058

Provide a secure, HIPAA compliant transaction component of the portal that allows:
• Authorized trading partners to submit EDI files for immediate processing and retrieval of the corresponding response
acknowledgement
• Authorized users to retrieve claims histories
• Providers to initiate enrollment using an online application process
• Providers and other entities to enroll as EDI trading partners using an online application process
• Authorized users to view claim status information, payment history, recipient eligibility and benefit information
• Authorized users to look-up procedure rates
• Authorized users to check on the progress of their submitted batch transactions (Dashboard)

Technical Architecture

XX

CR3.2, PM2.6

1

Section:
Page:

TEC059

Provide low bandwidth versions of State-specified pages for easy access.

Technical Architecture

XX

NA

1

Section:
Page:

TEC060

Provide in the bid response any mobile platform support options the solution currently supports and relevant use options
for the department if the solution is selected under this procurement.

Technical Architecture

XX

NA

1

Section:
Page:

TEC061

Provide detailed and current documentation on all system edits and audits that reflects the adjudication process in the
MMIS.

Technical Architecture

XX

NA

1

Section:
Page:

TEC062

Provide the functionality to fully customize any combination of bundling/unbundling of service procedure codes via a
Web Portal using a COTS rules-based engine.

Technical Architecture

XX

NA

1

Section:
Page:

TEC063

Provide the ability to author messages that providers can view upon accessing the portal.

Technical Architecture

XX

CR3.4

1

Section:
Page:

TEC064

Provide the ability to send and receive electronic messages or data files to/from specific provider via the web-portal.

Technical Architecture

XX

NA

1

Section:
Page:

TEC065

Ensure web based application is compatible with standard browser technology.

Technical Architecture

XX

NA

1

Section:
Page:

TEC066

Ensure web based application allows users to inquire, access, update and/or delete data based upon role.

Technical Architecture

XX

TP1.16

1

Section:
Page:

TEC067

Ensure web based application provides access to audit trails information including but not limited to action, date, time,
and user for adds, updates and deletes from the relevant web-based application screen. The contractor shall monitor and
examine system activity in accordance with audit polices and procedures adopted by the NYS.

Technical Architecture

XX

SP3.3

1

Section:
Page:

TEC068

Ensure web based application has an integrated on-line help function for all applications.

Technical Architecture

XX

NA

1

Section:
Page:

TEC069

Propose a COTS state-of-the-art Business Rules Engine that operates across all MITA business areas supported by the
MAS.

Technical Architecture

XX

NA

1

Section:
Page:

TEC070

Allow for rules to be implemented in a real-time enterprise environment and applied if required and approved by the
Department.

Technical Architecture

XX

NA

1

Section:
Page:

TEC071

Follow the State’s strategic information architecture plans as documented in P04-001 Principles Governing the NYS
Information Technology Enterprise Architecture (http://www.its.ny.gov/tables/technologypolicyindex.htm).

Technical Architecture

XX

NA

1

Section:
Page:

TEC072

Ensure the Rules Engine is structured in a modular concept so the same rules can be used by different services or be
called as a service itself.

Technical Architecture

XX

NA

1

Section:
Page:

TEC073

Allow for rules to be tested against production data prior to installation.

Technical Architecture

XX

NA

1

Section:
Page:

TEC074

Contain a process for built-in rule review and approval process that will identify any conflicts in business rules as they are
Technical Architecture
being developed.

XX

NA

2

Section:
Page:

TEC075

Produce documentation regarding all business rules.

XX

NA

1

Section:
Page:

Technical Architecture

Technical Architecture XX NA 1 Section: Page: TEC086 Ensure all documents and deliverables must be produced in a format approved by the Department. Technical Architecture XX NA 1 Section: Page: TEC085 Provide the Department with electronic access to this correspondence. XX NA 1 Section: Page: Technical Architecture . approved by the Department. PR1. Technical Architecture XX NA 1 Section: Page: TEC080 Ensure the COTS Correspondence Management System has the ability to store any information submitted by a member or Technical Architecture provider. and archive document and document purging (per HIPAA security provisions) Technical Architecture XX NA 1 Section: Page: TEC089 Ensure the COTS Content Management Product can share documents among teams and other organizational entities on a Technical Architecture need to know basis. Excel spreadsheets. Technical Architecture XX PR1. including access to images of all written correspondence. The Department requires access for a period of seven (7) years after the contract. e-mails or electronically submitted documents and retrieve all documents from the document repository. faxed documents. Technical Architecture XX NA 1 Section: Page: TEC092 Ensure the COTS Content Management Product has a virtual rescanning capability that will auto correct a skewed document and automatically adjust document resolution. version control. Technical Architecture XX NA 1 Section: Page: TEC091 Ensure the COTS Content Management Product is programmable to accommodate user-defined field edits (i.TEC076 Develop and implement a Document Management Plan.1 2 Section: Page: TEC082 Ensure the COTS Correspondence Management System supports different notifications to be sent to providers and /or members. Intelligent Character Recognition and Optical Mark Recognition capabilities with a minimum of 90% accuracy rate. g. in a central repository. inclusion or exclusion of special characters). based on business rules. PDF's) to be shared. This Plan must describe how the contractor will electronically manage the documents and attachments produced throughout the life of the project and which at a minimum must: • Address how documents will be provided in a centralized repository and available to staff and users in a timely manner in all phases of the contract • Describe how State staff will access the information in the repository • Describe access and security rules • Describe keyword/indexing • Describe how the COTS Correspondence Management System integrates into the process of Document Management Technical Architecture XX NA 2 Section: Page: TEC077 Ensure the COTS Correspondence Management System contains a collaborative document management environment that will allow electronic files (e. archived and maintained by the contractor for seven (7) years beyond the term of the contract and any extension(s) of the contract. document level security.6 1 Section: Page: TEC079 Ensure the COTS Correspondence Management System targets specific populations and produce mass mailings. Word documents. Technical Architecture XX NA 1 Section: Page: TEC083 Ensure the COTS Correspondence Management System supports letter generation capabilities which are first presented to Technical Architecture the user for modification and release. managed Technical Architecture and controlled in a secure fashion. Technical Architecture XX NA 1 Section: Page: TEC088 Ensure the COTS Content Management Product can provide core document library services. images of hard copy documents. XX NA 1 Section: Page: TEC090 Ensure the COTS Content Management Product has advanced Optical Character Recognition. Technical Architecture XX NA 1 Section: Page: TEC087 Ensure the COTS Content Management Product captures and stores. collaborated upon. Technical Architecture XX ME4. Technical Architecture XX NA 1 Section: Page: TEC093 Ensure the COTS Content Management Product can access the database to extract data to pre-populate the index fields. XX NA 1 Section: Page: TEC081 Ensure the COTS Correspondence Management System meets all HIPAA privacy requirements and all State & Federal requirements for PHI and PII. which must be approved by the Department.10. XX NA 1 Section: Page: TEC084 Ensure all written and official electronic correspondence between the Department and the contractor must be in a format prescribed by the Department and logged. which is based upon the proposed Document Management Methodology. XX NA 1 Section: Page: TEC095 Ensure the COTS Content Management Product allows for all images to be governed by the same security and confidentiality rules that govern other data stated within this RFP.e. including check-in/checkout. XX NA 1 Section: Page: TEC078 Ensure the COTS Correspondence Management System tracks all correspondence related to a member or provider and link tracking events to electronic documents. Technical Architecture XX NA 1 Section: Page: TEC094 Ensure the COTS Content Management Product has imaging needs to include red-filtering or other techniques to improve Technical Architecture readability.

into the proposed Document Repository.4 1 Section: Page: TEC112 Provide the capability to extract data from a report file and deliver the extracted information to a user. e-mails and other documents to the original document. PM5. Technical Architecture XX NA 1 Section: Page: TEC104 Ensure the COTS Content Management Product allows for all historic images from the FileNet and eMedNY system and Technical Architecture new images from the contractor's application to be available to both contractor and State staff from the beginning of the Operation phase. XX NA 1 Section: Page: TEC102 Ensure the COTS Content Management Product can attach notes. Technical Architecture XX NA 1 Section: Page: TEC098 Ensure the COTS Content Management Product can assign a control number to each document and image. Technical Architecture XX NA 1 Section: Page: TEC109 Ensure the COTS reporting tool has the capability to support cross-tabs. Technical Architecture XX NA 1 Section: Page: TEC115 Ensure the Automated Letter Generator provides the functionality to send letters by mail. annotations. Technical Architecture XX NA 1 Section: Page: TEC097 Ensure the COTS Content Management Product can access any document(s) through a single sign-on.TEC096 Ensure the COTS Content Management Product allows for all image data to be backed-up and archived in accordance with the data requirements within this RFP including Disaster Recovery.4 1 Section: Page: TEC111 Convert current eMedNY reports. Technical Architecture XX PM5 1 Section: Page: TEC108 Ensure the COTS reporting tool is scalable in both volume and numbers of users. Technical Architecture XX NA 1 Section: Page: TEC107 Provide a Reporting tool for all operational and ad-hoc reporting. Technical Architecture XX NA 1 Section: Page: TEC114 Provide a COTS product to automatically generate letters to providers. Technical Architecture XX NA 1 Section: Page: TEC119 Ensure the Automated Letter Generator allows for the retrieval and reproduction of all generated letters. The tool must have the ability to report on large data sets (expressed as either terabytes of data or millions of input rows) to State users. Technical Architecture XX NA 1 Section: Page: TEC103 Ensure the COTS Content Management Product can scan either simplex or duplex on a user defined bases by document type. with the same look as the original piece of paper that was scanned. Technical Architecture XX NA 1 Section: Page: TEC117 Ensure the Automated Letter Generator initiates system-generated letters to members and providers based on enrollment and status. Technical Architecture XX NA 1 Section: Page: TEC110 Ensure the COTS reporting tool can store reports in the proposed Document Repository. all of which are key to end-user and report developer satisfaction. XX NA 1 Section: Page: TEC105 Allow assignment or routing of tasks to State staff with electronic alerts. and in reducing the report development load on IT. after the Department reviews for appropriateness. Technical Architecture XX NA 1 Section: Page: TEC116 Ensure the Automated Letter Generator integrates with the required content management and workflow management functionality. Technical Architecture XX PM5. Viewed documents/images displayed on workstations must have the full image. escalation or notification. Technical Architecture XX NA 1 Section: Page: TEC106 E-mail alerts of processing events that require State staff action. All documents/images must also be able to be retrieved by secondary indices. Technical Architecture XX NA 1 Section: Page: TEC101 Ensure the COTS Content Management Product allows for images to be retrieved through a LAN server available to both Technical Architecture the contractor and State staff. Technical Architecture XX NA 1 Section: Page: TEC100 Ensure the COTS Content Management Product can print documents/images to a local/network printer and provide the capability to fax the image. members and other stakeholders. whether individually or mass. data drilling and prompting and filtering. email or fax. Technical Architecture XX PM5. Technical Architecture XX NA 1 Section: Page: TEC118 Ensure the Automated Letter Generator supports the use of letter templates that are easily updated including Department letterhead and electronic signatures. Technical Architecture XX NA 1 Section: Page: . Technical Architecture XX NA 1 Section: Page: TEC099 Ensure the COTS Content Management Product can store documents/images by the control number and make documents/images accessible by online search via hypertext link from all screens that reference the image. Technical Architecture XX NA 1 Section: Page: TEC113 Provide the ability to run reports using user defined parameters.

monitoring and control of jobs. business process modeling tools. such as duration of execution. flat files. and report provider written. XX NA 1 Section: Page: TEC136 Support secure data extraction and distribution to the MDW within the timeframes allocated for the large volumes of data that need to be captured from a variety of datasets. Technical Architecture XX NA 1 Section: Page: TEC128 Call Center must provide multiple language options (at a minimum. staff must include Spanish. with the ability to access third-party translators in additional languages) Technical Architecture XX NA 1 Section: Page: TEC129 Ensure Call Center Management System can provide multiple language options and services for individuals with hearing impairment.1 1 Section: Page: TEC131 Provide the ability to keep the data receipt content in a “pre-processed” form to be able to be sent to data consumers as a representation of the submitted "raw" data. Chinese-Cantonese. the date and form of response from the contractor. the provider number. Technical Architecture XX NA 1 Section: Page: . including what the respondent told the provider. data quality tools. the form of the inquiry (e.csv. data modeling tools. Technical Architecture XX NA 1 Section: Page: TEC127 Ensure Call Center Management System can transfer a call to Department staff.TEC120 Provide toll free access lines into the Call Center. recording and printing statistics. and application run-time environments in a timely fashion. Sources are Technical Architecture listed in the Procurement Library. Secure distribution may include distributing data through a dedicated Technical Architecture FTP line or through an encrypted disks physically delivered to MDW. . Technical Architecture XX NA 1 Section: Page: TEC121 Log. the respondent. and indicating Technical Architecture calls that have been placed on hold for a specific time limit. verify and process all data that is currently extracted (outbound) from eMedNY. verify and accurately process all data that is currently received (inbound) to eMedNY.. etc. XX NA 1 Section: Page: TEC137 Provide the capability to extract and securely distribute full and/or incremental datasets from the contractor's application in an acceptable format including but not limited to . telephone). size of extract. XML.g. Technical Architecture XX NA 1 Section: Page: TEC138 Provide secure dedicated FTP (1 primary and 1 failover) for data delivery to the MDW. automatic alerts to operators when errors occur during the process.csv. Technical Architecture XX NA 1 Section: Page: TEC141 Generate administrative reports that will detail and summarize the data extraction and distribution activities. and table unloads.xml. track. provider type. Russian. flat files. Sources are listed in the Procurement library. relational database data dictionaries and catalogs. and telephone inquiries in a proposed COTS Contact Management System Technical Architecture XX NA 1 Section: Page: TEC122 Log the date and subject of the inquiry. RO6.1. Chinese-Mandarin. electronic. messaging and transactions. Technical Architecture XX NA 1 Section: Page: TEC123 Provide and maintain a Call Center Management System for several functions including but not limited to provider and member inquiries and assistance. Technical Architecture XX NA 1 Section: Page: TEC132 Provide the capability to receive and process both full and incremental datasets for use by the contractor's application in an acceptable format including but not limited to . and table unloads. Technical Architecture XX NA 1 Section: Page: TEC133 Provide the capability to “pull” data from an outside source. Technical Architecture XX NA 1 Section: Page: TEC134 Resolve any discrepancies identified during the processing of inbound files. data extraction tools. XX NA 1 Section: Page: TEC125 Ensure Call Center Management System can provide personalized routing and call handling based on caller identified language and inquiry. Technical Architecture XX NA 1 Section: Page: TEC135 Provide the ability to extract. and notifications to requestor concerning the details of the extract. Technical Architecture XX NA 1 Section: Page: TEC124 Ensure the Call Center Management System can answer calls in sequence. query tools. and relevant comments. static documentation libraries. Technical Architecture XX NA 1 Section: Page: TEC130 Provide the ability to accept. Technical Architecture XX NA 1 Section: Page: TEC142 Provide the ability to capture metadata from data mappings. and provider name. Technical Architecture XX CR1. Technical Architecture XX NA 1 Section: Page: TEC126 Ensure Call Center Management System can produce reports on both electronic and voice transactions. Technical Architecture XX NA 1 Section: Page: TEC139 Schedule data extractions based on time and occurrence of events Technical Architecture XX NA 1 Section: Page: TEC140 Provide deletion/cleanup of extracted datasets.

1 2 Section: Page: TEC159 Develop and maintain claim payment procedures (with State approval) and guidelines for an on-line real-time POS adjudication system that ensures accurate POS editing and responses to pharmacy providers while providing accuracy of Technical Architecture claim payments for covered expenses only.3 3 Section: Page: TEC157 The POS shall include a ProDUR denial/override process. Technical Architecture XX NA 1 Section: Page: TEC161 Provide a flexible pharmacy claim processing system that allows for periodic amendments to the pricing formula at no additional cost to the State.g. . real time adjudication of pharmacy claims with edits and audits that support the Department’s policies and objectives. but not limited to. for inquiry purposes. This would include current edit code as well as a history of prior edit codes. the Older American's Act.1. for Prospective DUR edits. and the Rehabilitation Act Section 508. XX POS1.1 1 Section: Page: TEC154 Provide Health Home network ad hoc reporting capability and alerts to State staff for changes in Health Home network (e. All reimbursement information to pharmacy providers must agree with the semi-monthly claim cycle reimbursement. and maintain all external interfaces to administer operations as identified in the procurement library Technical Architecture . Technical Architecture XX NA 1 Section: Page: TEC152 Develop. POS2. XX NA 1 Section: Page: TEC146 Perform all design. high dose reasons. Technical Architecture XX NA 1 Section: Page: TEC150 Provide dual authentication sign-on for users with update capability. Technical Architecture XX NA 1 Section: Page: TEC145 Take over maintain and develop the Medicaid EHR Incentive Program Application Support Service (MEIPASS). 7 days a week.1. attestations. Technical Architecture XX NA 1 Section: Page: TEC155 Provide State EPIC staff with on-line query access for the most recent three years of premium payment historical data.7.1 2 Section: Page: TEC160 Track the progress and status of individual claims through on-line inquiry. Technical Architecture XX NA 1 Section: Page: TEC156 Implement and maintain a pharmacy POS solution for on-line. implement. POS4. The POS system must inform the pharmacist of member eligibility and exactly how much to collect from the member. The on-line system must be capable of selecting claims by key fields. Pharmacy providers must be offered the flexibility to override any denials by resubmitting the claim with DUR intervention and outcome codes. POS2. overutilization. with exception for Department approved scheduled downtime. Technical Architecture XX NA 1 Section: Page: TEC151 Ensure all user interfaces are compliant with recognized usability standards. Technical Architecture XX NA 1 Section: Page: TEC144 Include the technical infrastructure to extract metadata and send to MDW in formats defined in the Procurement Library.3 2 Section: Page: TEC158 Maintain a State-approved POS denial/override and messaging process. archiving and retrieval of Medicaid EHR Incentive Program applications. the Americans with Disabilities Act. Technical Architecture XX POS4. the online mechanism to accept provider attestations and CQMs and distribute payments to hospitals and health care Technical Architecture professionals who meet the program participation criteria established by CMS and provide comprehensive information on the EHR Incentive program. and other State systems necessary for administration of the Medicaid EHR Incentive Program.TEC143 Provide the ability to extend and/or customize the capabilities to capture metadata from sources not currently defined or anticipated. implementation and operation tasks for the Medicaid EHR Incentive Payment System (MEIPASS).1. Designated State staff at State designated locations must have access to this read only online inquiry system.External Interfaces XX NA 1 Section: Page: TEC153 Maintain Health Home network information mapping network providers by NPI and/or MMIS Provider ID to the appropriate health home. in accordance with NCPDP standards. The POS must interface with the MMIS to maintain records claims and claims payment and facilitate timely claims payment in accordance with service level agreements. including. The ProDUR system must be comprehensive and flexible with Technical Architecture multiple safety edits including the ability to deny on-line POS claims for safety reasons including but not limited to: serious drug-to-drug interactions. but discovered and required in later phases of the project. XX POS4. and related Technical Architecture communications with providers XX NA 1 Section: Page: TEC149 Provide and maintain detail documentation on the edit programming logic executed by the system. POS4. Technical Architecture XX NA 1 Section: Page: Technical Architecture XX POS1. including Date of Service. Technical Architecture XX NA 1 Section: Page: TEC147 Establish and maintain of all required interfaces and validations with the CMS National Level Repository (NLR). The POS solution shall be available 24 hours per day. This information must be accessible through a web-portal. Technical Architecture XX PR4. and therapeutic duplication. Technical Architecture XX NA 1 Section: Page: TEC148 Automated processing. provider enrollment and disenrollment).

ability to locate a participating pharmacy by zip code and city. 7 days a week. The site must be available 24 hours a day. XX NA 1 Section: Page: TEC170 Provide the capability to print a paper application form (in English or Spanish) on the NYPS website. Technical Architecture XX NA 1 Section: Page: TEC164 Provide capability that allows a dispensing pharmacist to electronically override certain business rules following NCPDP Technical Architecture standards XX NA 1 Section: Page: TEC165 Ensure POS system is kept up-to-date with the latest patient safety rules and regulations and demonstrate the ability to electronically message pharmacists related to safety issues prior to the dispensing of the prescription drug. patient history. or any other changes that affect data exchange with the provider community. due date.16 1 Section: Page: TEC175 Ensure capacity to interface with claims data from the Office of Mental Health (OMH). Technical Architecture XX NA 1 Section: Page: TEC172 Provide capability to switch operations from the production to failover hardware or a failover environment within 5 minutes if there is a disruption to the production environment. etc.3 2 Section: Page: TEC163 Update on-line claim files with POS activity. Technical Architecture XX NA 1 Section: Page: . priority. and links to State partners in the Program operations including key pharmacy chains and manufacturers: links to related sites for pharmaceutical and health benefits (with State approval) with all applicable privacy and HIPAA requirements. without any loss of data. Data Access and Data Delivery ). as well as on a daily basis to allow for maintenance of the production environment. software or network malfunctions. Technical Architecture XX NA 1 Section: Page: TEC174 Provide a provider accessible test environment which shall allow the provider community to test the application and data exchanges (Data Acquisition. Technical Architecture XX NA 2 Section: Page: TEC166 Transmit daily the submitted product (NDC11) termination date to the contractor’s claims processing system (point of sale) for processing and denying claims from the CMS Product File and/or Manufacturer Product File.35. and personal health record information. Technical Architecture XX NA 2 Section: Page: TEC173 Design the capability to switch operations from the production environment to the failover in the event technical problems incapacitate the production server(s). frequently asked Technical Architecture questions. Technical Architecture XX NA 1 Section: Page: TEC177 Describe the ability of your solution to receive and integrate clinical data with administrative data when conducting prior approval/prior authorization. XX PI3. Technical Architecture XX NA 1 Section: Page: TEC176 Provide a member portal capable of allowing members access to benefit plan. but is not limited to. explanation of benefit. and simultaneously update member files with POS claims processing information. and an on-line application process where a potential member may apply directly in either English or Spanish. Technical Architecture XX NA 2 Section: Page: TEC178 Provide means and access by the State to audit and monitor performance under the contract. XX NA 1 Section: Page: TEC169 Provide an online tool that will provide. access to information regarding the NYPS and Program benefits. except for regularly scheduled maintenance. goal date. Technical Architecture XX NA 1 Section: Page: TEC168 Develop and maintain an electronic POS rebate system that accurately incorporates the discount process for NYPS pricing Technical Architecture together with the data management and rebate invoicing responsibilities. Technical Architecture XX CA2. A list of historical Technical Architecture terminated NDCs will be provided for the initial implementation.TEC162 Provide online access and search capability for a rolling two-year history of adjudicated pharmacy claims history data by approved State staff. drug pricing information indicating the amount to be paid under the Program for all drugs (this will be updated quarterly by successful contractor). The bidder shall describe their approach to failover to eliminate to the maximum extent possible any business outages due to hardware. This environment will be utilized by new providers or upon interfaces. Technical Architecture XX NA 1 Section: Page: TEC171 Describe the contractor's approach to provide NYS staff online access to quickly identify their current tasks. XX NA 2 Section: Page: TEC167 Provide daily overnight processing of submitted pricing and product data for NYPS. coding. The contractor will also be responsible for archiving old histories back to the beginning of the Technical Architecture Program (to comply with Freedom of Information Law (FOIL) requests) with procedures to readily retrieve and load such claim records. file format. CR1.

POS1. Allow certain providers capability to override alerts. Technical Architecture All alerts must maintain State approved parameters for content and ability to override.5.13. These audits include but are not limited to. OSC audit routines currently flag claims using OSC Edit 02014. Technical Architecture XX POS1. Technical Architecture XX NA 1 Section: Page: TEC191 Provide State. including the pharmacy and prescriber National Provider Identifier (NPI) and authorization IDs for electronic submission of claims. XX NA 1 Section: Page: TEC188 Provide OSC immediate notification of proposed programming and logic changes within the MMIS that would bypass the Technical Architecture OSC audit routines or OSC edits to pend claims.4.3.12 1 Section: Page: TEC187 OSC audit staff are authorized to perform audits related to the State’s Medicaid program. or deny any claim from processing based upon OSC defined edit criteria. 1 Section: Page: TEC181 Provide POS system capability to inquire and return to the pharmacy provider the status of the claim and any errors or alerts associated with the processing. POS2. XX NA 1 Section: Page: XX NA 1 Section: Page: TEC189 Support OSC audit routines through online capability for authorized OSC staff to pay and report. POS4. whether such programs are generated by the audit staff. conform to federal and State policies. POS4. POS2. • Real-time access to drug file and pharmacy claims history.4. XX POS4. Technical Architecture XX POS3.3. TEC190 Provide online capability to modify OSC audit routine criteria. and the value of claims approved for payment is not less than or greater than the check amount. Technical Architecture XX ME1. and current PTAR users (MMTPs and PTAR facilities) with on-line query access for the most recent three years of transportation claim payment historical data. such as: • Edit failures • ProDUR alerts • Member (Beneficiary) or coverage restrictions • Prior authorization missing • Required coordination of benefits. 2 Section: Page: TEC184 Provide POS functionality and capability to facilitate pharmacy drug referral certification and authorization transactions as specified by 45 CFR Part 162. and generates alerts (messages) to providers as required by State policy. • Refill to soon • Requires generic substitution • Deny experimental drugs • Requires unit dose (or not) • Package size not approved • Drug Efficacy Study Technical Architecture XX POS2. auditing claims before and after payment as well as storing. audit routines shall be run to independently audit claim processing. POS2. • Real-time access to member eligible on the date of service and not otherwise restricted • Real-time access to check claims against state-defined service limitations Technical Architecture XX POS1. Technical Architecture XX NA 1 Section: Page: . 3 Section: Page: TEC182 Provide POS functionality to identify and flag individual drugs and compounds for manual pricing intervention.6. • Real-time access to benefit business rules. pend.5. Pended claims shall not be paid in Financial Technical Architecture cycles until review and resolution by OSC. • Real-time access to the State’s drug and formulary file or maintains an up to date copy for POS use. Programming and logic changes to OSC edits will be controlled and authorized in writing only by OSC. retrieving and executing programs on-line. 3 Section: Page: TEC180 Provide the capability to assign a unique control number to each claim received through the POS system for tracking and monitoring purposes. POS1. 1 Section: Page: TEC186 Provide the capability to track members auto-assigned in a managed care plan though an indicator.4.1. POS1. such as pending all claims submitted by a specific provider. Technical Architecture XX POS2. As part of the production system’s payment cycles. Technical Architecture XX POS2. transportation managers.2. checks are appropriately issued for claims approved for payment. These audit routines provide assurances such as: no check is issued without supporting claims.TEC179 Maintain a State-approved POS which provides: • Real-time access to provider eligibility. POS1.3.18. Modifications to criteria used by OSC for the purpose of flagging Medicaid claims for each payment cycle based on known audit risks will be limited solely to authorized OSC staff.16. 2 Section: Page: TEC183 Process electronic adjustments of paid claims submitted through the Pharmacy POS system. or based on multiple conditions or combinations of conditions within a claim. are part of the contractor’s production system. or are generated by Technical Architecture contractor staff. 1 Section: Page: TEC185 Provide automated capabilities to verify that services are medically appropriate.6.2.

captures and reports transactions for providers disbursement of roundtrip MetroCards to eligible Medicaid Members at the medical site at the time of the medical appointment. XX NA 1 Section: Page: TEC194 Provide functionality where oversight agencies can execute queries and/or computer programs against the system reference and master files used by the system to adjudicate claims. Technical Architecture XX NA 1 Section: Page: TEC196 Provide web based capability and functionality to restrict recipients to a primary providers. Technical Architecture XX NA 1 Section: Page: TEC193 Provide an audit module capability to suspend or deny claims from processing. The module must have the capability to be updated Technical Architecture real-time through a portal. a browser based NYHRA product which edits. This module would have the capability for the Department to insert business rules to suspend or deny claims. Technical Architecture XX NA 1 Section: Page: TEC195 Provide a solution/capabilities to determine that a recipient is physically present at point of service. Technical Architecture XX NA 1 Section: Page: .TEC192 Takeover system administration and maintenance functions for PTAR from NYC.

Attachment E: Requirements Traceability Matrix .g. other real-time transactions (e. prior authorization) . Web based applications.SLA Service Level Agreement Technical Architecture Production Environment Hours of System Availability Access Rights User Acceptance Test Environment Hours of System Availability Disaster Recovery Backup Disaster Recovery Execution Failover Real-time Transactions including but not limited to Web Portal..

Inbound Files Outbound Files Notification of errors of inbound and outbound files reconciliation Reconciliation of errors of inbound and outbound files IVR Connections Batch Transactions Data Quality Audit Security and Confidentiality Risks and Vulnerabilities Reporting .

and unrestricted access Access Termination Eligibility and Enrollment Provider Enrollment Applications .Risks and Vulnerabilities Reporting Business Relationship Management HIPAA requirements Care Management Prior Approval Authorization Consistency Contract Management Key Staff Project Implementation Dates / Go-Live Full. uninterrupted.

Provider Recertification Application Provider File Maintenance Request Provider Termination Member Eligibility Batch Transactions Member Eligibility real-time Transactions Support Verification of Member eligibility Financial Management Payment Calculation Payment 1099 Reporting 1099 Reporting Timely Payments Account reconciliation .

Member Management Hours of Call Center Availability Call Center Time to Answer Call Center Hold Time Call Center Question/Issue Resolution Blockage Rate Telephone Abandonment Rate Inquiry Resolution Explanation of Benefits Member Satisfaction Performance Management .

DOH User Requests Operations Management Electronic Claims Adjudication Electronic Claims Adjudication Pricing Reference Files Non-Electronic Claims Adjudication Suspended Claims Uphold processing standards State & Federal Data Delivery Reporting Plan Management SLA Reporting .

SLA Reporting Provider Management Correspondence (both hardcopy and electronic) Hours of Call Center Availability Call Center Time to Answer Call Center Hold Time Call Center Responsiveness .

Blockage Rate Telephone Abandonment Rate Provider Satisfaction .

except for scheduled State approved downtime. the Department may at its sole discretion declare the backup site the new primary site.SLA Definition Technical Architecture Ensure that all contractor. Ensure that User Acceptance Test Environment is operational 7 am – 7 pm ET. Demonstrate a disaster recovery capability no less than every two (2) calendar years. budget. Ensure NYS and federal staff access to retrieve claims.: Requirements Traceability Matrix . . at which time the contractor will have thirty (30) days to secure and make operational a new backup site. the Department shall require the contractor to convert to the backup site within twenty-four (24) hours of notification by the Department to do so. These backups must be executed in such a way that any data set can be restored from the backup medium within twelve (12) hours of the discovery and notification that a restoration is needed. On a weekly basis the contractor will back up all databases and other data and store the backups at a secure off-site location.Saturday) and extended hours when requested by the State. 6 days/week (Monday. Back up on a daily basis all data files that reside on the multiple environments. member. Failover of the production environment must occur within 5 minutes. seven days a week. and report information including all supporting materials and correspondence through web-based application. Provide production failover and redundancy capabilities in the event of technical difficulties in the production environment. In the event the contractor cannot return to the original production site within seven (7) calendar days. provider. In the event the primary site becomes unavailable and/or the failover procedures cannot be successfully executed. One hundred percent (100%) of all real-time transactions must not be greater than thirty (30) seconds. state. Response time for users accessing real-time transactions must not be greater than two (2) seconds for at least ninety percent (90%) of the transactions and response time must not be greater than five (5) seconds for at least ninety nine percent (99%) of the transactions. and other stakeholder elements of the production environment are operational and available without interruption 24 hours a day.

.Process inbound files at a frequency as defined by the Department. maintain and archive information on each member’s Medicaid benefits. for. activities or services specified in this RFP. This notification must take place no later than one (1) business day of the transaction processing date. Receive. Each successive year of operations: Quarterly random data quality audits must achieve a minimum of ninety-nine point nine percent (99. The data received from the contractor must be of the highest quality (i. Reconcile errors identified during the processing of transaction files and reprocess business partner transactions within one (1) business day of receipt of process-able files. claims history. ACA. The contractor shall prepare and present a remediation plan outlining the extent of the security breach or to address correction of vulnerabilities that would allow a potential breach within ten (10) days of discovery. The contractor must use or disclose PHI only to perform functions. Provide sufficient in-bound access so that Medicaid callers are connected with the interactive voice response (IVR) system(s) within two (2) telephone rings at least ninety-nine percent (99%) of the time. or HITECH regulations. and payment information to support claims payment and other financial processes to ensure its ability to comply with the data reporting requirements. .9%) data quality accuracy rate per quarter. process. Support and monitor the processing of transaction files and notify the Department of all transactions that have not been processed successfully. The contractor must maintain appropriate systems and mechanisms to obtain. The contractor must notify the Department within twenty four (24) hours of discovery of any security breach or vulnerabilities identified to the system or program information utilized under the contract.e. Process outbound files at a frequency as defined by the Department. if done by the Department. provided that such use or disclosure would not violate the HIPAA. and send receipt to originator of each batch transactions within 24 hours. provider information. or on behalf of the Department. First year of operation: Quarterly random data quality audits must achieve a minimum of ninety-nine percent (99%) data quality accuracy rate per quarter. transaction response shall be within ten (10) seconds at a minimum ninety-nine percent (99%) of the time. accuracy and completeness). acknowledge.

and must comply with any other applicable (current and future) Federal and State laws regarding privacy and confidentiality.The contractor must notify the Department within twenty four (24) hours of discovery of any security breach or vulnerabilities identified to the system or program information utilized under the contract. Provide sufficient policies and procedures that explain and ensure consistency of decisions through inter-rater reliability in approving or denying prior approvals. Health Information Technology for Economic and Clinical Health Act (HITECH) Breach Notification Rule. except for applications sent to OMIG for further pre-enrollment review. . unless there are substantive changes to the scope of the release. and treatment plans. and treatment plans shall be reviewed by another clinician to ensure consistent decisions. Provide full. and MAS contractor employees by the end of their last business day or within one (1) workday of notification by the Department for Department staff or contractors. Care Management Process to completion one hundred percent (100%) of requests within one (1) business day of receipt of complete information. uninterrupted and unrestricted access to the Department and other authorized State agencies and representatives to all accounts established under the contract used to administer NYS payments to Medicaid providers.127. Terminate system access for all terminated or transferred State employees. State Contractors. to all records relating to Vendor performance under this Agreement. remote and on-site) supporting the NYS Medicaid Program in accordance with 42 CFR 433. prior authorizations. At a minimum ten percent (10%) of each reviewer’s prior approvals. delivered to the Department within 30 days of contract award. and to all contractor systems and records (both prior to and after certification. Contract Management The contractor must fill a vacant key staff position identified within this RFP within thirty (30) calendar days. prior authorizations. Business Relationship Management The contractor must comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The contractor guarantees Go-Live dates for Release One and Release Two as agreed upon with the initial work plan. The contractor shall prepare and present a remediation plan outlining the extent of the security breach or to address correction of vulnerabilities that would allow a potential breach within ten (10) days of discovery. Eligibility and Enrollment Process to completion a minimum of ninety nine percent (99%) of all clean provider applications (a provider enrollment application that is not missing information) within thirty (30) business days of receipt.

432 (a). except for scheduled State approved downtime.Collect and process to completion a minimum of ninety nine percent (99%) of all provider re-certifications within State approved timelines and in accordance with ACA requirements. 98% of member enrollment files transmitted in real-time must be received in real-time. At a minimum. Disenroll one hundred percent of Medicaid providers identified/approved by the NYS within one (1) business day of notification. as required by 42 CFR 455. Produce and transmit electronically original and corrected 1099 files for the Internal Revenue Service (IRS) and NYS Department of Tax and Finance in accordance with federal and State regulations. or payments that should have been denied that are not recovered. Produce and provide through electronic transmission a check register. Process to completion a minimum of ninety-eight percent (98%) of all clean provider maintenance updates within two (2) business days of receipt. seven days a week. Ensure that all contractor eligibility verification methods for receipt and response of eligibility inquiries are available without interruption 24 hours a day. At a minimum. Provide the Department monthly reconciliation for each bank account maintained under the contract. The process will include post-enrollment site visits of providers who are designated as moderate or high categorical risks to the Medicaid program. and all shares reports to the Department within twenty-four (24) hours of completing the Department’s approved payment cycle. Contractor caused incorrect payments may result from either the contractor’s failure to utilize available information or by a failure to process the claim or transaction correctly. Produce and mail to providers 1099 earnings reports in accordance with federal and State regulations. duplicate payments. The remaining two percent (2%) must be processed by the next business day. . Disburse claims and all other payments on the Department’s approved payment cycle. Financial Management The contractor shall be liable for the actual amount of all contractor caused incorrect payments. EFT register. to be done prior to completion of recertification. ninety-eight percent (98%) of the eligibility batch files must be processed within twelve (12) hours of receipt.

member materials. using a statistically valid sample of members. The contractor must send the requesting party. including. The percentage of incoming calls to the telephone line in which the caller disconnects after fifteen (15) seconds but prior to the call being answered by a customer service representative will not exceed three percent (3%). peer specialists. At least 98% of calls placed on hold will be answered within two (2) minutes or less. (Eligibility Help Desk) Resolve all information requests or questions via telephone within two (2) business days. an estimate of how long it will take to answer the question or to provide the requested information. All calls must be answered within fifteen (15) seconds.Member Management The Call Center (Member Services Help Desk) must be available 8:00 AM (ET) to 5:30 PM (ET) weekdays and from 9:00 AM (ET) to 1:00 PM (ET) on the weekend and State approved designated holidays. Resolve ninety-five percent (95%) of member inquiries received by the Customer Service Center during the initial call. and satisfaction with complaint resolution process. within two (2) business days of receipt of the request. The contractor’s staff will provide input on the design of the survey process and the questions included in the survey. The contractor guarantees that no more than one percent (1%) of incoming calls will be blocked by a busy signal calculated on a monthly basis. After hours calls and messages must be returned within one (1) business day. Performance Management . an acknowledgment. The contractor must notify the Department within twenty-four (24) hours of any delayed requests including the estimated response date. calculated and reported on a monthly basis. Produce and distribute an explanation of benefits (EOB) within 45 days of the claims payment An annual member satisfaction survey shall be conducted by the Department or Department’s designee. Requests of an unusual nature requiring significant research must be answered as expeditiously as possible. The survey shall assess contractor specific performance related to member services.

Time during which claims are under review by the Department will not count toward the adjudication standard. Extract and provide to the Department requested information for federal reporting in the requested format necessary for submission within seven (7) days of request. plan management. Plan Management The contractor must maintain the necessary data in appropriate log files to measure its performance and report monthly on all SLAs illustrating daily metrics against the SLAs defined in this RFP. or pend paper claims within seven (7) calendar days of receipt by the contractor. quarterly. Correct all suspended claims for those within contractor responsibility within thirty (30) business days of suspension. Operations Management Adjudicate a minimum of ninety-eight percent (98%) of all claims within one (1) hour of receipt. summary data or standard management reports are successfully processed no later than one (1) business day after the submitted request. and performance management reporting at the schedule defined per report. Pay. weekly. Process inbound files according to HIPAA standard formats based on industry standards and Department requirements. In the event that processing the request requires more than one (1) business day due to volume of NYS requests or processing time of a request. Produce all daily. Batch files containing reference data required to price claims must be processed on the date and frequency specified by the Department. the contractor must notify the user within twelve (12) hours of the submitted request and process requests based upon the priority set by NYS. suspend. . monthly. deny.Ensure that program management user requests for program data. and annually operational. Reprocess erroneously denied claims within three (3) business days of discovery of erroneous denial.

Respond to the remaining two percent (2%) within twenty (20) business days of receipt by the contractor. Provider Management Acknowledge in writing 100% of correspondence within 7 business days of receipt. All calls must be answered within three (3) rings or fifteen (15) seconds. The contractor must send the requesting party. For Pharmacy providers. . within two (2) business days of receipt of the request. the Call Center (Provider Relations Help Desk) must be available 7:00 AM (ET) to 10:00 PM (ET) weekdays and from 9:00 AM (ET) to 1:00 PM (ET) on the weekend and State approved designated holidays. The contractor must notify the Department within 24 hours of any delayed requests including the estimated response date. Requests of an unusual nature requiring significant research must be answered as expeditiously as possible. an estimate of how long it will take to answer the question or to provide the requested information.If the Department notifies the contractor that damages will be assessed because of nonconformance with an SLA and the log files are not maintained or are damaged in such a way that the contractor cannot substantiate its performance against an SLA it will be construed that the contractor did not meet the SLA in question. At least ninety-eight percent (98%) of calls placed on hold will be answered within two (2) minutes or less. Responses are not complete until response is available to Department staff in the document repository. including. (Provider Relations Help Desk) Resolve all information requests or questions via telephone within two (2) business days. The Call Center (Provider Relations Help Desk) must be available 8:00 AM (ET) to 5:30 PM (ET) weekdays and from 9:00 AM (ET) to 1:00 PM (ET) on the weekend and State approved designated holidays. an acknowledgment. After hours calls and messages must be returned within one (1) business day. Respond to at least ninety-eight percent (98%) of all written provider correspondence (inquiries/complaints) with a written response within fifteen (15) business days of receipt of the provider’s correspondence by the contractor.

An annual provider satisfaction survey shall be conducted by the Department or Department’s designee. denials/appeals. The survey shall assess contractor specific performance related to provider relations/call management. . clinical management processes. The contractor’s staff will provide input on the design of the survey process and the questions included in the survey.The contractor guarantees that no more than one percent (1%) of incoming calls will be blocked by a busy signal calculated on a monthly basis. calculated and reported on a monthly basis. and satisfaction with complaint resolution process. using a statistically valid sample of providers. authorization information. The percentage of incoming calls to the telephone line in which the caller disconnects prior to the call being answered by a customer service representative will not exceed 3%.

Section: Page: $1. the Department may assess a penalty of up to one percent (1%) of the annual Operations Base Fee for each Section: missed or incorrect restoration from backup files for each missed twelve (12) hour period and one percent (1%) of the annual Operations Base Fee for each missed or Page: incorrect weekly off-site backup for each missed one day (24 hour) period. The vendor should document its approach to requirements and indicate in Attachment E the location of a response to a requirement by filling in the column “Response Reference”.000 per hour or any portion thereof that response time does not meet the times designated. Section: Page: $500/hour penalty for disruptions in the User Acceptance Test Environment. a penalty of up to one percent (1%) of the annual Operations Base Fee for every day thereafter.Attachment E: Requirements Traceability Matrix -SLA provides a comprehensive listing of all project service level agreemnts as listed in the RFP.000 per day that the requests are not accessible as per the SLA. Section: Page: If backup/recovery strategy is not executed as defined. Section: Page: . If conversion to the backup site within twenty-four (24) hours is not executed or a new backup site is not operational within thirty (30) days of declaring the backup site the new primary site. Damages Response Reference nical Architecture $1. Section: Page: One percent (1%) of the annual Operations Base Fee if the failover does not successfully occur within five (5) minutes.000 per minute penalty for disruption in production environment. the Department may assess a penalty of up to two percent (2%) of the annual Operations Base Fee. Section: Page: If backup/recovery strategy is not executed as defined. Section: Page: $5.

000 for each occurrence of failure to reprocess and reconcile unsuccessful transactions within one (1) business day Section: Page: $1. and the actual amount of all contractor caused Page: incorrect payments. whichever is greater Page: $10.000 per file Section: Page: $5. Section: Page: Up to two percent (2%) of the quarterly Operations Base Fee for each quarter that the MAS fails to meet the data defect percentage quality audit requirement for the Section: applicable contract year.000 per transaction or the full fine. And Section: Page: .000 per file not responded to within the 24 hour time frame. as defined.$1.000 per day per occurrence below the 99% standard. $10.000 per day per incident the Department is not notified.000 for each occurrence of failure to notify the Department of unsuccessful processing within one (1) business day Section: Page: $5. settlement.000 per file Section: Page: $1. and litigation cost resulting the Section: wrongful disclosure of PHI. Section: Page: $1.

or contractor Section: systems are not accessible as per the SLA. Section: Page: And $10.000 per day that the requests are not processed as per the SLA.000 per month if standard is not met. Page: $1.000 per day per incident that the remediation plan for a breach is not executed according to the department approved plan lationship Management The vendor shall be solely responsible for any fine and settlement resulting from the contractor's violation and all litigation costs that arise from alleged violation.000 per day that requested accounts. Section: Page: e Management $10. Section: Page: ity and Enrollment $25. unless modifications to Go-Live dates have been submitted and agreed upon by the Department in writing. Section: Page: .000 per day or any portion thereof that account termination response time does not meet the designated timeframe.$10. Section: Page: $1. vendor performance records. Page: ract Management $1. Section: Page: Less than ten percent (10%) will result in a penalty of up to one percent (1%) of the Section: annual Operations Base Fee.000 per day or any portion thereof past the agreed upon Go-Live date that systems and operations are not implemented and fully functional. Section: Page: $10.000 per day the position is vacant after thirty (30) days.000 per day that remediation plans are not received as per the SLA.

000 per provider per day plus liability for the amount of any payment made and Section: not recovered while the provider was excluded from the Medicaid Program as Page: discussed in Claims and Adjustment Processing Accuracy – Damages. Section: Page: Up to two percent (2%) of total amount of paid claims in payment cycle. Page: $200. Up to one percent (1%) of the monthly Operations Base Fee for any month in which check register.000 per member file above the threshold not processed in real-time.000 per eligibility file not processed within the standard time.000 if 1099’s are not accurate or produced and distributed in accordance with Section: federal and State deadlines.$25.000 per month if standard is not met.000 plus any penalties imposed on the Department by the IRS if 1099 files are not accurate or produced and distributed in accordance with federal and State deadlines. Section: Page: .000 per month if standard is not met. Section: Page: $200.000 per hour or any portion thereof that the system fails to support verification of member eligibility. Section: Page: $1. Section: Page: $5. EFT register. and all shares reports are not produced and distributed within 24 hours of completing the Department’s agreed upon payment cycles or such payment cycle is not completed upon the approved schedule. Section: Page: $10. Section: Page: $1. Section: Page: $10. $1. Section: Page: cial Management The contractor shall be fiscally responsible for any incorrect payments or duplicate payments resulting from negligent contractor performance that cannot be recovered Section: by the State within ninety (90) calendar days from the identification of the Page: problem.000 per month if standard is not met.

ber Management

$5,000 per hour or any portion thereof that the call center is not available

Section:
Page:

$.15 for each call not serviced as per the SLA.

Section:
Page:

$.15 for each call not serviced as per the SLA.

Section:
Page:

$500 per occurrence of not meeting the standard.

Section:
Page:

For each .01% to .50% of incoming calls to the telephone line that are blocked by a
Section:
busy signal, in excess of the standard of one percent (1%) calculated on a monthly
Page:
basis, the contractor shall reimburse the Department $50,000.

$.15 for each call not serviced as per the SLA

Section:
Page:

$5,000 per month that threshold is not met

Section:
Page:

$.25 for each EOB per day after the 45 days that the EOB is not distributed.

Section:
Page:

A favorable average rating is > 3.5 on a 5-point Likert scale resulting in a yearly
bonus payment of $500,000.

Section:

An acceptable average rating is ≥2.5 and ≤ 3.5 on a 5-point Likert scale resulting in Page:
no bonus or punitive assessment to the contractor.
An unacceptable average rating < 2.5 on a 5-point Likert scale resulting in a yearly
penalty of $500,000.
mance Management

$500 per file not successfully processed within twenty four (24) hours or
department approved timeline.

Section:
Page:

tions Management
$.25 per claim per day for each claim that was not adjudicated within one (1) hour Section:
of receipt.
Page:

$.35per claim per day for each claim that was processed incorrectly.

Section:
Page:

Amount of any overpayment or underpayment for claims processed using outdated Section:
files plus ten percent (10%).
Page:
$.75/claim for each claim that was not processed within the seven (7) calendar
days.

Section:
Page:

$.75/claim for each claim that was not processed within the thirty (30) calendar
days.

Section:
Page:

$1,000 per file not reprocessed correctly within twenty four (24) hours.

Section:
Page:

$5,000 per day past the seven day standard request time.

Section:
Page:

$2,000 for each report not produced within an agreed time frame.

Section:
Page:

n Management

The damages for the appropriate SLA where performance was not met or log files
were not maintained to confirm performance was met will be assessed by the
Department.

Section:
Page:

The damages for the appropriate SLA where performance was not met or log files
were not maintained to confirm performance was met will be assessed by the
Department.

Section:
Page:

der Management

$500 per correspondence that does not meet the standard per day.

Section:
Page:

$5,000 per hour or any portion thereof that the call center is not available.

Section:
Page:

$.15 for each call not serviced as per the defined standard in the SLA.

Section:
Page:

$.15 for each call not serviced as per the SLA.

Section:
Page:

$500 per occurrence.

Section:
Page:

15 for each call not serviced as per the SLA A favorable average rating is > 3.5 on a 5-point Likert scale resulting in Page: no bonus or punitive assessment to the contractor.5 on a 5-point Likert scale resulting in a yearly penalty of $500.000. .50% of incoming calls to the telephone line that are blocked by a Section: busy signal. the contractor shall reimburse the Department $50. in excess of the standard of one percent (1%) calculated on a monthly Page: basis.000.01% to .5 on a 5-point Likert scale resulting in a yearly bonus payment of $500. An unacceptable average rating < 2.000. Section: Page: $.5 and ≤ 3. Section: An acceptable average rating is ≥2.For each .