Questions for HPMS: Medical Claims TPA Question Section D. Benefit Section Plans. of RFP #3 Response 1. Please describe the types of benefit changes HPMS makes 1. Please into the describe current claim the types processing of benefit system and changes how these HPMS changes makes into are made the current by HPMS. claim processing system and how these changes are made by HPMS. 2. Please describe the definition of a unique electronic payer identification number. How is it used to process a claim? Section D. Benefit Plans. #3 Section E. Claims Processing 2. C. Health Plans will periodically make additions and deletions to their covered benefits. For example, a plan may want to add coverage for physical therapy services. Currently, HPMS does not have the ability to update benefit changes into our TPA s claim processing software. These changes are communicated in writing to our TPA who updates the appropriate processing software. 3. 2. Please In an effort describe to understand the definition HPMS of a support unique electronic needs in contracting payer with a identification TPA for medical number. claims How is it processing, used to process please a claim? describe frequency and types of medical claims that are typically processed within a bidder s claims processing system. 4. Does HPMS mean notification on a claim by claim basis or an overall claim status update? 3. In an effort to understand HPMS support needs in contracting with 5. Please a TPA for describe medical what claims HPMS means processing, by setting please up describe a direct connection frequency and between types the of medical SQL Server claims that database are typically at HPMS processed and the bidder s within a bidder s systems. claims Section E. Claims Processing 2. C. n. Section E. Claims Processing 2. o. Section E. Claims Processing 2. n. Section G. Eligibility/System Access 1. Related to electronic claim submission, each payer is assigned a unique identifier in order for a clearing house to properly transmit a provider s claim to the correct payer for processing. HPMS is looking for the bidder to provide a unique payer ID for all of our plans separate from any of the bidder s other lines of business. Paper and electronic claims are received daily. These include claims submitted on a UB-04 form, CMS-1500 form, or equivalent electronic form (834).
processing system. 4. Does HPMS mean notification on a claim by claim basis or an overall claim status update? Section E. Claims Processing 2. o. Overall claim status update. 5. Please describe what HPMS means by setting up a direct connection between the SQL Server database at HPMS and the bidder s systems. Section G. Eligibility/System Access 1. This is HPMS s preferred method of communicating member information to and from vendor. This direct connection could be in the form of a VPN connection between a server located at HPMS and a server housed by the bidder that will allow automatic communication for member eligibility and provider and claim information. This should allow real-time or nightly updates of the information. 6. Please specify the type of equipment that HPMS anticipates the bidder would need to provide. Section G. Eligibility/System Access 1. c. HPMS would require the bidder to provide any additional hardware and or software that is needed to electronically communicate with the vendor s database. Depending on the requirements for the electronic communication this may or may not include a server and software. If a separate server is required, the server and software would need to comply with standards set by Ingham County MIS departments
7. Please describe how recipient ID numbers for Plan A members appear. Does HPMS reflect the ID number consistent with the way the State assigns the ID number? Or, does HPMS manipulate the recipient ID number in any other way? Section G. Eligibility/System Access #5. The Medicaid ID number (recipient ID) is in the 10 digit format used by MDCH. This is not used in any way to construct the County Health Plan member ID number. This is a unique identifier assigned to members for all plans within the HPMS system. We use Member ID as the primary identifier of the member. 8. Please describe how Plan B ID numbers appear. Does HPMS reflect these ID numbers with a mix of alpha characters? Is there a consistent representation among all Plan B programs or is there variation? If there is variation, please provide examples. Section G. Eligibility/System Access # 5. ID numbers for all members appear in the following format: HPMS######. This ID format is consistent with all medical plans that are administered by HPMS. 9. Please specify the how the use of group numbers assigns members to a provider. In this same statement, what is the definition of provider? Section G. Eligibility/System Access #6. Contracted primary care providers, (PCP) are all assigned a group number in HPMS s system. Members are assigned to a PCP by a group number. 10. Please identify the tools HPMS currently has or is available, i.e., MS Access. Section H. Analysis and Reporting #3 HPMS has many tools that allow analysis and reporting. We have MS access available, but are moving away from this method due to its limitations. Newer analysis and reporting are run through SQL Server databases
and Reporting services. 11. HEDIS standards work within certain defines such as continuous enrollment years. Please identify the standards, including those that are modified, that HPMS uses or wishes to apply when measuring claims data using HEDIS requirements. Please identify how the bidder will be provided prior year(s) claims data by HPMS in order to evaluate various HEDIS measurement standards that meet HPMS requisites. Section H. Analysis and Reporting #6 HPMS will provide the bidder with a minimum of 5 years previous claims history in a format that is mutually acceptable to both organizations. If for some reason claims data is unavailable, HPMS is minimally looking forward to having HEDIS capability in the future. We are interested in the following standards and measurements: Effectiveness of Care (measurements: Comprehensive Diabetes Care, Use of Imaging Studies for Low Back Pain, Flu Shots for Adults Ages 50-64) Access & Availability (measurements: Adults Access to Preventive/Ambulatory Health Services) Cost of Care (measurements: Relative Resource Use for People w/ - Diabetes, Asthma, Acute Low Back Pain, and Cardiovascular Conditions) 12. HPMS indicates that there are 16 Plans in 32 Michigan counties. Please define what HPMS means by a network. Section I. Provider Network Each of the 16 plans is responsible for serving residents in designated counties. Each health plan may have its own set of provider networks within these counties. A group of Health Plan service providers that are all
related by some mechanism such as contracted reimbursement rate, hospital affiliation, or provider specialty. 13. HPMS indicates that County Health Plans maintain multiple networks. Please indicate the number of networks that HPMS is referring to and the number of providers in each network. Section I. Provider Network and #4 Currently, there are around 20 networks (most plans have only one). However, there are plans with more than one and HPMS expects to see this increase as health plans move towards differing reimbursement rates for certain provider types and the need for provider group classifications. The number of providers is each network varies greatly. 14. Please define HPMS current process for updating provider information. Please specify file transfer methodology, frequency of updates and format for uploading. Please provide a sample document. Section I. Provider Network. #4 In the scenario where a direct connection is available, we can share provider information. This would eliminate the need to send file updates and allow for a realtime or automated nightly update. If we are not able to share information through a direct connection. We will need to send provider information weekly. The structure of this file has not yet been finalized. 15. Please describe how fee schedules are provided to the bidder from the County Health Plans. Please include format and specifications that are included to Section K. Reimbursement #2 We expect the bidder to receive Medicaid fee screens directly from MDCH. File format for these depends on MDCH production. Currently, these
communicate fees. appear to be Excel based files. 16. Please provide an example of a customized fee schedule currently being used. Section K. Reimbursement #2 Customized fee schedules will be based off current or previous published Medicaid (or another payer s i.e. Medicare) fee screens. For example, reimbursements rates for some plans are 8% above current Medicaid rates. 17. HPMS states that the bidder should be able to receive, implement and update fee schedules from the State of Michigan Medicaid Fee Schedule. Please specify how HPMS expects the customized fee schedules to work. Section K. Reimbursement #2 See above answer. Customized fee screens would be based on another published fee schedule, most likely Medicaid or Medicare. HPMS would provide the base fee schedule if not Medicaid. Payment rates would then be the same or a percentage/ dollar amount above the base fee schedule rate. 18. Please specify how many customized fee schedules are anticipated. Section K. Reimbursement #2 At this time, all HPMS administered plans share two customized fee schedules (one being capitated) outside of the current Medicaid fee schedule. However, HPMS expects this number to increase. The bidder should have the ability to allow each plan to have a minimum of one customized fee schedule.
19. Please clarify how the PA is applied. Is this done at the CPT Code level or at the service level? Section L. PA and Medical Review #1 HPMS currently authorizes medical services at the CPT code and service level. Not all covered services currently require prior authorization and each plan varies in what services do require prior authorization. Currently, an authorization may be given for a general service (i.e. PFT) or for a specific CPT code. If an authorization was given for a service, the plan would define a group of CPT codes that are payable. 20. Please specify how HPMS notifies the bidder. Section M. Payment Recovery #1 A monthly file is sent listing members eligible for payment recovery. 21. Please clarify if this applies to Plan A only or if COB is also intended for Plan B programs. Section M. Payment Recovery #1 COB claims are currently processed for both Plan A and B. This processing does not necessarily mean a payment will be generated. Some plans allow other medical coverages and some plans do not. 22. Please clarify if HPMS expects the bidder will send member EOBs. Section M. Remittance Advices #3 No health plan currently sends member EOB s. However, many plans are looking to do this within the next year. These EOBs may be per claim but most likely will be a periodic (i.e. monthly/quarterly/yearly) summary EOB. We would like to know the bidder s capabilities related to both types (per claim
and summary) of member EOB production. 23. We understand and are aware of the funding constraints County Health Plans periodically experience. What mechanisms are used when funding delays occur? Please describe how funding delays that affect provider payment are handled. Section M. Remittance Advices #6 Most health plans manage cash flow so releases of checks are not delayed. However, occasionally, a plan may have to delay the release of checks until funds are available. In this case, the CFO of the plan would notify the contact person that funds are not available yet and not to release checks until further notice. 24. Please identify the timeframe(s) that will be expected by either HPMS or the County Health Plans to transfer funds. Please identify if there are variances in notification and funding timeframes among the County Health Plans. If there are variances, please describe each variance. Section M. Remittance Advices #6 Normally, CFOs of the plans respond within three days to the notice that the checks are ready for release. On occasion, a CFO may delay due to insufficient funds but communication is expected between the CFO and TPA in this instance.