On May 29th, the Texas Health and Human Services Commission issued its request for proposal for the contract management of Texas Medicaid.
So if you are so inclined, you can take the place of Xerox as the state’s Medicaid claims administrator. Xerox was terminated as the prime contractor by HHSC in May of last year and sued by the state over its allegedly fraudulent Medicaid orthodontic prior authorization process.
You might need more than a laptop and Microsoft Access and Excel. But maybe not much more. If you send in a proposal, good luck!
Here are some of the details. The full documentation is available online.
Per the RFP document, the agency is looking for the following:
The State of Texas, by and through the Texas Health and Human Services Commission (HHSC), is seeking a qualified Contractor to take over the operation of the Texas Medicaid Management Information System (TMMIS) and performance of Claims Administrator functions which support Texas’ medical benefit programs in accordance with the specifications contained in this Request for Proposal (“RFP”).
HHSC is seeking to accomplish:
- Procure a ‘take over in place’ contract. The Contractor will maintain existing technology and business operations currently performed by Accenture State Healthcare Services, LLC and its subcontractors (referred to as the “incumbent contractor” in this document) at the Riata Trace facilities in Austin, Texas. The Contractor will maintain the current Disaster Recovery site located at the AT&T facility in Dallas, Texas.
- Ensure that critical services continue to be provided to Texas’ medical benefit program clients and providers without interruption or delay, and with no degradation in quality.
- Continue efficient and effective business functions and processes in support of Texas’ medical benefit programs.
- Improve integration among the State’s healthcare delivery systems.
The Contractor will provide an array of services for Texas’ medical benefit programs’ providers and their clients including, but not limited to:
- Provider enrollment for fee for service and managed care providers
- Verification of Medicaid client eligibility and enrollment
- Identification and verification of non-Medicaid insurance (i.e., Third Party resources)
- Management of third party liability tort cases and cost avoidance for fee-for-service and managed care
- Medical necessity determination and level of care for nursing facilities
- Processing medical prior authorizations for fee-for-service and managed care populations
- Claims adjudication for both fee-for-service and also for certain services for managed care clients (e.g., private duty nursing)
- Financial management and administrative reporting
- Managing incoming client and provider calls (i.e., Call Center)
- Processing and reporting of managed care organization and managed transportation organization encounters
- Fair hearing administration
- Management of the Texas Medicaid Electronic Health Record (EHR) Incentive Program for adoption and meaningful use of EHR technology for both fee-for-service and managed care providers
- Third party recoveries and cost avoidance, including tort recoveries for both fee-for-service and managed care organizations
Contracted services also includes system support, infrastructure, data center operations, and other technology support functions for the on-going operation of the TMMIS to support services for the Texas’ medical benefit programs’.
The new contractor will have the following responsibilities as far as dental and medical policies:
1.1. Medical and Dental Policy (MDP)
The Contractor will support the implementation and maintenance of State developed medical and dental policies for Medicaid and the CSHCN Services Program. Contractor staff will participate in the review of medical and dental policies, analyze potential system and operational impacts, implement State-approved policies, update policy and provider manuals and notify providers of changes to medical and dental policies. Contractor staff will provide information to support the State’s calculation of client services, fiscal impacts and utilization review development, and provide claims information as requested. The Contractor will also perform activities associated with updates to medical and dental policies as it pertains to coding initiatives.
1.1.2. Contractor Responsibilities
The following Table 30 provides the detailed responsibilities that the Contractor will need to fulfill upon takeover of the Medical and Dental Policy services for TMMIS.
Table 30 – Contractor Responsibilities for Medical and Dental Policy
|
Reqmt. Id** |
Sub-Category |
Requirement Detail |
|
MDP – 0001 |
General |
Contractor and/or subcontractor medical and dental policy staff will perform activities associated with updates and implementation of medical/dental benefit policies for all State programs as directed by the State in relation with International Classification of Diseases (ICD) , Healthcare Common Procedure Coding System (HCPCS), and Current Procedural Terminology (CPT), Current Dental Terminology updates, National Correct Coding Initiative (NCCI). |
|
MDP – 0007 |
General |
Participate in the medical/dental policy development meetings, as directed by the State. |
|
MDP – 0014 |
Publications |
Submit medical/dental policy manuals additions, changes, and deletions to the appropriate State program for review and approval before incorporation into the medical/dental policy manuals in a timeframe, media, and content as defined by the State. |
|
MDP – 0015 |
Publications |
Maintain provider procedures manuals that are consistent with the medical/dental policy manuals. |
|
MDP – 0018 |
Publications |
Distribute State-approved policy revisions and associated rate changes to State-approved business partners in an electronic format (45) calendar days before the operational implementation, or as directed by the State. |
|
MDP – 0029 |
Research, Analysis and Development |
Support the State’s development of medical/dental policy related to coding changes (i.e. HCPCS, ICD, NCCI) by providing: a) A concise description of the findings and policies impacted; b) Clinical research including references to peer-reviewed medical/dental policy literature and publications; c) Research from Medicare, other federal and State agencies, commercial insurance carriers, and appropriate professional organizations; d) Claims information as requested; e) Administrative impact analysis of TMMIS systems and other State-approved business partners, and a prudent estimate of the costs associated with this impact; and f) The policy implementation plan and timeline approved by the State. |
|
MDP – 0031 |
Research, Analysis and Development |
Provide information upon request to HHSC-SDS to support Estimated Client Services Fiscal Impact (ECSFI), Utilization Review and Post Implementation Utilization Review development to allow a continuation of the collaborative Medical Policy Review process. |
|
MDP – 0037 |
Research, Analysis and Development |
Document activities related to coding work (i.e. HCPCS, ICD, NCCI) in a format and in a timeframe approved by the State. |
|
MDP – 0038 |
Research, Analysis and Development |
Obtain written approval from assigned State staff on timelines for medical/dental policy implementations. |
|
MDP – 0041 |
Research, Analysis and Development |
Support review of the Medical/Dental processes and procedures at least annually, or as directed by the State. |
|
MDP – 0045 |
Research, Analysis and Development |
Support the State’s development of medical/dental policy by analyzing potential system and operational impacts related to all State medical/dental policy changes and providing a prudent estimate of the costs associated with the impact; providing claims information as requested, and recommending an implementation plan of action based on timeframes, media, and content as defined by the State. |
|
MDP – 0047 |
Research, Analysis and Development |
Define, plan, and manage all Medical/Dental project activities related to coding changes (i.e., HCPCS, ICD, NCCI) to ensure that State-approved timelines are established and met, progress is tracked and reported to the State, and quality control checks are implemented to achieve project objectives. |
|
MDP – 0050 |
Research, Analysis and Development |
Medical/Dental policy development support and operational implementation must be in accordance with, and consistent with, the scope, benefits, exclusions, and limitations of the Medicaid program, CSHCN Services Programs and other Texas programs, and must be approved by the State. |
|
MDP – 0056 |
Research, Analysis and Development |
Identify and provide a report of Medical/Dental policies impacted by coding changes (i.e., HCPCS, ICD, NCCI) within timeframes and in a format and content approved by the State. |
|
MDP – 0058 |
Research, Analysis and Development |
Update medical and dental policies with coding recommendations (e.g., NCCI, HCPCS, and ICD) as directed by the State and within timelines approved by the State. |
|
MDP – 0060 |
Research, Analysis and Development |
Review and assess impacts of CMS required code set migrations (e.g., ICD-9 to ICD-10, HCPCs, etc.) on Medical/Dental policies, and submit to each program for approval prior to implementation. |
|
MDP – 0061 |
Research, Analysis and Development |
Lead and participate in the ICD-10 Migration Analysis Workgroups by comparing the codes to the General Equivalence Mappings (GEMs), along with recommendations provided in a State-approved coding management tool, to document the prioritized mapping decisions. |
|
MDP – 0062 |
Staffing |
Provide an ICD-10 certified coder with broad current outpatient billing/coding experience to assist in operationalizing medical policy development related matters or other projects as specified by the State. The certified coder must demonstrate competency in the knowledge and skills specified. |
|
MDP – 0067 |
Staffing |
Ensure that the Contractor’s Senior Medical Officer reviews specific analysis provided to the State medical/dental policy team to ensure accuracy of research before submission to the State. |
|
MDP – 0069 |
Staffing |
The Contractor’s Medical Director/Dental Director and physician staff must participate in and be able to provide input and clinical analysis on specific policies which they support, during the medical/dental policy development process, including the medical/dental policy development meetings. |
** – HHSC acknowledges that there are gaps in the Requirements Id in the Table above, due to previous requirement(s) being modified for this functional area.