(1) Vendor needs to provide medicaid billing and collections service.• Eligibility Review and Coverage Determination– Upon notification or placement of a new out–of–state (OOS) Medicaid patient, contractor will review the case to determine if valid OOS Medicaid coverage exists. During this process, contractor will determine (a) if the patient is eligible, (b) the program type eligibility, (c) benefits available for the OOS service, (d) other primary insurance, and (e) if a managed care organization is involved.• Authorization and Notification– Contractor notifies the agency for all inpatient and outpatient services that require notification.• Billing and Follow–Up– Contractor will bill all assigned OOS claims based on the verification information obtained.• Reimbursement Review– Once a claim is paid, Contractor will review the payment to make sure that the claim was paid in full according to the respective state’s fee schedule.• Provider Enrollment– Contractor will be responsible for enrolling hospital and employed providers as needed and maintaining its provider enrollment with each state.• Appeals, Appeals Process, and Hearings– if a claim is denied or underpaid, Contractor will pursue the appeal process if it is available. The appeals process includes, but is not limited to, appealing or responding to an appeal of any decision determination or order.– Contractor must be able to accept 837 transaction files daily.(2) All the questions must be submitted no later than August 26, 2024.
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