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MB-4471 - USA (Kentucky) - Pharmacy Benefit Manager Services - Deadline October 6,2020

Product (RFP/RFQ/RFI/Solicitation/Tender/Bid Etc.) ID: MB-4471

Government Authority located in Kentucky; USA based organization looking for expert vendor for information technology support services.

[A] Budget: Looking for proposal

[B] Scope of Service:

Vendor needs to provide pharmacy benefit manager services for the commonwealth Medicaid managed care program.
- The Commonwealth Medicaid FFS program will retain responsibility for processing FFS pharmacy claims, supporting the development of the Kentucky Medicaid PDL, and processing federal and State
supplemental drug rebates.
- The Contractor will maintain expert knowledge of PBM industry regulations, best practices, and innovations, and make program improvement recommendations to DMS for consideration. Throughout this contract, the MCO PBM will ensure compliance with all Kentucky and federal statutes, regulations, and policies for pharmacy benefit services provided to eligible Beneficiaries by eligible pharmacy Providers as it performs the following scope of work.
- The Contractor must provide a copy of its URAC (formerly known as Utilization Review Accreditation Commission) Pharmacy Benefit Management accreditation certificate, or other proof that URAC Pharmacy Benefit Management accreditation will occur on or before the pharmacy contract effective date. The successful Contractor will be required to maintain URAC Pharmacy Benefit Management accreditation during the entire term of this contract, including runout.
- Provide an online, real-time claims processing system and supports for receipt, adjudication, and notification to billing pharmacy Providers regarding the disposition of a claim.
- Adjudicate and report on all claims and pharmacy Provider payments in accordance with DMS-defined program policy, established reimbursement minimum fee schedules, state and federal statutes and regulations, and the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This includes the ability to establish adjudication rules customized for each DMS program by category codes, eligibility status, beneficiary attributes (e.g., age, medical condition), drug or drug class (e.g., brand/generic status, drug coverage status, PDL status), Medicare- Medicaid dual eligible status and other criteria specified by DMS.
- Provide the ability to apply an Internal Control Number (ICN) to each claim and its supporting documentation, regardless of submission format, to track claims, conduct research, perform reconciliations, and for audit purposes.
- Ensure the system is capable of adding, changing, or removing claim adjudication processing rules to accommodate State and Federal required changes to the pharmacy program within thirty (30) calendar days, unless otherwise approved.
- Identify and deny claims that contain invalid prescribing provider numbers including where the Taxonomy/National Provider Identifier (NPI) or prescribing provider number is missing or is invalid.
- Identify any liable third party, and ensure that Medicaid is the appropriate payer of last resort.]
- For more information describe in document.

[C] Eligibility:

- Onshore (USA Organization Only);

[D] Work Performance:

Performance of the work will be Offsite. Vendor needs to carry work in their office location.

Expiry Date : Tuesday, 6 October, 2020

Category : Medical Billing and Coding

Country : USA

State : Kentucky

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