Attachment e Requirements Traceability Matrix 2

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:
Section:
Page:
Section:
Page:
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
BUS002
Designate one or more persons responsible for the security of each facility.
Management

Relationship
NA
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).
Management

Relationship
NA
Section:
Page:
BUS004
Provide complete segregation of State data, documents and files from that of other contractor customers.
Management

Relationship
NA
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.
Management

Relationship
NA
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:
ETINs
EFTs
Web Portal Users
Management

Relationship
NA
Section:
Page:
BUS007
Accept Trading Partner and Security Agreement applications via hard copy, fax, and the Web Portal.
Management

Relationship
NA
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:
Security Packet A for real-time (Direct Connection) processing
Management
Security Packet B for batch processing
Trading Partner Agreements

Relationship
NA
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

Relationship
NA
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.
Management

Relationship
NA
Section:
Page:
BUS011
Image, edit, verify, index and route for processing hard copy and electronic applications, maintenance and termination
requests for:
Managed Care contracts
ETIN
Web Portal User
EFT
Management

Relationship
MC1.5
Section:
Page:
BUS012
Comply with all relevant provisions of regulations promulgated under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), American Recovery and Reinvestment Act of 2009 (ARRA) and Health Information Technology for
Management
Economic and Clinical Health (HITECH) Act including privacy and security regulations.

Relationship
RI4.1, ME4.1
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.

Relationship
RO5.2; RI4.2
Section:
Page:
BUS014
Use or disclose Protected Information (PHI) only to perform functions, activities or services specified in this RFP, for, or
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.

Relationship
RI4.1, ME4.1,
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
Management
the data breach provisions of the NYS Technology Law.

Relationship
BE1.8, ME4.1
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.
Management

Relationship
NA
Section:
Page:
BUS017
Ensure PHI is rendered unusable, unreadable or indecipherable to unauthorized individuals in accordance with Department Business Relationship
of Health and Human Services Guidance published April 27, 2009.
Management

Relationship
NA
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

Relationship
NA
BUS019
Provide a solution that complies with the Federal Information Security Management Act (FISMA) regulations for security Business Relationship
and privacy.
Management

Relationship
NA
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

Relationship
NA
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.

Relationship
NA
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.
Management

Relationship
NA
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.
Management

Relationship
SP2.1, SP2.2
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.
Management

Relationship
SP1.3
BUS025
Provide a user friendly interface for Security Administrators to grant, manage and revoke access for individuals.
Management

Relationship
SP1.4
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

Relationship
SP1.4
BUS027
Ensure applications provide detailed system audit trails on all inquiries, adds, updates or deletes to the database completed Business Relationship
by an authorized user. Audit trails must include user, action, time, and record changed.
Management

Relationship
SP3.1, PR3.5
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
Management

Relationship
BE1.8
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.
Management

Relationship
NA
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.
Management

Relationship
SP2.3, SP2.4
Section:
Page:
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Page:
BUS031
Provide a solution to enforce the principle of least privilege access e.g. limiting individual access to specific applications,
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.

Relationship
SP1.7
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.
Management

Relationship
NA
Section:
Page:
BUS033
Ensure there is never a connection to the States 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 States computer network, the contractor must secure its own connected systems in a manner consistent Management
with the States then-current security policies, which the State will provide to the contractor on request.

Relationship
NA
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).
Management

Relationship
SP2.3, SP2.4
Section:
Page:
BUS035
Implement mechanisms to safeguard data integrity and confidentiality of data passing over both internal and public
networks.
Management

Relationship
SP2.3, SP2.4
BUS036
Put in place a firewall between the contractor's private network and the connection to the State's network.
Management

Relationship
NA
BUS037
Keep confidential any information passing through the contractor's network.
Management

Relationship
NA
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

Relationship
NA
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.
Management

Relationship
NA
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.
Management

Relationship
SP1.1
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.
Management

Relationship
SP1.1
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

Relationship
SP3.5
Section:
Page:
BUS043
Detect, report and prevent hacking, intrusion and other unauthorized use of contractor resources.
Management

Relationship
NA
BUS044
Assign discrete security roles for creating, deleting and updating data.
Management

Relationship
NA
BUS045
Assign unique user identification to identify and track each user of the system, including authorized providers or other
non-employee users.
Management

Relationship
SP1.1
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.
Management

Relationship
NA
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.
Management

Relationship
NA
BUS048
Terminate electronic sessions after a specified time of inactivity on all systems, this time may vary by function.
Management

Relationship
NA
BUS049
Log unauthorized access attempts by IP identification, user ID, date and time.
Management

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

Relationship
NA
BUS050
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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.
Management

Relationship
SP1.2
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
Management

Relationship
NA
Section:
Page:
BUS053
Provide accountability control to record access, including attempts at access by non-authorized individuals.
Management

Relationship
NA
BUS054
Provide system access to all new State and contractor staff within two (2) workdays of request.
Management

Relationship
NA
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.
Management

Relationship
NA
Section:
Page:
BUS056
Protect power and telecommunications cabling carrying information or supporting information services from interception
or damage. 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.

Relationship
NA
Section:
Page:
BUS057
Obtain prior Department approval for the use of any equipment by the contractor, its subcontractors, agents or others
working with it from outside the contractors premises. The security provided must be equivalent to that for on-site
equipment used for the same purpose, taking into account the risks of working outside the contractors premises. This
Management
equipment may include, but is not limited to, all forms of personal computers, personal digital assistants or similar devices
that are used for home working or are being transported away from the normal work location.

Relationship
NA
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.
Management

Relationship
NA
Section:
Page:
BUS059
Provide facility security which includes, but is not limited to, Security Access Reader Card System, security personnel,
and outside surveillance cameras with recordings archived for thirty (30) calendar days to contractor's facility.
Management

Relationship
NA
Section:
Page:
BUS060
Provide visitor logs and supervised visitor access to contractor's facility.
Management

Relationship
NA
Section:
Page:
BUS061
For quality improvement and system enhancement purposes, conduct quarterly status user group meetings for each of up
to six (6) user groups identified by the Department. Quarterly meetings must begin within ninety (90) calendar days of the
Management
contract start date.
BR02 Manage Business

Relationship Communication
NA
Section:
Page:
BUS062
Support the transition of current business partner users (providers, trading partners, etc.) to the contractor's application and Business Relationship
describe approach to minimize impact on current users.
Management

NA
Section:
Page:
BUS063
Utilize web-based technology with compatibility with all major web browsers, including, but not limited to, Internet
Explorer, Firefox, Safari, Google Chrome, and mobile platforms to support sharing of information with providers and
members.
Management

NA
Section:
Page:
BUS064
Provide the ability to automatically generate, track and maintain member and provider correspondence, including, but not Business Relationship
limited to, individual letters, form letters, labels, memos and e-mails.
Management

NA
Section:
Page:
BUS065
Communicate with providers regarding the Business Relationship process for Trading Partner and Security agreements,
ETINs, EFTs, and Web Portal Users including but not limited to the following types of requests:
Applications
Maintenance
Terminations
Management

NA
Section:
Page:
BUS066
Prepare, produce and distribute Business Relationship notifications via mail, electronic and/or Web Portal, when
appropriate, including but not limited to:
EFT agreements
ETIN agreements
Web portal user agreements
Management

NA
Section:
Page:
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Page:
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, CPU-to-CPU) processing
Security Packet B for batch (FTP, Electronic Gateway (BBS)) processing
Trading Partner Agreements
Management

NA
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.
Management

NA
Section:
Page:
BUS069
Produce information packets when Trading Partner and Security Agreements are approved.
Management

NA
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.
Management

NA
Section:
Page:
BUS071
Ensure the Web Portal provides ETIN applications, instructions and related materials as required by the Department.
Management

NA
Section:
Page:
BUS072
Generate automated letters and/or electronic notifications to providers with active ETINs as directed and approved by the Business Relationship
Department.
Management

NA
Section:
Page:
BUS073
Produce information packets when ETINs are approved.
Management

NA
Section:
Page:
BUS074
Send automated letters/notices to providers with ETINs informing them when the ETIN is terminated.
Management

NA
Section:
Page:
BUS075
Provide the capability to generate annual ETIN recertification notices as directed by the Department.
Management

NA
Section:
Page:
BUS076
Automatically identify ETINs that are to expire within a period specified by the Department and notify the providers based Business Relationship
on Department defined business rules.
Management

NA
Section:
Page:
BUS077
Generate automated letters and/or electronic notifications to providers with active EFT agreements as directed by the
Department.
Management

NA
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

NA
Section:
Page:
BUS079
Ensure that the Web Portal provides Web Portal user applications, instructions and related materials as required by the
Department.
Management

NA
Section:
Page:
BUS080
Generate automated letters and/or electronic notifications to users of the Web Portal as directed and approved by the
Department.
Management

NA
Section:
Page:
BUS081
Produce information packets when Web Portal user access is approved.
Management

NA
Section:
Page:
BUS082
Send automated letters/notices to users informing them when their Web Portal access is terminated.
Management

NA
Section:
Page:
BUS083
Ensure that the Web Portal provides EFT applications, instructions and related materials as required by the Department.
Management

NA
Section:
Page:
BUS084
Receive, review for completeness and process hard copy and fax termination requests for:
ETINs
EFTs
Web Portal Users
Transactions failing the completeness review must be returned to the submitter without further processing. Send
automated letters/notices to providers informing them when the aforementioned is terminated.
Management

NA
Section:
Page:
BUS085
Receive, review for completeness and process hard copy and fax maintenance requests for:
ETINs
EFTs
Web Portal Users
Transactions failing the completeness review must be returned to the submitter without further processing.
Management

Relationship Information
NA
Section:
Page:
BUS086
Review maintenance requests, make determinations, and update information as specified by the Department for:
ETINs
EFTs
Web Portal Users
Management

NA
Section:
Page:
BUS087
Maintain Trading Partner and Security Agreement information with date specific history as required by Department
business rules.
Management

NA
BUS088
Provide the capability to image, index and associate hard copy and fax Trading Partner and Security Agreement
applications and route for processing.
Management

NA
BUS089
Provide the capability for users of provider area of the Web Portal to enter Trading Partner and Security Agreement
applications.
Management

NA
BUS090
Edit Trading Partner and Security Agreement applications entered through the provider area of the Web Portal based on
Department business rules for data presence, validity, inter-field relationships, and completeness. Errors returned must be
Management
clearly identified to facilitate correction by the user.

NA
Section:
Page:
BUS091
Provide the capability through the provider area of the Web Portal to modify, save and delete Trading Partner and Security
Agreement applications entered prior to submission, along with the capability to review and/or print applications prior to
Management
and after submission.

NA
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.
Management

NA
BUS093
maintenance requests
Management

NA
BUS094
Track each Trading Partner and Security Agreement maintenance transaction through all the steps in the maintenance
process
Management

NA
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.
Management

NA
BUS096
Provide the capability to view, add and update Trading Partner and Security Agreement information via the web-based
application as required by the Department.
Management

NA
BUS097
Provide the capability to perform mass updates to Trading Partner and Security Agreement information as required by the Business Relationship
Department.
Management

NA
BUS098
Support and manage the annual ETIN re-certification process.
Management

NA
BUS099
Maintain New York Prescription Saver (NYPS) agreements with approximately 4,000 participating pharmacies serving the Business Relationship
NYPS Program.
Management

NA
BUS100
Coordinate Medicaid transportation administrative function between the Department and transportation managers.
Management

NA
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BUS101
Review termination requests and update information as specified by the Department for:
ETINs
EFTs
Web Portal Users
Management
BR04 Terminate Business

Relationship
NA
Section:
Page:
BUS102
Terminate Trading Partner and Security Agreements in accordance with Department policies. The termination of a Trading
Partner and Security Agreement must result in the discontinuation of applicable services including but not limited to:
Access to the provider area of the Web Portal
Management
Ability to submit electronic and hard copy transactions

Relationship
NA
Section:
Page:
BUS103
Provide the capability for users to enter Trading Partner and Security Agreement termination requests via the provider area Business Relationship
of the Web Portal
Management

Relationship
NA
BUS104
Provide the capability to view, add, change, and terminate Trading Partner and Security Agreements based on Department Business Relationship
business rules through the web-based application.
Management

Relationship
NA
BUS105
termination requests
Management

Relationship
NA
BUS106
Provide the capability to automatically terminate groups of Trading Partner and Security Agreements based on criteria
determined by the Department.
Management

Relationship
NA
BUS107
Automatically update information associated with a Trading Partner and Security Agreement termination based on
Department business rules.
Management

Relationship
NA
BUS108
Maintain the data associated with a terminated Trading Partner and Security Agreement as specified by the Department.
Management

Relationship
NA
BUS109
Accept ETIN termination requests via hard copy, fax, and the Web Portal.
Management

Relationship
NA
BUS110
Provide the capability to view, add, change, and terminate ETINs based on Department business rules through the webbased application.
Management

Relationship
NA
BUS111
Provide the capability to image, index and associate hard copy and fax ETIN termination requests
Management

Relationship
NA
BUS112
Provide the capability to automatically terminate groups of ETINs based on criteria determined by the Department.
Management

Relationship
NA
BUS113
Automatically update information associated with an ETIN termination based on Department business rules.
Management

Relationship
NA
BUS114
Maintain the data associated with a terminated ETIN as specified by the Department.
Management

Relationship
NA
BUS115
Accept Web Portal User Termination requests via the Web Portal.
Management

Relationship
NA
BUS116
Provide the capability to view, add, change, and terminate Web Portal Users based on Department business rules through
the web-based application.
Management

Relationship
NA
BUS117
Provide the capability to automatically terminate groups of Web Portal Users based on criteria determined by the
Department.
Management

Relationship
NA
BUS118
Update information associated with a Web Portal User termination automatically based on Department business rules.
Management

Relationship
NA
BUS119
Maintain the data associated with a terminated Web Portal User as specified by the Department.
Management

Relationship
NA
BUS120
Accept EFT termination requests via hard copy, fax, and the Web Portal.
Management

Relationship
NA
BUS121
Provide the capability to review and approve EFT termination requests received from providers via the web-based
application.
Management

Relationship
NA
BUS122
Provide the capability to image, index and associate hard copy and fax EFT termination requests
Management

Relationship
NA
BUS123
Provide the capability to automatically terminate groups of EFTs based on criteria determined by the Department.
Management

Relationship
NA
BUS124
Automatically update information associated with an EFT termination based on Department business rules.
Management

Relationship
NA
Maintain the data associated with a terminated EFT as specified by the Department.
Management

Relationship
NA
BUS125
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CM01 Establish Case
WA1.4
Section:
Page:
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.
CM02 Manage Case Information
NA
Section:
Page:
CAR003
Describe the contractors experience with coordinating primary care, specialty medical, dental, pharmacy and behavioral
health services over the last five years. Include in this description, at a minimum, challenges the organization has
encountered in collaborating with providers, health plans, government health programs, Regional Health Information
Organizations (RHIO) and other contractors or carveouts as well as solutions considered and implemented.
Care Management
NA
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
NA
Section:
Page:
CAR005
Identify, by member, the screening and related diagnosis and treatment services the member receives for Early and
Periodic Screening Diagnosis, and Treatment, (EPSDT).
Care Management
CA4.3
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, employment or other criteria for reporting, management, Care Management
managerial oversight.
NA
Section:
Page:
CAR007
Receive, store, and make available electronically individuals approved plan of care (POC) and identify the date a
participants POC assessment is completed and the date of the next POC re-evaluation. Generate monitoring reports to
determine if services approved in the plan of care are provided.
Care Management
WA3.1, WA3.2,
WA3.3
Section:
Page:
CAR008
Capture and provide member data to support case identification, tracking, and reporting for the EPSDT services covered
under Medicaid.
Care Management
CM03 Manage Population Health

BE1.7
Outreach
Section:
Page:
CAR009
Establish and maintain an adjudicated prior authorization record, 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
CA5.9, CA5.11
Section:
Page:
CAR010
Enable prior authorization staff to send requests for additional information on paper or electronically.
Care Management
CA5.4
CAR011
Support retroactive entry of prior authorization requests.
Care Management
CA5.6
CAR012
Provide the capability to change the services authorized and to extend or limit the effective dates of the authorization.
Maintain the original and the change data in the prior authorization record.
Care Management
CA5.12
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CAR013
Receive, 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.e.
Care Management
American Indian Health Program) . Transactions failing the completeness review must be returned to the submitter
without further processing.
CA5.1
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CAR014
Receive, review for completeness and process prior authorization attachments.

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
CA5.13, CR2.4
Section:
Page:
CAR015
Image; edit; OCR and/or data enter; verify; and index prior approvals/prior authorizations and associated materials
Care Management
CA5.14
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CAR001
Identify the date a member is assessed to meet a waiver level of care (LOC) and the date of the LOC reevaluation.
CAR002
Care Management
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CAR016
Produce and distribute rosters via mail, electronic and/or Web Portal when appropriate including but not limited to:
Personal care
Transportation rosters
Care Management
NA
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CAR017
Enter, review, and make prior approval/prior authorization determinations in real time based on Department approved
regulations, policies and procedures within specified timeframe.
Care Management
NA
CAR018
Perform the initial telephone prior approval/prior authorization request determinations with trained, clinical professionals
Care Management
available for consultation with the prescriber, when required.
NA
CAR019
Support and monitor individual or mass updates (i.e., regular and irregular updates) to the Prior Approval / Authorization
records.
Care Management
NA
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.
NA
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.
Care Management
NA
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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.g. VPN or leased line)
Interactive Voice Response (IVR) (e.g., DiRAD & ARU)
Batch transmission (e.g. FTP and Secure FTP)
Point of Service (POS) Device (e.g. VeriFone)
Care Management
NA
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CAR023
Accept, 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 5.1, D.0, and 1.1 - batch)
NYS proprietary format
Other Industry Standard paper and electronic formats
Care Management
NA
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Page:
CAR024
Enforce Authorization edits based on Department business rules. All changes to edits must be reviewed and approved by
Care Management
NYS.
NA
Section:
Page:
CAR025
Enable administrative updates of authorizations in the Authorization Registry. State and contract staff must have the
capability to enter criteria via the web-based application that will be used to perform these updates.
Care Management
NA
Section:
Page:
CAR026
Accept and process real time pharmacy prior approval/prior authorization transactions received from the Preferred Drug
Program, Clinical Drug Review Program or other pharmacy prior authorization programs as determined by the
Department
Care Management
POS3.1
Section:
Page:
CAR027
Track each prior approval/prior authorization through all the steps in the authorization process as defined by the
Department.
Care Management
NA
CAR028
Assign to each prior approval/prior authorization a unique prior approval/prior authorization number for tracking and
monitoring purposes.
Care Management
CA5.7
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, and to establish multiple prior approvals/prior authorizations for the same service to Care Management
override multiple service restrictions separately.
NA
Section:
Page:
CAR030
Provide the capability to override prior approval/prior authorization requirements based on prescriber specialty, dispensing
Care Management
provider qualifications or other criteria established by the Department.
NA
Section:
Page:
CAR031
Notify the provider per Department guidelines of specific prior approval/prior authorization types, prior approval/prior
authorization requests and resulting determinations.
Care Management
NA
Section:
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CAR032
Edit prior approval/prior authorization information based on Department business rules for data presence, validity, interfield relationships, completeness, claims history, eligibility, UR edits, submitting and ordering provider, timeliness for
change requests, prior approval/prior authorization history including duplication, and all prior approval/prior
authorization edits.
Care Management
CA5.10, CA5.8
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CAR033
Provide the capability to modify, save and delete prior approvals/prior authorizations and supporting materials prior to
submission, along with the capability to review and/or print prior approvals/prior authorizations and supporting materials Care Management
both prior to and after submission.
NA
Section:
Page:
CAR034
Provide the functionality to automatically enforce Department defined business rules to make a determination on prior
approval/prior authorization requests.
Care Management
CA5.8
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CAR035
Provide the capability to modify, 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
NA
Section:
Page:
CAR036
Provide the capability to search, enter, inquire on, and update all information related to prior approvals/prior
authorizations via the web-based application.
Care Management
CA5.5
CAR037
Implement and enforce service limits to each transaction based on Department business rules.
Care Management
NA
CON001
Where Department policy guidance is not readily available in writing, the contractor will contact the Department to seek
policy guidance and will return the providers call. The contractor will incorporate such guidance in the appropriate
Manual and/or database
Contractor Management
CO02 Manage Contractor

Communication
NA
Section:
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CON002
Serve as the Prime Contractor and be solely responsible for integration of all work to be performed, regardless of whether
Subcontractors are used. As Prime Contractor, 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.g., Drug
Rebate/ Pharmacy Pricing and MDW) staff to ensure the success of the project. Further, the contractor is the
Departments 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, inactions, and performance of all Subcontractors.
CO07 Manage Contract
NA
Section:
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CON003
Receive, capture, and provide the capability to view Managed Care Organization (MCO) contract and administrative
information electronically including but not limited to geographic locations, capitation rates, covered services,
organization name, organization type, contract start and end dates, contract period/year, capitation effective date,
maximum enrollment threshold, enrollee count, members per month, and re-insurance threshold.
ME2.2, MC1.1,
MC7.1
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CON004
Perform periodic reconciliations of State member records with Enrollment Broker, MCO, and Primary Care Physician
enrollment records.
MC2.7
Section:
Page:
CON005
Ensure any design or business process model documents required for MMIS certification present the design in an
understandable fashion, with cross referenced requirements, design artifacts and narrative description.
NA
Section:
Page:
CON006
Support the receipt, processing and response to HIPAA and NYS proprietary transactions.
BE1.11
CON007
Support and monitor the receipt and processing of files received from all sources (e.g., providers, WMS/HIX, CMS, OIG)
as specified by the Department.
RO6.2
CON008
Develop, transmit, and monitor the generation of files to be distributed to all sources (e.g., providers, MDW, CMS) as
specified by the Department.
ME2.7, PI3.10
CON009
Support and monitor transactions received in files; identify transaction discrepancies including errors and pends; and
perform notification processes based on Department business rules.
BE1.11
CON010
Support and monitor real time inbound/outbound transactions, 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
POS4.3
CON011
Support and monitor all channels applicable to the specific transaction (e.g., eligibility verification transactions, claim
transaction, prior approval/prior authorizations transactions).
NA
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.
NA
CON013
Facilitate a project kickoff meeting with contractor and Department team members that clearly articulates topics including,
but not limited to the following:
Project organization
Project communication
Team member responsibilities
Key project processes
Project work plan
NA
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CON014
Take a proactive approach to identification, tracking, managing and resolving issues that may result in affecting the
project.
NA
CON015
Disclose any risks found by the contractor within one (1) business day to the Department.
NA
CON016
Develop and execute a Project Management Plan (PMP) within the first 30 calendar days of contract award, approved by
the Department, that is based upon industry best practices and standards. The PMP shall include:
Quality Management
Scope Management
Requirements Management
Issue Management
Risk Management
Change Management
Configuration Management
Performance Management
Communication Management
NA
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. The work plan shall adhere to industry best practices and
standards for project management, and be broken down into Work Breakdown Structures (WBS), including key tasks,
milestones, resources, deliverables, and task dependencies.
NA
Section:
Page:
CON018
Submit the initial work plan to the Department within 30 days of contract award for review and approval. Work plan must
be continually updated/maintained on at least a weekly basis throughout the duration of the contract.
NA
Section:
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CON019
Establish and staff a Program Management Office (PMO) that manages the PMP and reports directly to the Department
Project Management group. The PMO shall also integrate with other relevant state contractors and entities.
NA
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.
NA
Section:
Page:
CON022
Participate in a weekly status meeting with Department personnel. For this meeting, the contractor shall produce and
distribute an updated status report at least 24 hours before the meeting.
NA
Section:
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NA
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CON023
Use a project management tool accessible by State staff, in addition to the contractor's team, that includes the following
capabilities:
Issue and Risk Management
Scope Management
Configuration Management
Change Management
Action Item Management
This tool must maintain project information for the full lifecycle of the project.
CON024
Make all project management documentation available online to Department and contractor staff, including, but not
limited to the PMP, work plan, status report, and status meeting agenda and minutes.
NA
Section:
Page:
CON025
Maintain a Requirements repository that will be used throughout the life of the contract. The tool shall be updated with the
requirements in Attachment E within 30 days of contract award. 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.
NA
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CON026
Describe the approach and methodology that will be used for timing for risk identification and tracking and monitoring
risks. 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, assign risk management responsibility, and create a risk management strategy.
NA
Section:
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CON027
Identify the contractor staff that will be involved in the risk management process.
NA
Section:
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CON028
Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and
availability of PHI within the first 90 days of the project and then annually thereafter. The findings must be issued to the Contractor Management
Department, and include a mitigation strategy for all potential risks and vulnerabilities.
SP2.5
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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
NA
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
NA
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.
NA
Section:
Page:
CON031
Develop, produce, and maintain a Certification plan that defines the contractors approach to federal MMIS certification.
It must describe the processes and procedures that will be used to manage Certification requirements throughout the
Planning and Implementation Phase; manage the certification activities; processes and procedures that will be used to
create the certification documents and assist during the CMS visit; and how these activities are integrated with the
contractors project management system. The plan must define the contractors 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, 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
NA
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CON032
Establish and staff a Certification Team to participate in all certification activities including the creation of the
Certification Plan. The certification team must work with the Department's Certification Team to plan and review
certification schedules, reports required for the certification process, and updates to related communication vehicles.
NA
Section:
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CON033
Develop the Certification Checklist Traceability Deliverable, in conjunction with the State Quality Assurance contractor,
which must trace Certification Checklist requirements to functionality, testing, and supporting documentation throughout Contractor Management
the Planning, Implementation, Certification, and Operations Phases.
NA
Section:
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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
System documentation including: Source Code Library; User Manual; Operating Procedures; MITA Assessment;
Acceptance Test Plan; Acceptance Test Results Deliverable; and, 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
NA
Section:
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CON035
In conjunction with the State Quality Assurance contractor, identify and collect the documentation and outputs of the
targeted MMIS processes required to support the CMS certification review. This includes documentation, report printouts,
training and preparation, and other documents as requested by the Department during the certification preparation process.
The contractor will ensure all other documentation required by CMS is provided in the Certification Review Package.
NA
Section:
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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.
NA
Section:
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CON037
Prepare draft Certification Review Package materials for review and approval of the State.
NA
CON038
Conduct walk-through of certification review deliverables.
NA
CON039
Archive first-run test claims and reports until receipt of certification.
NA
CON040
Archive first-run of federally required reports to be included in certification documentation.
NA
CON041
Assist the Department in preparing for and conducting the CMS certification site-visit, and responding to CMS inquiries
during and after the site-visit.
NA
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.
NA
CON043
Develop a Corrective Action Plan to address any issues impacting the certification process, make the required changes,
modify the certification review documentation as necessary and support the re-review by CMS.
NA
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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.
NA
Section:
Page:
CON045
Be responsible for any applicable damages pursuant to the contract terms relative to the delivery of a federally certified
MMIS, to include liquidated damages as specified in this RFP.
NA
Section:
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CON046
Provide detailed Staffing and Organization Plan for each phase of the project; 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,
including at a minimum title, description, required education/training/certification, required experience, on-site/off-site
designation and specific skills/knowledge
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, including responsibility
descriptions, to carry out the requirements herein
An identification of all subcontractors, their respective roles, and rationale for filling that role with a subcontractor
A description of the contractors staffing plans for managing the staff to ensure that project deadlines are met
A depiction of staff loading by project phase
NA
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NA
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NA
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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. The contractor
pharmacy staff is also required to be current on the latest industry standards and developments, to proactively analyze the
impact on the Program, and to keep contractor and State management apprised of such in a timely manner.
NA
Section:
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CON050
Provide a dedicated EPIC outreach manager to direct, support and assist in outreach activities.
NA
Section:
Page:
CON051
Provide an annual Staffing and Organization Plan detailing how the project staff is actually organized, where the staff is
located and how communication is handled between remote sites and the project site.
NA
Section:
Page:
CON052
Ensure that all direct work is performed in the United States.
NA
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SP1.6
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CON047
Obtain Department approval for the Staffing and Organization Plan within 30 days of contract award, and seek approval
for any revisions to the plan.
The contractor must:

Not alter the number of Key Staff as proposed without the written approval of the Department, which shall not be unreasonably
withheld. If the Department gives written approval of the termination, transfer or reassignment of Key Staff such personnel will remain
assigned to the performance of duties under this contract until replacement personnel, approved by the Department, are in place
performing the Key Staff functions
Replace staff only with staff of comparable experience, training and ability to the incumbent in the position
Will submit a Staff Skills Matrix for each person filling a Key Staff position. 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. Account Executive (Available Onsite at Project Facility upon request);
b. Account Manager (Onsite at Project Facility 4 Days Per week);
c. DDI/Configuration Manager (Onsite at Project Facility 4 Days Per week);
d. Operations Manager (Onsite at Project Facility 4 Days Per week);
e. Transition Manager (Onsite at Project Facility 4 Days Per week);
f. Compliance Manager (Onsite at Project Facility 4 Days Per week);
g. Information Security Officer (Available Onsite at Project Facility upon request);
h. Data Conversion Manager (Onsite at Project Facility 4 Days Per week);
i. Quality Assurance Manager (Onsite at Project Facility 4 Days Per week);
j. Customer Service Manager (Available Onsite at Project Facility upon request);
k. Medical Director (Available Onsite at Project Facility upon request);
l. PBM Manager (pharmacy prior approval) (Available Onsite at Project Facility upon request);
m. Clinical Manager (medical prior approval) (Available Onsite at Project Facility upon request)
n. MEIPASS Operations Manager (available Onsite at Project Facility 4 Days per week)
Develop, maintain, and execute, in conjunction with and approved by the Department, an Annual Training Plan. The
Training Plan shall demonstrate the commitment of the contractor staff to meet the learning needs of the system required
for contractor staff, Providers, and Department staff. The contractor Annual Training Plan shall be reviewed and approved
at least 60 days prior to the beginning of the contract year.
CON053
The Annual Training Plan must:

Identify inputs, analysis, and methods to be used to define training requirements
Define training topics, schedule, and location of quarterly provider training seminars, provider association meeting
workshops, in-house provider bi-weekly training sessions, Regional Local Departments of Social Services (LDSS)
meetings and provider site training
Define beginner, intermediate and advanced training courses to be conducted
Define training modules, curriculum, and tools to be used to delivery training
Include annual POS, EFT, and electronic claims submission marketing plans
Include plans for Department staff training, 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
CON054
Conduct an annual training needs assessment with the States staff to ensure that the development of the Training Plan
addresses the training needs of Department and stakeholders using the contractor's system(s). Provide a recommended
training course list to support each user's security role as an output of the training needs assessment.
PI3.16, SP1.6
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CON055
Deliver detailed training during the project initiation task, on the contractor's processes to be used to complete the scope of
work. This training must be specific to the quality management, risk management, scope management, project
management and SDLC methodologies proposed by the contractor. This training must transfer knowledge, to Department
staff, of the contractors 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,
requirements management and overall design and development programs so that they can productively participate in the
deliverable production and review process.
NA
Section:
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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. This training must be specific to the proposed technical architecture,
configuration management, requirements management, content management, 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.
PI3.16
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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. For each course contained in the
curriculum, a course outline, or syllabus must be developed and stored in the document repository.
PI3.16
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CON058
Create Instructor Guides and Trainee Guides for the initial train-the-trainers training performed as part of the MAS
Project. The Instructor Guide will provide all of the material necessary to conduct the class, so that future trainers have a
step-by-step procedure to follow to deliver training to new staff. The Trainee Guide will contain actual course content that
is pertinent to the trainee, as well as the training exercises, quizzes, and reference material associated with the specific
course. 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.
NA
Section:
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CON059
Develop all training materials for seminar and Web-based delivery, 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.
NA
Section:
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CON060
Develop a training plan and training materials for contractor provider support staff and provide at regular intervals. The
training must include topics representing all levels of complexity encountered by contractor staff and broken out by
organization structure.
NA
Section:
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CON061
Provide comprehensive training, related documentation and materials, and an evaluation component for users from the
State, LDSS, the contractor, and other supporting contractors.
NA
CON062
Provide on-line access to training schedule and meeting information through the Web Portal for Department staff.
NA
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.
NA
CON064
Offer Provider training through a variety of presentation methods (as approved by the Department). For example: webbased, workshops, training sessions, presentations at professional association meetings, individual training as needed, and
distribution of Provider manuals. Onsite training shall be provided at contractor site or other locations approved by the
Department.
NA
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CON065
Educate providers across the State, at no charge to the providers, about the NYS health insurance programs supported by
the MAS, the claims processing system, proper billing, and prior approval/prior authorizations procedures through
workshops, training sessions, presentations at professional association meetings, and individual training, as needed or as
required by the Department.
NA
Section:
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CON066
Perform analysis of provider inquiry, billing patterns (e.g. fraudulent and excessive billing), and process for referrals based
on Department-approved criteria to identify providers who require training and on-site assistance.
CR1.12, PM2.1
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CON067
Conduct provider visits as needed to train providers in program billing procedures and to provide claim resolution
assistance.
NA
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CON068
Log, track, and report provider on-site visits via the Contact Management System that includes but is not limited to: date
visit requested, who made the request, provider name, number(s), reason for visit, visit content and outcomes, follow-up
action required, staff performing visit, and date visit made.
NA
Section:
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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.
NA
Section:
Page:
CON071
Perform quarterly provider training seminars, provider association meeting workshops, provider advisory groups, in-house
provider bi-weekly training sessions, and on-site provider training.
NA
Section:
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CON072
Conduct quarterly training in central locations throughout the state, approved by the Department for new hires in the
Department or refresher training to Department staff.
NA
CON073
Provide specialized training related to policy changes affecting specific provider prior to implementing new policies and
services.
NA
CON074
Track and report when newly enrolled providers complete the initial training tutorial.
NA
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.
NA
CON076
Offer training to office staff or third-party billers or authorized submitters who submit claims on behalf of providers.
NA
CON077
Conduct in-service training for the contractors provider services team and Department staff, as needed.
NA
CON078
Present mock training sessions for Department approval and update training materials as necessary prior to delivering
training.
NA
CON079
Provide on-line access to training schedule and meeting information through the provider Web Portal for authorized
providers, Department staff, and stakeholders.
NA
CON080
Distribute provider training questionnaires at all training sessions to solicit questions from providers that are not addressed
during the session.
NA
CON081
Maintain and submit to the Department the Provider Training Sign-In Sheets for all providers (by provider type) who
participate in training sessions.
NA
CON082
Prepare a Department-approved Training Evaluation Forms for distribution at training sessions; 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.
NA
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CON083
Define contractor analysis criteria to be used to identify providers who require on-site training and billing assistance for
Department approval.
NA
Section:
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CON084
The contractor will be responsible for provider outreach, developing training materials, conducting training seminars, and
assisting providers in the installation and maintenance of the electronic claims submission tools.
NA
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CON085
Train all Department staff and providers on all major system changes that occur during the life of this contract.
NA
Section:
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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). 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.
NA
Section:
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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.
NA
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CON088
Ensure the training environment contains a separate but complete set of database tables, that allows training data to be
created specifically to support the Training Materials independent of the development and testing databases, while
maintaining privacy.
NA
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CON089
Implement Configuration Management procedures to ensure migration of program code and data to the Training
Environment is properly managed and executed. A schedule of migration frequency must be developed to avoid training
session interruptions.
NA
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CON090
Perform periodic backups on the information stored in the training environments databases. The contractor must have the
ability to restore the environment within twelve (12) hours if necessary.
NA
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CON091
CON092
Ensure that the Training Environment supports users' security roles mirroring production and support user access to all
users of the system(s).
Maintain a project facility for this contract within a ten (10) mile radius of the NYS Capitol building. The facility shall
provide adequate workspace for contractor project management, departmental liaison, design, development, and
implementation leads, provider relations, and member relations staff as well as designated state staff.
NA
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Provide and maintain adequate workspace, computers, LAN connections, digital telephones, individual phone numbers,
and all office supplies for no less than 100 Medicaid program staff, including the Department, OSC, OIG, and authorized
consultant staff. Access to the project facility shall be available twenty-four (24) hours per day, seven (7) days per week
without prior notice, admission, escort or other requirements.
CON093
Computers must adhere to Transaction Processing Performance Council (TPC) benchmarks and have suitable, sufficient
processor speed, memory and hard drive space to operate and support the current release of Microsofts operating system
and Office Suite software, as well as any additional equipment and software necessary to access and utilize MMIS
functions as well as associated State systems including the MDW, OHIP Data Mart, the internet and e-mail. The PCs must
have at a minimum 21" flat-screen monitor and be sized to reflect "power-user" status. The PCs must be refreshed every
three (3) years.
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. NYS parking will be within easy access to the facility
mentioned above. Parking for State will be designated and reserved. This space must be available throughout the entire
contract period and at no additional cost to the State. In addition, handicap parking must meet all local, State and Federal
requirements for number and design.
NA
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CON095
Medicaid program staff, including Department, Office of State Comptroller (OSC), Office of Medicaid Inspector General
(OMIG), 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, the Department's LAN or OSC'S LAN, and the internet
NA
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CON096
Absorb all costs related to securing and maintaining the contractors project and computer facilities and any other of its
locations for the life of the project.
NA
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CON097
Provide courier service to the Department, OSC, and OMIG office buildings with pickup and delivery service two (2)
times each business day. One (1) run shall be in the morning and one (1) run in the afternoon.
NA
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CON098
Provide accessibility to the project, call center and IT facilities used by the contractor for this Contract by authorized
Department staff, OSC staff, OIG staff and authorized consultant staff during business hours without prior notice, escort or Contractor Management
other requirements.
NA
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CON099
Observe all Occupational Safety and Health Administration (OSHA), environmental impact and fire code requirements,
building codes and all handicapped accessibility regulations.
NA
CON100
Provide and maintain all necessary telecommunications circuits between the Department offices and the contractor's
facilities.
NA
CON101
Ensure physical security of checks during matching, stuffing and mailing process.
NA
CON102
Maintain a Department-approved secure check vault storage area for checks prior to release to providers.
NA
CON103
Provide secure storage for physical and electronic historical records.
NA
CON104
Maintain multi-purpose meeting room(s) at the contractors facilities used for this project, available to the Department,
with all necessary equipment to support program meetings with State Staff (e.g., white boards, LCD projectors).
NA
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CON105
Provide a training room within the contractor's project facility with the capacity to handle up to fifteen (15) students at a
time, support computer based training, provide each student with desk space and his/her own PC, and access the training
environment.
NA
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CON106
Receive Department approval for all proposed off-site procedures, locations, and protocols.
NA
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CON107
Develop and maintain operational policy and procedure manuals for all MAS business processes.
NA
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CON108
Submit a Business Continuity Plan to the Department for approval within thirty (30) calendar days of contract signing that
is based upon the contractors business continuity and disaster recovery methodology. The plan shall address backup and
recovery, failover, disaster recovery and business continuity, checkpoint/restart capabilities, retention and storage of back
up files and software, and hardware and network back-up.
SP1.5
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CON109
Notify the Department of all discrepancies, errors, failed file transmissions, or abnormal interactions with external
interfaces during any file transfer process.
BE1.11
CON110
Inform the Department immediately of any incidents that cause the failure of any component of the MAS.
NA
CON111
Notify the Department within one (1) hour of any disruption in service.
NA
CON112
Provide for a back-up processing capability at remote site(s) from the contractor's primary site(s) such that normal
payment processing, as well as other system and Department services deemed necessary by the Department, can continue Contractor Management
in the event of a disaster or major hardware problem at the primary site(s).
NA
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CON113
Back up all data files that reside on the multiple environments on a daily basis. 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. On a weekly Contractor Management
basis the contractor will back up all databases and other data and store the backups at a secure off-site location.
NA
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CON114
Provide a backup/recovery component comprised of a high capacity backup and recovery infrastructure for all data. Secure
backups include database data, files, operating system and RDBMS software, and program code.
NA
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CON115
Ensure the frequency, speed, and flexibility provides the capacity needed to meet the Department's service levels and
Disaster Recovery requirements detailed in this RFP.
NA
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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. All back-ups must be transferred to the successor contractor as described in the Department approved
Transition Plan.
NA
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CON117
Develop and maintain an automated scheduling system for running the back-up processes for all environments.
NA
CON118
Develop and maintain a process to verify that all back-up and restoration processes were run appropriately and stored in a
proper location.
NA
CON119
Support restoration and recovery of lost or corrupted data or software.
NA
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), as well as to allow for maintenance of the production
environment.
NA
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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; 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.
NA
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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. In the event the contractor cannot return to the
original MMIS site within seven (7) calendar days, the Department may at its sole discretion declare the back-up site the Contractor Management
New primary site, at which time the contractor will have thirty (30) days to secure and make operational a New back-up
site.
NA
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CON123
Ability to operate the Call Center if the primary site becomes unusable or unsafe, and provide sufficient office space
within twenty-four (24) hours of notification by the Department to continue all activities previously being conducted at the Contractor Management
primary site.
NA
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CON124
Ensure the Business Continuity Plan contains a section for a Disaster Recovery Plan that addresses recovery of all MAS
functions, human resources and the technology infrastructure. The DRP must be available and present at the Department's Contractor Management
site and at an offsite location approved by the Department.
NA
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CON125
Develop, maintain and submit to the Department, all proposed off-site procedures, locations and protocols for review and
approval prior to implementation.
NA
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CON126
Ensure that each aspect of the DRP is detailed as to both contractor and Department responsibilities, and must satisfy all
requirements for federal MMIS certification.
NA
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CON127
Modify the DRP, 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. Modifications Contractor Management
to the DRP must be submitted to the Department for review and approval.
NA
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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. The contractor must
also provide a walk-through of its DRP during the first calendar quarter of each year for the life of the contract.
NA
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CON129
Execute the DRP test annually (at no cost to the Department, 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. The DRP test must be included as a part of Acceptance Testing and be executed annually, at the
anniversary date of the contract, after the implementation of the Operations Phase. The test at the remote site must be
performed for all input, processing and output procedures functions.
NA
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CON130
Produce a report summarizing the hot site processing test results to the Department within thirty (30) calendar days of the
completion of the test. This report must include remediation steps taken to resolve any issues discovered during the test.
BE1.11
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CON131
Perform an annual review of the disaster recovery back-up site, procedures for all off-site storage and validation of
security procedures. A report of the back-up site review must be submitted within thirty (30) calendar days of the review.
The Department reserves the right to inspect the disaster recovery back-up site and procedures at any time with twentyfour (24)-hour notification.
NA
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CON132
Establish, along with the Department, a hierarchy of critical services and infrastructure to determine the order that services
must be restored.
NA
CON133
Provide Customer Service Center functions for providers and members via a Call Center, Correspondence, and a Web
Portal.
NA
CON134
Provide dedicated toll-free call center telephone number(s) within the continental United States.
NA
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. 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. When the call center is not operating, callers must be able to leave messages that are
returned within twenty-four (24) hours.
NA
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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.
Department overrides of procedures must be documented, maintained, and accessible for audit purposes.
NA
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CON137
Provide and execute quality assurance procedures to ensure that the financial management system disburses, tracks, and
accounts for Medicaid payments accurately.
NA
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CON138
Submit the annual payment cycle schedule by the last State business day in September each year for Department approval.
Release to the Provider community and OSC as required by the Department.
NA
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CON139
Perform monthly bank account reconciliation and submit Department-approved reports within ten (10) workdays of the
end of each reporting month.
NA
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.
NA
CON141
Monitor, triage and route for resolution all returned undeliverable mail sent to providers, members, and other entities as
specified by the Department. Resolution must occur within 30 days of receipt of the undeliverable mail.
NA
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CON142
Assist audit staff from the Department, OSC, the federal Department of Health and Human Services (DHHS), Office of
Attorney General (OAG), and Office of Medicaid Inspector General (OMIG) or other authorized personnel who perform
audits relating to the NYS Medicaid program.
PI3.14
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CON143
Assist Department staff in responding to audit findings or requests for information.
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CON144
Provide the audit staff with support, as directed by the Department, OSC, and OMIG, including but not limited to:
Access to all contractor personnel and facilities
Access to all information (e.g., transaction information, member registry, provider registry, and reference information
and pricing information)
All application programs and libraries
All systems programs and libraries
Access to the operating system, including job accounting/software
Access to all documentation including but is not limited to: software and operating manuals; documentation (e.g., rules,
regulations, memos, internal reports, and detail design)
Use of facilities and the right to photocopy any and all documentation
NA
CON145
Notify the State of any changes made to the contractor's application and adjustments to edits.
NA
CON146
Support and monitor the preparation and production and distribution of reports as specified by the State.
PI3.7
CON147
Distribute reports via hard copy, electronic, reporting repository and/or the web-portal as specified by the Department.
NA
CON148
Support periodic archiving of program information based upon agreed criteria and schedules with the Department.
NA
CON149
Maintain all hard-copy forms, attachments, and other documents in accordance with State retention requirements and
dispose of in accordance with Department-approved procedures.
NA
CON150
Develop and implement a Security, Privacy and Confidentiality Plan approved by the Department for all projects and all
major system enhancements. The approved plan will be integrated into the Contractor's Standard Operating Procedure.
NA
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CON151
Ensure the Security, Privacy, and Confidentiality Plan is aligned with the NYS Office of Cyber Security and Critical
Infrastructure Coordination, Cyber Security Policy P03-002, NYS Information Technology Policies, Standards and
Guidelines (http://www.dhses.ny.gov/ocs) and NYS Department of Health Security Requirements document, located in the
Procurement Library.
NA
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CON152
Ensure the Security, Privacy, and Confidentiality Plan is aligned with NYS Information Technology Policies, Standards
and Guidelines G07-001, Identity and Access Management: Trust Model.
NA
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CON153
Ensure the Security, Privacy, and Confidentiality Plan aligns with National Institute of Standards and Technology SP 800Contractor Management
63 Electronic Authentication Guidance.
NA
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CON154
Ensure the Security, Privacy, and Confidentiality Plan is aligned with the Certification Commission for Healthcare
Information Technology Security Criteria for 2007 Certification of Inpatient EHRs.
NA
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CON155
Include a description of all security tools, hardware and software the contractor is using and how they integrate to form a
comprehensive security architecture.
NA
CON156
Include a description of the approach to monitoring potential security violations and the actions that will be taken if
violations are detected.
NA
CON157
Deliver an initial Security, 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,
located in the Procurement Library.
NA
CON158
Revise the Security, Privacy and Confidentiality Plan annually, on the anniversary date of the contract, based on an annual
risk assessment and submit for Department review and approval.
NA
CON159
Submit an updated Security, Privacy and Confidentiality Plan to the Department for review and approval thirty (30)
business days prior to the start of operations.
NA
CON160
Facilitate, document, and deliver outcomes for state approval of configuration sessions with the Department, Office of
State Comptroller (OSC), and Office of Medicaid Inspector General (OMIG) participants.
NA
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CON161
The contractor must implement a governance process over the initial configuration, integration and testing of the MAS
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Provide the following deliverables during the implementation phase:

Business Design Document
Requirements Validation
Test Plans
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CON163
Develop a Business Process Analysis, in conjunction with the State Quality Assurance contractor, identifying changes
needed to support use of the new system. The Analysis must employ Value-Added Chain (VACD) and Event-driven
Process Chain (EPC) diagrams, as appropriate. The Business Process Analysis shall include, but not be limited to, 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
NA
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CON164
Develop and implement an approved Requirements Validation Plan and methodology. At a minimum the plan must:
Define the goals, expectations, 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
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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 contractors system in advance of the joint development sessions. This Contractor Management
overview must be held periodically for new staff, as directed by the Department
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CON162
CON166
Conduct a series of joint development sessions with Department staff and other stakeholders, beginning within 15
business days of the project kick-off meeting, 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, sessions to review functional expectations and
establish configuration will take place in lieu of joint development sessions.
CON167
Collect documentation and requirements from the joint development sessions (i.e., 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.
NA
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CON168
Prepare a detailed Requirements Validation Document that will be managed as a baseline to guide work to be performed in
subsequent Project tasks. 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
NA
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CON169
Develop and maintain a Requirements Traceability Matrix to associate finalized requirements with the work products that
satisfy them. At a minimum this matrix must identify where each of the approved requirements will be addressed in
subsequent design, development and testing deliverables.
NA
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CON170
Develop a Logical Design Document detailing how and where each requirement is met by the new system; its conceptual
architecture; and a Logical Data Model demonstrating how data flows through the business model. At a minimum the
Logical Design Document shall:
Identify general flow of functions in a flow diagram; the flow diagram must identify all major processes
Include sample layouts for all outputs, including screen layouts and print report layouts, and identify output frequencies
Document all applicable policy and business rules; Define the business rules structures and how they will be
incorporated into the process flow
NA
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CON171
Develop the System Architecture and Infrastructure Plan to describe how external system interfaces will be implemented
NA
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CON172
Describe and execute on the standards for software products. This is to be a description of the standards to be followed for
representing requirements, design, code, test cases, test procedures, and test results.
NA
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CON173
Provide a User Manual for any State staff reviewers and users. At a minimum the User Manual must:
Provide a software user step-by-step instructions for accomplishing tasks and work processes, creating reports, fixing
errors and troubleshooting
Be available and maintained on-line via the R-MMIS
Have instructions for sequential functions (for example, balancing instructions must follow the actual flow of the
process)
Include consistent definitions of codes and terms, abbreviations, and field names throughout various sections of Manual
Include error message descriptions for all fields incurring edits, and the steps necessary to correct such errors
Include tables of valid values for data fields (for example, provider types and claims types), including codes and
descriptions in English, presented on screens and reports
Include illustrations of screens used in the subsystem, with all data elements on the screens identified by number; 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, with descriptions of code values and data element numbers for reference to the
data dictionary
Include for each process and procedure the user, their location within the organization and the purpose (outcome) of the
process or procedure
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CON174
Develop Business Operating Procedures, which must provide details on how any new business processes are supported.
NA
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CON175
Develop, maintain and implement a Comprehensive Test Plan, approved by the Department, for testing the MAS. The
Plan must be updated at least annually. At a minimum the Plan must:
Describe each type of testing and detail the contractor's approach to each
Describe how test scenarios, test cases and test results will be traced to requirements
Describe the processes, 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
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CON176
Conduct Integration Testing to test business functionality as well as related technical functionality and provide a report of
test results.
NA
CON177
Specify the criteria the contractor will use in determining the completion of each System Test activity.
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CON178
During System Integration Testing the contractor must:

Verify all edits, audits, and creation of data, etc.
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, stress
test)
Validate the accuracy of the data
NA
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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.
NA
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CON180
Develop the Systems Integration Testing (SIT) Test Results Report. At a minimum the deliverable must:
Provide an overview of the testing effort
Document the disposition of all test cases, including expected and actual results
Identify and classify all defects, 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, 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
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CON181
The contractor must support the user community during User Acceptance Testing (UAT). 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. This will include issues such as security, privacy, test scenarios, test scripts, etc.
Provide training on the system, process and tools that will be used to execute the UAT and training on the operation of
the technical environment to support user validation
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, navigating the UAT environment and reviewing the test results. Assist the users in the preparation of testing
material
Provide access to authorized Department staff and contractors to the UAT environment, assist with test data, test cases
and test scripts
NA
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CON182
Perform volume and stress tests as directed by the Department, to demonstrate the ability to process expected workloads
accurately within prescribed time frames.
NA
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CON183
Report the results of the Stress and Performance Test. Demonstrate in the report that the Stress and Performance Test met
testing completion criteria identified in the Stress and Performance Test Plan.
NA
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CON184
Document the disposition of all test cases, including expected and actual results
NA
CON185
Identify and classify all defects that were found, including the status of defect resolution as of the date of the report and
implications from the testing for system implementation
NA
CON186
Detail the steps that were taken if the software or hardware experienced performance issues
NA
CON187
Complete comprehensive Parallel Testing, in which users test all functions in a production-like controlled and stable
environment, including but not limited to, converted files, proper functioning of edits, audits, and business rules; the
accuracy of claim records payment and file maintenance; and the format and content of all system outputs.
NA
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CON188
Monitor, track, and record Parallel Test testing results and discrepancies reported by the Department. Parallel Testing
results must be documented, 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, but not be limited to, problems
identified, description of problem, type of problem, corrective steps taken, and resolution of problem.
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CON189
Update the Business Process Analysis that was developed during Requirements Validation, identifying changes the
Department agrees to make to its business processes in order to support the use of the system.
NA
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CON190
Report business change management status as part of the Monthly Project Status Report and weekly project status
meetings.
NA
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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
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CON192
Develop and implement a Data Conversion Plan to convert data files from the prior MMIS to the contractors data system.
At a minimum the plan must:
Define the processes, procedures, 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. Include discussion as to whether the conversion process will be
implemented in phases. This shall address the following:
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
NA
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CON193
Develop the Data Conversion Specifications and Mapping document. 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. 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
NA
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CON194
Develop a Data Conversion Test Plan. 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
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CON195
Develop a comprehensive Operational Readiness Review (ORR) Plan approved by the Department, which identifies the
strategy and procedures, roles and responsibilities for all activities in the review effort. The ORR Plan must include
extensive checklists for each functional area containing items related to the preparedness of that function for a successful
implementation.
NA
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CON196
Track, report and respond to all problem conditions reported during the review and prepare an ORR corrective action plan
for problem correction and resolution.
NA
Section:
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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. The final ORR report
must contain the completed checklists, signed off by key state stakeholders during the review process and the status and
results of the ORR corrective action plan activities.
NA
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CON198
Develop ORR checklists focusing on the additions, changes and omissions resulting during the transition from the
eMedNY system to the MAS. While many of the following functional areas may not be exposed to any change from the
transition to the MAS, they must be included in the ORR process to verify this fact. 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
NA
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CON199
Update the System Implementation Strategy deliverable, approved by the Department, describing its approach to ensuring
that the system is ready to be implemented and that Department approvals have been obtained to initiate operations. To be
ready for implementation, the application must satisfy all requirements specified in the RFP and documented during the
requirements validation and systems design activities. 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.
NA
Section:
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CON200
Work in conjunction with Department staff to complete implementation activities in a manner that does not disrupt
recipient and provider services (e.g., all functions must work correctly, efficiently, and in a timely manner) and smoothly
transition system operation and maintenance from the contractor system develop staff to operations staff.
NA
Section:
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CON201
Develop an Implementation Contingency Plan as a companion plan to the Implementation Plan, and an extension of the
Implementation Strategy required with the contractor's proposal. The Implementation Contingency Plan sets forth detailed
descriptions of activity integration and resources to accommodate backup activities should the implementation results not
come out as anticipated. The plan must clearly define each implementation outcome and the backup activities that will
occur for each if problems occur. The plan must also contain the criteria for determining if each activity is successful and
the triggering mechanism for implementing the contingency plan.
NA
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CON202
Provide comprehensive reports to the State detailing audits planned, initiated, in progress, completed, findings, recoveries
based on actual findings (no projections).
NA
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CON203
Provide full cooperation with the State, any other authorized State agency, and any law enforcement authorities with audits
and in the investigation, documentation, and litigation of possible fraud and abuse cases or any other possible misconduct
which may affect the Program, consistent with the requirements of Appendix A: Standard Clauses for New 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. The contractor must respond in a timely fashion to
all State audit requests for information and/or clarification.
PI3.11
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CON204
Allow for the monitoring, verification, and validation of the timeliness and accuracy of all payments for services under the
state plan. This will include regular audits by OMIG, OSC, as well as an independent auditor.
NA
Section:
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CON205
Provide the Office of the State Comptroller, CMS, the Inspector General of the United States, and their authorized
representatives with access to all records relating to contractor performance under this contract for the purposes of
examination, audit, and copying.
NA
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CON206
The contractor may not establish any State of New York Medicaid Program related bank account unless such account and
the depository bank is expressly approved by the NYS OSC
NA
Section:
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CON207
Utilize a State approved bank located in NYS to provide banking services. The contractor must provide separate banking
services and fiscal accountability necessary to maintain payment and refund functions of each program (e.g. Elderly
Pharmaceutical Insurance Coverage (EPIC), NYPS, etc.).
NA
Section:
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CON208
Provide the State, by the fifteenth day of each month, an accounting of all banking transactions, including payments,
transfers, charges and credits, made during the previous month for each account. The accounting must be in a State
approved format and, at a minimum, be in accordance with generally accepted financial accounting standards.
NA
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CON209
Provide separate banking services and fiscal accountability for deposits to the following account owned by NYS - Refunds
and recoveries account. The refund and recoveries receipt account is for the deposit of Medicare Part D plan recoveries,
State settlements and pharmacy refunds. The NYS OSC will periodically transfer funds from this account to a separate
NYS account managed by the State.
NA
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CON210
The contractor must complete and provide to the State reconciliations for the revenue and disbursement account. 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, ensuring the cumulative accuracy and agreement of the financial records of the Contractor Management
contractor and the bank. All account reconciliations must be in a State approved format and, at a minimum, be in
accordance with generally accepted accounting standards.
NA
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CON211
The contractor must additionally complete, and provide to the State, a monthly reconciliation of the States escrow account
utilized exclusively for funding the disbursement account. 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, also ensure the cumulative accuracy and agreement of the financial records of the State and the
bank. 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. Any remaining differences between the
uncleared items and the State escrow account balance must be fully researched and documented by the contractor. The
reconciliations must be in a state approved format and, at a minimum, be in accordance with generally accepted
accounting standards.
NA
Section:
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CON212
Collateral to secure deposits must be pledged as required by the NYSOSC and NYS Finance Law. The contractor may not establish any
EPIC, NYPS, MEIPASS or Medicaid related bank account unless such account and the depository bank is expressly approved by the
NYSOSC. Accordingly, all banking proposals and procedures will be subject to prior review and approval by the NYSOSC. It is the
contractor responsibility to open and maintain the bank accounts for the Program. All bank charges are the liability of the contractor
and must be built into the applicable claims administrative fee.
NA
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CON213
Provide internal audit function to ensure the integrity of the EPIC Program. As part of this function, the contractor will be
responsible for conducting a semi-monthly prepayment audit, prior to the release of any reimbursement, for all
disbursement accounts: the pharmacy provider EFT and checking accounts, member excess co-pay refund account, and fee
refund account. For the prepayment audit, the contractor must audit a sample of checks meeting the criteria specified by
the State in the prepayment audit procedures. In addition, detailed reviews of several system generated exception reports Contractor Management
are required to confirm the accuracy of payments. Confirmation of claim information directly with the pharmacy or
member is expected when needed to ensure the accuracy of payments. The contractor will retain prepay audit work papers
and related documentation for future reference and make these available to the State upon request. The contractor, upon
State request, may be required to perform internal audits of selected operations within the contactor.
NA
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CON214
Maintain fully separate accounting information for each program administered under the contract.
NA
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CON215
Implement a paper pricing data-entry verification process or alternate process acceptable to the State, to ensure accuracy.
NA
CON216
Document current system data to new system data and provide status reports identifying conversion issues and mitigation. Contractor Management
NA
CON217
Support online entry, maintenance, and reporting of system and operational change requests.
NA
CON218
Provide online reporting of operational performance metrics accessible by NYS staff.
NA
CON219
Document how workflow-related data is to be processed, routed, tracked, and controlled.
NA
CON220
Identify, document, and maintain throughout the life of the contract all NYS Medicaid policies and business rules
supported by the contractor's solution.
NA
CON221
Perform internal auditing of all aspects of the program
NA
NA
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CON222
Support weekly, monthly, quarterly and annual Management and Administrative Reporting System (MARS) reporting
cycles.
NYS requires historical MARS reports converted from their current Open text Alchemy format into more usable formats
for users (ex. PDF, TXT, CSV, Excel)
After conversion, non-PHI reports need to be remotely accessible on demand by designated MARS users through a
secure portal. 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, they must be securely archived and only made accessible to the
appropriate users through the portal
CON223
Provide, at no additional cost to the State, 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 contractor must
respond to each audit with a proposed Corrective Action Plan within 30 calendar days of the audit, if necessary.
NA
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CON224
Identify the requirements, produce, and maintain all necessary production reports to be produced by the contractor
necessary for State oversight of the contractors administration of the Medicaid Program
NA
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CON225
Identify, research, and resolve any erroneous data from external interface data sources
NA
Section:
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CON226
Preserve and make available all other pertinent books, documents, papers, 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.
NA
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CON227
Records, which relate to appeals, audits or litigation that have been initiated and not resolved at the end of seven years,
will be retained until resolution of the findings.
NA
CON228
Provide online access to thirty six (36) months of history related to claims, prior authorization, and point of sale data.
NA
CON229
Online inquiry is available for 36 months of adjudicated claims history and any claims still in process.
NA
CON230
Define report specifications and online screens to be provided by the contractor that will allow the State to monitor status
of Health Insurance Premium Payment (HIPP) cases.
NA
CON231
Perform Member & Provider Satisfaction surveys through an independent contractor and methodology, approved by NYS. Contractor Management
MC4.12
CON232
Collateral to secure deposits must be pledged as required by the NYSOSC and NYS Finance Law. The contractor may not
establish any Preferred Diabetic Supply related bank account unless such account and the depository bank is expressly
approved by the NYSOSC. Accordingly, all banking proposals and procedures will be subject to prior review and
approval by the NYSOSC. It is the contractor responsibility to open and maintain the bank accounts for the Program. All
bank charges are the liability of the contractor and must be built into the applicable claims administrative fee.
NA
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CON233
Maintain parallel MMIS operations to future contractors during the turnover phase to ensure proper functioning of edits,
audits, and business rules; the accuracy of claim records payment and file maintenance; and the format and content of all
system outputs.
NA
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CON234
The State (and thereby HHS [i.e. 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 433.127 supporting the NYS
Medicaid Program. This must include read, write, and override permissions within the MMIS necessary to manage,
monitor, control, and oversee all aspects of the contractor, including all aspects of Medicaid services delivery, member and
provider management, and payment for services.
NA
Section:
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The State shall include the Department, Office of State Comptroller (OSC), and Office of Medicaid Inspector General
(OMIG). All requests for access to systems and records by CMS will be read-only and will come through the State agency
in writing.
CON235
Request approval by designated NYS authorized representatives for any changes made to program business rules and
adjustments to edits.
NA
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CON236
Notwithstanding the foregoing, when records are sought in connection with a fraud or abuse investigation, as defined
respectively in 10 NYCRR 98.1.21 (a) (1) and (a) (2), all costs associated with production and reproduction shall be the Contractor Management
responsibility of the contractor.
NA
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CON238
Internal controls, to include procedures, processes and systems, must be proposed that describe oversight activities that
allow for the assessment of the fiscal agents quality of performance and adherence to federal regulations related to claims
processing timeliness. Federal regulations address timely filing requirements by providers and timely processing by the
fiscal agent. 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.
NA
Section:
Page:
CON239
In accordance with Federal regulation 42 CFR 447.45, allow providers to submit claims up to 12 months from the date of
service. Medicaid providers are required by federal law to submit claims for services rendered in a timely manner.
NA
Section:
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Propose internal controls, to include procedures, processes and systems, and describe oversight activities to assess the
fiscal agents quality of performance and adhere to federally mandated claims processing accuracy requirements. These
activities include prepayment and post-payment reviews which ensure claims processing accuracy. Federal accuracy
standards consider risk factors associated with beneficiary eligibility, third-party liability, policy violations, limitations,
documentation, medical necessity, coding errors, data entry errors, duplication, pricing, and system logic.
CON237
Please note:
Federal regulation 42 CFR 447.45 requires prepayment and post-payment claim reviews to ensure the accuracy of
Medicaid payments. 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.
Checking that the number of visits and services delivered are logically consistent with the recipients characteristics and
circumstances, such as type of illness, age, gender, service location.
Verification that the claim does not duplicate or conflict with one reviewed previously or currently being reviewed.
Verification that a payment does not exceed any reimbursement rates or limits in the State plan.
Checking for third party liability.
Post-payment claim reviews consist of developing and reviewing recipient utilization profiles, provider service profiles,
and exceptions criteria and identifying exceptions so the agency can correct inappropriate practices or misutilization of
recipients and providers.
In addition to implementing federally required prepayment and post-payment reviews, several controls are required to
ensure effective oversight of claims processing, in particular, accuracy. 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 agents controls,
annual contract performance evaluations, on-going monitoring of the fiscal agents claims processing and system test plan
to detect errors in and outside the MAS, reviews of the fiscal agents internal quality assurance audit findings and
oversight of the fiscal agents surveillance and utilization reviews of potential overpayments to providers or beneficiaries.
The contractor must propose procedures, processes and systems that will be used to test that the internal controls are
working effectively. This may include having an auditor test a sample of claims to calculate timeliness of claims
processing and to identify aged claims, policies related to timely filing, review of the fiscal agents timely filing business
practice manual and the provider general billing manual, involvement of the MAS Contractor / fiscal agents quality
assurance staff, internal capabilities to produce and review audit reports related to claims processing timeliness, and
survey samples of providers to assess their perception of the timeliness of the fiscal agents claims processing.
NA
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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. The contractor must provide support to the Department during the PERM review process,
including selection of samples, production of hard-copy documents, and gathering of other required data. The contractor's
staff shall assist Department staff in responding to CMS inquiries. This level of support shall also be provided to all other
State audit agencies or their designees.
NA
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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.
NA
CON244
Describe the contractor oversight activities that will be used to monitor the internal controls and adhere to federally
mandated claims processing accuracy requirements.
NA
CON245
Describe the current internal audit function and overall governance structure, including at a high level the functions size,
charter, and reporting responsibilities.
NA
CON246
Describe the internal audit functions processes and practices for complying with the institute of Internal Auditors
International Standards for the Professional Practice of Internal Auditing, including the date of the functions last Quality
Assurance Review.
NA
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CON247
Describe how the internal audit function supports the development and implementation of internal controls processes,
standards and criteria for solutions and approaches included in this response.
NA
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CON248
Please provide a copy of your most current SSAE16 SOC 1 report.
NA
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CO08 Close out Contract
NA
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NA
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CON240
CON241
CON249
CON250
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. The contractor must provide a means to audit and track for
accuracy. Any time an error is identified by the contractor or identified by another party, including the Department and/or
OMIG and OSC, and communicated to the contractor, 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
Impact of the error to all impacted stakeholders, 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 contractors system and/or services, the contractor will assume the risk, bear the
financial burden to fix the error and its downstream impacts, and make any modifications necessary to prevent similar
errors in the future. Additionally, the contractor will be responsible for any financial damages to the Department that
results from such errors.
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. This Plan must include: Proposed approach to the transition to a successor
contractor, Tasks and sub-tasks for the transition, Schedule for the transition, all Department data, files and user and
operations documentation, A statement of resource requirements that would be required by the Department or a successor
contractor(s) to take over the MAS, risks associated with the transition and proposed mitigation strategies for each risk
identified, and recommendations for continued processing in the event the transition is not completed by the transition
date.
Provide technical support and assistance with Transition at the end of this contract, in order to complete a controlled
transition to the Department or successor contractor(s).
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CON251
Cooperate with the successor contractor(s), while providing all required transition services. This will include meeting with
the successor and devising work schedules that are agreeable for both the Department, the contractor, and the successor
contractor(s).
NA
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CON252
Maintain financial management responsibilities through the effective date of the transfer of responsibility and through the
completion of the reconciliation of final cycle processing including cycle data and report output.
NA
Section:
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CON253
Provide access to employees by the Department or the new contractor and actively encourages transfer of system and
operations knowledge.
NA
CON254
Provide a written commitment to work with the Department and successor contractor(s) in planning and performing
Transition Phase activities.
NA
CON255
Transfer all source non-proprietary program code, manuals, desk level procedures, and all related documentation when
requested by the Department.
NA
CON256
Inventory and transfer all work-in-progress in accordance with the Department-approved Transition Plan.
NA
CON257
Identify, schedule, and implement any remaining system modifications, deficiencies, patches, or fixes, that must be in
place prior to a system freeze.
NA
CON258
Include the Department and successor contractor staff in the design of any program changes underway during the
transition period. In fulfilling this requirement, the contractor must clearly identify each change and provide all updated
user documentation that may result from system changes.
NA
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CON259
Provide operations and technical applications walk-throughs with Department and successor contractor staff.
NA
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CON260
Perform the following closeout services including: Final reconciliation, Final settlement of all outstanding financial
transactions, Final settlement of all contractor invoices, Final reconciliation of all accounts receivable, Final assessment of Contractor Management
any liquidated damages, An independent audit by an entity with no contact or relationship with the contractor.
NA
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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, MDW, eligibility system and QA contractors.
NA
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CON262
Participate in scheduled contract coordination meetings between the Department, the incumbent MMIS contractor, MDW
contractor, QA contractor and any other applicable contractors throughout the remaining period of the incumbent MMIS Contractor Management
contract and ongoing meetings after implementation.
NA
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CON263
Cooperate with the eMedNY contractor during turnover activities and meet all requirements specified for the successor
MMIS contractor in the eMedNY Turnover Plan, located in the Procurement Library. This will include meeting with the
incumbent and devising work schedules that are agreeable for both the Department and incumbent MMIS contractor.
NA
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CON264
During the planning and implementation phase, 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.
NA
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CON265
Coordinate MMIS certification activities with the MDW, Health Insurance Exchange, and other systems as necessary.
NA
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CON266
All program data used to facilitate and administer the NYSs Medicaid program under this contract, with exclusion only to
proprietary code of the contractor, is the sole property of the NYS Department of Health. Upon close out of the resulting
contract of this procurement or upon request of the NYS Department of Health, the contractor must prepare, package, and
turnover all program data to the department.
NA
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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
BE2.1
ELG002
Receive and process member eligibility information and generate acknowledgement and notification when member
information is received from external sources.

Management
EE01 Determine Medicaid

Eligibility
NA
ELG003
Determine income eligibility and eligibility for premium assistance for all new EPIC members and renewals based on
online information exchanges with the NYS Department of Taxation and Finance, and the Social Security Administration
Management
(SSA)TPQ process.
EE01 Determine Member

Eligibility
BE2.1
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ELG004
Accept, 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

Management
EE02 Enroll Member
NA
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
EE02 Enroll Member
NA
ELG006
Provide the capability to view member CBIC information via the web-based application.

Management
EE02 Enroll Member
NA
ELG007
Identify and resolve invalid or incomplete EPIC application information

Management
EE02 Enroll Member
NA
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 Homes provider
network
Lead Health Home has capacity to serve member

Management
EE02 Enroll Member
NA
ELG009
Produce and distribute ANSI X12N 820 and X12N 834 transaction.

Management
EE02 Enroll Member
NA
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.

Management
EE02 Enroll Member
NA
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.
Management
EE03 Disenroll Member
ME1.7
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
ELG013
Provide a means to accept, respond to, 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

Management
EE04 Inquire Member Eligibility
BE3.1, BE3.2, BE3.3,

BE3.4, BE3.5
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ELG014
Support all channels approved by the Department for eligibility verification transactions.

Management
EE04 Inquire Member Eligibility BE1.5
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ELG015
Accept, process, capture, and respond to electronic eligibility inquiry transactions received in HIPAA standard formats
including:
HIPAA X12 270 eligibility, coverage or benefit inquiry (version 5010)
HIPAA X12 271 eligibility, coverage or benefit response (version 5010)
NCPDP 5.1 and D.0

Management
EE04 Inquire Member Eligibility BE4.1, BE4.2, ME2.1
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ELG016
Support, generate, and distribute scheduled client eligibility maintenance and discrepancy reports (e.g., presumptive
eligibility and death reports). contractor maintains historical reference of discrepancies and their solution within fields in
the System that are usable for both eligibility and claims payment.

Management
EE04 Inquire Member Eligibility NA
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ELG017
Establish and maintain a process to allow pharmacies to verify member eligibility during call center hours.

Management
EE04 Inquire Member Eligibility NA
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ELG018
Develop and manage a provider enrollment and recertification process per regulations 42 CFR 455, and state 18NYCRR
502/504, 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

Management
EE05 Determine Provider

Eligibility
WA2.2, MC1.8
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ELG019
Accept and capture traditional and nontraditional provider enrollment information, including applications and supporting
materials via hard copy, fax, or Web Portal, on entities or individuals meeting the qualifications contained in the provider
Management
agreement including geographic locations and capitation or FFS rates

Eligibility
WA2.1, MC1.8
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ELG020
Provide the capability for User to enter enrollment application information and upload supporting materials in industry
standard formats (including, but not necessarily limited to, Microsoft Word, PDF, and JPG). Enrollment application
information requirements are dependent upon the category of service (COS) for which the provider is enrolling.

Management

Eligibility
MC1.8
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ELG021
Edit enrollment application information based on Department business rules for data presence, validity, inter-field
relationships, and completeness. Errors returned must be clearly identified to facilitate correction by the user.

Management

Eligibility
BE1.11, BE1.5, PR1.2
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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. Terms and
Management
conditions must be available for user review.

Eligibility
NA
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ELG023
Accept ETIN applications via hard copy, fax, and the Web Portal.

Management

Eligibility
NA
ELG024
Allow Web Portal users to register online for access to the secure areas of the portal based on security rules defined

Management

Eligibility
BE1.11
ELG025
Provide the ability to obtain and to process provider fingerprints.

Management

Eligibility
NA
ELG026
Conduct background checks on providers owners, officers, directors, partners, agents, managing employees, affiliates and
subcontractors for sanctions, terminations, exclusions, affiliation with individuals debarred by State or Federal Agencies,
Management
listed in Abuse Registries, or otherwise unqualified to provide service.

Eligibility
PR2.5, WA2.5
ELG027
Conduct background checks and third party validation on all information submitted by providers to identify any
disqualifying events.

Management

Eligibility
NA
ELG028
Accept and capture provider recertification applications and supporting materials via hard copy, fax, or Web Portal.

Management

Eligibility
NA
ELG029
Conduct provider enrollment/screening in compliance with the Patient Protection and Affordable Care Act (PPACA) rules Eligibility and Enrollment
and regulations (e.g., ownership and ownership exclusions are to be screened as directed under PPACA).
Management

Eligibility
WA2.2, PR2.3
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ELG030
Enable State access to web-based application to approve and deny enrollments as well as process specific enrollment
terminations (e.g. pursuant to 18NYCRR, Part 504.7(a) and OMIG terminations). Web-based application must have the
ability to pend enrollments for State review based on criteria defined by the State. Web-based application must have the
flexibility to change the pend criteria as directed by the State.

Management

Eligibility
WA2.2
Section:
Page:
ELG031
Track each provider enrollment application through all the steps in the enrollment process. Generate automated letters
and/or electronic notifications to providers based on the status of the application for enrollment (e.g. pending status,
approval, or rejection of their applications).

Management

Eligibility
PR1.10, PR1.2, PR1.3,

PR1.9
Section:
Page:
ELG032
Maintain all information related to approved and denied applications for a period specified by the Department.

Management

Eligibility
PR1.2
ELG033
Ensure all provider information is available in the Provider registry upon completed enrollment.

Management

Eligibility
PR2.3
ELG034
Produce monthly statistical reports which outline provider enrollment, application rejections, provider maintenance and
provider termination activity.

Management

Eligibility
PR1.2
ELG035
Support, document, and maintain an appeals process for provider enrollment rejections, denials, terminations, and changes
to program participation eligibility effective dates in accordance with and State guidelines and federal guidelines contained
Management
in CFR 431.105.

Eligibility
PR1.7
Section:
Page:
ELG036
Schedule, manage, administer and complete recertification in conjunction with Medicare recertification (within 12 months
of Medicare) in order to minimize duplicative credentialing and site visits, criminal background and fingerprinting for
higher risk providers as defined by CMS and the Department. It is the Department's intent to launch the provider reManagement
certification process as soon as possible after contract signing. Vendors should describe within their response how they
propose to complete provider re-certification operations for all Medicaid participating providers by July, 2015.

Eligibility
NA
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ELG037
Receive, review and process:

Hard copy provider enrollment applications and supporting documentation
Hard copy and fax disenrollment requests
Hard copy and fax maintenance requests

Management
EE06 Enroll Provider
PR1.2
Section:
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Incomplete applications must be returned to the submitter without further processing.

ELG038
Perform pre-enrollment credentialing and screening activities for Title XIX pursuant to State and federal requirements
found at 42 CFR, Section 455 as well as 18NYCRR, Parts 502 and 504.

Management
WA2.2
ELG039
Image, Optimal Character Recognition (OCR) and/or data enter, edit and verify hard copy or fax enrollment applications
and supporting materials received as directed by Department.

Management
NA
ELG040
Electronically associate enrollment applications and all supporting materials (including any supporting materials not
received with the original application).

Management
NA
ELG041
Accept and process Electronic Funds Transfer (EFT) applications via hard copy, fax, and the Web Portal.

Management
NA
ELG042
Provide the capability through the Web Portal to modify, save and delete EFT applications entered prior to submission,
along with the capability to review and/or print applications prior to and after submission.

Management
NA
ELG043
Be responsible for the pharmacy enrollment function of NYPS. Provider relations shall be required by the contractor to
educate participating providers on the NYPS as needed.

Management
NA
ELG044
Allow online Health Homes enrollment and disenrollment.

Management
NA
ELG045
Create alerts/extracts for Health Home user accounts communicating changes in member Medicaid eligibility or Manage
Care enrollment

Management
NA
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.

Management
NA
ELG047
Process provider enrollment and contracting which supports multiple provider enrollment roles, as required by the
Department, 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

Management
ME2.3
Section:
Page:
ELG048
Enroll pharmacies registered in a contiguous state when such enrollment is certified as necessary by EPIC (see Section
253 of Title 3 of the NYS Elder Law). 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).
NA
Section:
Page:
ELG049
Receive and process pharmacy provider enrollment forms and signed agreements; notifying pharmacy providers of
enrollment determinations. Providing pharmacy providers written notification, per EPIC policy, of determinations to deny
Management
enrollment, stating reasons for denial and outlining rights to appeal.
NA
Section:
Page:
ELG050
Produce monthly statistical reports which outline provider enrollment, application rejections, provider maintenance and
provider termination activity.

Management
NA
ELG051
Accept and capture providers' disenrollment requests and supporting materials via hard copy, fax, or Web Portal.

Management
EE07 Disenroll Provider
NA
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.

Management
NA
ELG053
Terminate providers based on information received from external agencies and Department defined rules.

Management
NA
ELG054
Inactivate or suspend all providers not responding to recertification or relicensure requirements in accordance with
guidelines from the Department.

Management
NA
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ELG055
Track each provider disenrollment request through all the steps in the disenrollment process.

Management
NA
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.

Management
EE08 Inquire Provider

Information
PM2.6
ELG057
Provide the capability through the web-based application to retrieve and batch individual provider enrollment files
(including the enrollment application, all supporting materials and correspondence) in an industry standard file format
(e.g. PDF) accessible.

Management

Information
NA
Section:
Page:
ELG058
Respond to requests for provider enrollment status and other provider information from providers, stakeholders, or
business associates via the provider area of the Web Portal and the Customer Service Center.

Management

Information
PM4.9
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.
Preparation of retroactive reports (reverse crossover) to Medicare Part B or the provider, as appropriate, for all claims
paid by Medicaid that should have been paid by Medicare part B.
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
TP2.10, TP2.13,
TP2.14, TP2.15,
TP2.7, TP2.8, TP2.9
Section:
Page:
FIN002
Maintain all data required to support recoupments, including the following:

Recoupment amount
Recoupment payment schedule or percentage
Reason for recoupment (e.g., court orders, tax liens, audits, negative retroactive rate adjustments, negative claim
balances)
Payment history (e.g., audit trail of payment source, amount, and date)
Current recoupment balance due
Recoupment balance paid

Recoupment
NA
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.

Recoupment
NA
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.

Recoupment
NA
Section:
Page:

Recoupment
FI4.3
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.
FIN006
Review, identify and resolve premium payment discrepancies. Contractor must either confirm accuracy of plan discrepant
amount or calculate a revised discrepant amount.
FM08 Prepare Member Premium

NA
Invoice
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), then the claim is flagged and routed for manual review for:
Possible incorrect procedure
Possible incorrect billed amount
When too high, possible need for individual consideration.

Recoupment
CA2.16
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.
FM02 Manage TPL Recovery
NA
FIN009
Generate automated TPL billing information to providers for members with third party coverage.
TP2.2, TP2.6
FIN010
Identify claims with trauma diagnosis codes, accident codes and indicators and routes verification against TPL coverage,
TP1.4
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FIN011
Monitor TPL third party avoidance and collections per State Plan. Provide the ability to produce TPL data and cost
avoidance reporting as required by federal and State rules and regulations.
PM2.3
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.
NA
Section:
Page:
FIN013
Track and associate to individual claims all financial transactions by source, including but not limited to:
Third Party Recovery (TPR)
Fraud and abuse recoveries
Provider payments
TP2.11, TP2.4
Section:
Page:
FIN014
At request of the Drug Rebate/Pharmacy Pricing Administrator, prepare extracts of pharmacy claims history required by
drug manufacturer rebate process. Claims must include all NDC and other data needed to support the rebate process, 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
FM04 Manage Drug Rebate
POS6.2
Section:
Page:
FIN015
Maintain current NCPDP standards.
FM04 Manage Drug Rebate
NA
Section:
Page:
FM06 Manage Accounts

Receivable Information
PM2.7, PM2.9
Section:
Page:
FIN016
Monitor payment processes and perform analysis which:

Identifies payments by type such as, but not limited to, abortions and sterilizations
Monitors accumulated liability for deficit payments
Alerts administration when significant change occurs in daily, weekly, or other time period payments.
FIN017
Process accounts payable transactions to resolve outstanding credit balances as required by the Department.

NA
FIN018
Manage accounts receivable and collection activities as directed by the Department.

NA
FIN019
Develop an Accounts Receivable Management Plan including the management of delinquent accounts for approval by the
Department.

NA
FIN020
Establish accounts receivable balances at the Taxpayer, Entity, and Provider level.

NA
FIN021
Establish accounts receivable balances via the web-based application including but not limited to:
Recoupment amount
Reason for recoupment

NA
FIN022
Generate automated letters and/or electronic notifications to providers when a credit balance or accounts receivable has
been established.

FI3.14
FIN023
Image and index recoupment payments and associated documents (including correspondence) received from providers.

NA
FIN024
Review and take appropriate action on notices received through the Workflow Management System regarding accounts
receivable balances.

PM2.10
ME3.3, ME3.4
FIN025
Provide capability to support premium collection inquiries and produce premium collection reports..

FIN026
Withhold the federal share of payments to Medicaid providers to recover Medicare overpayments.

FI2.9
NA
FIN027
Identify payer issues and develop and implement action plans to improve collections.

FIN028
Conform to Generally Accepted Accounting Principles (GAAP) and to the State of New York and federal policy, law, and
regulation.

NA
FIN029
Maintain an accounts detail and summary section, containing each account the beginning balance, activity for the period,
pending credit, ending balance, the recoupment schedule, and totals; report weekly as directed by the Department.

PM2.10
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FIN030
Maintain Accounts Receivables information, including the handling of and accounting for liens, recoupments and
emergency provider payments.

TP2.12
FIN031
Maintain garnishments and tax levies and assignment information to be used in directing or splitting payments to the
provider and garnishor.

FI2.2
FIN032
Maintain capability to identify providers with accounts receivable balances and no claim activity by program during a
Department-specified number of months.

FI3.13
PM3.5
FIN033
Maintain lien information for recoupments.

FIN034
Monitor, manage and report on accounts receivable activity as directed by the Department.

NA
PM2.10
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FIN035
Report monthly, quarterly, and on request to the Department in aggregate and/or on individual accounts, as required.

FIN036
Collect principal and interest owed by providers on accounts receivable as directed by the Department.

NA
FIN037
Track dispute resolution contacts including but not limited to:

Pharmacies
Other billing providers

NA
FIN038
Log receipt data of each withholding or penalty request including the completion date of withholding or penalty; provides
reporting to Department on same.

NA
FIN039
Calculate simple or compound interest with different interest rates based on Department business rules with the flexibility
to waive interest on a case by case basis.

NA
FIN040
Allow providers to view accounts receivable information through the provider area of the Web Portal.

NA
FIN041
Provide the capability to search, inquire on and update all information related to recoupments via the web-based
application including but not limited to:
Recoupment amount
Reason for recoupment (e.g., court orders, tax liens, audits, negative retro rate adjustments, negative claim balances)
Payment history
Current recoupment balance due
Recoupment balance paid
Recoupment write-off

PM3.5
FIN042
Provide the capability to reconcile accounts with the designated Financial Institution based on the exchange of files.

NA
FIN043
Provide the capability to receive EFT for accounts receivable and reconcile those payments to accounts receivable by
TCN/Claim line.

NA
FIN044
Provide the capability to log, image, electronically associate checks received and reconcile those payments by TCN/Claim
line.

NA
FIN045
Apply payments received to accounts receivable balances.

NA
FIN046
Provide the capability to automatically balance quarterly invoicing and payments.

NA
FIN047
Provide the capability through the web-based application to retrieve and batch accounts receivable information (including
the original invoice, payment information, all supporting materials and correspondence) in an industry standard file format Financial Management
(e.g. PDF).

NA
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.

NA
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Page:
FIN049
Provide the capability to enter information related to the write-off of accounts receivable via the web-based application.

NA
FIN050
Provide the capability to automatically generate notices regarding accounts receivable balances based on Department
business rules taking into account dispute status.

ME3.1, PM2.10
FIN051
Maintain a process to calculate and apply interest (simple and compound) to accounts receivable balances based on

NA
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FIN052
Provide the capability to analyze utilization data to assist in the dispute resolution process.

NA
FIN053
Provide the capability to maintain the final dispute resolution agreement on unit quantity amounts.

NA
FIN054
Provide the capability to log, image, electronically associate, dispute resolution agreements received.

NA
NA
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FIN055
Provide the capability to track dispute resolution contacts including: pharmacies and other billing providers.

FIN056
Provide dashboard reporting for monitoring, tracking and reporting on dispute resolution activity.

NA
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

TP2.12, FI3.8, FI4.3
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.

NA
FIN059
Complete EPIC billing, collection and accounting for enrollment fees and enrollment fee refunds.

NA
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

Receivable Funds
FI4.1
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, repayments, & Offset

Receivable Funds
NA
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.

Receivable Funds
FI3.8
FIN063
Process Lump Sum Payment transaction for payments to a provider that are not related to a specific claim as required by
the Department.

Receivable Funds
NA
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.

Receivable Funds
NA
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Page:
FIN065
Provide support for identification and application of recovery funds and lump-sum payments. Provide the ability, in the
System, to identify claims currently, and previously, subject to audit or recovery down to the line detail level.

Receivable Funds
FI3.12
Section:
Page:
FIN066
Provide the capability to accept and process provider payments based on Department business rules.

Receivable Funds
NA
FIN067
Provide the capability to image and index recoupment payments and associated documents (including correspondence)
received from providers.

Receivable Funds
NA
FIN068
Provide the capability to electronically associate payments and other documents with the appropriate recoupment.

Receivable Funds
NA
FIN069
Provide the capability to enter payment information received including but not limited to payment amount, check
information, and date received.

Receivable Funds
NA
FIN070
Provide the capability to enter and maintain text notes associated with recoupment payments via the web-based
application.

Receivable Funds
NA
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

Receivable Funds
FI2.8
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FIN072
Receive, log, process and track payments received from providers for outstanding accounts receivable balances.

Receivable Funds
NA
FIN073
Support and monitor the production of letters to providers for checks that have not cleared within a period established by
the Department.

Receivable Funds
NA
FIN074
Support and monitor the production of stop payment orders for checks that have not cleared within a period established by
the Department.

Receivable Funds
FI3.9
FIN075
Assign a unique control number to each recoupment and payment.

Receivable Funds
NA
FIN076
Apply claims payment amounts to outstanding accounts receivable balances based on the Department's business rules
automatically.

Receivable Funds
NA
FIN077
Apply payments received from providers to the outstanding accounts receivable balances based on the Department's
business rules.

Receivable Funds
FI3.7
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.

Receivable Funds
NA
FIN079
Process premium, Spend-down, Co-Pay, and Buy-In payments received. Track exceptions where outstanding account
receivables have not been paid by eligible members

BE5.6, ME3.2
Invoice
FIN080
Provide the capability to process member cost sharing (e.g., copayments, LTC patient liability) on any service specified by
the state using a fixed amount or percent of charges.

CA4.8
Invoice
Track Medicare deductibles and coinsurance paid by Medicaid for all crossover claims, by member and program type.

FI3.1
Invoice

NA
Invoice
Section:
Page:
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FIN081
FIN082
Calculate monthly EPIC payments including but not limited to:

i.
Identifying EPIC seniors and their corresponding Medicare Part D plan coverage dates (retroactive payments may be
necessary).
ii.
Determining if EPIC member is eligible to have premiums paid based on their incomes.
iii. Identifying the monthly premium amount for the applicable Part D plan.
iv. Determining whether low income subsidy exists for current month or past months for EPIC member.
v. Identifying monthly premium amount covered by CMS if low income subsidy is in effect.
vi. Calculating monthly amount owed by EPIC to the Medicare Part D plan for each member, subsequent to any subsidy
payment, but no more than the low-income benchmark amount established by CMS. If necessary, 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.
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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.
FM09 Manage Contractor

Payment
FIN084
Calculate, maintain, and apply member cost sharing including but not limited to:
Patient liability amounts
Medicaid Co-Payments
Medicaid Premiums
FM10 Manage Member Financial

BE2.5, BE2.6
Participation
Section:
Page:
FIN085
Transmits member Buy-In information to and accepts Buy-In response information from CMS-specified Federal Medicare
Beneficiary database(s). Processes change transactions to update Buy-In member information. Identify and track errors Financial Management
or discrepancies between NYS and Federal Buy-In member information.

BE5.2, BE5.3, BE5.4
Participation
Section:
Page:
FIN086
Produce and transmit a Medicare Buy-In Premium Billing file to the Department's FMG. This file must contain distinct
summary records of monthly Medicare Buy-In debits and credits obtained from CMS.

NA
Participation
Section:
Page:
FIN087
Identify members who are enrolled in Medicare Part D, dual eligible, Low Income Subsidy (LIS), and other insurance
programs if applicable for the purpose of cost avoiding their claims at the POS (EPIC is the payer of last resort). The
contractors system must be capable of denying claims for those with other insurance, including sending messages to the
pharmacy regarding the need to bill the other payer first. In addition, the processing must include the ability to process the
remaining balance to the Program after payment by a primary payer. There must be systematic ability to override a denial.
The system must be capable of locking a few select members to specific pharmacies as identified by the State.

BE5.7, POS5.1
Participation
Section:
Page:
NA
FIN088
Verify, during claims payment, Health Home enrollment and pay to information to ensure correct payment disbursement

NA
Participation
Section:
Page:
FIN089
Support Health Home acuity score payment methodology. (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)

NA
Participation
Section:
Page:
FIN090
Monitor published pricing sources to identify market fluctuations and then accurately apply necessary price changes at the
NDC level.

NA
Participation
Section:
Page:
FIN091
Generate enrollment records, capitation payments, per-member per-month (PMPM), and premium payment transactions
monthly for each member enrolled in MCOs on the first of the month automatically. Payments via EFT or check will be
produced and reported on the X12 820 (5010 and future versions).
ME2.5, ME2.6,
FM11 Manage Capitation Payment ME2.8, MC2.4,
MC2.9
Section:
Page:
FIN092
Automatically generate capitation payment adjustment and void transactions for reconciliation of errors or corrections,
mass adjustment to rates according to State policy, and for each member whose enrollment in a Managed Care
Organization was retroactively modified or enrolls in another plan.
FM11 Manage Capitation Payment
MC2.5, MC2.6,
MC2.8
Section:
Page:
FIN093
Calculate PMPM capitation payment for the actual number of days of eligibility in a month (i.e., enrollee may not be
enrolled for a full month) based on State-defined rate factors such as age, sex, category of eligibility, health status,
geographic location, and other. Exclude enrollees who have terminated enrollment, disenrolled, or are deceased from the
monthly MCO capitation payment.
FM11 Manage Capitation Payment
ME2.5, MC2.1,
MC2.2, MC2.3
Section:
Page:
FIN094
Provide the capability to add premium, bonus and incentive payments based on Department business rules.
FM11 Manage Capitation Payment NA
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Page:
FIN095
Maintain accounting information and complete audit trail including but not limited to:
Accounts payable information
Accounts receivable information
General ledger information
FM13 Manage Accounts Payable

FI2.5
Information
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

FI2.5, FI3.10
Information
Section:
Page:
FIN097
Maintain and make available to the Department such records and reports concerning the contractor internal administrative
process as is necessary to permit the Department to verify the validity and accuracy of all bills for service.

NA
Information
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 Comptrollers 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, irrespective of cause

NA
Information
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.

NA
Information
Section:
Page:
FIN100
Support and monitor the process to generate a check to the provider when the payment received exceeds the accounts
receivable balance.

NA
Information
FIN101
Provide the capability to process accounts payable transactions to resolve outstanding credit balances as required by the
Department.

NA
Information
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

NA
Information
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. A Lump Sum Payment transaction must contain at a minimum the appropriate shares percentages, a valid
County Code and Category of Service.

NA
Information
Section:
Page:
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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. Cash Advance transactions must contain at a minimum preassigned shares percentages, a County Code, and a Category of Service.

NA
Information
Section:
Page:
FIN105
Update claim history and financial files with the check number, EFT number, warrant number, or other, date of payment,
and amount paid after the claims payment cycle.

FI2.1
Information
Section:
Page:
FIN106
Transmit records of recoupment identifying the claim affected and amounts to the MDW. Provide capabilities to perform
"what-if" analysis for proposed recoupments, rate changes or other proposed payment or eligibility changes.

NA
Information
Section:
Page:
FIN107
Maintain lien information to be used in directing or splitting payments to the provider and lien holder.

NA
Information
Section:
Page:
FIN108
Assign a general ledger code to every claim. General Ledger Codes are assigned based on Major Program Code, Claim
Type, Provider Type and additional criteria required by the Department.

NA
Information
Section:
Page:
FIN109
Provide the capability to view and update general ledger codes via the web-based application based on Major Program
Code, Claim Type, Provider Type and additional criteria required by the Department.

NA
Information
Section:
Page:
FIN110
Process EFT reimbursements to providers for EFT returns, cleared checks, uncleared checks, stop payment orders,
reissued checks and payment errors and also perform monthly bank reconciliation and other money management tasks.
Pharmacy providers are reimbursed via EFT, pharmacy provider cycle claims for NYSP are within two days from claim
adjudication.

NA
Information
Section:
Page:
FIN111
Reconcile accounts with the designated financial institution based on the exchange of files containing information related
to the status of checks and EFTs.

NA
Information
FIN112
Manage all aspects of the EFT process including the capability to reprocess failed EFTs.

FI3.3
Disbursement
1
1
FIN113
Support and monitor the production of EFT/checks by provider and ETIN.

NA
Disbursement
FIN114
Remove EFT payments from the banking file prepared for EFT transfers; and pull/remove associated remittance advices at
the Department's request.

NA
Disbursement
FIN115
Administer direct reimbursement to the American Indian Health Program (AIHP) providers and patients for deductibles
and copays.

NA
Disbursement
FIN116
Manage all aspects of the warrants process.

FI3.3
Disbursement
FIN117
Produce hard-copy checks for the payment cycle (for providers requesting that option) and maintain control of all hard
copy checks until distributed to providers. Monitor security of checks during the matching, stuffing and mailing process.

NA
Disbursement
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.

NA
Disbursement
FIN119
Manually pull and void provider check(s) and associated remittance advice(s) after printing at the Departments request.

NA
Disbursement
FIN120
Adjust (void) any claims associated with the payments (check or EFT) when the Department instructs the voiding of a
check/EFT.

NA
Disbursement

NA
Disbursement
FIN121
With written notice from the State, issue manual checks on an as-needed basis for any special payments as directed. The
contractor must arrange to have manual checks delivered via expedited (twenty-four hour) delivery upon request by the
State.
NOTE: Special processing requests for manual checks are infrequent. An example would be a member request for a
refund in an emergency situation.
FIN122
Exert controls and counts to prove that every check produced was actually mailed.

NA
Disbursement
FIN123
Facilitate and disburse payment of pharmacy provider claims; and refunding excess member co-payments

BE2.5
Disbursement
FIN124
Provide the capability to view and export, in a human readable format, all supporting claim information pertaining to a
payment including all raw claim data received through the claim transaction, as submitted, and process claim data.

NA
Disbursement
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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),
ownership, multiple provider specific reimbursement rates with begin and end dates, financial institution, account number,
payment amounts, and payment effective dates.

NA
Disbursement
Section:
Page:
FIN126
Upon initial establishment of State of New York Medicaid Program related bank accounts, 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, reporting timeframes and for cleared payments and payment
confirmation, and confirmation of NYS OSC and FMG access to such accounts.

NA
Disbursement
Section:
Page:
FIN127
Provide full, uninterrupted, 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.

NA
Disbursement
Section:
Page:
FIN128
Maintain all bank account established and administered under the contract as Zero Balance Accounts

NA
Disbursement
Section:
Page:
FIN129
Allow access to OSC and support random sampling reviews of manual checks and EFT transaction. This may include
involvement of the MAS Contractor / fiscal agents quality assurance staff to review payment amounts, check
information, and date received.

NA
Disbursement
Section:
Page:
FIN130
Provide separate banking services and fiscal accountability for facilitating NYS Medicaid transportation payment.

NA
Disbursement
FIN131
Generate Medicaid transportation payment transactions (EFT and paper check) to individual members for travel expenses
incurred.

NA
Disbursement
FIN132
Generate Medicaid transportation payment transactions to providers monthly for the costs of the dispensed MetroCards.

NA
Disbursement
FIN133
Maintain full responsibility for all federal form 1099 processing, including issuance to providers, submission of data to
federal and State tax authorities, and issuance of special forms such as B notices to providers for purposes of correcting Financial Management
mismatched employer identification numbers.
FM15 Manage 1099
FI2.3, FI2.4
FIN134
Produce and mail hard copy 1099 forms to providers as specified by the Department.
FM15 Manage 1099
NA
FIN135
Produce and distribute 1099 files to the Internal Revenue Service (IRS), NYS Department of Taxation and Finance, and
other entities specified by the Department.
FM15 Manage 1099
NA
FIN136
Produce replacement / corrected 1099s based on provider request, State, or contractor review, with approval from the
Department.
FM15 Manage 1099
NA
FIN137
Generate 1099 forms for the AIHP
FM15 Manage 1099
NA
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).
FM15 Manage 1099
NA
FIN139
Track all requests for replacement or corrected 1099s.
FM15 Manage 1099
NA
FIN140
Update the status of entities exempt from the 1099 reporting process.
FM15 Manage 1099
NA
FIN141
Maintain a cumulative pharmacy-specific accounting file after each payment cycle. Provide tax data following each
pharmacy-specific accounting file after each payment cycle for IRS reporting purposes.
FM15 Manage 1099
NA
Section:
Page:
FIN142
Provide capability to support the production of information and or reports to support the preparation of budget allocations
by fiscal years
FM17 Manage Budget

Information
PM1.3, PM1.4,
PM1.5, PM1.6, PM1.7
Section:
Page:
FIN143
Collect and maintain the data necessary to support the budget neutrality reporting requirements as specified in the NYSs
1115 Waiver, 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.
FM17 Manage Budget

Information
MC8.1, MC8.2
Section:
Page:
FIN144
Verify all banking transactions via online bank access to ensure timeliness and accuracy of the transaction.
FM18 Manage Fund
NA
Section:
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FIN145
Accept any responsibilities for overdraft penalties on checking accounts including but not limited to:
Depository
Disbursing
Special payment
FM18 Manage Fund
NA
Section:
Page:
FIN146
Maintain sufficient controls to track each financial transaction (e.g. Lump Sum, Advance Payments, etc.), balance batches,
and maintain appropriate audit trails on the claim and payment history files.
FM18 Manage Fund
FI2.3, FI2.5
Section:
Page:
FIN147
Generate a Financial Control Number (FCN) for every approved fiscal transaction.
FM18 Manage Fund
NA
FIN148
Provide files and reports with information necessary to compute the weekly funding as required by the Department.
FM18 Manage Fund
NA
FIN149
Provide the capability to view, add and update date specific shares funding (Federal, State and Local Governmental Unit)
information based on member aid category, charge indicator, services indicator (e.g. abortion, sterilization, family
planning, and long term care) as required by the Department via the web-based application.
FM18 Manage Fund
NA
Section:
Page:
FIN150
Provide the capability to assign weekly payment cycle funding information by various State agency appropriation pursuant
to Department accounting rules.
FM18 Manage Fund
NA
Section:
Page:
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 Programs contribution to the Public Goods Pool.
FM18 Manage Fund
NA
Section:
Page:
FIN152
Maintain separate bank accounts for benefits programs and special payments. Reimbursement from accounts shall be
under the direction of the Department. Any interest earned on this account shall accrue to the Department. Transfer
special payment account funds to the Department designated bank account at the direction of the Department. 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 .
FM18 Manage Fund
POS2.15
Section:
Page:
FIN153
Provide any fiscal agent operations support necessary for the MDW to complete CMS37 and CMS64 reporting.
FM19 Generate Financial Report NA
FIN154
Matches capitation summary data and FFS claims data to verify that the MCO payments do not exceed FFS upper limits.
FM19 Generate Financial Report MC4.7
FIN155
Generate reports of capitation payment with flexibility to sort/filter for various categories (e.g., by eligibility group, rate
cell, etc.).
FM19 Generate Financial Report MC6.1
FIN156
Provide State access to all financial information such as, but not limited to, paid amounts, outstanding amounts and
adjustment amounts and perform analysis of timely reimbursement.
FM19 Generate Financial Report PM2.5
FIN157
Perform analysis of billing habits and TPL payments to determine and propose where program cost reductions might be
achieved.
FIN158
Produce financial and program analysis reports as required by the Department using the Commercial Off-the-Shelf
(COTS) reporting tool. At a minimum, these reports must be comparable to the reports found in the Procurement Library.
FM19 Generate Financial Report PM1.1, PM5
FIN159
Produce basic NYPS management reports, addressing utilization, enrollment, costs, etc. for NYPS. Ad-hoc reporting
requests may be made from time to time.
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.
FIN161
Provide automated processes for performing periodic bank account or fund allocation reconciliations to include
management of bank accounts, processing of payments, recoveries and adjustments, and reconciliations.
FM19 Generate Financial Report FI2.6
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
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FIN163
Provide a monthly report listing all contractor or State identified inappropriate payments. This report will describe the
cause of the inappropriate payment, whether the inappropriate payment represents an incorrect payment, and an estimate
of the dollar amount of any incorrect payment. The Contract Administrator shall review the report, decide whether further Financial Management
research and analysis is required before correction of the problem, approve the plan for correction, and establish a
correction date.
Section:
Page:
FIN164
Develop, produce, and distribute Medicaid transportation expense reports including but not limited to recipient ID, name,
address, date of service, units approved, units used, and paid amount, for claims made by PTAR facilities, MMTPs, and
transportation managers.
Section:
Page:
Maintain current and historical information for all individuals eligible for medical benefits under Medicaid or other NYS
medical assistance and public health programs (i.e. American Indian Health Program, Cystic Fibrosis) as determined
appropriate for such programs, 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, Demographics, Eligibility Category, 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, 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
BE1.1, BE1.3, BE2.6,

ME1.1, ME1.2,
ME1.5, TP1.8, TP1.9,
PM4.5
Section:
Page:
MEM002
Maintain eligibility information so that it represents a complete history of every eligibility period and can reflect
retroactive coverage downgrades. 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. The overlapping stacked eligibility is a representation of the
eligibility data which is stored on the WMS/Health Benefits Exchange (HBE) Database.
ME01 Manage Member

Information
BE1.5, ME2.1
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, First Name, Middle Initial
Case Number
Date of Birth (DOB), age plus or minus five years
Gender
HBE account number
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM004
Accept and process updates of member eligibility information from NYC WMS, Upstate WMS, and HBE (when
available) at least daily. These eligibility updates must include processing for New eligible members, reinstated eligible
members and changes to existing member data, in accordance with Department business rules.
Member Management
ME01 Manage Member

Information
BE1.5, ME2.1
Section:
Page:
MEM005
Accept and process files received from NYC WMS, Upstate WMS, and HBE (when available) including but not limited
to.
RRE Transaction files which contain member restriction, 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
BE1.5
Section:
Page:
MEM001
MEM006
Processes all transactions that update the member data set (as defined in ME001) and benefit assignments. Edit data
received from eligibility systems for reasonableness, and controls and accounts for transactions with errors. Archive and
maintain member data and update transactions
Member Management
ME01 Manage Member

Information
BE1.2, BE1.3, BE1.6,

BE1.5, BE2.2
Section:
Page:
MEM007
Maintain current and historical records of benefit assignment(s) for members.
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM008
Maintain clinical, utilization and other indicators of special population, special needs status for such programs as lock-in,
Member Management
disease management, outcomes, and high dollar case management files.
ME01 Manage Member

Information
BE1.9
Section:
Page:
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, warning date and status
Overuse date
Status
Member Management
ME01 Manage Member

Information
BE2.4
Section:
Page:
MEM010
Profile all services provided to a member during a single episode of care.
Member Management
ME01 Manage Member

Information
BE1.13, PI2.7
Section:
Page:
MEM011
Maintain and update current TPL information. Generate and maintain an audit trail of all updates to the member insurance
Member Management
data, including those updates that were not applied due to errors, for a time period specified by the State.
ME01 Manage Member

Information
BE1.13, TP1.13,
TP1.14
Section:
Page:
MEM012
Develop and maintain cross-references files of health insurance carriers to employers.
Member Management
ME01 Manage Member

Information
BE1.12, TP1.15
MEM013
Maintain and provide the capability to review through the web-based application casualty-related information (e.g., motor
Member Management
vehicle accident and workers compensation information).
ME01 Manage Member

Information
TP1.2
MEM014
Collect and manage member information necessary to produce all reports to facilitate cost reporting and financial
monitoring of waiver programs.
Member Management
ME01 Manage Member

Information
WA5.1
MEM015
Collect and manage member information necessary to produce all utilization reports for monitoring cost neutrality of
waiver services to a target population.
Member Management
ME01 Manage Member

Information
WA5.2
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
Section:
Page:
MEM017
Accept and process the "member 621 eligible" file from the Department and apply updates to the Member registry. These
Member Management
are individuals who have been in an OMH/OMR facility for a period of five years or more and have subsequently been
enrolled in Medicaid.
ME01 Manage Member

Information
BE1.5
Section:
Page:
MEM018
Accept and process the member offender file from the Department of Criminal Justice Services (DCJS), this file contains
Member Management
members who are restricted from receiving services from Medicaid.
ME01 Manage Member

Information
NA
Section:
Page:
MEM019
Accept and process the Multiple ID file received from WMS/HBE which contains resolution information on members
with multiple member IDs. The processing must include applying corrective actions and establishing the relationship
between the original and current member IDs.
Member Management
ME01 Manage Member

Information
BE1.13, PI2.6
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
BE1.13
MEM021
Provide the capability via the web-based application to search, inquire on and update member data
Member Management
ME01 Manage Member

Information
BE1.12
BE2.5
MEM022
Initialize member Co-Pay amounts annually.
Member Management
ME01 Manage Member

Information
MEM023
Identify members who have reached their annual Co-Pay limit or who are exempt from Co-Pays.
Member Management
ME01 Manage Member

Information
NA
MEM024
Initialize service utilization limits for each member within general service categories specified by the Department
including but not limited to: Physician, Medical Clinic, Mental Health Clinic, Pharmacy, Laboratory, and Dental Clinic.
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
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MEM025
Accept and process data reconciliation files at least quarterly from the WMS/HBE systems (NYC and Upstate), the
reconciliation process must compare member data from the contractor's application with the WMS/HIX systems member
data and identify discrepancies. 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
Section:
Page:
MEM026
Apply Managed Care enrollment/disenrollment information received through automated interfaces to the Member registry
Member Management
as defined by the Department.
ME01 Manage Member

Information
ME1.1, ME1.2,
ME1.6, ME1.8, ME1.9
Section:
Page:
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
MC1.1, PM1.8
Section:
Page:
MEM028
Produce and transmit a file for the Manage Care Broker of Manage Care members whose eligibility has been added,
modified or removed at a frequency specified by the Department.
Member Management
ME01 Manage Member

Information
NA
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.
ME01 Manage Member

Information
NA
MEM030
Provide the capability via the web-based application to view, inquire on, add, 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
Section:
Page:
MEM031
Maintain member Medicare, Buy In and Medicare Savings Program information, including but not limited to:
Health Insurance Claim Number (HIC)
Medicare eligibility information (Part A, Part B, 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, Qualified Medicare Beneficiary (QMB),
Qualified Disabled Working Individual (QDWI), Specified Low Income Medicare Beneficiary (SLIMB) individuals and
Qualifying Individuals 1 (QI-1)
Member Management
ME01 Manage Member

Information
BE5.1, BE5.5
Section:
Page:
MEM032
Accept and process the monthly TPL Contractor Resource Update Files which contain new records, additions and changes
Member Management
to existing Medicaid/Medicare records.
ME01 Manage Member

Information
BE2.1, TP1.11, TP1.12
MEM033
Provide the capability to enter, inquire on and update Medicare and Managed Long Term Care information via the webbased application.
ME01 Manage Member

Information
NA
Member Management
Section:
Page:
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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, 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.g.
Railroad Retirement)
Maintain source identifiers of Medicare related information for Audit trail
Create views into source files, to assist contractor and Department staff in resolving discrepancies
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
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, to assist contractor and Department staff in resolving discrepancies
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM036
Accept and process the daily Buy-In CMS response file that contains Buy-In maintenance transactions.
Member Management
ME01 Manage Member

Information
NA
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.
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM038
Accept and process the Buy-In CMS monthly billing file from CMS which includes debit, credit, and action transactions
for Parts A and B.
Member Management
ME01 Manage Member

Information
NA
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
Section:
Page:
MEM040
Provide the capability to enter, inquire on and update Buy-In, Managed Long Term Care, and Medicare Savings Program
information via the web-based application.
Member Management
ME01 Manage Member

Information
NA
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, 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
Section:
Page:
MEM042
Identify all current and prospective dual eligible members (dual eligible members are eligible for Medicare and Medicaid
Member Management
concurrently).
ME01 Manage Member

Information
PM4.10
MEM043
Maintain and validate AIHP member enrollment based on data provided for member with each tribal nation.
Member Management
ME01 Manage Member

Information
NA
MEM044
Produce and transmit the Medicare Modernization Act (MMA) file to CMS on a schedule to be defined by the
Department. This file represents the NYS dual eligible and prospective dual eligible population.
Member Management
ME01 Manage Member

Information
TP1.1, TP1.10,
PM4.10
Section:
Page:
Section:
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Page:
MEM045
Accept and process the MMA response file received from CMS.
Member Management
ME01 Manage Member

Information
NA
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, 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
Section:
Page:
MEM047
Obtain and process all Medicare Part C Advantage Plan and the Medicare Part D Prescription Plan information from
CMS, including but not limited to:
Contract ID
Plan Description Name
Plan Type
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM048
Create and maintain registries with Medicare Part C Advantage Plan and the Medicare Part D Plan information that
include Contract ID, Carrier Name, Plan Type, and Benefit Plan.
Member Management
ME01 Manage Member

Information
NA
MEM049
Maintain crosswalk between Contract IDs, Carrier Name and current Carrier Code for both Medicare Parts C and D Plan
information.
Member Management
ME01 Manage Member

Information
NA
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
NA
MEM051
Provide the capability to inquire on Medicare Part D information via the web-based application.
Member Management
ME01 Manage Member

Information
MEM052
Automatically terminate Medicare Part D entitlement when all Medicare eligibility has ended.
Member Management
ME01 Manage Member

Information
NA
NA
Section:
Page:
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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
MEM054
Maintain all current and historical TPL Commercial Insurance information (Commercial and Medicare Part C), Carrier
data and Employer data for all applicable members, including but not limited to:
Source of TPL information (e.g., X12N 270 eligibility determination, 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
TP1.8, TP1.9
Section:
Page:
MEM055
Accept and process TPL contractor resource update files containing additions, closings and changes to commercial
insurance information, and employers, insurance companies, providers, member, and attorneys verification data.
Member Management
Verification data includes the type of insurance coverage for each policy (e.g., inpatient, outpatient, physician, pharmacy,
dental).
ME01 Manage Member

Information
BE2.1, TP1.12, TP1.7
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.
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM057
Accept and process the SSI Referral file from SSA which contains Commercial Insurance information.
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM058
Provide the capability to enter, inquire on, update and void Commercial Insurance information (Commercial and Medicare
Member Management
Part C), Carrier data and Employer data via the web-based application.
ME01 Manage Member

Information
NA
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
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. A history of "Good Cause" eligibility spans must be Member Management
maintained.
ME01 Manage Member

Information
NA
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
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
BE2.5, BE2.6
Section:
Page:
MEM063
Provide the capability to update prior approval/prior authorization upon final adjudication of the claim based upon
business rules defined by the Department, including the capability to record both service units used and those returned by Member Management
a void or adjustment.
ME01 Manage Member

Information
NA
Section:
Page:
MEM064
Track and maintain an audit trail for all transactions related to Commercial Insurance.
Member Management
ME01 Manage Member

Information
NA
MEM065
Track individual EPIC member personal data, as well as drug expenditures, and Part D status.
Member Management
ME01 Manage Member

Information
NA
MEM066
Provide monthly reports stating the counts of EPIC members who received Plan Reassignment letters generated by plan
Member Management
and by letter type.
ME01 Manage Member

Information
NA
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
MEM068
Provide monthly bypass report of all members who received a Plan Reassignment letter, but were later removed from the
Medicare Part D plan enrollment due to a legitimate reason (i.e., no longer active in EPIC).
Member Management
ME01 Manage Member

Information
NA
Section:
Page:
MEM069
Produce weekly, monthly and annual reports, in a State approved format, of the number of letters generated and actions
taken, 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
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.
Member Management
ME01 Manage Member

Information
NA
MEM071
Execute Health Home member loyalty algorithms and assign members corresponding member loyalty codes.
Member Management
ME01 Manage Member

Information
NA
MEM072
Create and disseminate member assignment and loyalty data to Managed Care Plans and Lead Health Homes online.
Member Management
ME01 Manage Member

Information
NA
MEM073
Process premium assistance updates received daily for recipients that are eligible for Medicare Buy-In and HIPP.
Member Management
ME01 Manage Member

Information
NA
MEM074
Provide for the employee share of HIPP to be reimbursed to the employee or paid to the employer or insurance carrier.
Member Management
ME01 Manage Member

Information
NA
MEM075
Verify HIPP recipient premium amounts.
Member Management
ME01 Manage Member

Information
NA
MEM076
Prepare, produce and distribute member notifications via mail, 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
Section:
Page:
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MEM077
Distribute notifications to members, providers and other stakeholders as specified by the Department via mail, electronic
and/or Web Portal.
Member Management

NA
Section:
Page:
MEM078
Generate automated casualty-related letters and/or electronic notifications to members, attorneys, motor vehicle
department, etc. according to State-specified criteria.
Member Management

TP1.6
Section:
Page:
MEM079
Prepare, produce and distribute member labels as specified by the Department.
Member Management

NA
Section:
Page:
MEM080
Prepare, produce and distribute Explanation of Benefit (EOB) notifications to selected members on a schedule determined
Member Management
by the Department.

NA
Section:
Page:
MEM081
Generate letters to inform members who have reached their Co-Pay maximum amount for the current fiscal year.
Member Management

NA
Section:
Page:
MEM082
Generate Third Party letters and track original and follow-up letters to employers, insurers, members and others to verify
health coverage and status changes.
Member Management

TP1.5
Section:
Page:
MEM083
Develop and maintain member information materials on the Web Portal including but not limited to:
Pharmacy Benefit information
Medical, personal care, 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

PM4.9
Section:
Page:
MEM084
Conduct periodic reviews of all member support materials on the Web Portal based on a schedule approved by the
Department.
Member Management

NA
Section:
Page:
MEM085
Reconcile Medicaid and Children's Health Insurance Program (CHIP) eligibility and enrollment with the New York Health
Member Management
Benefit Exchange, when operational, and other State eligibility and enrollment sources.

NA
Section:
Page:
MEM086
Prepare, produce and distribute notifications via mail, electronic and/or Web Portal when appropriate to inform both
members and providers regarding prior approvals/prior authorizations, including but not limited to:
Prior approvals/prior authorizations with pended and missing information
Prior approvals/prior authorizations decisions
Member Management

NA
Section:
Page:
MEM087
Prepare, produce and distribute notifications and attachments to inform members and/or providers on prior approval/prior
Member Management
authorization determinations.

NA
Section:
Page:
MEM088
Prepare, produce and distribute service request determinations to the provider and member or appropriate designee.
Member Management

NA
Section:
Page:
MEM089
Prepare, produce and distribute written notice of pharmacy prior approval/prior authorization to affected providers and
members as directed by the Department.
Member Management

NA
Section:
Page:
MEM090
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. Notices must be written in
English and other required languages in accordance with Department-approved procedures and content.
Member Management

NA
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.
Member Management

NA
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.
Member Management

NA
Section:
Page:
MEM093
Prepare, produce and distribute notifications to inform providers/submitters when prior approval/prior authorization is
required/missing.
Member Management

POS3.5;
Section:
Page:
MEM094
Provide the capability to produce on demand notifications and attachments to inform members and/or providers (including
Member Management
providers that are part of the treatment team) on prior approval/prior authorization information.

NA
Section:
Page:
MEM095
Maintain updated Department letterhead and electronic facsimiles of signatures of Department officials who sign
computer generated notifications.
Member Management

NA
Section:
Page:
MEM096
Provide members with individual benefit summary and detail reports on request, providing relevant information such as
EPIC Part D premium payments, copayments, and prescription purchases.
Member Management

NA
Section:
Page:
MEM097
Maintain inventory of standard written communications and notifications for members, and distribute all member
communications as required.
Member Management

NA
Section:
Page:
MEM098
Distribute State-approved plan notification letters to members that are selected for Plan Reassignment. 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

NA
Section:
Page:
MEM099
Support secure online client access to MMIS data, including claims data, Explanation of Medicare Benefits (EOMB), and
Member Management
other communications, through the web, based on the users security profile in accordance with technology policies.

NA
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. 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) contractors online transportation scheduling site.

NA
Section:
Page:
MEM101
Provide the ability for the client to track the progress of their hearing request for appeals online.
Member Management

NA
Section:
Page:
MEM102
Empower members by providing access to information and tools that can be used to improve their health.
Member Management

NA
Section:
Page:
MEM103
Provide solution to limit and review high utilization of medical, mental health and dental clinic, physician office,
pharmacy, and laboratory services on a beneficiary specific level based on medical condition under Department regulation,
directions and policy guidance, including exceptions to limits. Provide real time response to providers regarding nearing, Member Management
at and over threshold services and web, paper and fax submissions to override limits with clinical or administrative review
as directed by the Department.

NA
Section:
Page:
OPS001
Provide the capability to electronically associate the prior approval/prior authorizations to hard copy, digital and other
electronic media supporting materials received.
Operations Management
OM04 Submit Electronic

Attachment
NA
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.

Attachment
NA
OPS003
Provide the capability to electronically associate claim and prior approval/prior authorization attachments received by any
media to the appropriate claim and/or prior approval/prior authorization with prompt retrieval of attachments.

Attachment
CR1.14
OPS004
Provide the capability to image, OCR and/or data enter, edit and verify hard copy or fax claim attachments received as
directed by Department.

Attachment
NA
OPS005
Accept claim attachments via hard copy, fax, electronic, or Web Portal.

Attachment
NA
NA
Section:
Page:
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Page:
OPS006
Accept electronic attachments in Industry Standard format or as mandated by HIPAA (e.g., X12 275).

Attachment
OPS007
Generate electronic transaction acknowledgment in Industry Standard format or as mandated by HIPAA (e.g., X12 275).

Attachment
NA
OPS008
Identify, analyze, and correct errors that have resulted in improper claims processing (e.g., if final edit dispositions are
incorrect, incorrect loaded rate), trace to the source, reprocess as needed, and report to the Department.
OM05 Apply Mass Adjustment
NA
Section:
Page:
OPS009
Provide the ability to process, verify, and adjudicate mass adjustments for all paid and denied claims, capitation payments,
and zero pays.
NA
Section:
Page:
OPS010
Provide the capability to select previously adjudicated claim(s) to be reprocessed, adjusted, or voided using flexible
criteria to select batch.
NA
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. This process must be
executed based on a schedule approved by the Department. Retroactive rate adjustments can affect claims from 1978
forward.
MC2.6
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.
OM07 Process Claims
CR1.13
Section:
Page:
OPS013
Provide the capability to automatically verify that any data item that contains self-checking digits (e.g., member I.D.
Number) passes the specified check-digit test.
OM07 Process Claims
CA2.6, POS2.10
OPS014
Provide the capability to automatically verify that numeric items with definitive upper and/or lower bounds are within the
proper range.
OM07 Process Claims
CA2.7, POS2.5
OPS015
Provide and maintain system data entry procedures and ability to systematically conduct field validity edits and pre-editing
for hardcopy claims and claim adjustment/voids on:
Provider number
Member ID number
Procedure codes
Diagnosis codes
OM07 Process Claims
CR1.8
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, allow FFS payment to providers for services carved out of the MCO benefit package, and block
payment to FFS providers for services included in the MCO benefit package, with the exceptions stated per the State Plan.
OM07 Process Claims
MC5.1, MC5.2,
MC5.3, MC5.4
Section:
Page:
OPS017
Utilize quality and validation procedures to control, track, and ensure accuracy of captured claims to validate that all
claims received are processed.
OM07 Process Claims
CR1.6
OPS018
Processes batch 837 claims, rejecting only individual bad claims and accepting all others.
OM07 Process Claims
CR3.3
OPS019
Verify that suspended transactions have valid error/exception codes.
OM07 Process Claims
CA1.3
OPS020
Verify all claims for services approved or disallowed are properly flagged as paid or denied.
OM07 Process Claims
CA1.6
OPS021
Identify and track all edits and audits posted to claims.
OM07 Process Claims
CA1.13
OPS022
Maintain claim resolution (e.g., overrides or manual intervention) information by the individual user.
OM07 Process Claims
POS3.2
OPS023
Perform quality control procedures to screen and capture electronic images, date-stamp, Julian date, assign unique control
numbers and batch hardcopy claim forms and attachments, adjustment/void forms, and updated turnaround documents.
OM07 Process Claims
CR1.10
Section:
Page:
OPS024
Utilize data elements and algorithms to compute claim reimbursement for claims that is consistent with 42 CFR 447.
OM07 Process Claims
POS2.15
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.
OM07 Process Claims
CA2.23, POS3.4
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, periodicity, and dollar limitations.
OM07 Process Claims
CA2.24
Section:
Page:
OPS027
Provide the capability to pay claims per capita, from FFS.
OM07 Process Claims
CA2.25
OPS028
Price services billed with procedure codes with multiple modifiers.
OM07 Process Claims
CA2.32
OPS029
Price out-of-state claims according to NYS policy (i.e., at the local rate, at the other States rate or flags and routes for
manual pricing).
OM07 Process Claims
CA2.26
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
NA
Section:
Page:
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OPS031
Price Medicare coinsurance or deductible for crossover claims, depending on State policy, at the lower of the Medicaid or
Medicare allowed amount.
OM07 Process Claims
CA2.31
OPS032
Edit claims for consistency and payment limitations using the Medicare Correct Coding Initiative or similar editing
criteria, based upon the State Plan.
OM07 Process Claims
CA2.33, POS2.22
OPS033
Verify that the provider is eligible to render the specific service covered by the claim.
OM07 Process Claims
CA3.2
OPS034
Verify that the provider is eligible to provide the specific service covered by the plan to the specific member.
OM07 Process Claims
CA3.3
OPS035
Verify that the member was eligible for the particular category of service at the time it was rendered.
OM07 Process Claims
CA4.1
OPS036
Flag for review claims, for the same member, with a diagnosis and procedure which indicate an emergency that occurs
within one day of a similar claim from the same provider.
OM07 Process Claims
CA4.2
OPS037
Identify any incomplete claim batches that fail to balance to control counts.
OM07 Process Claims
CR1.17, RF1.2
OPS038
Routes and reports on claims that are processed that indicate the members date of death for follow-up by the member
eligibility or TPL personnel.
OM07 Process Claims
CA4.4
OPS039
Provide the capability to pend or deny claims for members assigned to the member lock-in program based on state
guidelines.
OM07 Process Claims
CA4.6
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
OM07 Process Claims
NA
OPS041
Provide ongoing assistance related to member and provider enrollment and claims processing for the AIHP.
OM07 Process Claims
NA
OPS042
Provide the capability to edit claims for beneficiaries in LTC facilities to ensure that services included in the LTC payment
rate are not billed separately by individual practitioners or other providers.
OM07 Process Claims
CA4.7
OPS043
Edit claims for newborns eligibility based upon NYS defined newborn enrollment policies and procedures.
OM07 Process Claims
CA4.9
OPS044
Limit benefits payable by beneficiary eligibility category or other beneficiary groupings.
OM07 Process Claims
CA4.11
OPS045
Maintain claim resolution (e.g., overrides or manual intervention) information by the individual user.
OM07 Process Claims
CA5.2
OPS046
Provide and maintain the capability to process standard financial transactions including recoupments and payouts which
cover more than one claim/service.
OM07 Process Claims
CR1.18
OPS047
Provide the capability to receive, process and send electronic health care service review, request for review, and response
transactions required by 45 CFR Part 162, as follows:
Retail pharmacy drug referral certification and authorization
Dental, professional and institutional referral certification and authorization (ASC X12N 278)
Internet submissions or prior authorization requests
OM07 Process Claims
CA5.3
Section:
Page:
OPS048
Accept, record, store, and retrieve documents submitted with or in reference to claim submission activity, such as:
Operative reports
Occupational, physical, and speech therapy reports
Durable Medical Equipment (DME) serial number, cost, and warranty data
Manufactures tracking data for implants
Waivers and demonstration specific requirements
These documents may be freeform or in HIPAA attachment format.
OM07 Process Claims
CR2.1, POS2.23
Section:
Page:
OPS049
Accepts other claim related inputs to the MMIS, including but not limited to:
Sterilization, abortion, and hysterectomy consent forms
Manual or automated medical expenditure transactions which have been processed outside of the MMIS (e.g., spenddown)
Non claim-specific financial transactions such as fraud and abuse settlements, insurance recoveries, and cash receipts
Electronic cost reports
Disproportionate share reports
Drug rebate
Any other inputs required for services under the States approved plan
OM07 Process Claims
CR2.5
Section:
Page:
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Page:
OPS050
Record and identify that all required claim attachments, per the reference records or edits, have been received and
maintained for audit purposes.
OM07 Process Claims
CA2.27, OM033,
POS2.19
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.
OM07 Process Claims
WA1.3
OPS052
Accesses individual beneficiary claims histories to extract data needed to produce annual report to CMS on cost neutrality
and amount of services.
OM07 Process Claims
WA5.3
OPS053
Identify and track claims designated as mandatory pay and chase, makes appropriate payments and flags such claims for
future recovery (i.e. identifies services provided to children who are under a medical child support order, and flags
diagnosis information to identify prenatal care services provided to pregnant women and preventive pediatric services
provided to children.)
OM07 Process Claims
TP1.17, POS5.2
Section:
Page:
OPS054
Receive, review for completeness, process, and apply program specific edits for claim transactions and claim attachments
for NYS waiver programs. Transactions failing the completeness review must be returned to the submitter without further Operations Management
processing.
OM07 Process Claims
WA4.1, WA4.2
Section:
Page:
OPS055
Provide the capability to prevent or suspend waiver payments for members who have become ineligible for Medicaid.
OM07 Process Claims
WA4.3
Section:
Page:
OPS056
Provide the capability to prevent or suspend payments for waiver services furnished to individuals who are inpatients of a
hospital, nursing facility or Intermediate Care Facilities for individuals with Mental Retardation (ICF/MR) and sends
notice to the provider of the admission.
OM07 Process Claims
WA4.4
Section:
Page:
OPS057
Limit payment for services provided to waiver program participants to those described within the members approved plan
of care and deny claims exceeding dollar or utilization limits approved in waiver or exceeding the approved individual
waiver budget cap.
OM07 Process Claims
WA4.5
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. Notify the provider of claims denied because of TPL coverage.
OM07 Process Claims
TP2.5
Section:
Page:
OPS059
Receive, 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. Transactions failing the completeness review
must be returned to the submitter without further processing.
OM07 Process Claims
CR2.2
Section:
Page:
OPS060
Perform manual review and resolution of pended claims and refer claims requiring policy decisions to the Department.
OM07 Process Claims
NA
OPS061
Support distribution of broadcast messages on remittances.
OM07 Process Claims
NA
OPS062
Image; edit; OCR and/or data enter; verify; and index paper claims (e.g. UB04, NY CMS 1500 &15002, eMedNY 150003,
Claim form A (Dental & Transportation), Pharmacy claim form, American Indian Health Plan Claims, Cystic Fibrosis
Program claims) and claim attachments as directed by Department. Perform quality control procedures to verify that the
electronic image is legible and meets quality standards.
OM07 Process Claims
CR1.9
Section:
Page:
OM07 Process Claims
CR1.15
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.g. VPN or leased line)
Batch transmission (e.g. FTP and Secure FTP)
Section:
Page:
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Page:
OPS064
Maintain all information related to claims adjudication including but not limited to:
Provider information (e.g., billing, servicing/rendering, pay to, ordering, prescribing, attending, supervising, operating)
Member information (e.g., member ID, name, address, gender, date of birth)
Service information (e.g., procedure codes, revenue code, rate codes, dates of service, admission/discharge dates, service
units, diagnosis, total charges, non-covered charges, Co-Pay, third party payment)
NYS prescription serial number on all pharmacy claims
Adjudication information (e.g., edit information, pricing, adjudication codes, pend tracking information)
Adjustment and void transaction information
OM07 Process Claims
BE2.6
Section:
Page:
OPS065
Process ordered ambulatory claims submitted in the 837I Institutional claim format as a Professional claims.
OM07 Process Claims
NA
Section:
Page:
OPS066
Derive the correct reimbursement amount using the rate code and zip plus 4 information from the claim. In cases where
the rate code and zip plus 4 combination is not found, the correct reimbursement amount is derived based on the lowest
payment amount for that rate code.
OM07 Process Claims
NA
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.
OM07 Process Claims
NA
OPS068
Adjust pricing based upon Department business rules including but not limited to discount rates or markup rates.
OM07 Process Claims
NA
OPS069
Use and apply pricing methodologies for Over the Counter (OTC) drugs based on Department business rules.
OM07 Process Claims
NA
OPS070
Provide the capability to price the claim from a prior approval/prior authorization (e.g., an excess pay situation,
item/service not available in the area for the maximum price on file, or there is prior approval/prior authorization required
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.
OM07 Process Claims
NA
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
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
Section:
Page:
OPS072
Use a variety of pricing factors within Department approved pricing methodologies. 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. 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, and immunization administration
Brand and generic indicators
Drugs grouped by generic code, therapeutic class, NDC or other code sets determined by the Department
Pharmacy Program (e.g. HIV)
Program type or plan type
Provider attributes
Member attributes
Other pricing factors as determined by the Department
OM07 Process Claims
CA2.28, PM1.15
Section:
Page:
OPS073
Determine the price for pharmacy supply claims based on the procedure code and the General Fee schedule as specified by
OM07 Process Claims
NA
OPS074
Price claims based on pricing information and reimbursement methodologies applicable for the claim's date of service.
OM07 Process Claims
NA
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OPS075
Apply a variety of claims pricing methodologies for pharmacy supply claims. Pricing factors and methodology shall be
reviewed and approved by the Department
OM07 Process Claims
NA
OPS076
Accept or reject claim attachments based on standards established by the Department.
OM07 Process Claims
NA
OPS077
Provide the capability to promptly retrieve, view, and print claim attachments.
OM07 Process Claims
NA
OPS078
Generate electronic receipt notifications that contain claim attachment information as specified by the Department.
OM07 Process Claims
NA
OPS079
Accept and process all paper and electronic Medicare crossovers for Medicare Part A, B, C and D services in accordance
with State and HIPAA requirements.
OM07 Process Claims
CR2.3
OPS080
Perform adjustments to original and adjusted claims and maintain records of all previous processing.
OM07 Process Claims
NA
OPS081
Update provider payment history and recipient claims history with all appropriate financial records and reflect adjustments
in subsequent reporting, including claim-specific and non-claim-specific recoveries.
OM07 Process Claims
PM3.7
Section:
Page:
OPS082
Allow the disposition of edits to be easily changed to pay, to suspend to a specific location, suspend to the provider/state
staff for correction, deny, recycle, and report on the Remittance Advice/835 with a remittance remark and or adjustment
reason code. All changes to edits must be reviewed and approved by NYS.
OM07 Process Claims
BE1.11, POS2.6,
POS2.7, POS2.8
Section:
Page:
OPS083
Support transition to allow electronic claim submission by providers and tribal nations for the AIHP and the Cystic
Fibrosis Program.
OM07 Process Claims
NA
OPS084
Transmit records of adjustments, recoupment, and reprocessing to the MDW identifying the claim effected and changes
including recoupment amounts
OM07 Process Claims
NA
OPS085
Provide across program standard editing and maintain separate edits specific to the Cystic Fibrosis Program, AHIP, and
Medicaid Program
OM07 Process Claims
NA
OPS086
Accept and transmit 834 transactions with the New York Health Benefit Exchange when operational.
OM07 Process Claims
ME1.15
OPS087
Provide the capability to assign a unique control number to each claim for tracking and monitoring purposes.
OM07 Process Claims
CR1.2
OPS088
Accept, enforce data validity standards, process, and respond to electronic claims transactions received in HIPAA standard
formats including:
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, when applicable
Future claims attachments
OM07 Process Claims
CR3.1
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
CMS 1500
ADA Dental Claim Form
CMS UB-04
Capture information contained on those forms based on Department business rules.
OM07 Process Claims
CR1.3, CR1.4, CR1.5
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.
OM07 Process Claims
PR4.2
OPS091
Process NCPDP claims from providers participating in NYS medication coverage programs where the providers are
enrolled only with a proprietary Provider Identifier.
OM07 Process Claims
NA
OPS092
Reject pharmacy claims exceeding limits (i.e., number of refills, days from date written) established by the Department.
OM07 Process Claims
NA
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, DUR overrides, excess income/spenddown override, and skilled
nursing facility override based on Department business rules. (Overrides allow a previously rejected claim to be approved
for payment via POS submission)
OM07 Process Claims
NA
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OPS094
Provide the option of issuing rejections or warnings for conflicts detected by Prospective Drug Utilization Review
(ProDUR) edits, depending on the conflict and/or its severity based on Department business rules.
OM07 Process Claims
NA
Section:
Page:
OPS095
Support consistent and accurate application of the programs mandatory generic provisions.
OM07 Process Claims
NA
Section:
Page:
OPS096
Distinguish between A-rated generic drugs and authorized generic drugs requiring generic substitution, A rated generics
not requiring substitution including but not limited to NTI drugs and non-A rated generic drugs.
OM07 Process Claims
NA
Section:
Page:
OPS097
Provide the capability for providers to enter and submit claims and supporting materials; track claim status and review
claims adjudication information.
OM07 Process Claims
CR3.2, PM2.6
Section:
Page:
OPS098
Apply program specific edits to claim information for all NYS benefit programs based on Department business rules for
data presence, validity (including for prior authorization, TPL coverage prior to payment, cost share of premium or
enrollment fees, if service is covered, if date of service fall within coverage period, if alternate pricing prior to payment) ,
inter-field relationships, and completeness. Hierarchically assigns status and disposition of claims that fail edits. Suspend
claims with exceptions/errors and routes for correction to the organizational entity that will resolve the exception/error.
Errors returned must be clearly identified to facilitate correction by user.
OM07 Process Claims
BE1.11, WA4.6,
WA4.7, WA4.8,
CA1.10, CA1.12,
CA1.2, CA2.1,
CA2.13, CA2.2,
CA2.3, CA2.4, CA2.5,
CA2.8, CA2.9, TP2.1,
POS2.11, POS2.12,
POS5.3
Section:
Page:
OPS099
Provide the capability to electronically associate images of paper claims with electronic claim information.
OM07 Process Claims
NA
Section:
Page:
OPS100
Process adjustments to reflect all claim information including but not limited to:
Document claims header
Line
Procedures
Diagnoses
OM07 Process Claims
NA
Section:
Page:
OPS101
Provide document level processing with a disposition determination for every line. For Professional and Dental claims, if
any line on a claim pends, the entire document must be pended. Combinations of lines which pay or deny do not affect the Operations Management
disposition of the document.
OM07 Process Claims
NA
Section:
Page:
OPS102
Provide the capability to selectively apply edits based on Department business rules including but not limited to:
Major program code (e.g., waiver program)
Claim transaction
Media type
Claim type
Entity or provider level
OM07 Process Claims
CA4.10
Section:
Page:
OPS103
Provide the capability to use the prescriber specialty for pharmacy edits.
OM07 Process Claims
NA
OPS104
Derive the edit payment status (pay, deny/reject, pend) for each edit failure based on the date of service claim type, media
type and Department business rules.
OM07 Process Claims
NA
OPS105
Edit claim transactions based on Department business rules for member restrictions, exceptions and exemptions.
OM07 Process Claims
NA
OPS106
Edit claim transactions and perform alternate pricing based on Department business rules for TPL information.
OM07 Process Claims
NA
OPS107
Edit claim transactions based on Department business rules for the association between the billing and the servicing
providers.
OM07 Process Claims
NA
OPS108
Edit claim transactions based on Department business rules for limiting services by procedure to specific providers. (e.g.
breast cancer surgery)
OM07 Process Claims
NA
OPS109
Edit claim transactions based on Department business rules for ordering, prescribing, rendering, and/or referring provider
information.
OM07 Process Claims
NA
OPS110
Edit pharmacy claim transactions based on Department business rules (e.g., number of refills, days from date written).
OM07 Process Claims
NA
OPS111
Perform ProDUR edits and identify contra-indications and potential adverse events that may be associated with dispensing
the drug prescribed.
OM07 Process Claims
NA
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OPS112
Perform ProDUR edits on compound drug ingredients according to Department business rules.
OM07 Process Claims
NA
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. The solution, including the use of
commercially available packages, must easily adapt to changing edit requirements and be designed to enforce edits based
on a variety of combinations of parameters including but not limited to: frequency, quantity and duration of therapy for
selected drugs or drug classes; and diagnostic, medical and member data.
OM07 Process Claims
NA
Section:
Page:
OPS114
Reject transactions that do not meet minimum standards based upon Department business rules. (e.g. billing provider NPI
unknown)
OM07 Process Claims
NA
Section:
Page:
OPS115
Resolve and/or make pricing determinations, as well as clinical and administrative resolutions, for claims pended for edit
failures for adjudication in accordance with Department business rules and procedures.
OM07 Process Claims
NA
Section:
Page:
OPS116
Reprocess resolved pended claims through all edits for adjudication.
OM07 Process Claims
NA
Section:
Page:
OPS117
Provide the capability to price claims at both the document and line levels. This includes the ability to pay for lines
determined to be payable and not paying for lines that have been denied.
OM07 Process Claims
NA
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
OM07 Process Claims
BE2.5, CA2.29,
CA2.30, TP2.12,
TP2.3, POS2.20,
POS2.21
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
OM07 Process Claims
NA
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, edits for concurrent program enrollment and provider specific data.
OM07 Process Claims
CA2.34
Section:
Page:
OPS121
Provide the capability to adjust pricing based on Department business rules for the grouping of procedures performed
(e.g., surgical procedures subject to, or exempt from, multiple surgery reimbursement cutbacks).
OM07 Process Claims
NA
Section:
Page:
OPS122
Provide the capability to pay only the designated federal share for specific claims based on Department business rules.
OM07 Process Claims
NA
OPS123
Provide the capability to manually price pended claims.
OM07 Process Claims
NA
OPS124
Provide the capability to price the claim from a prior approval/prior authorization (e.g., an excess pay situation,
item/service not available in the area for the maximum price on file, 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.
OM07 Process Claims
NA
Section:
Page:
OPS125
Provide the capability to adjust the claim payment during the Utilization Review (UR) process via the web-based
application.
OM07 Process Claims
NA
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 claims dates of service and associate them Operations Management
with the original claim. Adjustments or voids can be submitted by the provider or Department.
OM07 Process Claims
NA
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OPS127
Determine the price for professional and dental claims based on the procedure code and the General Fee, 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
OM07 Process Claims
CA2.32
OPS128
Adjust the claim document including all line items.
OM07 Process Claims
NA
OPS129
Derive the claim type and assign the appropriate claim type, category of service and specialty code (where appropriate)
based upon Department business rules.
OM07 Process Claims
NA
OPS130
Process a claim transaction which meets the minimum standards through all applicable edits. All edit failures must be
recorded and included in the response transactions to the limit allowed by the transaction.
OM07 Process Claims
NA
OPS131
Edit claim transactions based on Department business rules for member eligibility (e.g., member eligible on date of
service).
OM07 Process Claims
NA
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
OM07 Process Claims
CA2.22, CA3.1
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, frequency, units and age/sex parameters)
Drug Formulary (NDC for rebates)
Revenue Codes
Rate Codes
OM07 Process Claims
CA2.12, CA2.9,
POS2.12
OPS134
Edit claim transactions based on Department business rules for the relationship between diagnosis and procedures or drug
formulary.
OM07 Process Claims
CA2.10, CA2.11
OPS135
Edit claim transactions based on the payable status for the procedure and/or diagnosis as specified by the Department.
OM07 Process Claims
NA
OPS136
Edit claim transactions based on Department business rules for combinations of procedure codes.
OM07 Process Claims
CA2.14
OPS137
Edit claim transactions to identify those requiring manual review and/or pricing to be done by the contractor based on
OM07 Process Claims
CA2.15
OPS138
Edit claim transactions at the entity and provider group level based on Department business rules for utilization review,
duplicate or near duplicate services. Examples include:
Outpatient claim submitted for a date of service which was previously covered under an inpatient claim.
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
OM07 Process Claims
CA2.18, CA2.19,
CA2.21, POS2.14
Section:
Page:
OPS139
Edit claim transactions at the entity and provider group level based on Department business rules for Utilization Review
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
OM07 Process Claims
BE2.3, CA2.22
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.
OM07 Process Claims
NA
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OPS141
Facilitate NYPS electronic claims processing. A unique feature of NYPS is the requirement that any drug covered by the
NYPS Program that has an NYPS contracted manufacturer discount (rebate), must have the rebate amount subtracted from
the member amount due at the point of service. In order to accomplish this, the contractor must develop a process that
assures the applicable, updated rebate amount is applied at the point of sale as an added discount for the NYPS member
(in addition to the Programs brand/generic drug discount). 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, Pharmacy Claims Processing Plan Administration Manual for what is covered under NYPS). The member is
responsible to the pharmacy after all applicable discounts.
OM07 Process Claims
NA
Section:
Page:
OPS142
In accordance with NYS Public Health Law 280, reimbursement to the provider pharmacy under the New York
Prescription Saver Program shall be adjudicated and paid within two business days for any rebates, dispensing
fees and drug costs not paid by the resident eligible for such program at the point of sale.
OM07 Process Claims
POS2.15
Section:
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OPS143
Perform a pre-payment audit of NYPS claims before making payments. Manual checks are issued to a very limited
number of pharmacy providers in emergency or unusual situations.
OM07 Process Claims
NA
OPS144
Provide the capability to execute claim edits and deny claims based on State approved utilization threshold business rules
OM07 Process Claims
NA
OPS145
Provide manual override capabilities to State approved utilization threshold business rules
OM07 Process Claims
NA
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. This number must be made part of the
adjudicated claim.
OM07 Process Claims
NA
Section:
Page:
OPS147
Provide functionality where claims adjusted or voided through audit cannot be re-adjusted or re-processed by the provider
without Department approval.
OM07 Process Claims
NA
Section:
Page:
OPS148
Track all claims, assign claim status (paid, suspended, pending or denied), and provide capability to identify duplicate
claims (originals, pending, and/or adjudicating) and reject duplicates.
OM07 Process Claims
CA1.1, CA2.17
Section:
Page:
OPS149
Provide the capability to electronically associate original claims (paid, suspended, pending or denied), resubmitted claims,
and duplicate claims received by any media.
OM07 Process Claims
NA
OPS150
Provide oversight capabilities to State staff to review claim submission and claim history information.
OM07 Process Claims
NA
OPS151
Provide capability to pend claims in real-time based on specific criteria, identified by the Department, for review for
program integrity and quality assurance purposes.
OM07 Process Claims
NA
OPS152
Track provider bills, comparing cumulative bill amounts to the spenddown amount and process claims once the
spenddown has been met. Pay bills retroactively if the spenddown amount is adjusted. Modify response to providers
when eligibility is checked. For households with more than one individual, apply amount of an individual's bills toward
the spenddown of other individuals in the household. Send monthly notification to recipients of bills used to offset
spenddown.
OM07 Process Claims
NA
Section:
Page:
OPS153
Screen and address calls regarding claim adjudication, including ambulatory patient groups (APG) claims based on
information in the appropriate policy manual
OM07 Process Claims
NA
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), as adjudicated, and of all mass or individual adjustments impacting the claim.
Include the ability to validate all claims received are processed. Full claims history must be made available to the State for
use by Program Management and Program Integrity.
OM07 Process Claims
CA1.5, CA1.9, CR1.6,

CR1.7, FI2.5
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, and to retrospectively analyze the effect of new or modified edits and audits after they are implemented.
OM07 Process Claims
NA
Section:
Page:
OPS156
Develop and execute an iterative process to adjudicate and pay up to twenty four (24) months of claims in the contractors
application that were previously adjudicated and paid by the current MMIS.
OM07 Process Claims
NA
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.0 or any newer NCPDP versions implemented by the contractor. Compound claims must be
reimbursed according to the applicable plan logic and benefit design.
OM07 Process Claims
NA
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OPS158
Receive, review for completeness and process pharmacy paper claim transactions and claim attachments. Transactions
failing the completeness review must be returned to the submitter without further processing.
OM07 Process Claims
NA
Section:
Page:
OPS159
Process all pharmacy claims, including no payment claims (zero pay) through the claims processing system subject to the
EPIC and NYPS Programs pricing logic and various business rules. The claims processing system must be flexible and
capable of integrating and enforcing the various utilization review, benefit design features and cost containment
components of the current and future Program including but not limited to:
i. messaging capability in the most recent NCPDP format;
ii. editing on Medicare Part D and other insurance edits;
iii. coordination of benefits with other payers;
iv. a concurrent DUR program to aid the pharmacist at the POS; and
v. tracking and covering drugs that are covered first by the Medicare Part D plan after any Medicare Part D deductible is
met. EPIC may also cover Medicare Part D excluded drugs.
OM07 Process Claims
NA
Section:
Page:
OPS160
Identify, analyze, and correct errors that have resulted in improper claims processing (e.g., if final edit dispositions are
incorrect, incorrect loaded rate), trace to the source, reprocess as needed, and report to the Department.
OM07 Process Claims
BE1.11
Section:
Page:
OPS161
The POS shall accept ASC X12N NCPDP claims required by 45 CFR Part 162.
OM07 Process Claims
POS2.1;
OPS162
Compares the claim against member history and benefit rules to determine if the claim complies with State standards.
OM07 Process Claims
NA
OPS163
Provide the capability to receive, review for completeness, process, and apply specific edits for e-visit and tele-health
claim transactions.
OM07 Process Claims
NA
OPS164
Receive, 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.
OM07 Process Claims
NA
Section:
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OM07 Process Claims
NA
Section:
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OPS165
Receive, process, and store NYC Medicaid transportation claims from the Public Transportation Automatic
Reimbursement System (PTAR) for NYC enrollees travel expenses.
Section:
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OPS166
Accept and process updates from claims processing that draw down or decrement authorized prior authorization
services.
OM08 Authorize Service
NA
Section:
Page:
OPS167
Receive, process, and store Medicaid transportation prior authorizations for member travel expenses for Nonemergency
ambulance, ambulette, taxi and livery services. Other offline Payments billed by PTAR facilities and MMTPs do not
provide prior authorization to the MAS Contractor.
OM08 Authorize Service
NA
Section:
Page:
OPS168
Generate a remittance statement for each provider with activity in a payment cycle even if no EFT/check is generated.
OM14 Generate Remittance

Advice
FI3.4
Section:
Page:
OPS169
Generate remittance advices (RA) and transmit to providers in either electronic or hard copy form as requested by the
provider. 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. HIPAA compliant RA codes
and messages must be used for denied and paid claims. Hard copy RA's must be produced in a proprietary format

Advice
FI3.15, FI3.4, FI3.5
Section:
Page:
OPS170
Generate remittance advices by provider and Electronic Transmitter Identification Number (ETIN). For providers with
multiple ETINs, this will generate multiple remittance advice statements.

Advice
NA
Section:
Page:
OPS171
Generate a monthly member level detailed premium remittance advice file by Carrier even if no EFT/check is generated.

Advice
NA
OPS172
Generate X12 277 Health Care Claim Status Notification (version5010) transactions for all pended claims.

Advice
NA
OPS173
Support the transmission of (RA) and Health Care Claim Status Notification transactions via the following channels:
Direct Connection (e.g. VPN or leased line)
Batch Transmission (e.g. FTP and Secure FTP)
Hard copy

Advice
NA
Section:
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OPS174
Provide prompt response to inquires regarding the status of any claim through a variety of appropriate technologies, and
tracks and monitors responses to the inquiries. Processes electronic claim status request and response transactions (ASC
X12N 276/277) required by 45 CFR Part 162
OM18 Inquire Payment Status
CA1.8
Section:
Page:
OPS175
Provide the capability via the web-based application to review all information (including historical) related to a claim
Claim and adjudication information (including images for paper claims and attachments)
Adjustment and void information
Provider information (e.g. billing provider, servicing provider, ordering provider, referring provider)
Reference information
Claim information
Member information
TPL Payment Information
NA
Section:
Page:
OPS176
Provide the capability to retrieve claims information (including all supporting materials and correspondence) and produce
it in an industry standard file format (e.g. PDF) accessible through the web-based application.
NA
Section:
Page:
OPS177
Provide the capability to confirm that a prior approval/prior authorization for claimed services exists when required by
NA
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.g. VeriFone)
Direct Connection including (e.g. VPN or leased line)
Batch Transmission (e.g. FTP and Secure FTP)
Provider Area of the Web Portal
NA
Section:
Page:
OPS179
Accept and process X12 276 Claim Status Request (version 5010) responding with the X12 277 Claim Status Response
(version 5010).
NA
Section:
Page:
FI3.11, PM2.7
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, dates, cycle, method
Remittance Advice information
Imaged copies of all paper claims or RA's
Capitation payments
Other payment information identified by the Department.
OPS181
Provide the ability for authorized system users to withhold or suspend provider payments after adjudication.
OM27 Prepare Provider Payment NA
Section:
Page:
OPS182
Calculate the payment amount for the provider by accumulating reimbursement amounts during the cycle to determine the
net payment amount. If the provider has an outstanding accounts receivable balance, the amount will be applied to that
balance based on Department business rules.
Section:
Page:
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.
OM27 Prepare Provider Payment PM3.3
Section:
Page:
OPS184
Produce at least one payment cycle per week with the capability to process extra payment cycles
OPS185
Generate EFT/checks by provider and Electronic Transmitter Identification Number (ETIN).
OM27 Prepare Provider Payment FI3.6
OPS186
Provide the capability to pay specific exempt providers as a separate payment cycle when normal payments are suspended
or otherwise not processed.
OPS187
Provide the capability to hold payment for individual claims, all claims processed, or all claims for a particular provider
Section:
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OPS188
Provide the capability to pay, adjust or suspend claims payments for all categories of providers or members within
specified categories on a run-to-run basis.
OM27 Prepare Provider Payment PI3.6
OPS189
Balance the RA payment amount to the check/EFT amount and reflect any and all adjustments.
OPS190
Provide an automated payment calculation process capable of determining and creating interim or emergency payments.
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
OPS191
Provide the capability to review check/EFT balancing information (including shares information) for the payment period
via the web-based application.
OPS192
Provide the capability through the web-based application to retrieve payment information.
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. Manual checks are issued for a Operations Management
variety of reasons including accelerated payments and replacement of damaged or misplaced system checks.
OM27 Prepare Provider Payment FI4.2
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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
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.
Section:
Page:
OPS196
Produce an EFT payment file, based on approved provider EFT agreements, for each payment cycle and transmit payment
authorizations to the designated Financial Institution for payment processing. In the event holidays, where Financial
Institution are closed for business to the public, are scheduled in-between transmission of EFT payment files and EFT
disbursement of funds, EFT payment files shall be produced one day earlier to eliminate delay of Medicaid payments.
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
Section:
Page:
OPS198
Provide the capability to track and correct any unsuccessful or incorrect EFT payments.
OPS199
Maintain all data required to support premium payment processing, including Medicare and Managed Care data.
OPS200
Automatically generate letters to providers for checks that have not cleared within a period established by the Department. Operations Management
OPS201
Maintain all current and historical reference data related to claims processing and provide capability to retrieve, as needed,
archived reference data for processing of outdated claims or for duplicate claims detection.
OM28 Manage Data
RF1.6, RF1.8
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OPS202
Maintain, process updates, respond to queries and report requests, 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, Federally Qualified Health Center
(FQHC), Rural Health Clinic (RHC), Indian Health Services (IHS) and hospital inpatient and outpatient reimbursement is
to be the lower of the providers usual and customary charge, the rate established by the State, or the amount which is
allowed under the Medicaid program. Usual and customary charges are calculated from the actual charges submitted on
provider claims for Medicaid payment.
Reimbursement for prescription drugs are usually processed by either a) Federal Upper Limit (FUL) or Maximum
Allowable Cost (MAC) with some drugs; the State defined Estimated Acquisition Cost (EAC), which is defined by the
Average Wholesale Price (AWP) less 15% to 20 % plus a dispensing fee (ranging anywhere from 0.50 to several dollars);
and/or plus a provider specific dispensing fee; or b) the providers usual and customary charge, paying the lesser of these
fees.
OM28 Manage Data
RF1.1, RF1.5
OPS203
Capture, store, protect, and ensure the integrity of all data.
OM28 Manage Data
SP2.5, POS2.23
OPS204
Continually improve the quality of data and information.
OM28 Manage Data
NA
OPS205
Manage information consistently across the program.
OM28 Manage Data
NA
OPS206
Collaborate with and take direction from the State on all issues surrounding data, including data governance, data
definitions, models, and metadata.
OM28 Manage Data
NA
OPS207
Provide data governance activities that support the Department Data Governance organization in meeting its goals.
OM28 Manage Data
NA
OPS208
Generate FFS claims reporting for services furnished outside of a capitation agreement (i.e., for services carved-out of
the managed care program).
OM28 Manage Data
MC6.2
OPS209
Employ an electronic tracking mechanism to locate archived source documents or to purge source documents in
accordance with HIPAA security provisions.
OM28 Manage Data
CR3.4
OPS210
Provide the ability to identify claims input for control and balancing (hardcopy and electronic media).
OM28 Manage Data
CR1.7
OPS211
Document and produce reports on the time lapse of claims payment, flagging or otherwise noting clean claims (error free)
that are delayed over 30 days. (See 447.45 CFR for timely claims payment requirements.)
OM28 Manage Data
CA1.7
Section:
Page:
OPS212
Log each batch into an automated batch control system and coordinate with other contractors to provide batch control,
balancing and scheduling of data load cycles (e.g., eligibility files, financial payment processing).
OM28 Manage Data
CR1.11
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, but not limited to, showing increases/decreases and cumulative year-to-date figures
after each claims processing cycle.
OM28 Manage Data
PM3.4
Section:
Page:
OPS214
Provide the ability to identify, track, and report unduplicated participants enrolled in 1915C programs, other waiver
programs, Federally-assisted program participants, and other long-term care services.
OM28 Manage Data
PI2.2, WA1.1, WA1.2
Section:
Page:
OPS215
Provide flexible reporting identifying services received by members who are enrolled in selected program(s) or who have
specified diagnoses.
OM28 Manage Data
PI2.4, PI2.5
OPS216
Produce automated reports providing information that reveals potential defects in level of care and quality of service.
OM28 Manage Data
PI3.1
OPS217
Provides ability to perform analyses and produce reports responsive to requests from NYS .
OM28 Manage Data
PI3.2
OPS218
Provide the capability to produce claim detail and special reports by provider-type and Beneficiary classification (e.g.,
category of serviceCOS) and other key variables (e.g., Group Practice, Submitter, Case, etc.).
OM28 Manage Data
PI3.4
OPS219
Provide reporting flexibility to vary time periods for reporting purposes and to produce reports on daily, monthly, quarterly
basis, or other frequency specified by NYS.
OM28 Manage Data
PI3.14
OPS220
Collects and stores data needed to produce reports to assess quality and appropriateness of care furnished to participants of
the waiver program
OM28 Manage Data
WA5.4
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OPS221
Deliver, at a minimum daily, all necessary data to support the Department metadata repository.
OM28 Manage Data
NA
OPS222
Deliver, at a minimum daily, all necessary data to support the MDW.
OM28 Manage Data
NA
OPS223
Maintain all information related to payments including but not limited to:
Provider information (e.g., billing, servicing/rendering, pay to, ordering, prescribing, attending, supervising, operating)
Member information (e.g., member ID, name, address, gender, date of birth)
Service information (e.g., procedure codes, revenue code, rate codes, dates of service, admission/discharge dates, service
units, diagnosis, total charges, non-covered charges, Co-Pay, third party payment)
Reference information (e.g., procedure, diagnostic, and formulary codes (42 CFR 447)).
Adjudication information (e.g., edit information, pricing, adjudication codes, pend tracking information)
Adjustment and void transaction information
OM28 Manage Data
BE2.6, FI4.3, PM2.8
Section:
Page:
OPS224
Provide the capability to view, 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, current and historical Part B premiums, and current Operations Management
and historical Part A premiums.
OM28 Manage Data
NA
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, 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.g., number of QI-1 beneficiaries, and QI-1 premium payments)
OM28 Manage Data
NA
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.
OM28 Manage Data
NA
Section:
Page:
OPS227
Maintain audit trail of all actions performed on a client record. This includes:
Eligibility, ineligibility and retro eligibility, and associated spans.
Enrollment/Disenrollment spans and benefit package enrollment, limitations and changes
Communication and notification, including notice of benefits to members (including time/date, user/source, and reason
for notice)
Requests for copies of personal records (including time/date, source, type, and status of request)
OM28 Manage Data
BE1.10, BE1.4, BE2.7
Section:
Page:
OPS228
Develops provider, physician, and member profiles sufficient to provide specific information as to the use of covered types
of services, including prescribed drugs.
PE03 Manage Compliance

Incident Information
PI4.2
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. Produce reports of members who exceed program norms, ranked in order of severity.
PE01 Identify Utilization

Anomalies
PI2.1, PI2.3
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, abuse and excessive billing.

Anomalies
PI3.12
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.

Anomalies
PI4.1
PFM004
Perform analysis of rendering, ordering, and billing practices to generate reports of aberrant utilization and/or billing
patterns.

Anomalies
PI1.8, POS6.3
PFM005
Apply clinically approved guidelines against episodes of care to identify instances of treatment inconsistent with
guidelines.

Anomalies
PI1.9
PFM006
Generate early warning reports of high cost services and service misutilization based on current payment data to quickly
identify high volume practices.

Anomalies
PI1.10
NA
PFM007
Describe how the MMIS will initialize utilization limits annually for each member.

Anomalies
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Anomalies
NA
Section:
Page:
PE02 Establish Compliance

Incident
FI3.16, FI3.17
Section:
Page:

Incident
CA5.15
Section:
Page:
Provide research and documentation to support administrative hearings, appeals, and court cases. Participate in these
activities upon request.

Incident
NA
Section:
Page:
PFM012
Provide expert testimony to support the pursuit of indictments and convictions of providers for Medicaid fraud. State
prosecutors frequently require expert testimony about the operation of the contractor's application and the validity of the
data.

Incident
NA
Section:
Page:
PFM013
Provide support to the Special Prosecutor and testify at grand juries or trials. The contractor may have to provide
assistance at more than one trial or grand jury in a day.

Incident
NA
Section:
Page:
PFM014
Participate in all fair hearings involving members or pharmacy providers. 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. Contractor staff familiar with the facts of the Performance Management
case must attend the fair hearings. Over the last five years of program operation there have been less than five fair
hearings.

Incident
NA
Section:
Page:
PFM015
Cooperate and participate in the resolution of State Fair Hearings and Provider Disputes at the request of the State.

Incident
NA
Section:
Page:
PFM016
Track and investigate claims flagged for follow-up because of third party discrepancies.

CA1.4
Section:
Page:
PFM017
Provide the capability to monitor services for suspected abusers using a pay and report, lock-in, or some equivalent
system function that will provide reports of the claim activity for these members as scheduled or requested.

CA4.5
Section:
Page:
PFM018
Supports capability to perform focused program integrity reviews and to generate reports of all reviews undertaken.

PI3.5
Section:
Page:
PFM019
Maintains a process to apply weighting and ranking of program integrity exception report items to facilitate identification
of the highest deviators.

PI3.15
Section:
Page:
PFM020
Prepare, produce and distribute EOBs.
PE05 Prepare REOMB
NA
PFM021
Provide the capability to inquire on, add and change EOB text by EOB code.
PE05 Prepare REOMB
NA
PFM022
Provide the capability to produce EOBs and instructions in multiple language options (at a minimum, include English,
Spanish, Chinese-Cantonese, Chinese-Mandarin, and Russian)
PE05 Prepare REOMB
NA
PFM023
Produce EOBs, within 45 days of the payment of claims, to all or a sample group of the members who received services
under the plan as described in 11210, based on criteria specified via the web-based application by the Department
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
PE05 Prepare REOMB
FI1.1
PFM024
Produce a file containing EOB information for the Department.
PE05 Prepare REOMB
NA
PLN001
Analyze Medicaid program costs and trends including break-even point between Medicare and Medicaid payments to
predict impact of policy changes on programs.
Plan Management
PL01 Develop Agency Goals and

PM1.17
Objectives
PFM008
Describe how the MMIS will maintain UT information for members
PFM009
Provide the ability to conduct pre-payment program integrity reviews to identify fraud, waste, abuse, upcoding,
unnecessary services and other irregular billing or service practices. Allow for withholding of payments in cases of fraud
or willful misrepresentation and supports refunding of federal share of provider overpayments within 60 days from
discovery of an overpayment for Medicaid services.
PFM010
Generates automatic approval and denial notices to requesting and assigned providers, case managers, and Beneficiaries
for prior authorizations. Denial notices to beneficiaries include the reason for the denial and notification of the
beneficiarys right to a fair hearing.
PFM011
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PLN002
Provide all necessary support to the Department in conducting ongoing change management sessions for all organizational
Plan Management
units affected by the replacement system.

NA
Objectives
PLN003
Accommodate development of Medicare integration strategies.
Plan Management

NA
Objectives
PLN004
Adhere to all MECT Checklist requirements. Refer to: https://www.cms.gov/Research-Statistics-Data-andSystems/Computer-Data-and-Systems/MMIS/MECT.html
Plan Management
PL02 Maintain Program Policy
NA
PLN005
Develop, maintain and execute a proactive approach to managing all aspects of CMS Certification, including CMS
certification checklists, throughout the contract.
Plan Management
NA
PLN006
Develop, produce, and maintain all reporting functions, files and data elements to meet current and future federal reporting
requirements, State and federal rules and regulations, federal MMIS certification requirements, and Part 11 of the State
Plan Management
Medicaid Manual.
PI3.8, PM2.4,
POS2.23
Section:
Page:
PLN007
Ensure that the contractor's application is CMS certifiable, based on the States evaluation using the checklists in the CMS
Toolkit as of the first day of operations. The application must meet federal requirements for certification and licensure as Plan Management
prescribed in 42 and 45 CFR throughout the contract.
NA
Section:
Page:
PLN008
Ensure that the contractor's application issues EOBs in accordance with the provisions of Section 10 of P.L. 95-142, which
Plan Management
amends section 1903(a)(3) of the Social Security Act.
NA
Section:
Page:
PLN009
Ensure that the contractor's application adjudicates claims, prior authorizations, and information required for payment of
services in accordance with all provisions of 42 CFR 447 and the approved State Medicaid Plan. Changes to business
rules effecting claim adjudication shall be reviewed and approved by NYS.
Plan Management
NA
Section:
Page:
Plan Management
FR1.1, FR1.6
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, Certification Checklists, which have been allocated Plan Management
to the MDW for fulfillment.
NA
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, program growth, industry standards, and to take
advantage of new or emerging technologies identified by the contractor at no cost to the State. This requirement shall not Plan Management
include non-proprietary discretionary maintenance activities requested by the NYSs Medicaid program and deviate from
industry standards.
NA
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.
NA
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. These
enhancements will include execution of a full SDLC methodology, from requirements definition through implementation
and operational support.
Plan Management
NA
Section:
Page:
PLN015
Maintain and operate the contractor's application in full compliance with the 45 CFR Part 164, P.L. 104-191, HIPAA, and
1902(a)(7) of the Social Security Act as further interpreted in regulations at 42 CFR 431.300 to 307 including but not
limited to:
a. transaction and code set standards;
Plan Management
b. privacy and security standards; and
c. identifier standards.
The contractor must modify the MMIS to remain in compliance with HIPAA requirements related to supported transaction
sets as they are promulgated.
NA
Section:
Page:
PLN016
Provide technical support to assist providers with issues and problems processing HIPAA and proprietary transaction sets. Plan Management
NA
PLN017
Support all electronic transactions covered under HIPAA in the approved electronic format using HIPAA standard codes
and messages.
NA
PLN010
Ensure that the contractor's application captures and maintains all data necessary, provides the State and HHS (i.e. CMS
and OIG) full access to, 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, section 4753]) (DW) or upon request of the State (and thereby CMS).
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
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PLN018
Provide a solution that complies with the MITA 3.0 Security Framework.
Plan Management
NA
Section:
Page:
PLN019
The POS shall comply with the latest NCPDP standards and HIPAA requirements. The current contractor utilizes NCPDP
Plan Management
standard Version 5.1 D.0 effective 1/1/12. The contractor is required to transition to newer versions as they become
available at no additional cost to the State.
NA
Section:
Page:
PLN020
Apply the current Department program methodology for distinguishing between brand and generic drug product allowed
to pharmacy claims adjudication.
Plan Management
NA
PLN021
Facilitate administration of the NYPS Program and EPIC Program in accordance with program policy.
Plan Management
NA
PLN022
Document electronically and maintain knowledge of all applicable federal and State provider enrollment and
certification/licensure regulations.
Plan Management
NA
PLN023
The contractor must provide necessary resources to the State for certification as per the approved Federal Certification
Plan.
Plan Management
NA
PLN024
The contractor must expeditiously correct any item that CMS will not certify on a schedule to be approved by CMS and
the State.
Plan Management
NA
PLN025
Support the Medicaid Electronic Health Record Incentive Program federal initiative created by the HITECH) through
ARRA, (Pub. L. 111-5) and 42 CFR Parts 412, 413, 422 Medicare and Medicaid Programs; Electronic Health Record
Incentive Program; Final Rule
Plan Management
NA
Section:
Page:
PLN026
Provide flexibility to alter program requirements in member eligibility, claims, provider enrollment, prior approval/prior
authorization and utilization management immediately during a State of Emergency to meet urgent needs of providers and Plan Management
members, upon direction by the Department.
SP1.5
Section:
Page:
PLN027
Audit compound pharmacy claims to ensure compliance with the Programs pricing logic.
NA
Section:
Page:
PLN028
Support the assessment of health outcomes through collection, aggregation, and reporting on evolving health care quality
measures including: health home core quality measures, the core set of childrens health care quality measures, and the
core set of health care quality measures for Medicaid-eligible adults as specifications are released by CMS. The health
Plan Management
home core set will require reporting at the health home provider level, while the full Medicaid-eligible adult core set of
health care quality measures will be reported in the aggregate at the state level. CMS defined measures will be determined
through analysis of claims data, to the extent possible, and data extractions from medical records.
PL04 Manage Health Plan

Information
NA
Section:
Page:
PLN029
Provide advice and recommendations regarding the Medicaid Pharmacy program. The Department is not under any
obligation to act on such advice or recommendation.
Plan Management

Information
NA
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

Information
NA
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.e., Medicare, prescription drug mandates, etc.)
Plan Management

Information
NA
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.

Information
NA
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.

Information
NA
Section:
Page:
Plan Management
Plan Management
Section:
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PLN034
Assist with recommendations and evaluation of proposed benefit design changes and implement any changes necessary to
accommodate program modifications resulting from legislation, or within the statutory discretion of the Department.
Plan Management
Recommendations must include a preliminary analysis of all associated costs, a clinical evaluation, and the anticipated
impact of proposed program modifications and contemplated benefit design changes on members.

Information
PM1.2, PM1.20
Section:
Page:
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. Prepare data extracts of pharmacy claims history as requested by
NYS for review.
Plan Management

Information
PM4.1, POS4.2,
POS6.3
Section:
Page:
PLN036
Analyze and report to the Department aberrant utilization and prescribing patterns for prescribers, providers, and members. Plan Management

Information
PM4.3
Section:
Page:
PLN037
Establish preliminary formulary coverage parameters for new drugs based on FDA approved indications, Federal Medicaid
requirements and the pharmacy program benefit structure and obtain Department approval before activating the new
Plan Management
drugs. Coverage parameters include but are not limited to quantity, frequency and duration limits and age/gender
restrictions.

Information
NA
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, fluctuating drug prices, and other conditions established by the Department such as regional
shortages.
Plan Management

Information
NA
Section:
Page:
PLN039
Analyze and report actual cost savings that result from SMAC pricing periodically, as defined by the Department.
Plan Management

Information
NA
PLN040
Develop information to assist providers and members in understanding all Pharmacy Management Programs.
Plan Management

Information
NA
PLN041
Develop letters and educational materials in order to promote the acceptance of the Preferred Drug Program, the
Mandatory Generic Program and the Clinical Drug Review Program.
Plan Management

Information
NA
PLN042
Manage and regularly review the formulary to ensure its accuracy.
Plan Management

Information
NA
PLN043
Administer the Preferred Drug Program (PDP) aimed at selected therapeutic classes or new product introductions,
including operation of a prior approval/prior authorization function for drugs.
Plan Management

Information
NA
PLN044
Develop clinical evaluations of relative clinical effectiveness based on thorough evidence-based pharmaceutical reviews
of current literature.
Plan Management

Information
NA
PLN045
Recommend and advise on the management of drugs/classes based on market analysis.
Plan Management

Information
NA
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.

Information
NA
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

Information
NA
Section:
Page:
PLN048
Develop educational materials to be used to encourage PDP compliance by providers, prescribers, and members.
Plan Management

Information
NA
Section:
Page:
PLN049
Design and implement targeted educational interventions aimed at changing prescribing patterns of outlier prescribers,
including but not limited to: mailings, electronic messages, face to face meetings with prescribers and other direct
interaction with prescribers.
Plan Management

Information
NA
Section:
Page:
PLN050
Recommend and advise on the management of drugs/classes that meet legislative criteria for the CDRP.
Plan Management

Information
NA
Section:
Page:
PLN051
Prepare and present recommendations regarding selected drugs/classes based on clinical evaluations and utilization/market
Plan Management
analysis to ensure the highest overall effectiveness of the CDRP program.

Information
NA
Section:
Page:
PLN052
Plan Management

Information
NA
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.
Plan Management

Information
NA
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Page:
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PLN054
Monitor the pharmaceutical industry to identify generic drugs expected to enter the market. Prior to the actual
introduction of the generic drug to market, 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.

Information
NA
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. The Department must determine how the program's mandatory generic
substitution provisions will be applied.

Information
NA
Section:
Page:
PLN056
Notify the Department regarding drugs that will result in a lower net cost to the program by enforcing mandatory generic
substitution, and with Department approval, 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.
Plan Management

Information
NA
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. The Department, in its sole discretion, 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. In
Plan Management
the event the Department decides to exercise its discretion not to enforce mandatory generic substitution, the contractor
shall apply SMAC pricing to the generic drug when dispensed, along with other pricing rules (such as lesser of logic), as
determined by the Department.

Information
NA
Section:
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PLN058
Assist the Department in determining whether or not mandatory generic substitution should be enforced, 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. 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. The Department, in its sole discretion, shall
determine based on such evidence how the programs mandatory generic substitution provisions will be applied. The
contractor will not consider and shall not act on availability information provided by 3rd party sources, including but not
limited to Medi-Span and First Data Bank.

Information
NA
Section:
Page:
PLN059
Plan Management

Information
NA
Section:
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PLN060
Review Medicaid program and financial results and make recommendations for program improvements.
Plan Management

Information
NA
PLN061
Perform administration of the Preferred Diabetic Supply Program (PDSP).
Plan Management

Information
NA
PLN062
Internally track performance and continuously investigate and present ways to improve contractor performance under the
contract.
Plan Management
PL05 Manage Performance

Measures
NA
PLN063
Submit a Quality Management Plan to the Department for approval within at least thirty (30) days of contract execution.
The Quality Management Plan shall be updated annually thereafter, and shall be submitted each year to the Department for Plan Management
approval.

Measures
NA
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PLN064
Perform regular and ongoing State-approved Quality Assurance (QA) reviews of operations. These procedures shall be
conducted, at a minimum, on a monthly basis.
Plan Management

Measures
PM5.1
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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, client eligibility for dates of service, etc.
System edits and audits for posting accuracy
Service authorizations for appropriateness and accuracy
Database and file updates to ensure timeliness and accuracy (i.e., eligibility, provider, reference, etc.)
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

Measures
NA
Section:
Page:
PLN066
Develop and implement corrective action plans, approved by the Department, based upon the findings made by the
Department, CMS, OSC, and the QA contractor.
Plan Management

Measures
NA
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PLN067
Provide State staff access to the quality management tool(s) used by contractor staff and the ability to produce reports.
Plan Management

Measures
NA
PLN068
Review manual, clerical, and operating procedures annually for setting accuracy and error levels and for monitoring
compliance. Report the findings from this review to the Department.
Plan Management

Measures
NA
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, quality, and structure of data in the source systems as an on-going process
Provide the data profiling metrics such as completeness, consistency, conformity, integrity, duplication, and accuracy in
easy-to-understand reports, charts, graphs, etc.
Continually measure and monitor the data quality within the MAS
Include audit and control processes that will identify, report, 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

Measures
CA2.2, CA2.3, CA2.4,

CA2.5
PLN070
Measure and report monthly performance against the Service Level Agreements (SLA) in this RFP.
Plan Management

Measures
POS2.6, POS2.7,
POS2.8
PLN071
Measure and report monthly performance against the PMP.
Plan Management

Measures
NA
PLN072
Develop a weekly status report to provide the State with an update on the progress towards achieving goals stated in the
work plan, activities by work stream, and a summary of project risks and issues. This template shall be submitted to the
State within 30 calendar days of contract award.
Plan Management

Measures
NA
Section:
Page:
PLN073
Provide monthly status reports which provide a brief summary of weekly reports and SLA performance metrics.
Plan Management

Measures
NA
Section:
Page:
PLN074
On an ongoing basis, monitor and improve:

System performance
Database performance
Network performance
Development time through the use of tools, user and programmer training, process improvements and the COTS
business rules engine
System ease of use
Training programs
Data quality
Testing processes and procedures
Plan Management

Measures
NA
Section:
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PLN075
Produce all reports necessary to oversee the MAS contract, maintain comprehensive list of standard PM reports, their
intended use, and a list of users of each standard PM report, and monitor contractor compliance with service level
agreements
Plan Management

Measures
PM5, PM5.2, PM5.3
Section:
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PLN076
Generate data for federally mandated reports for review of the State including data extract formats required for the MDW
Plan Management
(e.g. CSV and XML) to generate MDW report distribution and/or other data archiving.

Measures
PM5
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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

Measures
PM1.9
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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.
Plan Management

Measures
NA
Section:
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PLN079
Provide the capability to extract and distribute full and/or incremental datasets from the contractor's application in an
industry standard format (e.g. CSV, XML, flat files, table unloads).
Plan Management

Measures
NA
Section:
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PLN080
Research and respond to questions or issues raised by the Department or external organizations related to information in
any data extract.
Plan Management

Measures
NA
PLN081
Provide the capability to publish (push) the data to a destination where the data consumer can then retrieve (pull) the
data.
Plan Management

Measures
NA
PLN082
Provide the capability to trace and monitor the batch processes by including audit and control, error/exception handling,
balancing, and operational statistics.
Plan Management

Measures
NA
PLN083
Provide the capability to identify, correct, and report data quality/defect issues including data redundancy, incorrect values,
Plan Management
missing values, and inconsistent values of the data sources and to continually monitor the quality of the data extracted.

Measures
BE1.11
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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

Measures
RF1.7
Section:
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PLN085
Disclose all deficiencies found by the contractor within no more than one (1) business day to the Department.
Plan Management

Measures
NA
Section:
Page:
PLN086
Conduct walkthroughs and document results from the contractor executed System Testing. 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. Additional
Plan Management
documentation and related materials requested by the Department shall be provided no later than twenty-four (24) hours
after the request.

Measures
BE1.11
Section:
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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, overall Expenditures and expenditures by Plan Management
service type, Diagnoses, trending, and utilization. Provide the Department with ad hoc reporting capability,

Measures
NA
Section:
Page:
PLN088
Propose any best practices from other clients or existing operations to improve the quality, medical cost, and/or access
for State of NY Medicaid population at no additional administrative cost. These provisions will be evaluated by the
Department and included, as appropriate, in the final contract.
Plan Management

Measures
NA
Section:
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PLN089
Describe innovations that can be provided by the contractors system, irrespective of other requirements in Attachment E,
which might enhance the efficiencies, cost savings and quality improvements of the State Medicaid program. These must Plan Management
be available at no additional cost should the Department choose to take advantage of them.

Measures
NA
NA Unscored
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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. The contractor shall submit a plan to the Department
for establishment of these committees within 90 days of contract award.
Plan Management

Measures
NA
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PLN091
The contractor may be required to submit weekly, biweekly, monthly and quarterly operating statistics reports to the State
which provide summary information on all aspects of the contractor operations. The reports must summarize the
Plan Management
significant outcomes of each of the functional areas of responsibility such as claims processing, timely payment (timely
processing of provider claims 42 CFR 447.45) enrollment, tax match, call center, etc. The contractor must seek state staff
input for required data and format these reports in a State approved format.

Measures
PM2.2
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PLN092
Receive, process and submit to the MDW for analysis, quality and process measures from Lead Health Homes

Measures
NA
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Plan Management
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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, but not limited to, fiscal activities, participation metrics and projection.

Measures
NA
Section:
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PLN094
Provide online access to all reference tables with inquiry by the appropriate code. Maintain and display an audit trail of all
Plan Management
information changes, including errors in changes and suspended changes.
PL07 Manage Reference

Information
RF1.10, RF1.9
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PLN095
Manages and Maintains all data sets defined by the HIPAA Implementation Guides to support all transactions required
under HIPAA Administrative Simplification Rule (e.g., Gender, Reason Code) and HIPAA-required external data sets
(e.g., ICD-9; NDC).
Plan Management

Information
RF2.1, RF2.2
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PLN096
Supports code sets for the payment of Medicaid-covered non-health care services, (e.g. waiver services).
Plan Management

Information
RF1.14
PLN097
Update all procedure, diagnosis and drug reference files prior to each payment cycle when required.
Plan Management

Information
NA
PLN098
Provide and maintain, for each error code, a resolution code, an override, force or deny indicator, and the date that the
error was resolved, forced, or denied.
Plan Management

Information
CA1.14
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.
Plan Management

Information
NA
NA
PLN100
Support the receipt and processing of DRG Code Interface, E-APG grouper and other grouper files.
Plan Management

Information
PLN101
Support the receipt and processing of Medicare physician fees for Primary Care Payment Bump, CMS HCPCS update
files following the state's process and other procedure code files and the Mandate Lab Update file. Also will need to
process update requests from the state as needed.
Plan Management

Information
NA
PLN102
Support the receipt and processing of Health Professional Shortage Areas files.
Plan Management

Information
NA
PLN103
Support the receipt and processing of revenue code information from the National Uniform Billing Committee (NUBC)
files.
Plan Management

Information
NA
NA
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PLN104
Support the receipt and processing of all other benefit/reference files.
Plan Management

Information
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

Information
NA
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Page:
PLN106
Update the SMAC list and make corresponding updates to the drug formulary for pricing claims on a schedule determined
by the Department. For example, these updates would include SMAC prices for new products; 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.

Information
POS2.9
Section:
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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.

Information
NA
Section:
Page:
Plan Management
PLN108
Maintain, process, update, archive, 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,
Resource Utilization Groups (RUG)
Remittance Text
Drug Group Plan
Provider Rate Code and Price
Coverage status and pricing information on legend drugs, OTC items, 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
Plan Management

Information
RF1.12, RF1.13,
RF1.15, RF1.16,
RF1.17, RF1.18,
RF1.3, RF1.4, RF1.8,
PM2.9
PLN109
Provide the capability to inquire on, add and change Diagnosis Code information via the web-based application.
Plan Management

Information
NA
PLN110
Provide the capability to inquire on, add and change ICD-9 & ICD-10 Procedure Code information on the reference
registry via the web-based application.
Plan Management

Information
NA
PLN111
Support Medicaid provider and partners throughout the ICD-10 transition including testing of files making the transition
to ICD-10.
Plan Management

Information
NA
PLN112
Maintain grouper processes to support claims processing and pricing including but not limited to:
AP-DRG
APR-DRG
E-APG
Plan Management

Information
NA
PLN113
Accept and process at a frequency specified by the Department proprietary formats and industry standard formats (e.g.
excel spreadsheets) as specified by the Department.
Plan Management

Information
NA
PLN114
Accept and process the Bureau of Narcotics Enforcement (BNE) Prescription Serial Number Interface File.
Plan Management

Information
NA
PLN115
Provide the capability to inquire on, add and change Prescription Serial Number information via the web-based
application.
Plan Management

Information
NA
PLN116
Accept and process the quarterly and annual Healthcare Common Procedure Coding System (HCPCS) Update files
received from CMS.
Plan Management

Information
PM1.15
NA
PLN117
Accept and process the CMS Mandate Lab Update File.
Plan Management

Information
PLN118
Provide the capability to inquire on, add, delete and change via the web-based application Procedure Code information as
Plan Management

Information
NA
PLN119
Provide capability to inquire on, add, delete and change price information via the web-based application, including but not
Plan Management
limited to procedure pricing.

Information
NA
PLN120
Accept and process the Health Professional Shortage Areas (HPSA) file.
Plan Management

Information
NA
NA
NA
PLN121
Provide the capability to inquire on, add and change HPSA information via the web-based application.
Plan Management

Information
PLN122
Accept and process revenue code information from the National Uniform Billing Committee (NUBC).
Plan Management

Information
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PLN123
Provide the capability to inquire on, 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

Information
RF1.11
Section:
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PLN124
Provide capability to inquire on, add, delete and change price information via the web-based application, including but not
Plan Management
limited to revenue code pricing.

Information
NA
Section:
Page:
PLN125
Provide the capability to inquire on, 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

Information
NA
Section:
Page:
PLN126
Provide the capability to enter and maintain text notes associated with claim edit status information.
Plan Management

Information
NA
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.

Information
NA
PLN128
Provide the capability to develop new ProDUR edits and modify existing contractor-supplied ProDUR edits based on userPlan Management
defined configurable criteria.

Information
NA
PLN129
Maintain all current and historical reference information related to medical limit and step therapy editing for pharmacy
claims.
Plan Management

Information
NA
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.
Plan Management

Information
NA
PLN131
Update medical limit and step therapy edits with the most current parameters as updates for these parameters become
available.
Plan Management

Information
NA
PLN132
Provide the capability to inquire on, add and change via the web-based application date specific medical limit and step
therapy edit information within the Reference registry.
Plan Management

Information
NA
PLN133
Provide the capability to inquire on, add, 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
Plan Management

Information
NA
PLN134
Incorporate prior approval/prior authorization review criteria and written guidelines for prior approval/prior authorization
Plan Management
request processing as approved by the Department.

Information
NA
PLN135
Provide the capability to enter and maintain text notes associated with prior approval/prior authorization edit status
information.
Plan Management

Information
NA
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, NDC, and GPI.
Plan Management

Information
NA
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, CDRP, and Mandatory Generic Program) or
age/gender edit override.
Plan Management

Information
NA
PLN138
Maintain a drug formulary, in accordance with Department business rules, to support pharmacy drug claim adjudication,
pricing and other MMIS functions.
Plan Management

Information
NA
PLN139
Accept and process files to update drug formulary information in the Reference registry as required by the Department.
Plan Management

Information
NA
PLN140
Process the SMAC update file containing drug Generic Code Number Sequence Numbers, begin date and SMAC price
amount.
Plan Management

Information
NA
PLN141
Provide the capability to inquire on and change Drug information including but not limited to:
Drug Mass Change
DUR Filter
Plan Management

Information
NA
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

Information
NA
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PLN143
Provide the capability via the web-based application to search and inquire on historical and date/time-sensitive drug
formulary information.
Plan Management

Information
NA
PLN144
Maintain drug formulary data necessary to identify reused NDCs and provide historical access to their former formulas,
characteristics and pricing.
Plan Management

Information
NA
PLN145
Identify brand and generic drugs consistent with the Department's methodology.
Plan Management

Information
NA
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

Information
NA
Section:
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PLN147
Maintain drug coverage and/or limitations specified at various levels, (i.e., NDC, GSN, therapeutic class) that may vary by
population or plan and their effective dates. Drug coverage and limitations include, 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, i.e., units, dollar amount, days supply
Plan Management
Limits over time, i.e., units, dollar amount, days supply, 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

Information
NA
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Page:
PLN148
Update the drug formulary on a Department approved schedule that ensures pharmacy claims are paid according to the
most current drug data available.
Plan Management

Information
NA
Section:
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PLN149
Provide the capability to accept and process drug data from multiple contractors, including but not limited to First Data
Bank, Medispan, and Micromedex. One drug data contractor may be the primary source of drug data within the MAS,
while other contractors may be the source of specialized or proprietary drug data.
Plan Management

Information
NA
Section:
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PLN150
Maintain unlimited historical pricing segments, unrestricted by the limitations of the pricing data source (i.e., if drug
pricing source stores 10 occurrences of AWP price, 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).

Information
NA
Section:
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PLN151
Maintain listings of drugs that are specific to pharmacy management programs, 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.
Plan Management

Information
NA
Section:
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PLN152
Provide the capability to publish current formulary information, on a timetable determined by the Department, via the Web
Plan Management
Portal in formats approved by the Department.

Information
NA
PLN153
Maintain a record of the related benefit package for each claim.
Plan Management

Information
NA
PLN154
Maintain the benefit package associated with each program and recommend changes due to the release of New codes or
services.
Plan Management

Information
NA
PLN155
Create benefit packages for programs under the contract as specified by the State.
Plan Management

Information
NA
Plan Management

Information
NA
PLN156
Accept claims for recipients determined eligible by the Tribal nations approved to submit AIHP claims
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PLN157
Successfully implement program changes passed by the State, including participating in any pilot or demonstration
programs for the FFS population, in a timeframe negotiated and approved by the Department.
Plan Management

Information
NA
Section:
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PLN158
Maintain and update, based on a Department approved schedule, a drug formulary file to support pharmacy drug claim
adjudication and the Programs defined pricing, and ensure that pharmacy claims are reimbursed according to the most
current drug data available
Plan Management

Information
NA
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PLN159
A nationally recognized drug database source, (e.g. Medi-Span, etc.) must be utilized for formulary maintenance. Read
only on-line access to the formulary file data must be made available to staff at the State designated location. An update
of the drug formulary file must be performed at a minimum, weekly to disallow coverage for drugs excluded due to
changes in Drug Efficacy Study Implementation (DESI) status.
Plan Management

Information
NA
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PLN160
Maintain drug pricing data necessary to support Program pricing methodology, 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, unavailable and/or NYS
legislation changes the basis of reimbursement from AWP to an alternative benchmark. In the event the statutorily
mandated methodology of reimbursement changes during the term of the agreement, or other significant changes occur
affecting reimbursement, 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

Information
NA
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PLN161
Support all channels approved by the Department for provider rate setting transactions including, but not limited to,
emailing an excel file.
Plan Management
PL08 Manage Rate Setting
NA
PLN162
Accept and process provider rate setting transactions in industry standard formats
Plan Management
NA
PLN163
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
Plan Management
NA
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Plan Management
POS2.15
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PLN164
Provide the capability to manage various rate based reimbursement methodologies, including but not limited to:
Inpatient (DRG/Day)
Outpatient & Clinics (APG/Visit)
Nursing Homes
Managed Care Plans
Location-based reimbursement (institution/region)
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PLN165
Process provider rate transactions batches received from rate setting agencies. The transactions must be edited based on
business rules and held for review and final approval through the web-based application.
Plan Management
NA
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Page:
PLN166
Review batches and delete, modify, approve or reject individual records via the web-based application. Batches must be
approved to be added to the provider rate registry.
Plan Management
NA
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PLN167
Provide the capability to search, view, enter, and update provider rate information via the web-based application. New and
Plan Management
updated transactions must be edited based on Department business rules.
NA
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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
NA
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Plan Management
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.
Plan Management
NA
PRV001
Support the State assess of adequacy of the NYS FFS provider network. This includes identifying and collecting data on
the number and types of providers and provider locations.
Provider Management
PM01 Manage Provider

Information
NA
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

Information
PI1.1
PI1.2
PRV003
Identifies deficiencies and generates reports on levels of care and quality of care by provider type.
Provider Management

Information
PRV004
Analyze and produce reports on the details of the practice of providers identified as exceptions or outliers.
Provider Management

Information
PI1.3
PI1.4
PRV005
Provide the capability to profile provider groups and individual providers within group practices.
Provider Management

Information
PRV006
Automatically identify exceptions to norms of practice established by the agency for any type of provider covered by the
State plan.
Provider Management

Information
PI1.5
PI1.6
Section:
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PRV007
Displays all data by NPI or by a subset of the providers practice.
Provider Management

Information
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.
Provider Management

Information
WA5.5, PM3.2
Section:
Page:
PRV009
Requires (when appropriate), accepts the NPI in all standard electronic transactions mandated under HIPAA, and
maintains the 10-digit National Provider Identifier.
Provider Management

Information
PR4.1, PR4.2
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. 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. Flags and routes for action
if multiple internal State assigned provider numbers are assigned to a single provider.

Information
PR1.4, PR1.5, PR4.3,

PR4.4
Section:
Page:
PRV011
Provide the ability to manage relationships to other Medicaid provider IDs for the same provider (e.g., multiple provider
roles, numbers used before the NPI was established, erroneously issued prior numbers, multiple NPIs for different
subparts). Captures/crosswalks subpart NPIs used by Medicare (but not Medicaid) to facilitate coordination of claims
processing.
Provider Management

Information
PR4.5
Section:
Page:
PRV012
Maintain indicators to identify providers that are FFS, MCO network only, waivers, and other State health care program
participants.
Provider Management

Information
PR3.10
Section:
Page:
PRV013
Use consistent provider naming conventions to differentiate between first names, last names, and business or corporate
names and to allow flexible searches based on the provider name, allowing last name, first name, middle name, initial,
credentials, and degrees (for example) to be divided into separate fields.
Provider Management

Information
PR1.12
Section:
Page:
PRV014
Record the provider termination and/or denial reason/explanation, as determined by Department business rules, with a
searchable reason and explanation.
Provider Management

Information
WA2.4
Section:
Page:
PRV015
Process and maintain all data from provider credit, history of claim recovery, and adjustment transactions. Facilitate
distribution / collection to or from the appropriate parties, including providers, members, or insurers.
Provider Management

Information
FI2.7, FI3.2
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.
Provider Management

Information
PM1.16
Section:
Page:
PRV017
Conduct provider training sessions each year and tailor these sessions to the needs of the new provider as well as providers
Provider Management
that are experienced in billing for Medicaid services. Sessions must also be tailored to provider type. Contractor staff
must provide on-site assistance to a provider whenever requested.

Information
NA
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, EFT, Web Portal user, and data exchange agreement transactions
Other transactions identified by the Department

Information
NA
Section:
Page:
Provider Management
PRV019
Image; edit; OCR and/or data enter; verify; index and route for processing:
Hard copy enrollment applications; and supporting documents
Hard copy and fax disenrollment requests
Hard copy and fax provider information maintenance requests
Provider Management

Information
NA
Section:
Page:
PRV020
Provide imaging services for all existing hard copy provider enrollment files within 24 months of the implementation.
Imaging services include the electronic association of the document to the appropriate provider, member and/or
transaction.
Provider Management

Information
NA
Section:
Page:
PRV021
Accept and capture provider maintenance updates and supporting materials via hard copy, fax, or Web Portal. Track and
control reconciliation of errors in transactions that are intended to update provider information.
Provider Management

Information
PR3.1, PR3.3
Section:
Page:
PRV022
Maintain provider data with date specific history as required by Department business rules including but not limited to :
NPI, demographic data, ownership, authorized submitter, multiple provider specific reimbursement rates with begin and
end dates, current and historical multiple address capabilities for providers, certification numbers (e.g. Drug Enforcement Provider Management
Administration (DEA) numbers, Clinical Laboratory Improvement Amendments (CLIA) certification, etc.), and specific
procedures each provider is authorized to cover.

Information
PR1.8, PR2.4, PR2.7,

PR3.4, PR3.6
Section:
Page:
PRV023
Maintain facility data with date specific history as required by Department business rules.
Provider Management

Information
NA
PRV024
Maintain Public Goods Pool data with date specific history as required by Department business rules.
Provider Management

Information
NA
PRV025
Provide the capability to review provider information maintenance requests and all supporting materials; verify credentials
available through electronic interfaces or using information available from the MAS; send email or letter requesting
Provider Management
information to the applicant; and update information based on policies established by the Department via the web-based
application.

Information
PR3.1
Section:
Page:
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, x-ray-facilities, 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.
Provider Management

Information
PR3.8
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.
Provider Management

Information
NA
Section:
Page:
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PRV028
Receive, process and maintain information received from external sources (e.g., NYS Education Department, CLIA, CMS
Provider Management
and NPPES) related to both enrolled and unenrolled providers. Notify Department as specified by the Department.

Information
NA
Section:
Page:
PRV029
Produce and transmit extract files to external entities containing provider information in a format and at a frequency
Provider Management

Information
PR3.2
Section:
Page:
PRV030
Edit provider maintenance information based on Department business rules for data presence, validity, inter-field
relationships, and completeness. Errors returned must be clearly identified to facilitate correction by the user.
Provider Management

Information
NA
Section:
Page:
PRV031
Maintain ETIN information with date specific history as required by Department business rules.
Provider Management

Information
NA
PRV032
Provide the capability to image, index and associate hard copy and fax ETIN applications
Provider Management

Information
NA
PRV033
Edit ETIN applications entered through the provider area of the Web Portal based on Department business rules for data
presence, validity, inter-field relationships, and completeness. Errors returned must be clearly identified to facilitate
correction by the user.
Provider Management

Information
NA
Section:
Page:
PRV034
Provide the capability through the provider area of the Web Portal to modify, save and delete ETIN applications entered
prior to submission, along with the capability to review and/or print applications prior to and after submission.
Provider Management

Information
NA
Section:
Page:
PRV035
Provide the capability for applicants to check the status of ETIN application processing through the provider area of the
Web Portal.
Provider Management

Information
NA
PRV036
Review ETIN applications; note application deficiencies; send email or letter requesting information to the applicant; and
Provider Management
set application status to approve, pend, deny

Information
NA
PRV037
Maintain Web Portal user information with date specific history as required by Department business rules.
Provider Management

Information
NA
PRV038
Process Web Portal users registration for access to the secure areas of the portal based on security rules defined by the
Department.
Provider Management

Information
NA
PRV039
Edit Web Portal user applications entered on the Web Portal for data presence, validity, inter-field relationships, and
completeness. Errors returned must be clearly identified to facilitate correction by the user.
Provider Management

Information
NA
Section:
Page:
PRV040
Provide the capability to modify, save and delete Web Portal user applications entered prior to submission, along with the
Provider Management
capability to review and/or print applications prior to and after submission.

Information
NA
Section:
Page:
PRV041
Track each Web Portal user application through all the steps in the application process
Provider Management

Information
NA
PRV042
Provide the capability for applicants to check the status of Web Portal user application
Provider Management

Information
NA
PRV043
Review Web Portal user applications; note application deficiencies; send email or letter requesting information to the
applicant; and set application status to approve, pend, or deny via the web-based application.
Provider Management

Information
NA
PRV044
Maintain EFT information with date specific history
Provider Management

Information
PR3.11
PRV045
Provide the capability to image, index and associate hard copy and fax EFT applications
Provider Management

Information
NA
PRV046
Edit EFT applications entered through the Web Portal for data presence, validity, inter-field relationships, and
completeness. Errors returned must be clearly identified to facilitate correction by user.
Provider Management

Information
NA
PRV047
Provide the capability for applicants to check the status of EFT application processing through the provider area of the
Web Portal.
Provider Management

Information
NA
PRV048
Provide the capability to review and update EFT applications based on policies established by the Department via the webProvider Management
based application.

Information
NA
PRV049
Provide the capability to view, add and update EFT information as required by the Department via the web-based
application.
Provider Management

Information
NA
PRV050
Review EFT applications; note application deficiencies; send email or letter requesting information to the applicant; and
set application status to approve, pend, or deny.
Provider Management

Information
NA
PRV051
Provide the capability to transmit a test EFT to the designated Financial Institution and verify that the EFT transaction was
Provider Management
processed in accordance with Department policies and procedures.

Information
NA
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PRV052
Accept ETIN maintenance requests via hard copy, fax, and the Web Portal.
Provider Management

Information
NA
PRV053
Image, index and associate hard copy and fax ETIN maintenance requests
Provider Management

Information
NA
PRV054
Edit ETIN maintenance requests entered through the provider area of the Web Portal based on Department business rules
for data presence, validity, inter-field relationships, and completeness. Errors returned must be clearly identified to
facilitate correction by user.
Provider Management

Information
NA
Section:
Page:
PRV055
Provide the capability through the provider area of the Web Portal to modify, save and delete ETIN maintenance requests
entered prior to submission, along with the capability to review and/or print maintenance requests prior to and after
submission.
Provider Management

Information
NA
Section:
Page:
PRV056
Review and update ETIN maintenance requests based on policies established by the Department via the web-based
application.
Provider Management

Information
NA
PRV057
View, add and update ETIN information as required by the Department via the web-based application.
Provider Management

Information
NA
PRV058
Perform mass updates to ETIN information as requested by the Department.
Provider Management

Information
PR3.9
NA
PRV059
Support the annual ETIN re-certification process in accordance with Department business rules.
Provider Management

Information
PRV060
Automatically grant a grace period as specified by the Department before terminating an ETIN when it reaches the
expiration date.
Provider Management

Information
NA
NA
Section:
Page:
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PRV061
Accept Web Portal user maintenance requests via hard copy, fax, and the Web Portal.
Provider Management

Information
PRV062
Image, index and associate hard copy and fax Web Portal user maintenance requests and route for processing via the
Workflow Management System.
Provider Management

Information
NA
PRV063
Edit Web Portal user maintenance requests entered through the provider area of the Web Portal based on Department
business rules for data presence, validity, inter-field relationships, and completeness. Errors returned must be clearly
identified to facilitate correction by the user.
Provider Management

Information
NA
Section:
Page:
PRV064
Provide the capability through the Web Portal to modify, save and delete Web Portal user maintenance requests entered
prior to submission, along with the capability to review and/or print maintenance requests prior to and after submission.
Provider Management

Information
NA
Section:
Page:
PRV065
Review and update Web Portal user maintenance requests based on policies established by the Department via the webbased application.
Provider Management

Information
NA
PRV066
View, add and update Web Portal user information as required by the Department via the web-based application.
Provider Management

Information
NA
PR3.9
PRV067
Perform mass updates to Web Portal user information as requested by the Department.
Provider Management

Information
PRV068
Accept and process Electronic Funds Transfer (EFT) maintenance requests via hard copy, fax, and the Web Portal.
Provider Management

Information
NA
PR3.11
Section:
Page:
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PRV069
Maintain EFT information with date specific history as required by Department business rules.
Provider Management

Information
PRV070
Image, index and associate hard copy and fax EFT maintenance requests .
Provider Management

Information
NA
PRV071
Edit EFT maintenance requests entered through the provider area of the Web Portal based on Department business rules
for data presence, validity, inter-field relationships, and completeness. Errors returned must be clearly identified to
facilitate correction by user.
Provider Management

Information
NA
Section:
Page:
PRV072
Provide the capability through the provider area of the Web Portal to modify, save and delete EFT maintenance requests
entered prior to submission, along with the capability to review and/or print maintenance requests prior to and after
submission.
Provider Management

Information
NA
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.
Provider Management

Information
PR3.11
Section:
Page:
PRV074
Review and update EFT maintenance requests based on policies established by the Department via the web-based
application.
Provider Management

Information
NA
PRV075
View, add and update EFT information as required by the Department via the web-based application.
Provider Management

Information
NA
Section:
Page:
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Page:
PRV076
Perform mass updates to EFT information as requested by the Department.
Provider Management

Information
PR3.9
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, member and/or
transaction.
Provider Management

Information
NA
Section:
Page:
PRV078
Track and support any established provider review schedule to ensure providers continue to meet program eligibility
requirements. Notify providers, in writing, that are due for recertification prior to the end date of the current license,
certification/ licensure, or provider agreement, according to business rules.
Provider Management

Information
PR2.2
Section:
Page:
PRV079
Track and support provider enrollment and ongoing provider updates for NPIs, State licenses, Specialty Board certification
Provider Management
as appropriate, review team visits when necessary, on entity or individual meeting the qualifications contained in the
provider agreement, geographic locations, capitation or FFS rates, and any other State and/or federal requirement.

Information
WA2.1, WA2.3, PR2.1
Section:
Page:
PRV080
Provide the capability to restrict prior approvals/prior authorizations for a specific provider, group or by zip code as
instructed by the Department.
Provider Management

Information
NA
PRV081
Receive and process Lead Health Homes, Primary Care Physician, and managed care plan rosters containing all of the
providers and members in their network.
Provider Management

Information
ME2.4, MC1.2
PRV082
Provide online search capability of Managed Care, Health Home, 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

Information
NA
Section:
Page:
PRV083
Allow Health Homes online single record modification of members and providers within their network
Provider Management

Information
NA
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. At a minimum, validation shall include member eligibility, managed care
enrollment, provider status.
Provider Management

Information
NA
Section:
Page:
PRV085
Receive and process managed care plan rosters containing eligible members for determining capitation payment amounts.
Provider Management
Managed Care enrollment includes Medicaid and CHIP through Medicaid Managed Care (approximately 3.3 million
members) , Family Health Plus (430,000 members), and Child Health Plus (340,000 members).

Information
NA
Section:
Page:
PRV086
Provide and maintain a toll free telephone number for providers to request prior authorizations.
Provider Management

Communication
NA
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 type, etc.
Provider Management

Communication
PR1.11
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.

Communication
PM3.1, PM3.8
Section:
Page:
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Page:
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PRV089
Receive, 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, correction and payment
Medicaid Coverage and Payment Policy
Pharmacy Benefits Management programs
Use of various access channels. (e.g., provider Web Portal and IVR)
Transaction including but not limited to claims; eligibility inquires, prior approval, prior authorizations, service
authorizations; and Threshold Override Applications (TOAs)
Provider Management

Communication
NA
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, correction and payment issues
Pharmacy Benefits Management programs
Use of various access channels such as the provider Web Portal and IVR
Provider Management

Communication
NA
Section:
Page:
PRV091
Receive, track and resolve member inquiries guidelines including but not limited to:
Medicaid Coverage and Payment Policy
Pharmacy benefit information
Medical, personal care, transportation & waiver services benefit information
Utilization Threshold information
Other information specified by the Department
Provider Management

Communication
NA
Section:
Page:
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

Communication
NA
Section:
Page:
PRV093
Receive and respond to provider and member inquiries from providers, labelers, members, stakeholders or business
associates as specified by the Department.
Provider Management

Communication
PR1.6
Section:
Page:
PRV094
Prepare and maintain standard response templates or scripts for routine provider, and member inquiries regarding
eligibility, billing, service limits, enrollment, invoices, and other questions for use by call center staff. Templates require
prior Department approval for content and use. Provide a "knowledge database" for use by call center staff with
Department review and approval.
Provider Management

Communication
NA
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.
Provider Management

Communication
NA
PRV096
Produce and transmit, at the request of the provider, specific information related to the requesting provider (e.g., list of
affiliated practitioners, addresses, and active rates).
Provider Management

Communication
PR1.6
PRV097
Receive, acknowledge, image, index and route correspondence
Provider Management

Communication
PR1.10, PR1.6
PRV098
Review, track and respond to all written inquiries from providers, members, and other stakeholders.
Provider Management

Communication
PR1.6
Section:
Page:
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PRV099
Develop and maintain provider support materials on the Web Portal based on Department approval, including but not
limited to:
Provider manuals
Companion guides
Provider enrollment, claims, 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.
Provider Management

Communication
NA
Section:
Page:
PRV100
Conduct annual reviews of all provider support materials on the Web Portal based on Department rules.
Provider Management

Communication
NA
Section:
Page:
PRV101
Prepare, produce and distribute provider notifications via mail, 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

Communication
NA
Section:
Page:
PRV102
Prepare, 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.

Communication
NA
PRV103
Prepare, produce and distribute notifications to inform providers and members of the outcome of TOA processing via
mail, electronic and/or Web Portal when appropriate.
Provider Management

Communication
NA
PRV104
Prepare, produce and distribute personal care and transportation rosters to ordering providers, and billing provider.
Provider Management

Communication
NA
PRV105
Prepare, produce and distribute account receivable notifications to providers via mail, electronic and/or Web Portal, when
Provider Management
appropriate.

Communication
NA
PRV106
Prepare, produce and distribute notifications regarding 1099/W2 reporting to providers via mail, electronic and/or Web
Portal, when appropriate. 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.

Communication
FI4.4, FI4.5, PR3.7
Section:
Page:
PRV107
Prepare, produce and distribute publications in electronic, and as required hard-copy, formats, including but not limited to:
FAQs
Quick reference information
Training schedules
Help guides
Provider Management
Packets
Supplemental Companion Guides
Provider manuals
Provider bulletins
Maintain all current and historical publications.

Communication
NA
Section:
Page:
PRV108
Notify affected providers of changes to their provider manual via email, the Web Portal or other electronic communication. Provider Management

Communication
NA
Section:
Page:

Communication
NA
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, Cystic Fibrosis, and AIHP)
PRV109
Provider Management
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, Cystic Fibrosis, and American Indian Health Program)
Section:
Page:
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Page:
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Page:
PRV110
Design, prepare, 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

Communication
NA
Section:
Page:
PRV111
Prepare, produce and distribute provider packets via mail, electronic and/or Web Portal as specified by the Department
Provider enrollment
EFT
ETIN
Web Portal User Access
Provider Management

Communication
NA
Section:
Page:

Communication
NA
Section:
Page:
PRV112
Provide data entry services for all transactions and forms that require processing and cannot be accommodated using OCR
services. These include but are not limited to:
Provider enrollment forms
Provider Paper claim forms
Provider Management
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. Terms and conditions must be
available for user review.
Provider Management

Communication
NA
Section:
Page:
PRV114
Generate letters and/or electronic notifications automatically to provider applicants and enrollees as directed and approved
Provider Management
by the Department.

Communication
NA
Section:
Page:
PRV115
Produce the enrollment packet for newly enrolled or reenrolled providers:

Enrollment determination letters when enrollment is denied
Disenrollment letters
Provider Management

Communication
NA
Section:
Page:
PRV116
Provide the ability for providers to order Department forms via the provider area of the Web Portal. This will include
tracking the order from receipt through fulfillment. The order status must be available to the requestor through the
provider area of the Web Portal.
Provider Management

Communication
NA
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.

Communication
NA
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.
Provider Management

Communication
PR2.6
PRV119
Provide the capability to easily change or tailor standard letters and electronic messages.
Provider Management

Communication
NA
PRV120
Provide the capability to generate recertification notices as directed by the Department.
Provider Management

Communication
NA
PRV121
Generate notices to providers for accounts receivable amounts due based on Department business rules.
Provider Management

Communication
NA
PRV122
Generate an electronic receipt notification for all Web Portal user applications which contains applicant/provider
information as specified by the Department.
Provider Management

Communication
NA
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.
Provider Management

Communication
NA
Provider Management

Communication
NA
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

Communication
NA
PRV126
Provide functionality for Health Home providers to enter, edit, and submit practice rosters for lead Health Home approval. Provider Management

Communication
NA
PRV127
Accept files of Health Home eligible members, member loyalty and provider networks.

Communication
NA
Provider Management
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PRV128
Maintain provider support materials on the provider area of the Web Portal without requiring authentication, including but
not limited to:
Provider Manuals (e.g. procedure codes, diagnosis codes, service limits, 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
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PRV129
Perform at least four (4) surveys, developed by the contractor and approved by the Department, each calendar year that the
contractor's application is operational to obtain feedback from the provider community and report results,
Provider Management
recommendations for improvement to address provider concerns, and the contractor must implement improvements
approved by the Department.
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Produce and distribute notifications, publications and related materials to educate providers, members, and other
stakeholders regarding program guidelines, policies, and procedures.
Provider Management
PRV131
Prepare and maintain control of incoming and outgoing NYS Medicaid program mail.
Provider Management
PRV132
Provide the capability to alert stakeholders to important messages on the provider area of the Web Portal.
Provider Management
PRV133
Provide the ability to send providers email and electronic alert messages by provider COS, provider type, or other criteria
Provider Management
as determined by the Department.
PRV134
Develop, implement and monitor a detailed comprehensive cost effective outreach plan for the EPIC and New York
Prescription Saver Programs. Producing (with Department review and approval) outreach and marketing materials.
Provider Management
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
PRV136
Implement and monitor effective strategies for educating community-based partners and other partners to assist in
recruiting and enrolling new members.
Provider Management
PRV137
Provide monthly reports and analyses of outreach and enrollment figures, including information such as outreach activities
Provider Management
that took place, numbers of people enrolled and cost effectiveness.
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Document the process flows and scripts for reaching out to pharmacies
Provider Management
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PRV139
Maintain and update appropriate forms and instructional material for provider enrollment, banking information,
participating provider agreements and disclosure of ownership statements.
Provider Management
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PRV140
Develop a pricing appeal process, research submitted issues and take appropriate action as approved by the Department.
Provider Management
PM07 Manage Provider Grievance

NA
and Appeal
PRV141
Provide recommended actions to the State as a result of pharmacy review and audit, such as suspension and termination
from the EPIC network
Provider Management
PM08 Terminate Provider
NA
TEC001
Follow the States guidelines and constraints for information technology architecture as documented in P04-001 Principles
Governing The NYS Information Technology Enterprise Architecture
Technical Architecture
(http://www.its.ny.gov/tables/technologypolicyindex.htm).
XX
NA
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TEC002
Follow the States 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).
XX
NA
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TEC003
Implement system controls to ensure data integrity during software program changes and promotion to production
XX
SP1.10
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TEC004
Provide a Blue Button solution based on federal/CMS open source standards that allows Medicaid members to view,
print, download or share their health information with the click of a mouse on a blue-button icon.
XX
NA
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TEC005
Ensure that all MAS operational data from the System is delivered to the MDW in order to support reporting and analysis. Technical Architecture
XX
NA
TEC006
Ensure that all Systems data from the MMIS are delivered to the MDW in order to support reporting and analysis.
XX
NA
TEC007
Provide the data to the MDW to develop, produce, and maintain all reporting functions, files and data elements to meet
current and future federal and State reporting requirements, State and federal rules and regulations, federal MMIS
certification requirements, and Part 11 of the State Medicaid Manual. Modifications to federal and State reporting
requirements made after System implementation will be applied using the approved Change Management Process.
XX
NA
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TEC008
Participate in MDW design sessions with MDW personnel for the implementation of system changes to the MDW and
data needs of the MDW.
XX
NA
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TEC009
Capture and provide to the MDW all data that will be required to produce for submission to CMS the federally required TMSIS files. This includes but is not limited to the following functionality:
Maintain data sets required for T-MSIS reporting.
Merge outside data sources into T-MSIS data if required.
Provide and maintain T-MSIS data for adjudicated claims (e.g. Inpatient hospital, Long term institutional care,
Prescription drugs, etc.).
Conform to and maintain reporting requirements from T-MSIS File Specifications and Data Dictionary document.
Meet T-MSIS submission and timeline reporting
XX
FR1.1, FR1.2, FR1.3,

FR1.4, FR1.5, FR1.6
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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, for any calendar year or fiscal year and for all current and
future HCBS Waivers or waiver related programs, in accordance with CMS requirements.
XX
NA
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TEC011
Capture and provide to the MDW all data required (e.g., COFRS, cash collections, claims payment, etc.) 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, CMS-64, CMS-21, and CMS-21b.
XX
NA
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TEC012
Capture and provide online access by the Department all data required for the MDW to produce CMS-416 EPSDT reports,
both quarterly and annually, that contain client demographics and program participation, and detail and summary data to Technical Architecture
meet federal and State reporting requirements.
XX
BE1.7, FR2.1
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TEC013
Provide technical controls and indicators to suppress beneficiary identification for confidential services, generation of
documents, and so that users are not able to view sensitive information or other information which they have no business
need to view.
XX
BE1.8
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TEC014
Provide system support for the sending and receiving of electronic claims transactions, containing valid codes, required by
45 CFR Parts 160 and 162, 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, when applicable
Future claims attachments required under HIPAA
XX
NA
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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.
XX
CA1.11
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TEC016
Provide the ability to view online and transmit in response inquires and report requests the data dictionary information for
any given System field while viewing the actual data in the System.
XX
SP1.9
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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).
XX
NA
TEC018
Provide and store all reports in the medium designated by the State.
XX
PI3.13
TEC019
Require authentication of the receiving entity prior to a system initiated session, such as transmitting responses to
eligibility inquiries
xx
SP1.1
TEC020
Provide the capability to send electronic alert messages to State staff on potential violations of privacy safeguards, such as
inappropriate access to confidential information, and generates alerts for conditions that violate security rules.
XX
SP1.8, SP3.2
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TEC021
Establish indicators that can be set to restrict distribution of PHI in situations where it would normally be distributed, and
tracks disclosures of PHI, and provide authorized users access to and report on the PHI disclosures.
XX
SP4.2, SP4.3
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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
XX
SP3.4
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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
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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.
XX
NA
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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.
XX
NA
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TEC026
Ensure that the contractor's application architecture is a system based on a standards-based service oriented architecture
(SOA); employ an n-tier, component-based, application-computing architecture with an integrated enterprise service bus.
XX
NA
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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.
XX
NA
TEC028
Provide a technical architecture which can advance the Department's goal of achieving a higher MITA maturity level.
XX
NA
TEC029
Ensure that the contractor's application architecture allows for remote data access.
XX
NA
TEC030
Ensure that the contractor's application architecture is configured in such a way and robust enough to implement the SLAs
defined in this RFP.
XX
NA
TEC031
Ensure that the contractor's application architecture can support geocoding for all transactions processed.
XX
NA
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.
XX
NA
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.
XX
NA
TEC034
Notify the Department within one (1) hour for any unexpected system outage or detected breach.
XX
NA
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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.
XX
NA
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TEC036
Ensure the system supports a variable workload (i.e., routinely exhibits peaks or spikes due to retro claims processing,
large batch updates etc.).
XX
NA
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TEC037
Install, configure, enhance, operate and maintain data lines for any required access to the Department network from the
contractors project site. These lines will terminate at the point of demarcation on the Department network to be
determined by the Department network services staff.
XX
NA
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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.
XX
NA
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TEC039
Provide an adequate number of dedicated POTS lines at each facility for dial-up access into the network from Albany,
New York.
XX
NA
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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
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TEC041
Submit to the Department, prior to installation, plans for all connections to the State network.
XX
NA
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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 contractors data center.
XX
NA
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TEC043
Ensure that authorized staff have access to the appropriate environments (i.e. UAT, Training, Production).
XX
NA
TEC044
Put in place a firewall and proxies between its private network and the connection to the State's network.
XX
NA
TEC045
Provide access to the contractor's application for remote users, through a variety of communication channels and protocols. Technical Architecture
XX
NA
TEC046
Provide access to the contractor's application for external computer systems, through a variety of communication channels
and protocols.
XX
NA
TEC047
Support the VeriFone terminals custom software.
XX
NA
TEC048
Support providers in the connectivity to the provider network, ensuring open standards, high speed connectivity and
maximizing provider participation.
XX
NA
TEC049
Provide software necessary to utilize the contractor's solution by State users at no cost to the State.
XX
NA
TEC050
Ensure the Web Portal is compatible with standard browser technology.
XX
NA
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.
XX
NA
TEC052
Ensure the Web Portal is operational and accessible 24/7, except for Department approved scheduled downtime.
XX
NA
TEC053
Provide navigation that users can easily understand, including easy navigation between screens through help menus and
other user documentation.
XX
NA
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.
XX
NA
TEC055
Allow users to view and copy information including but not limited to, provider manuals, instructions, bulletins, program
descriptions, eligibility criteria, Medicaid Updates and forms
XX
NA
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
portal access.
XX
NA
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TEC057
Allow providers, members, trading partners, the State and the States designees to register online for access to the secure
areas of the portal.
XX
PR1.1
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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)
XX
CR3.2, PM2.6
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TEC059
Provide low bandwidth versions of State-specified pages for easy access.
XX
NA
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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.
XX
NA
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TEC061
Provide detailed and current documentation on all system edits and audits that reflects the adjudication process in the
MMIS.
XX
NA
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.
XX
NA
TEC063
Provide the ability to author messages that providers can view upon accessing the portal.
XX
CR3.4
TEC064
Provide the ability to send and receive electronic messages or data files to/from specific provider via the web-portal.
XX
NA
TEC065
Ensure web based application is compatible with standard browser technology.
XX
NA
TEC066
Ensure web based application allows users to inquire, access, update and/or delete data based upon role.
XX
TP1.16
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.
XX
SP3.3
TEC068
Ensure web based application has an integrated on-line help function for all applications.
XX
NA
TEC069
Propose a COTS state-of-the-art Business Rules Engine that operates across all MITA business areas supported by the
MAS.
XX
NA
TEC070
Allow for rules to be implemented in a real-time enterprise environment and applied if required and approved by the
Department.
XX
NA
TEC071
Follow the States 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).
XX
NA
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.
XX
NA
TEC073
Allow for rules to be tested against production data prior to installation.
XX
NA
TEC074
Contain a process for built-in rule review and approval process that will identify any conflicts in business rules as they are
being developed.
XX
NA
TEC075
Produce documentation regarding all business rules.
XX
NA
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TEC076
Develop and implement a Document Management Plan, approved by the Department, which is based upon the proposed
Document Management Methodology, which must be approved by the Department. 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
XX
NA
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TEC077
Ensure the COTS Correspondence Management System contains a collaborative document management environment that
will allow electronic files (e. g. Excel spreadsheets, Word documents, PDF's) to be shared, collaborated upon, managed
and controlled in a secure fashion.
XX
NA
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TEC078
Ensure the COTS Correspondence Management System tracks all correspondence related to a member or provider and
link tracking events to electronic documents.
XX
PR1.10, PR1.6
TEC079
Ensure the COTS Correspondence Management System targets specific populations and produce mass mailings.
XX
NA
TEC080
Ensure the COTS Correspondence Management System has the ability to store any information submitted by a member or
provider.
XX
NA
TEC081
Ensure the COTS Correspondence Management System meets all HIPAA privacy requirements and all State & Federal
requirements for PHI and PII.
XX
ME4.1
TEC082
Ensure the COTS Correspondence Management System supports different notifications to be sent to providers and /or
members, based on business rules.
XX
NA
TEC083
Ensure the COTS Correspondence Management System supports letter generation capabilities which are first presented to
the user for modification and release.
XX
NA
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, archived and maintained by the contractor for seven (7) years beyond the term
of the contract and any extension(s) of the contract.
XX
NA
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TEC085
Provide the Department with electronic access to this correspondence, including access to images of all written
correspondence. The Department requires access for a period of seven (7) years after the contract.
XX
NA
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TEC086
Ensure all documents and deliverables must be produced in a format approved by the Department.
XX
NA
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TEC087
Ensure the COTS Content Management Product captures and stores, in a central repository, images of hard copy
documents, faxed documents, e-mails or electronically submitted documents and retrieve all documents from the
document repository.
XX
NA
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TEC088
Ensure the COTS Content Management Product can provide core document library services, including check-in/checkout, version control, document level security, and archive document and document purging (per HIPAA security
provisions)
XX
NA
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TEC089
Ensure the COTS Content Management Product can share documents among teams and other organizational entities on a
need to know basis.
XX
NA
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TEC090
Ensure the COTS Content Management Product has advanced Optical Character Recognition, Intelligent Character
Recognition and Optical Mark Recognition capabilities with a minimum of 90% accuracy rate.
XX
NA
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TEC091
Ensure the COTS Content Management Product is programmable to accommodate user-defined field edits (i.e. inclusion
or exclusion of special characters).
XX
NA
TEC092
Ensure the COTS Content Management Product has a virtual rescanning capability that will auto correct a skewed
document and automatically adjust document resolution.
XX
NA
TEC093
Ensure the COTS Content Management Product can access the database to extract data to pre-populate the index fields.
XX
NA
TEC094
Ensure the COTS Content Management Product has imaging needs to include red-filtering or other techniques to improve
readability.
XX
NA
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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.
XX
NA
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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.
XX
NA
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TEC097
Ensure the COTS Content Management Product can access any document(s) through a single sign-on.
XX
NA
TEC098
Ensure the COTS Content Management Product can assign a control number to each document and image.
XX
NA
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. All
documents/images must also be able to be retrieved by secondary indices.
XX
NA
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TEC100
Ensure the COTS Content Management Product can print documents/images to a local/network printer and provide the
capability to fax the image.
XX
NA
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TEC101
Ensure the COTS Content Management Product allows for images to be retrieved through a LAN server available to both
the contractor and State staff. Viewed documents/images displayed on workstations must have the full image, with the
same look as the original piece of paper that was scanned.
XX
NA
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Ensure the COTS Content Management Product can attach notes, annotations, e-mails and other documents to the original
document.
XX
NA
TEC103
Ensure the COTS Content Management Product can scan either simplex or duplex on a user defined bases by document
type.
XX
NA
TEC104
Ensure the COTS Content Management Product allows for all historic images from the FileNet and eMedNY system and
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
TEC105
Allow assignment or routing of tasks to State staff with electronic alerts.
XX
NA
TEC106
E-mail alerts of processing events that require State staff action, escalation or notification.
XX
NA
TEC107
Provide a Reporting tool for all operational and ad-hoc reporting.
XX
PM5
TEC108
Ensure the COTS reporting tool is scalable in both volume and numbers of users. 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.
XX
NA
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TEC109
Ensure the COTS reporting tool has the capability to support cross-tabs, data drilling and prompting and filtering, all of
which are key to end-user and report developer satisfaction, and in reducing the report development load on IT.
XX
NA
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Ensure the COTS reporting tool can store reports in the proposed Document Repository.
XX
PM5.4
TEC111
Convert current eMedNY reports, after the Department reviews for appropriateness, into the proposed Document
Repository.
XX
PM5, PM5.4
TEC112
Provide the capability to extract data from a report file and deliver the extracted information to a user.
XX
NA
TEC113
Provide the ability to run reports using user defined parameters.
XX
NA
TEC114
Provide a COTS product to automatically generate letters to providers, members and other stakeholders.
XX
NA
TEC115
Ensure the Automated Letter Generator provides the functionality to send letters by mail, email or fax, whether
individually or mass.
XX
NA
TEC116
Ensure the Automated Letter Generator integrates with the required content management and workflow management
functionality.
XX
NA
TEC117
Ensure the Automated Letter Generator initiates system-generated letters to members and providers based on enrollment
and status.
XX
NA
TEC118
Ensure the Automated Letter Generator supports the use of letter templates that are easily updated including Department
letterhead and electronic signatures.
XX
NA
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TEC119
Ensure the Automated Letter Generator allows for the retrieval and reproduction of all generated letters.
XX
NA
TEC120
Provide toll free access lines into the Call Center.
XX
NA
TEC121
Log, track, and report provider written, electronic, and telephone inquiries in a proposed COTS Contact Management
System
XX
NA
TEC122
Log the date and subject of the inquiry; the provider number, provider type, and provider name; the form of the inquiry
(e.g., telephone); the date and form of response from the contractor; the respondent; and relevant comments, including
what the respondent told the provider.
XX
NA
TEC123
Provide and maintain a Call Center Management System for several functions including but not limited to provider and
member inquiries and assistance.
XX
NA
TEC124
Ensure the Call Center Management System can answer calls in sequence, recording and printing statistics, and indicating
calls that have been placed on hold for a specific time limit.
XX
NA
TEC125
Ensure Call Center Management System can provide personalized routing and call handling based on caller identified
language and inquiry.
XX
NA
TEC126
Ensure Call Center Management System can produce reports on both electronic and voice transactions.
XX
NA
TEC127
Ensure Call Center Management System can transfer a call to Department staff.
XX
NA
TEC128
Call Center must provide multiple language options (at a minimum, staff must include Spanish, Chinese-Cantonese,
Chinese-Mandarin, Russian, with the ability to access third-party translators in additional languages)
XX
NA
TEC129
Ensure Call Center Management System can provide multiple language options and services for individuals with hearing
impairment.
XX
NA
TEC130
Provide the ability to accept, verify and accurately process all data that is currently received (inbound) to eMedNY.
Sources are listed in the Procurement library.
XX
CR1.1, RO6.1
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.
XX
NA
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 .csv, .xml, flat files, and table unloads.
XX
NA
TEC133
Provide the capability to pull data from an outside source.
XX
NA
TEC134
Resolve any discrepancies identified during the processing of inbound files.
XX
NA
TEC135
Provide the ability to extract, verify and process all data that is currently extracted (outbound) from eMedNY. Sources are
listed in the Procurement Library.
XX
NA
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. Secure distribution may include distributing data through a dedicated Technical Architecture
FTP line or through an encrypted disks physically delivered to MDW, etc.
XX
NA
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 .csv, XML, flat files, and table unloads.
XX
NA
Section:
Page:
TEC138
Provide secure dedicated FTP (1 primary and 1 failover) for data delivery to the MDW.
XX
NA
TEC139
Schedule data extractions based on time and occurrence of events
XX
NA
TEC140
Provide deletion/cleanup of extracted datasets; monitoring and control of jobs; automatic alerts to operators when errors
occur during the process; and notifications to requestor concerning the details of the extract, such as duration of execution, Technical Architecture
size of extract.
XX
NA
Section:
Page:
TEC141
Generate administrative reports that will detail and summarize the data extraction and distribution activities.
XX
NA
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TEC142
Provide the ability to capture metadata from data mappings, data modeling tools, business process modeling tools,
relational database data dictionaries and catalogs, data quality tools, query tools, data extraction tools, messaging and
transactions, static documentation libraries, and application run-time environments in a timely fashion.
XX
NA
Section:
Page:
TEC143
Provide the ability to extend and/or customize the capabilities to capture metadata from sources not currently defined or
anticipated, but discovered and required in later phases of the project.
XX
NA
Section:
Page:
TEC144
Include the technical infrastructure to extract metadata and send to MDW in formats defined in the Procurement Library.
XX
NA
Section:
Page:
TEC145
Take over maintain and develop the Medicaid EHR Incentive Program Application Support Service (MEIPASS), the
online mechanism to accept provider attestations and CQMs and distribute payments to hospitals and health care
professionals who meet the program participation criteria established by CMS and provide comprehensive information on
the EHR Incentive program.
XX
NA
Section:
Page:
TEC146
Perform all design, implementation and operation tasks for the Medicaid EHR Incentive Payment System (MEIPASS).
XX
NA
Section:
Page:
TEC147
Establish and maintain of all required interfaces and validations with the CMS National Level Repository (NLR), and
other State systems necessary for administration of the Medicaid EHR Incentive Program.
XX
NA
Section:
Page:
TEC148
Automated processing, archiving and retrieval of Medicaid EHR Incentive Program applications, attestations, and related
communications with providers
XX
NA
Section:
Page:
TEC149
Provide and maintain detail documentation on the edit programming logic executed by the system. This would include
current edit code as well as a history of prior edit codes. This information must be accessible through a web-portal.
XX
NA
Section:
Page:
TEC150
Provide dual authentication sign-on for users with update capability.
XX
NA
Section:
Page:
TEC151
Ensure all user interfaces are compliant with recognized usability standards, including, but not limited to, the Americans
with Disabilities Act, the Older American's Act, and the Rehabilitation Act Section 508.
XX
NA
Section:
Page:
TEC152
Develop, implement, and maintain all external interfaces to administer operations as identified in the procurement library Technical Architecture
External Interfaces
XX
NA
TEC153
Maintain Health Home network information mapping network providers by NPI and/or MMIS Provider ID to the
appropriate health home.
XX
PR4.1
TEC154
Provide Health Home network ad hoc reporting capability and alerts to State staff for changes in Health Home network
(e.g. provider enrollment and disenrollment).
XX
NA
TEC155
Provide State EPIC staff with on-line query access for the most recent three years of premium payment historical data.
XX
NA
XX
POS1.7, POS2.1,
POS4.3
Section:
Page:
TEC157
The POS shall include a ProDUR denial/override process. The ProDUR system must be comprehensive and flexible with
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, overutilization, high dose reasons, and therapeutic duplication.
XX
POS4.1, POS4.3
Section:
Page:
TEC158
Maintain a State-approved POS denial/override and messaging process, in accordance with NCPDP standards, for
Prospective DUR edits. Pharmacy providers must be offered the flexibility to override any denials by resubmitting the
claim with DUR intervention and outcome codes.
XX
POS4.1
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
claim payments for covered expenses only. The POS system must inform the pharmacist of member eligibility and exactly Technical Architecture
how much to collect from the member. All reimbursement information to pharmacy providers must agree with the semimonthly claim cycle reimbursement.
XX
POS1.1, POS2.1
Section:
Page:
TEC156
Implement and maintain a pharmacy POS solution for on-line, real time adjudication of pharmacy claims with edits and
audits that support the Departments policies and objectives. 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.
The POS solution shall be available 24 hours per day, 7 days a week, with exception for Department approved scheduled
downtime.
Section:
Page:
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TEC160
Track the progress and status of individual claims through on-line inquiry. The on-line system must be capable of
selecting claims by key fields, including Date of Service, for inquiry purposes. Designated State staff at State designated
locations must have access to this read only online inquiry system.
XX
NA
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.
XX
NA
Section:
Page:
TEC162
Provide online access and search capability for a rolling two-year history of adjudicated pharmacy claims history data by
approved State staff. The contractor will also be responsible for archiving old histories back to the beginning of the
Program (to comply with Freedom of Information Law (FOIL) requests) with procedures to readily retrieve and load such
claim records.
XX
PI3.3
Section:
Page:
TEC163
Update on-line claim files with POS activity, and simultaneously update member files with POS claims processing
information.
XX
NA
TEC164
Provide capability that allows a dispensing pharmacist to electronically override certain business rules following NCPDP
standards
XX
NA
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.
XX
NA
Section:
Page:
TEC166
Transmit daily the submitted product (NDC11) termination date to the contractors claims processing system (point of
sale) for processing and denying claims from the CMS Product File and/or Manufacturer Product File. A list of historical Technical Architecture
terminated NDCs will be provided for the initial implementation.
XX
NA
Section:
Page:
TEC167
Provide daily overnight processing of submitted pricing and product data for NYPS.
XX
NA
Section:
Page:
TEC168
Develop and maintain an electronic POS rebate system that accurately incorporates the discount process for NYPS pricing
together with the data management and rebate invoicing responsibilities.
XX
NA
Section:
Page:
TEC169
Provide an online tool that will provide, but is not limited to, access to information regarding the NYPS and Program
benefits; ability to locate a participating pharmacy by zip code and city; drug pricing information indicating the amount to
be paid under the Program for all drugs (this will be updated quarterly by successful contractor); frequently asked
questions; 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. The site must be available 24 hours a day, 7 days a week, except for regularly scheduled maintenance.
XX
NA
Section:
Page:
TEC170
Provide the capability to print a paper application form (in English or Spanish) on the NYPS website, and an on-line
application process where a potential member may apply directly in either English or Spanish.
XX
NA
Section:
Page:
TEC171
Describe the contractor's approach to provide NYS staff online access to quickly identify their current tasks, due date, goal
date, priority, etc.
XX
NA
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, without any loss of data. The bidder shall describe their
approach to failover to eliminate to the maximum extent possible any business outages due to hardware, software or
network malfunctions.
XX
NA
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), as well as on a daily basis to allow for maintenance of the production environment.
XX
NA
Section:
Page:
TEC174
Provide a provider accessible test environment which shall allow the provider community to test the application and data
exchanges (Data Acquisition, Data Access and Data Delivery ). This environment will be utilized by new providers or
upon interfaces, file format, coding, or any other changes that affect data exchange with the provider community.
XX
CA2.35, CR1.16
Section:
Page:
TEC175
Ensure capacity to interface with claims data from the Office of Mental Health (OMH).
XX
NA
TEC176
Provide a member portal capable of allowing members access to benefit plan, explanation of benefit, patient history, and
personal health record information.
XX
NA
TEC177
Describe the ability of your solution to receive and integrate clinical data with administrative data when conducting prior
approval/prior authorization.
XX
NA
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TEC178
Provide means and access by the State to audit and monitor performance under the contract.
XX
NA
Section:
Page:
TEC179
Maintain a State-approved POS which provides:

Real-time access to provider eligibility, including the pharmacy and prescriber National Provider Identifier (NPI) and
authorization IDs for electronic submission of claims.
Real-time access to the States drug and formulary file or maintains an up to date copy for POS use.
Real-time access to benefit business rules.
Real-time access to drug file and pharmacy claims history.
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
XX
POS1.1; POS1.2;
POS1.3; POS1.4;
POS1.5; POS2.3;
POS2.4; POS2.18;
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.
XX
POS1.6;
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, such as:
Edit failures
ProDUR alerts
Member (Beneficiary) or coverage restrictions
Prior authorization missing
Required coordination of benefits.
Refill to soon
Requires generic substitution
Deny experimental drugs
Requires unit dose (or not)
Package size not approved
Drug Efficacy Study
XX
POS2.2;
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TEC182
Provide POS functionality to identify and flag individual drugs and compounds for manual pricing intervention.
XX
POS2.13;
TEC183
Process electronic adjustments of paid claims submitted through the Pharmacy POS system.
XX
POS2.16;
TEC184
Provide POS functionality and capability to facilitate pharmacy drug referral certification and authorization transactions
as specified by 45 CFR Part 162.
XX
POS3.3;
TEC185
Provide automated capabilities to verify that services are medically appropriate, conform to federal and State policies, and
generates alerts (messages) to providers as required by State policy. Allow certain providers capability to override alerts. Technical Architecture
All alerts must maintain State approved parameters for content and ability to override.
XX
POS4.4; POS4.5;
POS4.6;
Section:
Page:
TEC186
Provide the capability to track members auto-assigned in a managed care plan though an indicator.
XX
ME1.12
Section:
Page:
TEC187
OSC audit staff are authorized to perform audits related to the States Medicaid program. These audits include but are not
limited to, auditing claims before and after payment as well as storing, retrieving and executing programs on-line, whether
such programs are generated by the audit staff, are part of the contractors production system, or are generated by
contractor staff. As part of the production systems payment cycles, audit routines shall be run to independently audit
claim processing. These audit routines provide assurances such as: no check is issued without supporting claims; checks
are appropriately issued for claims approved for payment; and the value of claims approved for payment is not less than or
greater than the check amount.
XX
NA
Section:
Page:
TEC188
Provide OSC immediate notification of proposed programming and logic changes within the MMIS that would bypass the
OSC audit routines or OSC edits to pend claims.
XX
NA
Section:
Page:
XX
NA
Section:
Page:
TEC189
Support OSC audit routines through online capability for authorized OSC staff to pay and report, pend, or deny any claim
from processing based upon OSC defined edit criteria, such as pending all claims submitted by a specific provider, or
based on multiple conditions or combinations of conditions within a claim. Pended claims shall not be paid in Financial
cycles until review and resolution by OSC.
OSC audit routines currently flag claims using OSC Edit 02014.
Section:
Page:
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TEC190
Provide online capability to modify OSC audit routine criteria. 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. Programming and logic changes to OSC edits will be controlled and authorized in writing only by OSC.
XX
NA
Section:
Page:
TEC191
Provide State, transportation managers, 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.
XX
NA
Section:
Page:
TEC192
Takeover system administration and maintenance functions for PTAR from NYC, a browser based NYHRA product which
edits, captures and reports transactions for providers disbursement of roundtrip MetroCards to eligible Medicaid Members Technical Architecture
at the medical site at the time of the medical appointment.
XX
NA
Section:
Page:
TEC193
Provide an audit module capability to suspend or deny claims from processing. This module would have the capability for
the Department to insert business rules to suspend or deny claims. The module must have the capability to be updated
real-time through a portal.
XX
NA
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.
XX
NA
TEC195
Provide a solution/capabilities to determine that a recipient is physically present at point of service.
XX
NA
TEC196
Provide web based capability and functionality to restrict recipients to a primary providers.
XX
NA
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Attachment E: Requirements Traceability Matrix

- SLA
Service Level Agreement
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, Web based applications, other real-time transactions
(e.g., prior authorization)
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
Business Relationship Management

HIPAA requirements
Care Management
Prior Approval
Authorization Consistency
Contract Management
Key Staff
Project Implementation Dates / Go-Live
Full, uninterrupted, and unrestricted access
Access Termination
Provider Enrollment Applications
Provider Recertification Application
Provider File Maintenance Request
Provider Termination
Member Eligibility Batch Transactions
Member Eligibility real-time Transactions
Support Verification of Member eligibility

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
DOH User Requests
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
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
Provider Satisfaction
quirements Traceability Matrix

- SLA
Definition
Ensure that all contractor, state, provider, member, and other
stakeholder elements of the production environment are
operational and available without interruption 24 hours a day,
seven days a week, except for scheduled State approved
downtime.
Ensure NYS and federal staff access to retrieve claims, budget,
and report information including all supporting materials and
correspondence through web-based application.
Ensure that User Acceptance Test Environment is operational 7
am 7 pm ET, 6 days/week (Monday- Saturday) and extended
hours when requested by the State.
Demonstrate a disaster recovery capability no less than every two
(2) calendar years.
Back up on a daily basis all data files that reside on the multiple
environments. 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.
In the event the primary site becomes unavailable and/or the
failover procedures cannot be successfully executed, 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. In the event the contractor cannot return to
the original production site within seven (7) calendar days, the
Department may at its sole discretion declare the backup site the
new primary site, at which time the contractor will have thirty
(30) days to secure and make operational a new backup site.
Provide production failover and redundancy capabilities in the
event of technical difficulties in the production environment.
Failover of the production environment must occur within 5
minutes.
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. One hundred percent (100%) of all real-time
transactions must not be greater than thirty (30) seconds.
Process inbound files at a frequency as defined by the

Department.
Process outbound files at a frequency as defined by the
Department.
Support and monitor the processing of transaction files and notify
the Department of all transactions that have not been processed
successfully. This notification must take place no later than one
(1) business day of the transaction processing date.
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.
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; transaction response shall be within ten (10) seconds
at a minimum ninety-nine percent (99%) of the time.
Receive, process, acknowledge, and send receipt to originator of

each batch transactions within 24 hours.
The data received from the contractor must be of the highest

quality (i.e., accuracy and completeness). The contractor must
maintain appropriate systems and mechanisms to obtain, maintain
and archive information on each members Medicaid benefits,
provider information, claims history, and payment information to
support claims payment and other financial processes to ensure its
ability to comply with the data reporting requirements.
First year of operation: Quarterly random data quality audits must

achieve a minimum of ninety-nine percent (99%) data quality
accuracy rate per quarter.
Each successive year of operations: Quarterly random data quality

audits must achieve a minimum of ninety-nine point nine percent
(99.9%) data quality accuracy rate per quarter.
The contractor must use or disclose PHI only to perform
functions, activities or services specified in this RFP, for, or on
behalf of the Department, provided that such use or disclosure
would not violate the HIPAA, ACA, or HITECH regulations, if
done by the Department.
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. 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.
Business
Relationship
Management
The contractor must comply with the Health
Insurance
Portability
and Accountability Act (HIPAA) of 1996, Health Information
Technology for Economic and Clinical Health Act (HITECH)
Breach Notification Rule, and must comply with any other
applicable (current and future) Federal and State laws regarding
privacy and confidentiality.
Care Management
Process to completion one hundred percent (100%) of requests
within one (1) business day of receipt of complete information.
Provide sufficient policies and procedures that explain and ensure

consistency of decisions through inter-rater reliability in
approving or denying prior approvals, prior authorizations, and
treatment plans. At a minimum ten percent (10%) of each
reviewers prior approvals, prior authorizations, and treatment
plans shall be reviewed by another clinician to ensure consistent
decisions.
Contract Management
The contractor must fill a vacant key staff position identified
within this RFP within thirty (30) calendar days.
The contractor guarantees Go-Live dates for Release One and

Release Two as agreed upon with the initial work plan, delivered
to the Department within 30 days of contract award, unless there
are substantive changes to the scope of the release.
Provide full, 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, to all records
relating to Vendor performance under this Agreement, and to all
contractor systems and records (both prior to and after
certification, remote and on-site) supporting the NYS Medicaid
Program in accordance with 42 CFR 433.127.
Terminate system access for all terminated or transferred State
employees, State Contractors, 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.
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, except for applications sent to OMIG for
further pre-enrollment review.
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.
The process will include post-enrollment site visits of providers
who are designated as moderate or high categorical risks to the
Medicaid program, as required by 42 CFR 455.432 (a), to be
done prior to completion of recertification.
Process to completion a minimum of ninety-eight percent (98%)
of all clean provider maintenance updates within two (2) business
days of receipt.
Disenroll one hundred percent of Medicaid providers
identified/approved by the NYS within one (1) business day of
notification.
At a minimum, ninety-eight percent (98%) of the eligibility batch
files must be processed within twelve (12) hours of receipt. The
remaining two percent (2%) must be processed by the next
business day.
At a minimum, 98% of member enrollment files transmitted in
real-time must be received in real-time.
Ensure that all contractor eligibility verification methods for
receipt and response of eligibility inquiries are available without
interruption 24 hours a day, seven days a week, except for
scheduled State approved downtime.
The contractor shall be liable for the actual amount of all

contractor caused incorrect payments, duplicate payments, or
payments that should have been denied that are not recovered.
Contractor caused incorrect payments may result from either the
contractors failure to utilize available information or by a failure
to process the claim or transaction correctly.
Produce and provide through electronic transmission a check

register, EFT register, and all shares reports to the Department
within twenty-four (24) hours of completing the Departments
approved payment cycle.
Produce and mail to providers 1099 earnings reports in

accordance with federal and State regulations.
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.
Disburse claims and all other payments on the Departments
approved payment cycle.
Provide the Department monthly reconciliation for each bank
account maintained under the contract.
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.
After hours calls and messages must be returned within one (1)
business day.
All calls must be answered within fifteen (15) seconds.
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. Requests of an unusual nature
requiring significant research must be answered as expeditiously
as possible. The contractor must notify the Department within
twenty-four (24) hours of any delayed requests including the
estimated response date. The contractor must send the requesting
party, within two (2) business days of receipt of the request, an
acknowledgment, including, an estimate of how long it will take
to answer the question or to provide the requested information.
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.
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%), calculated and reported on a monthly
basis.
Resolve ninety-five percent (95%) of member inquiries received
by the Customer Service Center during the initial call.
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 Departments designee, using a statistically valid
sample of members. The survey shall assess contractor specific
performance related to member services, member materials, peer
specialists, and satisfaction with complaint resolution process.
The contractors staff will provide input on the design of the
survey process and the questions included in the survey.
Ensure that program management user requests for program data,

summary data or standard management reports are successfully
processed no later than one (1) business day after the submitted
request. 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, the contractor must notify the user
within twelve (12) hours of the submitted request and process
requests based upon the priority set by NYS.
Adjudicate a minimum of ninety-eight percent (98%) of all

claims within one (1) hour of receipt. Time during which claims
are under review by the Department will not count toward the
adjudication standard.
Reprocess erroneously denied claims within three (3) business
days of discovery of erroneous denial.
Batch files containing reference data required to price claims
must be processed on the date and frequency specified by the
Department.
Pay, deny, suspend, or pend paper claims within seven (7)
calendar days of receipt by the contractor.
Correct all suspended claims for those within contractor
responsibility within thirty (30) business days of suspension.
Process inbound files according to HIPAA standard formats based
on industry standards and Department requirements.
Extract and provide to the Department requested information for
federal reporting in the requested format necessary for submission
within seven (7) days of request.
Produce all daily, weekly, monthly, quarterly, and annually
operational, plan management, and performance management
reporting at the schedule defined per report.
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.
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.
Provider Management
Acknowledge in writing 100% of correspondence within 7

business days of receipt. 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 providers correspondence by the
contractor. Respond to the remaining two percent (2%) within
twenty (20) business days of receipt by the contractor. Responses
are not complete until response is available to Department staff in
the document repository.
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. For Pharmacy providers, 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.
After hours calls and messages must be returned within one (1)
business day.
All calls must be answered within three (3) rings or fifteen (15)
seconds.
At least ninety-eight percent (98%) of calls placed on hold will be
answered within two (2) minutes or less. (Provider Relations
Help Desk)
Resolve all information requests or questions via telephone

within two (2) business days. Requests of an unusual nature
requiring significant research must be answered as expeditiously
as possible. The contractor must notify the Department within 24
hours of any delayed requests including the estimated response
date. The contractor must send the requesting party, within two
(2) business days of receipt of the request, an acknowledgment,
including, an estimate of how long it will take to answer the
question or to provide the requested information.
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.
the caller disconnects prior to the call being answered by a
customer service representative will not exceed 3%, calculated
and reported on a monthly basis.

the caller disconnects prior to the call being answered by a
customer service representative will not exceed 3%, calculated
and reported on a monthly basis.
An annual provider satisfaction survey shall be conducted by the
Department or Departments designee, using a statistically valid
sample of providers. The survey shall assess contractor specific
performance related to provider relations/call management,
clinical management processes, authorization information,
denials/appeals, and satisfaction with complaint resolution
process. The contractors staff will provide input on the design of
the survey process and the questions included in the survey.
Attachment E: Requirements Traceability Matrix -SLA provides a comprehensive listing of all project service level agreemnts as listed in
the RFP. 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.
Damages
Response Reference
nical Architecture
$1,000 per minute penalty for disruption in production environment.
Section:
Page:
$1,000 per day that the requests are not accessible as per the SLA.
Section:
Page:
$500/hour penalty for disruptions in the User Acceptance Test Environment.
Section:
Page:
If backup/recovery strategy is not executed as defined, the Department may assess a Section:
penalty of up to two percent (2%) of the annual Operations Base Fee.
Page:
If backup/recovery strategy is not executed as defined, 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.
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, a penalty of up to one percent (1%) of the annual
Operations Base Fee for every day thereafter.
Section:
Page:
One percent (1%) of the annual Operations Base Fee if the failover does not
successfully occur within five (5) minutes.
Section:
Page:
$5,000 per hour or any portion thereof that response time does not meet the times
designated.
$1,000 per file

$1,000 per file
Section:
Page:
Section:
Page:
Section:
Page:
$5,000 for each occurrence of failure to notify the Department of unsuccessful

processing within one (1) business day
Section:
Page:
$5,000 for each occurrence of failure to reprocess and reconcile unsuccessful

transactions within one (1) business day
Section:
Page:
$1,000 per day per occurrence below the 99% standard.
Section:
Page:
$1,000 per file not responded to within the 24 hour time frame.
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, as defined, and the actual amount of all contractor caused Page:
incorrect payments.
applicable contract year, as defined, and the actual amount of all contractor caused Page:
incorrect payments.
$10,000 per transaction or the full fine, settlement, and litigation cost resulting the Section:
wrongful disclosure of PHI; whichever is greater
Page:
$10,000 per day per incident the Department is not notified.

And
$10,000 per day that remediation plans are not received as per the SLA.
And
Section:
Page:
$10,000 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.
Section:
Page:
re Management
$10,000 per day that the requests are not processed as per the SLA.
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.
Page:
ract Management
$1,000 per day the position is vacant after thirty (30) days.
Section:
Page:
$10,000 per day or any portion thereof past the agreed upon Go-Live date that
systems and operations are not implemented and fully functional, unless
modifications to Go-Live dates have been submitted and agreed upon by the
Department in writing.
Section:
Page:
$1,000 per day that requested accounts, vendor performance records, or contractor Section:
systems are not accessible as per the SLA.
Page:
$1,000 per day or any portion thereof that account termination response time does
not meet the designated timeframe.
Section:
Page:
ity and Enrollment
$25,000 per month if standard is not met.
Section:
Page:
Section:
Page:
Section:
Page:
$1,000 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.
$1,000 per eligibility file not processed within the standard time.
Section:
Page:
$1,000 per member file above the threshold not processed in real-time.
Section:
Page:
$5,000 per hour or any portion thereof that the system fails to support verification
of member eligibility.
Section:
Page:
cial Management
The contractor shall be fiscally responsible for any incorrect payments or duplicate
Section:
payments resulting from negligent contractor performance that cannot be recovered
by the State within ninety (90) calendar days from the identification of the problem. Page:
Up to one percent (1%) of the monthly Operations Base Fee for any month in which
check register, EFT register, and all shares reports are not produced and distributed Section:
within 24 hours of completing the Departments agreed upon payment cycles or
Page:
such payment cycle is not completed upon the approved schedule.
$200,000 if 1099s are not accurate or produced and distributed in accordance with Section:
federal and State deadlines.
Page:
$200,000 plus any penalties imposed on the Department by the IRS if 1099 files are
Section:
not accurate or produced and distributed in accordance with federal and State
Page:
deadlines.
Up to two percent (2%) of total amount of paid claims in payment cycle.
Section:
Page:
Section:
Page:
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:
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.
tions Management
Section:
Page:
$.25 per claim per day for each claim that was not adjudicated within one (1) hour
of receipt.
Section:
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.
der Management
Section:
Page:
$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:
Section:
Page:
$500 per occurrence.
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.
Section:
Page:
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.

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Attachment e Requirements Traceability Matrix 2

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What requirements must the contractor meet regarding facility security?

What requirements must the contractor meet regarding facility security?

What applications must the contractor process and how?

What applications must the contractor process and how?

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

The vendor should

Attachment E: Requirements Traceability Matrix

The Contractor must:

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

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