FUNCTIONS AND CAPABILITIES Sample Clauses
FUNCTIONS AND CAPABILITIES. A. Prior Authorizations. The Contractor shall provide an automated system that includes the following:
1. Enrollee eligibility, utilization, and Care Management information.
2. Edits to ensure enrollee is eligible, provider is eligible, and service is covered.
3. Predefined treatment criteria to aid in adjudicating the requests.
4. Notification to provider of approval or denial including specific reason for denial.
5. Notification to enrollees of any denials or cutbacks of service.
6. Interface with claims processing system for editing and payment.
FUNCTIONS AND CAPABILITIES. Produces standard, TDH-required reports and ad hoc reports from the data available in all MIS subsystems. All reports will be submitted as a paper copy or electronically in a format approved by TDH.
FUNCTIONS AND CAPABILITIES. ACES The ACES System was built using IBM IMS as a base and COBOL for the primary development language. The system has evolved since inception and now the legacy system is presently being decoupled and new functionality is being introduced using technologies like Java, web services, DB2, WebSphere MQ, and iLog rules engine. The high-level business functions that ACES supports are: letters and correspondence, case management, Interactive Voice Response (IVR), benefit verification, eligibility determination, address verification, and enrollment. Washington Connection Washington Connection serves as a self-service portal where individuals and families can check their potential eligibility for social and health programs and submit applications. The major software components of Washington Connection include Websphere MQ Enterprise Service Bus, iLog rules engine, DB2, SQL Server, and Tivoli Identity Management. Data Collected through Washington Connection is sent to ACES for eligibility determination. Enhancements planned for 2011 include the ability to report eligibility changes. ProviderOne ProviderOne, the state’s MMIS system, adjudicates claims, processes payments and acts as the central data and reporting repository. The system was implemented May 9th, 2010 with no major modification since the release. The core business functions the system provides are: client and provider services, managed care, work management, coordination of benefits (COB), claims processing, social services billing and payment (SSBP), and prior authorization. Ancillary components that interface with the core ProviderOne core include: correspondence, pharmacy point of sale, Oracle Financials, call center and integrated voice recognition (IVR), imaging, data warehouse, and federal reporting. OneHealthPort - Washington HIE Washington State Senate Bill 5501 established HCA oversight for development of Health Information Exchange (HIE) in the state; HCA choose OneHealthPort (OHP) to manage the implementation of the HIE. OneHealthPort was created by a coalition of health plans, physicians and hospitals and has multiple accountabilities to its Board, and the HCA serving as the state coordinating body. The high level business functions that the OneHealthPort system supports are: exchange health care information in secure fashion, X12 EDI, HL7, NCPDP transactions, trading partner management, provider registry, credentialing service, secure authentication, and Single Sign-On. Department of Socia...
FUNCTIONS AND CAPABILITIES. II-12 3.5.2 REPORTING REQUIREMENTS........................................ III-12 3.6
FUNCTIONS AND CAPABILITIES. II-13 3.6.2 REPORTING PRODUCTS............................................ III-14 3.7 QUALITY ASSURANCE...................................................... III-14 3.7.1
FUNCTIONS AND CAPABILITIES. III-14 3.7.2 REPORTING PRODUCTS.......................................III-16 3.8 MANAGEMENT AND ADMINISTRATIVE REPORTING..........................III-16 3.8.1 GENERAL REQUIREMENTS.....................................III-16 3.8.2