Pharmacy Adjudication FY27/28 for DBH

1. MISSION & GUIDING PRINCIPLES

1. PURPOSE

1. On-line adjudication of prescription claims by contracted retail pharmacies utilizing a pharmacy claims adjudication service.
2. Provision of a methodology for auditing purposes that meet the requirements of State Accounting and for reports reflecting the facility’s prescription detail when requested.
3. Electronic claims invoices.

1. BACKGROUND

1. SCOPE OF WORK AND DELIVERABLES

1. Laws and Regulations

1. Provide all services within a secure system that complies with HIPAA and 45 CFR 164
2. Ohio Revised Code, Chapter 4729.80
3. compliant with all applicable rules and regulations regarding the handling of prescription data.

1. General Requirements

1. The Contractor must provide all Deliverables with established federal and state standards and guidelines, assuming all responsibility and liability for all services.
2. The Contractor must provide services that assist local retail pharmacies in processing claims on 24 Hours / 7 Days basis. These services will include an override provision for emergency situations.
3. The network of available local retail pharmacies should be an open network of retail pharmacies located throughout the entire State of Ohio.

1. Contractor must provide services that assist compounding and specialty pharmacies in processing claims on 24/7 basis, including an override provision for emergency situations.  The Contractor must provide in their response their override procedures for override provisions in these emergency situations.
2. The Contractors’ network should include pharmacies that specialize in compounding and specialty medications and must include access to medications with restricted distribution.
3. The Contractor must provide training to OPS staff that explains the Contractor’s billing process upon the contract award and if the Contractor implements any revisions or new processes.
4. The Contractor must provide OPS with online access to the billing claims data.
5. The Contractor must provide a customized report in a Microsoft Excel file format, with filtering capabilities within their system and can be sent to OPS.
6. The Contractor must provide the customized reports must be sent to OPS on the 1 ^st day of the month immediately following the prior month for which the data is reporting on.
7. The Contractor must provide Prescription Data Elements for the billing and must include the following:
8. Processing Group Name.
9. Dispensing Pharmacy Name.
10. Dispensing Pharmacy Street Address.
11. Dispensing Pharmacy City.
12. Dispensing Pharmacy State.
13. Dispensing Pharmacy Zip Code.
14. Dispensing Pharmacy Phone Number.
15. Prescribing Physician’s Last Name.
16. Prescribing Physician’s First Name.
17. Processing Cardholder Number.
18. Patient’s Last Name.
19. Patient’s First Name.
20. Patient’s Gender.
21. Patient’s Birth Date.
22. The National Drug Code (NDC) of the product dispensed, including the NDC of all ingredients of compounded preparations.
23. Drug name, dosage form, and strength of drug dispensed.
24. Generic/Brand Code for drug dispensed.
25. Refill Number.
26. Prescription fill Date.
27. Prescription Number.
28. Metric Quantity Dispensed.
29. Day's Supply of Prescription.
30. Grand Total Dollar Amount Paid.
31. Ingredient Cost Dollar Amount Paid.
32. Dispensing Fee Dollar Amount Paid.
33. Administrative Fee included with claim.

1. CENTRAL PHARMACY OUTPATIENT (CPO). CPO assists Community Mental Health Boards with the economic purchase and dispensing of psychotropic medications to clients meeting specific clinical and income eligibility criteria. CPO required services shall include, but not be limited to, the following:

1. The system must accommodate the following plan limits, a provision that will limit prescription fills to a maximum of a 10-day supply with no refill for psychotropic medications that are not controlled substances and to a maximum of a 30-day supply for psychotropic medications that are controlled substances.  Psychotropic medications will be identified by a formulary provided by CPO.  Exceptions to these limits would require prior authorization of an override from a CPO pharmacist.
2. The Contractor must assure that a CPO phone number will appear on all retail screens for prior authorization use.

1. The Contractor must provide a system with following plan limits, a provision that will limit prescription fills to a five day supply, or one unit of use item (i.e. one inhaler, one small tube of cream, etc.). Exceptions to this limit would require a prior authorization code, including a thirty (30) day prescription.
2. The Contractor must assure that a CPI phone number will appear on all retail screens for prior authorization use.
3. The Contractor will provide an override process for emergency situations.

1. The Contractor must invoice the administrative fee for each adjudicated claim.
2. The Contractor must submit a summary invoice to Ohio Pharmacy Services that provides the total cost for CPO services and the total cost for CPI services. This invoice should not contain any patient-specific or prescription-specific information.
3. An additional statement for each operating unit of Ohio Pharmacy Services utilizing these services that must show all invoiced charges in detail.  Prescription Data Elements are listed section IV.B.10., shall be included in this statement.
4. The Contractor must provide an additional statement for each operating unit of Ohio Pharmacy Services utilizing these services that must show an A ccount for Prescription must be generated for each pharmacy provider which includes the following information:
5. 1. 1. 1. Name of Pharmacy Provider.
         2. Remit Address for Pharmacy Providing Service.
         3. Phone number of Pharmacy Provider.
6. The Contractor must provide a detail of claims reversed or adjustments made to payments.
7. A processing fee reimbursement must be credited to the applicable pharmacy for claims billed in error or reversed.
8. The Contractor must not charge, bill, or invoice for an amount greater than the sum of 1) the amount paid to the dispensing pharmacy for a claim, plus 2) the contract awarded administrative fee per prescription that results from this RFP.

1. IMPLEMENTATION PLAN.
2. The Project Implementation Plan shall include a description of how the requirements of the Project will be implemented.  The State requires that the implementation plan for the proposed solution be developed by the Contractor and approved by the State. In its proposal, Contractors must submit its project implementation methodology and draft implementation plan which it proposes to use for implementation of the project.  The Contractor must meet with the State to review potential technical and logistical issues of the proposed implementation plan. The Contractor must provide a finalized implementation plan based on the feedback received from the State. To ensure a timely and satisfactory implementation, the Contractor and the State must jointly agree to a final implementation plan. The Contractor must indicate a commitment to assume responsibilities and execute Program requirements by six (6) months after Contract award .
3. The implementation plan must include detail sufficient to give the State an understanding of how the Offeror’s knowledge and approach will:
4. Manage the Project;
5. Guide Project execution;
6. Document planning assumptions and decisions;
7. Facilitate communication among stakeholders;
8. Define key management review as to content, scope, and schedule; and
9. Provide a baseline for progress measurement and Project control.

1. TRANSITION PLAN.

1. The Offeror shall address the proposed transition process for ease of implementation of subsequent contractors should the need arise at the end of the Contract term.
2. Staff Availability & Knowledge Transfer.  The Offeror will play an integral role in providing knowledgeable human resources during a transitional period to ensure uninterrupted operations and availability of the Information System.  Consultations and expertise are required in addition to supplied documentation.  Experts are required in the facilities, technical, conceptual and functional facets of the Information System.
3. Documentation.  Documentation shall be made available to assist in the execution of a transition plan.  The Offeror is responsible for developing and maintaining documentation at all times during the Contract period.  All documentation will be made available to DMH upon DMH’s request.  The documentation shall include, but not be limited to:  user guides, program and system narratives, system flows and processing schedules, technical architecture & hardware specifications and the Disaster Recovery Plan.
4. Application Data.  The Offeror is responsible for maintaining current and accurate data.  If required, this data will be made available to assist in the execution of a transition plan.
5. Testing.  The Offeror shall collaborate with DMH in the creation of a comprehensive transition test plan and the identification of test scenarios, particularly DMH-specific scenarios.  All facets of testing will require execution including self-contained system testing, user acceptance and integrated testing with DMH. In addition, the Offeror must be prepared to provide test data required for testing of DMH system changes.
6. File Transfer Protocols.  The Offeror shall utilize existing secure file transfer protocols and parameters in exchanging data with DMH and its selected Offeror across approved network connection as defined in the Connectivity and Interface Requirements.
7. Correspondence.  Electronic copies of correspondence not available through DMH imaging systems will be transferred to DMH at the termination of the Contract resulting from this RFP.

1. MINIMUM QUALIFICATIONS OF CONTRACTOR

PART FOUR: EVALUATION OF PROPOSALS

1. Evaluation Process

1. DBH’s initial review of all proposals for timely submission;
2. An evaluation committee review of the proposals for defects and scoring;
3. DBH’s request for more information (clarifications, interviews, presentations, and/or demonstrations); and,
4. Negotiations or best offer requests.

1. Proposal Evaluation Criteria

In the proposal evaluation phase, DBH staff or reviewers selected by DBH (the committee) will rate the proposals submitted in response to this RFP based on the following criteria and weight assigned to each criterion.