Proposers payment integrity policies should cover a wide range of claim scenarios, from specialty pharmacy to inpatient to ambulance claims, and be updated regularly according to the latest rules and guidelines. Proposer shall be able to not only handle automated editing of standard claims but also offer expert prospective review of more complex claim scenarios. Proposer shall accommodate all providers, provider types (including, but not limited to DOFR, Contracted, Non-Contracted, Capitation, Fee for Service). Proposer shall support provider appeals through inquiry tools, appeal support models, and guidance that can rapidly justify payment decisions on each claim. Proposer shall configure the system to follow all local, state and federal regulations and GCHP rules during implementation.
