Specifications include, but are not limited to: The purpose of this RFQ is to procure and implement a software solution for online claim services that allows healthcare providers the ability to do direct data entry for new health care claims and submit corrected claims via the provider portal, enable solicited/unsolicited secure messaging and notifications on claims (i.e., additional documentation required, rejects, errors, paid, denied, etc.), submit and attach documents directly to claims, and route claim reconsiderations or claim/authorization attachments to appropriate teams to work. The solution must integrate with CareOregon’s online provider portal and claim processing system. All Work shall be performed OnShore (United States or a territory of the United States) and all data must remain within the continental United States. All Work shall be performed remotely and no travel reimbursement is authorized for this project. Services. The successful Quoter must offer a solution that provides: 1. Ability to export data/attachments to integrate with internal workflow tools. 2. API to allow integration with rest of the CareOregon ecosystem. 3. Single sign-on with existing Provider Portal. 4. Ongoing support for solution throughout the life of the Contract. 5. Direct Data Entry Functionality. Ability for provider to do Direct Data Entry (“DDE”) of new claims which would be converted to an 837 claim to CareOregon. Must be able to support 837D, 837I and 837P. Ability for Care Oregon to apply or relax standard and custom edits to DDE claims based on criteria such as Provider type, Claim form type, Type of Bill, Point of Service (“ POS”) etc. Ability for providers to correct errors on DDE claims. Secure environment for data/attachment exchange. Ability to submit corrections on rejected claims. 6. Claim Status Check and Messaging. Real-time or near real-time feedback through Smart Edits (EDI 276/277CA). Secure messaging via provider portal that link directly to claims and authorizations. Ability to transmit secure messages from the provider portal directly into workflows for the appropriate department to work and send a response back from the claims management system to the portal. Ability for CareOregon to control what pend messages are viewable to providers. 7. Submission of Attachments. Submission of attachments through online provider portal (i.e., post service claim appeals). Documents submitted must link to associated claims & authorizations; therefore, solution must have the ability to search for pended claims or authorizations. Ability to add additional documentation on claims or authorizations after initial submission. Allow assignment to internal user groups based on attachment type (claims/authorizations may require more than one attachment type, for example, medical records and itemized bill statement). Ability to display attachments for viewing. Ability to download attachments. Advanced search capabilities. Easy and organized retrieval of submission/attachments for internal and external users. 8. Document Routing and Attachment Workflow. Automatic routing based on custom business rules. Ability to provide status updates, notifications, and tracking to internal and external users.
