2.1 Claims Clearinghouse The awarded Bidder shall act as a central point of contact for the claims process by standing up a Claims Clearinghouse that supports the submission of claims or claims data by participating facilities and providers. The awarded Bidder shall receive, review, and process claims data for services related to the initiative, turning claims data into submittable claims or encounters, and ensure that this process is compliant with all Medicaid billing requirements. The awarded Bidder shall prioritize the implementation of a Claims Clearinghouse and satisfy the contractual requirements of operating the Claims Clearinghouse by September 1, 2025, as well as successfully complete any state required security reviews by no later than November 1, 2025. Specifically, the awarded Bidder shall be responsible for: A. Claims/Encounter Processing and Provider Support The awarded Bidder shall have the ability to create an Apple Health claim or encounter from data submitted by participating facilities and providers through billing modules from electronic medical record platforms, other electronic methods, or paper-based claims. The awarded Bidder must have the ability to check eligibility and be compliant with HIPAA data sharing. The awarded Bidder shall also provide TA to participating facilities and providers submitting claims data or submitting claims with service that meets the needs of each participating facility or provider. TA support includes: i) Onboarding facilities and providers. The awarded Bidder shall work closely with providers to ensure they understand the submission process, whether electronically or via paper processes, including how to prepare and submit claims information, upload supporting documentation, and monitor claim status through the awarded Bidder’s Claims Clearinghouse. ii) Assuring that the claim is associated with an approved CBHS client. iii) Notifying providers of any missing documentation and providing technical support as needed, to correct any claims data deficiencies. iv) Submitting claims and encounters through the awarded Bidder’s Claims Clearinghouse using data submitted by participating entities, ensuring data is complete, accurate, compliant with Medicaid rules, and submitted timely to the correct payer. HCA is developing updates to the ProviderOne Billing and Resource Guide to support the Initiative and a Policy and Operations Guide that will assist participating facilities and providers to implement and operate the Initiative. v) Providing a virtual help desk with trained staff available to assist participating providers with any technical issues or questions related to claim submissions. This support must be available during regular business hours, Monday - Friday 8am - 5pm Pacific Time. vi) Provide all contracted services including billing support provided to Adult Family Homes for all other providers not identified as Adult Family Homes who are paying for access directly. The awarded Bidder shall monitor written communications sent from HCA and will be responsible for updating systems within sixty (60) days to meet any changes to Apple Health billing/encounter guidelines, Encounter Data Reporting Guide, eligibility policy, and the CBHS Program and Billing Guide. The awarded Bidder shall have a process for communicating all relevant HCA policy changes to supporting providers to understand these changes and the impacts on their operations.
