Specifications include, but are not limited to: Proposer shall provide implementation services. a. Identify respective team members and responsibilities. b. Implement data interface and claims transmission. c. Provide guidelines for targeting claims. d. Account for any missing information. e. Implement rules for provider interface and negotiations. f. Establish periodic claim status meeting processes. g. CareOregon Contract Administrator to meet virtually each week with Proposer’s implementation manager during the implementation process. h. Proposer shall attend onsite meetings with CareOregon Contract Administrator as requested by CareOregon. i. Proposer shall provide three (3) months’ post-implementation support services at no additional charge to CareOregon. j. Data exchange testing. k. Notification of changes to be sent to Providers. Diagnosis Related Grouping (DRG) Audit Review & Overpayment Recovery Services a. Claim files shall be shared only via secure file transfer protocol (“SFTP”). Proposer shall review the extract claim file and select claims for audit review, notify providers of the intent to perform audit reviews, request supporting documentation, send its qualified personnel to perform the audit reviews, and provide a written summary of the audit review to CareOregon and the provider. b. Proposer shall be responsible for the following time sensitive tasks as part of provider appeals process: review provider appeal, send a determination letter to the provider, process appeals through its physician medical director if required...
