HSS27009-RWADAP_appB.pdf

PSA 999-99-99 Appendix B

Appendix B For

HSS-27-009 - RYAN WHITE AIDS DRUG ASSISTANCE PROGRAM

Project Requirements

Software as a Solution (SaaS) Product

1 Project Overview

1.1 Background and Purpose

The State of Delaware Department of Health and Social Services (DHSS), Division of Public Health (DPH), seeks to procure and implement an AIDS Drug Assistance Program (ADAP), Prescription Fulfillment Benefits & Information Management System (PBM), which is a statewide, contractor-hosted, web-based solution to support ADAP prescription processing, benefits administration, eligibility management, client enrollment, claims adjudication, reporting, and program oversight.

The system will centralize and streamline ADAP operations through a secure platform that supports coordination of prescription benefits among the State, pharmacies, and health insurance providers, while ensuring compliance with applicable state and federal requirements, including Health Insurance Portability and Accountability Act (HIPAA) and Ryan White HIV/AIDS Program standards.

1.2 Project Lifecycle

DHSS defines the “project” in Appendix B as the totality of work and activities throughout the contract period, which is delineated by a set of project lifecycle phases. The PBM system shall be organized and managed based on five distinct lifecycle phases: Planning Phase, Configuration and Customization Phase, Testing and Deployment Phase, Operations and Support Phase, and Project Transition-Out Phase.

1.2.1 Planning Phase

The Planning Phase includes all mandatory deliverables and activities required to proceed to Configuration and Customization. Deliverables include:

• Schedule and conduct meetings with the project team to discuss and finalize the format and content for each deliverable

• Provide deliverable: Project Schedule

• Provide deliverable: Change Management Plan

• Provide deliverable: Continuity of Operations Plan

• Provide deliverable: Data Conversion Plan

• Provide deliverable: Architecture Network Diagram

1.2.2 Configuration and Customization Phase

This phase includes activities to configure and customize the PBM system:

• Schedule and conduct meetings with the project team to discuss and finalize the format and content for each deliverable

• Spin-up the cloud instance for the SaaS product

• Configure the product

• Customize the product (e.g., data conversion, screen formatting, etc.)

• Implement the Data Conversion Plan

• Update the Project Schedule

• Provide deliverable: Training Plan

• Provide deliverable: Test Plan

• Provide deliverable: Product Deployment Plan

1.2.3 Testing and Deployment Phase

This phase includes implementing the Test Plan, Training Plan, and Deployment Plan.

Deliverables include:

• Schedule and conduct meetings with the project team to discuss and finalize the format and content for each deliverable

• Implement the Test Plan

• Implement the Training Plan

• Implement the Product Deployment Plan

• Update the Project Schedule

• Provide deliverable: User Guide

• Provide deliverable: Data Element Dictionary

1.2.4 Operations and Support Phase

This phase includes implementation of Continuity of Operations and Change Management Plans, ongoing system maintenance, help desk support, and data security monitoring.

• Schedule and conduct meetings with the project team to review operations monitoring and quality control reports, issue tracking, and change control tracking

• Implement the Continuity of Operations Plan

• Implement Change Management Plan

• Initiate Help Desk operations and incident management

• Provide ongoing maintenance and support

• Securely maintain all data and facilities

1.2.5 Project Transition-Out Phase

Upon termination of the contract, the contractor will provide a finalized copy of the Data Element Dictionary, and a copy of the database based on an agreed format and delivery method.

2 Project Team

2.1 DHSS Staff List

Name / Role Organization / Email Phone Robert Vella DHSS Executive Sponsor

Division of Public Health Chief, Communicable Disease

302-744-1143

Bureau Robert.Vella@delaware.gov

Michael Moore DHSS Technical Manager

Delaware Health and Social Services Information Resource Management Michael.moore@delaware.gov

302-255-9221

Douglas Trader DHSS Program Manager

Division of Public Health Program Administrator Douglas.Trader@delaware.gov

302-744-1007

David Dunnington DHSS Subject Matter Expert

Division of Public Health Eligibility Coordinator David.Dunnington1@delaware.gov

302-744-1050

Melissa Green DHSS Subject Matter Expert

Division of Public Health Management Analyst III Melissa.Green@delaware.gov

302-744-1081

Eric Andrews DHSS Information Systems Support Specialist

Division of Public Health Bureau of Health Information Systems Eric.Andrews@delaware.gov

302-744-4700

2.3 DHSS Roles

2.3.1 Information Resource Management (IRM)

In support of the DHSS and Office of the Secretary - Administration, the mission of Information Resource Management (IRM) is to provide quality, efficient and cost-effective support in the management of technology resources. IRM provides DHSS divisions with information technology planning and management, information technology purchasing, network telecommunications, and help desk services. IRM is represented on the project team as the DHSS Technical Manager.

2.3.2 Department of Technology and Information (DTI)

The Department of Technology and Information (DTI) is the state’s central information technology (IT) organization. DTI establishes and enforces the State’s IT policy and standards and provides enterprise technology services that enable other organizations to effectively fulfill their missions.

DTI does not actively participate in the project team and meetings but is available to IRM as necessary.

2.3.3 DHSS Executive Sponsor

The DHSS Executive Sponsor represents DPH senior management and is responsible for the success of a project and provides sustainability, strategic planning, guidance and resources to the project team and DHSS Project Manager as necessary. The DHSS Executive Sponsor attends the project meetings at their discretion.

2.3.4 DHSS Technical Manager

The DHSS Technical Manager serves as primary coordinator on behalf of IRM; attends project meetings as required, works with the project team to maintain the project plan and schedule;

provides DPH and vendor with technical consulting support; facilitates configuration and/or customization required within the state network (e.g., firewall rules, etc.); and manages the work assignments of IRM staff as required (e.g., providing vendor access to or copies of the Patient and needed data and images, etc.).

2.3.5 DHSS Program Manager

The DHSS Program Manager serves as primary business lead for all project phases on behalf of DPH, attends all project meetings; works with the project team to maintain the project plan and schedule; disseminates program information to the vendor as needed (e.g., business requirements, processes, workflows, forms, reports, etc.); and manages work assignments of program staff as required (e.g., review deliverables, perform testing, etc.).

2.3.6 DHSS Subject Matter Expert (SME)

The DHSS Subject Matter Expert (SME) contributes program knowledge and information in all project phases, understands the vendor software from a user perspective, understands program workflows related to patient scheduling, service delivery, imaging, and claims billing; attends project meetings as required, and reports to the DHSS Program Manager.

2.3.7 DHSS Information Systems Support Specialist (ISSS)

The DHSS Information Systems Support Specialist (ISSS) serves as the DPH liaison between program staff and IRM, and between program staff and vendor IT staff. The ISSS participates in all project phases; attends all project meetings; ensures the business requirements are properly communicated to the vendor; assists program staff to understand DTI policies and standards; and assists program staff to understand the created information system processes and data. The ISSS reports to both the DHSS Technical Manager and DHSS Program Manager.

2.4 Contractor Roles

2.4.1 Vendor Project Manager

The contracted Project Manager serves as the chief liaison to the DPH for all project phases, has authority to make day-to-day decisions, facilitates all project deliverables and activities; maintains the project schedule; schedules, hosts and leads all project meetings; authors and distributes agendas, meeting notes and weekly status reports; and ensures contracted staff attend project meetings as required.

2.4.2 Vendor Application Manager

The contracted Application Manager facilitates all SaaS product configuration; documents and communicates systems-related issues and downtime; coordinates with the contractor’s Help Desk as necessary; attends all project meetings as required; and contributes knowledge and information to inform the authoring of deliverables (e.g., Project Plan and Schedule, Architecture Network Diagram, Test Plan, etc.). The contracted Application Manager reports to the contracted Project Manager.

2.4.3 Vendor Database Manager

The contracted Database Manager develops and maintains the developed database(s); maintains data storage and retrieval systems; troubleshoots database issues; implements database recovery procedures and safety protocols; attends all project meetings as required; and contributes knowledge and information to inform the authoring of deliverables (e.g., Project Plan and Schedule, Data Conversion Plan, Interface Control Documents, Data Element Dictionary, etc.). The Database Manager reports to the Project Manager.

2.4.4 Training Manager

The contracted Training Manager develops and maintains training materials; schedules and conducts training sessions; communicates with users; attends all project meetings as required;

and contributes knowledge and information to inform the authoring of deliverables (e.g., Project Plan and Schedule, Training Plan, etc.). The Training Manager reports to the Project Manager.

3 Project Deliverables

The following subsections define the requirements and minimum data content for each deliverable. Each deliverable is submitted to DHSS as a standalone document and updated throughout the project per the vendors Change Management Plan. The Project Schedule, and Test Plan, are submitted to DHSS in Microsoft Excel format. All other deliverables are submitted in Portable Document Format (PDF) format. DPH acknowledges that the content and format associated with any deliverable is subject to change based on pre-existing documentation available from the vendor (e.g., Continuity or Operations Plan) or based on agreement reached during a project phase meeting.

3.1 Project Schedule

Vendor shall provide the Project Schedule in Microsoft Excel format and include task number, task description, assigned staff, task dependencies, task start and end dates, task duration, percentage completed, task completion date, and a project calendar depicting all tasks. For the duration of the project, Vendor will deliver to DHSS weekly an updated Project Schedule. Vendor will define tasks at a sufficient level to track the work assignments of Vendor and DHSS staff, which at a minimum includes deliverables, configuration, customization, conversion, training, testing and deployment. During the Operations and Support Phase, the Project Schedule will include issue resolution, change management, system downtime, or any other event or activity that requires tracking.

3.2 Change Management Plan

Vendor shall provide their Change Management Plan in PDF format and describe the change management process, both in terms of configuration and customization, define the method to request change, the process to rank and prioritize change requests (via a Configuration Control Board or equivalent), define the role of DPH, include a sample of any forms and artifacts used in the change management process (e.g., change request form, change approval form, UAT approval form, etc.), and list the project deliverables that will be updated (e.g., Project Schedule, Test Plan, User Guide, Data Element Dictionary, etc.).

3.3 Continuity of Operations Plan

Vendor shall provide their Continuity of Operations Plan in PDF format and describe their backup and recovery process of applications and data; and describe their methods to ensure all professional services are continued following a natural disaster, power outage, or any other event that impacts facilities, staffing, systems, or data. Vendor shall identify any associated vendors, provide documentation of recovery procedures and testing, define the communication method for alerting DPH of a disaster or event requiring the execution of the Continuity of Operations Plan, and define the Service Level Agreement (SLA) time to return to operations following notification to DPH.

3.4 Data Conversion Plan

Vendor shall provide their Data Conversion Plan in PDF format and describe their method to transform and import data and images from the current system hosted by current vendor. Vendor shall describe the approach to ensure data quality before and after the data conversion process, describe the manual and/or automated controls and methods to validate the conversion, and describe the process for data error detection and correction. Vendor shall include in their plan a data conversion specifications table that lists all source tables and fields, the target table and field for each source field, a data value mapping for each field when applicable, and data transformation rules when applicable.

3.5 Architecture Network Diagram

Vendor shall provide an Architectural Network Diagram in PDF format depicting the user’s interaction with the login, application and database servers, and interfaces with other systems (e.g., imaging), and include the IP addresses and port requirements.

3.6 Training Plan

Vendor shall provide a Training Plan in PDF format that describes their approach to training, includes a curriculum to demonstrate all core system functionality (e.g., user login; product configuration; online inquiry of patient, service, claim, and image information; reports and dashboards; and web portal), and includes a copy of all training materials or includes links to the training materials if available online.

3.7 Test Plan

Vendor shall provide a Test Plan in Excel format and document the test cases associated with unit and integrated testing. Vendor is required to work with DPH to identify the staff for testing, review the Test Plan with staff before testing begins, and facilitate one or more meetings with staff to execute the Test plan together. Vendor shall include in the Test Plan test cases for all core systems functionality associated with the product (e.g., user login; product configuration; online inquiry of patient, service, claim, and image information; reports and dashboards; and web portal), include DPH-specific configuration where applicable, and include test cases for all customization work (e.g., conversion, OKTA SSO). Vendor will include in the Test Plan a summary for each test case, and a series of test steps for each test case, instructions for executing each test step, the expected outcome, and columns for staff to record the actual outcome, and any testing notes.

3.8 Product Deployment Plan

Vendor shall provide a Product Deployment Plan in PDF format and describe their approach to deployment, describe the method to communicate with DHSS staff; include a readiness checklist for facilities, environments, applications, databases, operations, and Help Desk; describe their method to monitor operations and quality control; and include sample reports associated with operational monitoring and quality control.

3.9 User Guide

Vendor shall provide a User Guide in PDF format and include instructions and screen samples to navigate and use all core system functionality (e.g., user login; product configuration; online inquiry of patient, service, claim, and image information; reports and dashboards; and web portal).

Vendor will include a table of contents; organize and group the content by core functionality; and provide instructions for contacting the Help Desk.

3.10 Data Element Dictionary (DED)

Vendor shall provide a DED in PDF format and document all the table names, table descriptions, field names, field descriptions, field attributes, field positions, field sizes, valid values and primary keys associated with the application database. Vendor shall organize the DED with each table presented alphabetically as a separate section, order the fields for each table by position in the database, and depict the field information in a spreadsheet-like format.

4 Project Requirements (Note: Use of subcontractors WILL NOT be permitted for this project)

4.1 Offshore Prohibitions

Offshore is defined as not being within the United States or its territories. Offshore storage and transmission of DHSS data is prohibited.

Onshore project data and project artifacts including backup and recovery files in any form shall not be accessed by offshore staff and shall not be copied, processed, transmitted, or moved offshore. Vendor is permitted to engage offshore resources including sub-contractors for development and internal lower level (unit & integration) testing only. Vendor is prohibited from using State data in any form even if masked or obfuscated for offshore testing. All aspects of user acceptance testing and production operations will take place onshore.

Associated Link:

Offshore IT Staffing Policy

4.2 Data Classification Policy

Vendor shall abide by the terms and conditions established by the Delaware Data Classification Policy, which defines the roles and responsibilities of a Data Steward based on the data classification. The data classification for this procurement is State of Delaware Secret.

Associated Links:

Data Classification Policy

4.3 Cloud Hosting and Data Use Agreements

PDDS shall abide by the terms and conditions established in two separate agreements, the Delaware Cloud Services Agreement (CSA) and the Delaware Data Use Agreement (DUA), which govern remote hosting/cloud systems and accessing/storing State data outside of the State network respectively. Both agreements have columns identifying which provisions are mandatory depending on whether the data is defined as Public or Non-Public. The data for this procurement is defined as Non-Public. The mandatory clauses are identified by the checkmark in the appropriate Public/Non-Public column in each agreement.

Associated Links:

Delaware Cloud Services Terms & Conditions Agreement Delaware Data Usage Terms & Conditions Agreement Terms & Conditions Governing Cloud Services Policy Terms & Conditions Governing State Data Usage Policy

Signed agreements are required to sign a contract. Both the CSA and DUA were already vetted and approved by the Delaware Department of Technology and Information (DTI) and the Delaware Deputy Attorney General (DAG). During the Operations and Support Phase, vendor will renew both agreements every 12 months.

4.3.1 Criminal Background Check

All vendor staff working on this project will be subject to a Criminal Background Check (CBC).

Vendor will be solely responsible for the cost the CBC. DHSS will review the CBC results. DHSS at their sole discretion may request that a vendor staff be replaced if their CBC result is unsatisfactory.

4.3.2 Cyber Liability Insurance

All data in transit must be encrypted whether transmitted over a public or private network. If vendor cannot comply with the requirement to encrypt data at rest, then vendor must purchase adequate Cyber Liability Insurance to protect vendor and the State from data breaches and other cyber security issues. The selected vendor will present a valid certificate of cyber liability insurance for attachment to the contract prior to contract signature.

4.3.3 Subcontractors

Subcontractors are not required to sign the CSA or the DUA; however, the vendor will hold them responsible to the same or more stringent security requirements to ensure that State data is adequately secured.

4.4 HIPAA Regulations

PDDS shall certify compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and requirements as described in Department of Health and Human Services, Office of the Secretary, 45 CFR Parts 160, 162 and 164 along with the updated ARRA and HITECH act provisions, as well as all HIPAA requirements related to privacy, security, electronic transaction and code set standards, and provider enumeration (National Provider Identifier). The proposed solution must meet these cited requirements.

4.5 Business Associate Agreement

Because the data includes Protected Health Information (PII), which is covered by HIPAA regulations, a Business Associate Agreement (BAA) is required to sign a contract. Typically, a contract uses the DHSS or DPH BAA; however, DPH has agreed to use the vendor BAA, which was already vetted and approved by the Delaware Department of Technology and Information (DTI) and the Delaware Deputy Attorney General (DAG).

4.5.1 Subcontractors

Subcontractors are required to sign a BAA.

4.6 PDDS SaaS Agreement

The contract will include the vendor SaaS Agreement, which was already vetted and approved by the Delaware Department of Technology and Information (DTI) and the Delaware Deputy Attorney General (DAG).

4.7 DHSS Data Rights

All data covered by this contract is the sole property of DHSS. De-identified or derived/aggregated DHSS data is not exempted from this requirement. This provision shall survive the life of the contract. PDDS does not acquire any right, title, or interest in DHSS data under this contract.

Except as otherwise required by law or authorized by DHSS in writing, no DHSS data shall be retained by vendor for more than 90 days following the date of contract termination. After the 90-day timeframe the following provisions will remain in effect: vendor will immediately delete or destroy this data in accordance with NIST standards and provide written confirmation to DHSS;

vendor is expressly prohibited from retaining, transferring, repurposing, or reselling DHSS data except as otherwise authorized by DHSS in writing; vendor retains no ongoing rights to this data except as expressly agreed to by DHSS in the contract.

4.8 UAT and Training Environments

The User Acceptance Testing (UAT) and Training environments must be secured at a level equivalent to the security in place for the production environment. It must be sized and architected such that production-sized files can be copied over into UAT. The architecture must be equivalently configured so that performance and load testing will essentially produce the same results and expectations as testing in the production environment. Depending on the type of data (i.e., top secret/highly confidential, behavioral health) and specific security requirements around this data, there may or may not be an expectation to mask field values in the UAT and Training environments. Copying production data into lower environments may be prohibited especially for role-based training. Lower environments with production data that are secured in the same manner may be exempt from masking requirements as well however this may be subject to DHSS or Federal policies and regulations that override this potential exemption or explicitly disallow production data being copied into lower environments. The division Deputy Attorney General will be consulted on what is allowed/disallowed in non-production environments.

4.9 Data Masking in Non-Production Environments

While securing production data is of critical importance, migration of that data to lower environments (e.g., development, testing, training) presents its own set of challenges as lower environments typically are not as secure as the production environment. Masking of production data in lower environments usually involves deletion or obfuscation of actual PII-related field values such that they have no meaning as plain text and there is no identifiable method of translation back to the original values. If vendor intends to include production data in a non-production environment, then vendor is required provide a detailed description of their masking approach, and DPH will amend this section of Appendix B. Otherwise, if vendor does not intend to include production data in a non-production environment, then this section of Appendix B will be amended as such by DPH. This section must be amended before a contract can be signed.

4.10 Digital Accessibility Requirement

All deliverables produced under any resulting contract must comply with applicable federal and state digital accessibility laws, regulations, and policies in effect at the time of delivery, including Section 508 of the Rehabilitation Act and the current adopted version of the Web Content Accessibility Guidelines (WCAG) Level AA.

Accessibility must be incorporated into the creation of all documents, electronic content, software, websites, and other work products. Deliverables that do not meet applicable accessibility requirements may be rejected, and the Contractor shall remediate any deficiencies at no additional cost to the State.

Failure to comply with these requirements may constitute a material breach of contract.

4.11 Help Desk

Vendor must provide help desk services to all DHSS users by phone and email, and optionally through the internet using a secured online chat session. Vendor shall operate the Help Desk 24 hours per day and 7 days per week. Vendor will acknowledge all help desk tickets to the user(s) by email within 5 minutes of receipt, and assign the ticket priority (regular, priority) within 15 minutes of receipt. Vendor will resolve priority tickets within an hour of receipt, and regular tickets within 4 hours of receipt. In addition, vendor will provide emails to the user(s) alerting them of the ticket progress (in process, resolved, closed with no action), provide contact information of the staff assigned a ticket in process; and when a ticket is resolved or closed, an explanation of the resolution or closure.

4.12 Application Requirements

All components listed in this section are mandatory.

4.12.1 The System Will Be Comprised Of The Following Core Elements

a) Provide comprehensive pharmacy benefit and information management services

b) Administer client eligibility electronically with real-time functionality

c) Perform coordination of benefits and ensure payer of last resort compliance

d) Maintain a statewide pharmacy network

e) Adjudicate and process pharmacy claims

f) Perform pharmacy payment processing, including fiscal intermediary services

g) Manage and maintain the ADAP formulary

h) Provide ADAP program member technical support

i) Deliver robust reporting and data management functions

j) The Applicant must document a successful statewide Ryan White Part B/ADAP

Pharmacy Benefit and Information Management operation in two or more states.

4.12.2 Core PBM System Capabilities

4.12.2.1 Claims Processing & Adjudication

The Applicant must have the ability to:

a) Process real-time pharmacy claims adjudication in accordance with NCPDP standards

b) Adjudicate claims across retail pharmacies, clinic-based dispensing, and mail-order pharmacies

c) Apply configurable benefit structures, including Full ADAP (uninsured), co-pay assistance (insured), and Medicare Part D wrap-around

d) Enforce prior authorizations, quantity limits, and formulary edits at the point of sale

e) Allow the State to require prior authorizations on specified medications and enter approvals directly

f) Return clear and actionable messaging for claim approvals, denials, and rejections

g) Provide monthly billing statements and claims adjudication summaries

4.12.2.2 Formulary & Medication Management

The Applicant must have the ability to:

a) Maintain and administer a configurable ADAP formulary

b) Add, remove, and edit formulary medications in a timely manner

c) Track and search all medications, including both formulary-approved and non-formulary drugs

d) Apply utilization controls and clinical edits as defined by the State

e) Ensure all network pharmacies have access to an up-to-date formulary

f) Make the current ADAP formulary accessible online to clients, pharmacies, and providers in a clear, user-friendly format

g) Ensure the online formulary is updated in real time or near real time

h) Provide a publicly accessible formulary lookup tool with search functionality by drug name, drug class, or National Drug Code (NDC)

i) Ensure only formulary-approved medications are adjudicated at the point of service

4.12.2.3 Eligibility & Enrollment Management

The Applicant must have the ability to:

a) Add, edit, and track client eligibility records

b) Maintain eligibility periods and historical eligibility data

c) Manage client eligibility electronically in real time to ensure appropriate access at the point of service

d) Issue program eligibility identification cards to all eligible clients

e) Ensure eligibility cards allow access to services at all participating network pharmacies

f) Support multiple eligibility types, including Full ADAP and co-pay assistance

g) Perform eligibility updates in real time or via batch edits

h) Merge client records in the event duplicate entries are identified

i) Enforce eligibility at the point of adjudication

j) Reject claims for ineligible clients with clear denial messaging

4.12.2.4 Coordination of Benefits

The Applicant must have the ability to:

a) Coordinate benefits to ensure all other payers are billed prior to ADAP

b) Enforce payer of last resort requirements in all adjudicated claims

c) Differentiate between insured and uninsured clients at the point of adjudication

d) Indicate when a client is receiving premium assistance through an external program

4.12.3 Provider, Pharmacy, and Network Management

4.12.3.1 Statewide Pharmacy Network

The Applicant must have the ability to:

a) Maintain a statewide pharmacy network capable of serving all geographic regions of

Delaware

b) Ensure adequate pharmacy access for all eligible clients

c) Enroll and manage participating pharmacies

4.12.3.2 Pharmacy Network Management

The Applicant must have the ability to:

a) Track all pharmacies in the network

b) Track and report the number of clients utilizing each pharmacy

c) Produce reports identifying most utilized pharmacies by claim volume

4.12.3.3 Clinician & Prescriber Management

The Applicant must have the ability to:

a) Add and maintain clinicians participating in the Delaware ADAP network

b) Track prescriber information, including National Provider Identifier (NPI)

c) Generate prescriber utilization reports

d) Provide prescriber-level history and activity tracking

4.12.3.4 Eligibility Worker & Agency Management

The Applicant must have the ability to:

a) Add and track eligibility workers

b) Associate eligibility workers with their respective agencies

c) Maintain and track agency information for all participating organizations

d) Report on eligibility activity by worker and/or agency

4.12.4 Client & Enrollment Support Functions

4.12.4.1 Client Identification & Card Issuance

The Applicant must have the ability to:

a) Generate and mail client identification cards upon initial enrollment or recertification

b) Allow the State to print temporary client identification cards when needed

c) Maintain accurate client demographic and enrollment data

4.12.4.2 Client-Level Data Access

The Applicant must have the ability to:

a) Retrieve and display individual client claims history

b) Display date filled, pharmacy utilized, and amount charged to ADAP for each claim

c) Provide comprehensive patient-level utilization views

4.12.5 Financial Management & Billing

4.12.5.1 Invoice Generation

The Applicant must have the ability to:

a) Generate monthly, itemized billing statements

b) Provide invoices printed on agency letterhead and signed by an authorized representative

c) Submit invoices by the 25th of each month for the previous month

d) Ensure late invoices are processed in the following billing cycle

e) Provide detailed claim-level backup documentation

4.12.5.2 Pharmacy Payment Processing

The Applicant must have the ability to:

a) Provide fiscal intermediary services for pharmacy providers

b) Process payment for approved dispensed prescriptions

c) Provide explanation of benefits (EOB) documentation

d) Generate reports on payments made to fee-for-service providers

4.12.6 Reporting Requirements

4.12.6.1 The Applicant must have the ability to generate, export, and customize the following reports in Excel and CSV formats.

a) Provide electronic reports required for Ryan White Part B/ADAP grant compliance

b) Ensure all reports are compatible with the Health Resources and Services

Administration (HRSA) CAREWare system

c) Submit required data prior to HRSA reporting deadlines

d) Provide information for ADAP Data Reports (ADR)

e) Provide reports on medication dispensing data and drug usage by manufacturers

f) Support enrollment eligibility data management and reporting

g) Provide ad hoc reporting capabilities

h) Maintain secure data storage, tracking, and reporting systems

4.12.6.2 Standard Reports

The Applicant must have the ability to generate:

a) Suspended Claims Reports

b) Patient History Launch Reports

c) Pharmacy History Launch Reports

d) Doctor History Launch Reports

e) Pharmacy Scorecard Reports

f) Provider Report Card Reports

g) Clients with Eligibility Periods Reports

h) Clients with Expiring Eligibility Reports

i) Clients with Specified Group Number Reports

j) Member Enrollment Data Reports

k) Patient List Reports

l) Pharmacy List Reports

m) Doctor List Reports

n) Patient List Extract Reports

o) Drug Usage by Manufacturer Reports

p) Drug Cost Reports

q) Drug Usage Reports

r) Multiple Controlled Drug Usage Detail Reports

s) Brand vs. Generic Utilization Reports

t) Most Utilized National Drug Code (NDCs) Reports

u) Most Utilized Pharmacies by Claim Volume Reports

v) Prescriber Utilization Reports

w) Antiretroviral (ARV) Adherence Summary Reports

x) Adherence Monitoring Reports

4.12.7 Drug Rebate Support

4.12.7.1 Rebate Support

The Applicant must have the ability to:

a) Track all utilization data required to support drug rebate claims to manufacturers

b) Generate and maintain rebate invoicing data

c) Provide client-level data required for rebate submissions

d) Produce quarterly rebate reports in manufacturer-required formats

e) Support both Public Health Service (PHS) and Non-Public health Service (Non-PHS) pharmacy rebate submissions

f) Ensure complete and accurate data to maximize rebate recovery

4.12.8 System Access & User Interface

4.12.8.1 SaaS Platform

The Applicant must have the ability to:

a) Provide a fully SaaS-based, web-accessible system

b) Support secure internet-based applications

c) Provide role-based access for State staff and authorized users

d) Provide real-time access to claims, eligibility, and utilization data

4.12.8.2 User Functionality

The Applicant must have the ability for DHSS and Ryan White Central office to:

a) Allow users to search claims by client, pharmacy, drug, or date of service

b) Display full adjudication details for each transaction

c) Provide real-time visibility into claim status and history

d) Export data directly from the system interface

4.12.9 Customer Support Requirements

The Applicant must have the ability to:

a) Staff a help desk to provide assistance to ADAP clients (Delaware Ryan White enrollee or network pharmacy providers)

b) Provide helpdesk support with defined hours of operation M-F 9:00 AM to 9:00 PM

EST

c) Provide information regarding pharmacy locations

d) Respond to eligibility and prescription benefit inquiries

e) Offer escalation procedures for urgent pharmacy access issues

f) Assign a dedicated account manager to the State

4.12.10 Quality Assurance

The Applicant must have the ability to:

a) Ensure eligible ADAP clients receive professional and confidential prescription services in a timely and accurate manner

b) Maintain the integrity of all data associated with claims processing and billing

c) Develop and implement a quality assurance plan in collaboration with program administrators

d) Establish monitoring parameters to evaluate program performance

e) Improve operational efficiency through ongoing quality monitoring