Question_No._8_Flowchart.pdf

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Medical Claims Adjudication
Solicitation number
RFP-P0700NAS-14-0092
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Question No. 8 Flow Chart

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File Type Posted
Responses_to_Questions_9-30-2014.pdf PDF
RFP.pdf PDF
Attachment_I_-_Instructions_for_Offerors.pdf PDF
Attachment_II_-_SOW.pdf PDF
Attachment_III_-_Past_Performance_Questionnaire.pdf PDF
Attachment_V_-_Business_Management_Questionnaire.pdf PDF
Attachment_VI_-_Bank_Letter.pdf PDF
Attachment_IV_-_Subcontracting_Plan.pdf PDF

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Medical Claims Adjudication Process

Inmates require medical care

Institution staff notify

CMS

contractor;

appts. are scheduled

Institution staff notify PGBA that care is authorized

Care is delivered via CMS contract

CMS

contractor submits medical claims electronically to PGBA

CMS

contractor prepares & transmits invoice only to Institution

PGBA

adjudicates claims; sends EOBs to

Institution

Institution staff match EOBs with invoice

Institution staff notify

CMS

contractor of any deductions

Institution staff schedule invoice payment to

CMS

contractor

CMS contract prepared for transition to claims adjudication

CMS contractor submits provider data to PGBA

ACO sends written notification to

CMS contractor of implementation

HSD/ADM/PGBA

determines “go live” date

Medical Claims Adjudication Process

File details come from the government source that posted it. Updated .