Ryan white aids drug assistance program

The Bidder agrees to provide comprehensive pharmacy benefit & information management; client eligibility administration, coordination of benefits and payer of last resort program management, statewide retail pharmacy network management, claims processing, AIDS Drug Assistance Program (ADAP) formulary management, ADAP program member technical support, and reporting and data management as described: a. Client Eligibility - Client eligibility must be managed electronically with real time data to ensure that at the time of service, eligible clients receive approved items on the ADAP formulary. All eligible clients will be issued a program eligibility card, which will assure them service at any of the private pharmacies within the network. The Department will provide client eligibility information on a specified frequency that will allow for the timely delivery of program services. The Bidder is relying on the accuracy and completeness of client eligibility information provided by the Department and the Bidder will not be responsible for any errors committed by Department. b. Coordination of Benefits and Payor of Last Resort - Clients primary and secondary insurance is billed first to ensure that Ryan White Part B/ADAP is payor of last resort. c. Statewide Pharmacy Networks - A statewide retail pharmacy network must be available to dispense program formulary items in the various geographical areas where the eligible insured program members or those approved to access the retail pharmacy network are located. d. Claims Processing - Manage electronic claims adjudication for the retail pharmacy network according to the National Council for Prescription Drug Process (NCPDP) Telecommunication Standard 5.1 or above. Process electronic claims received from the network pharmacies providing prescription benefits to insured clients and those approved by the Department to access the retail pharmacy network. Provide Ryan White Part B/ADAP program a billing statement and a claims adjudication summary twice a month. Manage electronic claims adjudication for medical supplies that have been assigned an 11-digit NDC according to the National Council for Prescription Drug Process (NCPDP) Telecommunication Standard 5.1 or above. Provide a manual claim process for the billing of medical supplies that have not been assigned an 11-digit NDC. e. Pharmacy Payment Processing - Provide fiscal intermediary services for pharmacy providers to include payment of approved dispensed prescriptions and accompanying explanation of benefits (EOB). f. ADAP Formulary Management - All network pharmacies will have an up-to-date program formulary. Only items on the formulary will be approved at the time of service. g. ADAP Program Member Technical Support - Staff a help desk to provide information regarding pharmacy locations and to provide answers to most questions regarding the Delaware ADAP pharmacy benefit. h. Reporting and Data Management - Provide electronic report data that includes all of the data fields captured within the data management system that are required for Ryan White Part B/ADAP grant requirements such as ADAP reports, ADR reports and RSR reports. Report data must be submitted prior to reporting requirement due dates as specified by the Department. Please refer to the Scope of work on pages 3-5 of the RFP document and Appendix B - Scope of Work and Technical Requirements.