DDS RFI 25-70008 Medicare Part D Claims Services

The California Department of Developmental Services (DDS) is seeking to identify solution alternatives to replace the existing drug claims billing solution. The purpose of this document is to explain the claim services and reimbursement processes that must be provided by the vendor to the DDS Cost Recovery System (CRS). The services include claims submission and payment posting data for Medicare Part D Drug Claims services program, creating HIPAA compliant D.0 pharmacy claims format, submitting claims to the consumer Prescription Drug Plan (PDP), and converting 835 payment data transactions returned from the PDP to the format needed for posting by CRS. • The vendor will receive the drug claim data from the CRS billing system on a monthly basis, supplement the data for regulatory reasons, and submit the claims to one of several PDP’s. • The vendor will provide various reports from their system used to work claims and monitor claiming activity. • The vendor will also build and support GUI’s for back-end claim processing performed by business staff at DDS and DSH. • The vendor will provide a suite of GUI functions (dashboard) for back-end customer work, including claims that encountered errors, manual claims posting, PDP insurance profile updates, etc.