Provider Data Management and Credentialing Verification Solution for Medicaid Integrated Modular System (MIMS)

Background

The North Carolina Department of Health and Human Services (NCDHHS), specifically the Division of Health Benefits (DHB), is seeking proposals for a Provider Data Management Credentialing Verification Organization (PDM/CVO) solution as part of its Medicaid Integrated Modular Solution (MIMS). This initiative aims to replace the existing Medicaid Management Information System (MMIS) with a more comprehensive Medicaid Enterprise System (MES). The goal is to enhance provider data management functions, ensuring compliance with CMS standards and improving the overall experience for providers and Medicaid beneficiaries.

Work Details

The PDM/CVO solution will include the following key functionalities: 1. Consolidation of all provider data to minimize administrative redundancy. 2. Simplification of enrollment, data maintenance, and revalidation processes. 3. Facilitation of centralized credentialing for NCDHHS payers and health plans. 4. Mitigation of reimbursement errors due to outdated provider data. 5. Support for delegated enrollment and credentialing processes. 6. Alignment with National Committee for Quality Assurance (NCQA) standards. 7. Establishment of a centralized Credentialing Committee with representatives from NCDHHS payers and health plans. The solution will also feature a self-service portal for providers, enabling them to manage their applications and data efficiently, along with automated workflows for credentialing activities.

Period of Performance

The initial contract term is five years, with an option for two additional one-year extensions at the discretion of the Department.

Place of Performance

The services will be performed within North Carolina, specifically supporting the operations of NCDHHS and its associated healthcare programs.

Bidder Requirements

Offerors must comply with specific requirements including adherence to NCQA standards, implementation of robust security measures in line with federal and state regulations, and provision of IT solutions that support delegated enrollment activities by qualifying healthcare entities.