The Wyoming Integrated Next Generation System (WINGS) will replace the current Medicaid Management Information System (MMIS) through separate procurements. This page focuses on the Benefit Management System and Services (BMS) module. This module includes claims processing, adjustments, and coordination between modules and systems in order to facilitate accurate claims processing and benefit plan management according to Wyoming Medicaid business rules. Financial processes such as adjustments, withholding funds, accounts receivable, and accounts payable will also live in this module. Additionally, the functions related to Third Pary Liability (TPL) have been folded into the BMS module procurement. TPL ensures that proper coordination exists between Medicaid and any other entity or individual with the obligation to provide financial support for Medicaid services rendered to a member.
The Benefit Management System and Services (BMS) for Claims Processing, Financial Management, and Third Party Liability Services Request for Proposal (RFP) is anticipated to be released on the Public Purchase website in December 2018. BMS is the largest procurement covering a breadth of functionality. As such, there are a significant amount of reference materials and helpful information. For your ease of access, the WINGS Project is uploading all related RFP reference documentation on this page. You’ll find everything organized below.
Please be advised, any questions you may have related to the content below, need to be posed through Public Purchase once the RFP is officially released. No questions sent (via telephone calls, mail, email or faxes) before the RFP is officially released will be accepted nor answered.
BMS Scope Graphic The highest level of the graphic has been included in the body of the RFP; however, this scope graphic contains lower level content that Proposers will likely find helpful in understanding the breadth of the procurement. The BMS requirements have been organized around this graphic.
High Level BMS View In an effort to visually represent major aspects of the BMS procurement, this graphic was created. It does not include all aspects of the procurement; however, it should be helpful in understanding high level aspects of the scope. Included in-scope functionality is represented by green boxes.
Process Claim Flow This graphic represents the current process for processing Medicaid claims. The graphic contains a high level flow, with several sub-processes included in the additional pages within this graphic. The Agency would like to note that although this is the current process, the Agency remains flexible to Proposers’ methods of claims processing.
Process a Claim, One Page This graphic goes hand in hand with the Process Claim Flow, above. It is the same content, just arranged differently. Instead of being organized as a higher level with lower levels of detail, this graphic arranges the claim processing flow on one page.
List of Current Benefit Plans This document provides the name of the current benefit plans as well as a short description of the plans.
Benefit Plan List This document provides a more in depth look at benefit plans. This matrix includes the plan start date, plan, plan description, associated program codes, hierarchy (which plan should pay first if a member is eligible for more than one plan), the applicable fee schedule, covered services, copay applicable, an other information.
List of Current Fee Schedules This is the list of fee schedules. This document also includes start and end dates for fee schedules as well as a short description.
Claim Pricing Methodologies This spreadsheet gives an overview of current institutional and professional payment methodologies utilized by the Agency.
Claim Type and Payment Methodologies This table is pretty straightforward. It includes claim types, service areas, and how those claims are priced.
General Grievance & Appeal Process This is the general grievance and appeal process taken by providers and members, generalized to include the WINGS’ BMS Contractor role.
Current MMIS GUI This graphic is a snapshot of the current Medicaid Management Information System (MMIS) graphical user interface. This is the basic landing page for system users, before delving into specific subsystem functionality. The purpose of including this is to share a limited system view into the current user experience.
“Appropriate Payer Solution” – WY Bulletin The current Fiscal Agent employs an “Appropriate Payer Solution” which specifically targets nursing facility claims and performs a pre-payment analysis to ensure that claims are being billed appropriately. The current Fiscal Agent, Conduent (formerly Xerox), administers the Appropriate Payer Solution subcontracted with Dart Chart. This document is being supplied to you for informational purposes.
“Appropriate Payer Solution” – Facility Administrator Letter The current Fiscal Agent employs an “Appropriate Payer Solution” which specifically targets nursing facility claims and performs a pre-payment analysis to ensure that claims are being billed appropriately. The current Fiscal Agent, Conduent (formerly Xerox), administers the Appropriate Payer Solution subcontracted with Dart Chart. This document is being supplied to you for informational purposes.
“Appropriate Payer Solution” – DART Chart Outbound Data Structure to WY MMIS The current Fiscal Agent employs an “Appropriate Payer Solution” which specifically targets nursing facility claims and performs a pre-payment analysis to ensure that claims are being billed appropriately. The current Fiscal Agent, Conduent (formerly Xerox), administers the Appropriate Payer Solution subcontracted with Dart Chart. This document is being supplied to you for informational purposes.
Claim Processing Edits & Exceptions This spreadsheet contains claim edits currently being used by the Fiscal Agent. Edits are numbered 1-999. Included is the edit text, resolution text, a human interpretation of the edit, how frequently the edit has been used in the last three years, and the type or setting to which the edit applies. Anyone requesting access to the edits and exceptions for Medicaid claims processing needs to fill out the attestation stating they are a legitimate MMIS Contractor before being given access. Please use the link and follow the instructions to gain access.
Provider Network Performance 2018 This document includes performance metrics related to provider enrollment, outputs and efficiencies, and background to program performance.
Wyoming Medicaid Website This is a link to the Wyoming Medicaid Website. There is a lot of information that will be helpful to you in understanding Wyoming Medicaid.
Fiscal Agent Landing Page for Medicaid Providers This page is the public facing website, maintained by the current Fiscal Agent, filled with provider specific information related to Wyoming Medicaid.
Current Medicaid Provider Manuals Provider manuals and bulletins can be found on this page. This site is maintained by the current Fiscal Agent.
Wyoming State Plan The State Plan is a contract between a State and the Federal government, enabling the delivery of health care. It ensures that a State abides by Federal rules and gets FFP. The State Plan sets out groups to be covered, services provided and limitations, reimbursement methodologies, and administrative requirements.
Wyoming State Rules The Secretary of State’s Office is the repository for rules and regulations, and provides this centralized system to promote transparency and ease of access to rules by state agencies and the public.
TPL Program Report 2018 This document provides metrics and outcomes related to TPL spanning multiple years, including projections for 2019.
TPL Program Snapshot 2018 This document includes expenditures for the program, a program description, program cost notes, staffing, events that have shaped the program, and metrics.
Institutionalized Medicaid Member; State Plan This document is related to TPL activities where a Medicaid eligible member has been institutionalized for at least six (6) months. For those that may have property resources, Medicaid expects the member to repay Medicaid funds expended on the recipient’s behalf if they no longer intend to return home. This document provides some additional detail surrounding this scenario.
Bipartisan Budget Act of 2018 This document is an informational bulletin to provide additional details around the new laws that impact and modify TPL rules.
TPL Compliance Library Links These links provide additional information specific to TPL: Wyoming Statutes, Code of Federal Regulations, and the CMS State Medicaid Manual.
The Deficit Reduction Act: Important Facts for State Government Officials This document, released by Health and Human Services, contains topics such as: new options for benefit packages, New options for premium and cost sharing, re-balancing long term care, and documentation of citizenship.
Important Deficit Reduction Act Facts This goes hand in hand with the Deficit Reduction Act: Important Facts for State Government Officials, above. This is additional content Proposers may find helpful, especially related to the TPL aspect.
Medicaid and CHIP FAQ This document provides frequently asked questions related to Medicaid and CHIP and covers the identification of Medicaid beneficiaries’ TPL resources and coordination of benefits with Medicaid.
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) This is a State Medicaid Director letter which provides guidance on MIPPA with topics that include: extension of the qualifying individual program, application of the low income subsidy resources tests to Medicare Savings Programs, Eliminating Barriers to Enrollment, among others.
Medicaid Estate Recoveries – Financial Eligibility Requirements & Options This document provides general financial eligibility requirements and options related to Medicaid estate recoveries.
General TPL Purpose This document provides an overview and general purpose of TPL as described in Wyoming State Statutes.
TPL Requirements – Payment of Claims This document is Wyoming’s State Plan under Title XIX of the Social Security Act relating to Payment of Claims. Topics include: diagnosis and trauma edits, data exchanges, and paid claims follow up.
SPA – Liens & Recoveries This document is Wyoming’s State Plan under Title XIX of the Social Security Act related to liens and adjustments or recoveries.
For those who are interested in Wyoming Department of Health procurement activities and timelines, please note they are subject to change–please see Public Purchase for official Request for Proposal (RFP) notices and releases, and stay tuned for future updates!
These documents can be changed at the sole discretion of the State. This page was last updated on January 9, 2019.