Services Offered
The Maximus Provider Services solution offers a web-based self-service tool that:
- Has successfully earned CMS modular certification.
- Allows providers to electronically enroll and revalidate provider record information. The self-service enrollment and maintenance portal is configurable by provider criteria such as provider role, provider risk level, provider classification, and other required criteria.
- Supports provider maintenance activities for external and internal users that are founded on business process-driven workflow automation principles.
- Collects required information to support decisions regarding approval or denial of a provider’s enrollment request.
- Accepts the electronic attachment of supporting documentation and collect required electronic signatures.
- Leverages integrated automated workflow so that data and documentation are routed to appropriate unit responsible for decisions on provider enrollment applications.
- Allows providers to complete periodic updates and revalidation of their enrollment information via the self-service web portal.
- Adheres to NIST security standards and all federal and state requirements and all laws, rules, and regulations such as HIPAA and the Affordable Care Act (ACA).
Option A Services Offered
Maximus Provider Services offers the following Option A services:
Self-Service Member Eligibility and Limit Verification Inquiry
- Real-time verification of eligibility through the Self-Service Portal and provides eligibility information including benefit plan enrollment, care management enrollment, waiver program information, program limits, service limits, and TPL information on the self-service portal to providers and other users authorized by the State.
Self-Service Claim Status Inquiry
- Real-time claims status inquiry to allow providers to check the status of their claims.
Self-Service Warrant and Remittance Advice Inquiry
- Access to remittance advice and warrant information through the self-service portal for the provider and other users authorized by the State.
Claims Based Medical History
- Access to member medical history on the self-service portal to allow providers with the authorized roles to access a member’s medical histories interactively.
View, Upload, and Download HIPAA Compliant Healthcare Transactions
- Authorized users can view, upload, and download HIPAA compliant healthcare transactions on the self-service portal.
Self-Service Online Provider Appeal Request
- Functionality for providers to request appeals with automated workflow integration that will route appeals to the appropriate work unit or user.
Self-Service PCCM Member Display
- Display and download functionality to allow providers enrolled in care management programs to view their caseload and download their member registries.
Self-Service Online Claims Entry
- A real-time direct data entry claims solution for all claim types, corrections, void and replacement claims via the self-service portal and reject claims that fail front-end edits.
Option B Services Offered
Maximus Provider Services offers the following Option B services:
Conduct Provider Site Visits
- Upload the results of the Agency on-site visit evaluation of the provider into the provider’s profile within the Provider Services module.
Include Reference Documentation
- Access to current and historical provider manuals and other reference documentation, as necessary, within the provider portal.
Customer Relationship Management
- A Customer Relationship Management (CRM) tool to manage correspondence with providers, including capturing interactions with providers through free-form text, pre-defined data elements, and be capable of searching logged correspondence on command. The CRM tool will support attachments; linking of documents and information within the tool; and routing of correspondence and captured information through the workflow to specific individuals.
Provider Call Center
- A provider call center for new and revalidation applications and enrollments with enrollment support for providers during the enrollment process, such as responding to provider questions about their responses on applications and additional activities (e.g., fielding questions related to changes in provider information, financial information, provider suspension for administrative reasons, or for other reasons such as IRS “B” Notices).
Interactive Voice Response System
- An Interactive Voice Response (IVR) System to welcome and route incoming provider calls; convey educational alerts during hold times; and intelligently queue providers until call center staff is available. The IVR system will include the ability for the provider to leave a message, during or outside, normal business hours.
Qualified Staffing
- Staffing to review provider information, maintenance requests, and all supporting materials in order to verify provider changes prior to updating the provider records. Staffing will review and approve or deny low-risk, high-volume enrollments per Agency criteria. Moderate and high-risk enrollments will be routed to and reviewed by Agency internal staff before a final enrollment decision is made.
Collect and Enter Provider Financial Information in State Financial Systems
- Services to support the collection of financial packet/information from providers and enter the information into a state financial system; following up with the provider in the event discrepancies are identified by State auditors; and subsequent work from the provider’s submission of initial financial information and includes essential updates to financial information.
How to Order Services from Maximus
1. Contact Paula Wales with Maximus at 720.635.6476 or paulawales@maximus.com.
2. Prepare a Statement of Work (SOW) consisting of the documents below in compliance with the Terms and Conditions of this Master Agreement and submit to Maximus:
- A Participating Entity’s Participating Addendum (“PA”), which can be downloaded here.
- The State of Montana Agreement titled, “Contract between the Montana Department of Public Health and Human Services and Maximus,” subject to the order of precedence in subsection 24.9 of the agreement.
3. These documents shall be read to be consistent and complementary. Any conflict among these documents shall be resolved by giving priority to these documents in the order listed above. Contractor terms and conditions that apply to this Master Agreement are only those that are expressly accepted by Montana and must be in writing and attached to this Master Agreement as an Appendix or Attachment.
4. Upon selection of Maximus, begin SOW and pricing negotiations.
5. With both parties in agreement, submit a purchase order that includes our Master Agreement Number: 18091790020. View our contract page.
Maximus Contact Information
Paula Wales, Vice President, Human Services
Maximus
1891 Metro Center Drive
Reston, VA 20190
paulawales@maximus.com
720.635.6476