Supplement6:

Workers’ Compensation Managed Care Information System (WC-MCIS)

Glossary

Following are terms used throughout this RFP, their abbreviations, and definitions. Additional definitions are provided in Appendix G of the MCO Agreement (See Supplement 3) and in the Information Systems Documentation – Ohio Bureau of Workers’ Compensation and the Health Partnership Program System Supplier that will be provided to offerors who sign a non-disclosure agreement and attend the pre-proposal conference.

Complete Term(s) / Acronym, abbreviation, short reference term (if applicable) / Definition
Accredited Standards Committee / ASC / Standards organization chartered to develop X12 electronic transaction standards.
Ambulatory Payment Classifications / APC / Component of Outpatient Prospective Payment System (OPPS)
American National Standards Institute / ANSI / Private, non-profit organization that oversees the development of products, services, processes, systems, and personnel in the United States. ANSI charters ASC to develop the X12 standards BWC uses in many file exchanges.
BWC-Certified Provider / N/A / A provider enrolled with BWC who has agreed to abide by the rules of HPP. This includes agreeing to management by MCOs and acceptance of BWC fee schedule amounts as payment in full.
Contractor / N/A / The entity who is awarded the Contract resulting from this RFP. This entity is responsible for managing and paying all subcontractors used in fulfillment of contract requirements.
Diagnosis Related Group / DRG / Case classification used in the Inpatient Prospective Payment System.
Direct-Pay bills / N/A / A subset of HPPN payments that is processed at BWC and paid directly to providers or injured workers. These payments are for services requested directly by BWC or the IC, primarily independent medical examinations and file reviews.
Disability Evaluators' Panel / DEP / BWC-specific network of providers certified to perform independent medical exams and file reviews for Ohio workers' compensation cases.
Enrolled Provider / N/A / Provider actively registered (but not necessarily certified) in BWC's systems. Providers musts be enrolled in order to be reimbursed for servcies. Non-certified providers can be reimbursed for emergency services or in cases where there are no certified providers available near the injured worker to provide a medically-necessary service.
Explanation of Benefits / EOB / Coding system used by BWC to explain how medical services were paid or why they were denied.
Generic Product Identifier / GPI / 14-character hierarchical classification system for drug products. BWC uses this system in identifying groups of drugs that may be reimbursed or blocked from reimbursement in specific cases.
Health Partnership Program / HPP / Ohio's managed care program for Worker's Compensation.
Health Partnership Program System Supplier / HPPSS / Collective infrastructure provided by the Contractor performing services described in this RFP.
HPP Payments / N/A / Within BWC's payment processes, HPP Payments are medical payments processed by Managed Care Organizations. They are paid on a daily cycle.
HPPN Payments / N/A / Non-HPP Payments. These include drug bills approved by BWC's pharmacy benefit manager as well as all direct-pay bills.
Incumbent Contractor, Incumbent / N/A / The entity who holds the current contract supporting the services required by this RFP.
Information Systems Documentation – Health Partnership Program for Ohio Bureau of Workers’ Compensation and Managed Care Organizations / MCO IS Doc, MCO IS Documentation, MCO Implementation Guide / Standards and file layouts used by managed care organizations participating in HPP. A subset of these must be used by the Contractor providing services described in this RFP.
Information Systems Documentation – Ohio Bureau of Workers’ Compensation and the Health Partnership Program System Supplier. / IS Doc, IS Documentation, Implementation Guide / Standards and file layouts used by the Contractor providing services described in this RFP.
Inpatient Prospective Payment System / IPPS / Pricing methodology used for inpatient hospital bills.
Offeror / N/A / Entity responding to the RFP; potential supplier.
Outpatient Prospective Payment System / OPPS / Pricing methodology used for outpatient hospital bills.
Pharmacy Benefits Manager / PBM / Organization providing pharmacy benefits, in this case on BWC's behalf.
Administrative Payment Value (or Policy Administrative Payment Value) / APV / Premium amount or estimated amount used as a proxy for a premium amount in calculating MCO payments.
Trading Partner / N/A / Entity participating in exchange of electronic data.
Workers' Compensation Managed Care Information System / WC-MCIS / Software solution(s) supporting BWC’s managed care processes described in this RFP.