Pharmacy Adjudication FY27/28 for DBH

MISSION & GUIDING PRINCIPLES The mission of the Ohio Department of Behavioral Health (DBH) is to provide statewide leadership of a high-quality mental health and addiction prevention, treatment and recovery system that is effective and valued by all Ohioans. DBH strives to be a national leader in implementing a comprehensive, accessible, and quality-focused system of addiction and mental health care and wellness for all Ohio citizens.   PURPOSE Ohio Pharmacy Services requires prescription adjudication services for the purpose of reimbursing a broad network of pharmacies in circumstances in which Ohio Pharmacy Services is unable to supply or fill our customer’s prescription.  The network of pharmacies must include retail, specialty, and compounding pharmacies.  The retail pharmacies must be local to the customers of Ohio Pharmacy Services and able to provide same day filling of prescriptions.  The specialty pharmacy network must be sufficient to provide restricted distribution specialty medications and products.  The compounding pharmacy network must be sufficient to provide up to and including compounded sterile preparations.  The requested prescription adjudication services will primarily be used for immediate emergency prescription fills with duration and quantity restrictions and for specialty and compounded medications that Ohio Pharmacy Services is unable to procure or produce.   On-line adjudication of prescription claims by contracted retail pharmacies utilizing a pharmacy claims adjudication service.  Provision of a methodology for auditing purposes that meet the requirements of State Accounting and for reports reflecting the facility’s prescription detail when requested. Electronic claims invoices.   BACKGROUND Ohio Pharmacy Services of the Ohio Department of Behavioral Health was established by state statute, ORC Section 5119.44, to provide certain goods and services to the state, as well as county, municipal and eligible community agencies. Ohio Pharmacy Services serves state behavioral health hospitals, state correctional facilities, county health departments, community mental health and addiction agencies, free clinics, county jails, and non-profits throughout Ohio by providing centralized procurement and distribution services for pharmaceuticals, over-the-counter medications, medical & laboratory supplies, and personal care products.  Ohio Pharmacy Services includes, but is not limited to, the following operating units:  Central Pharmacy Inpatient (CPI), Central Pharmacy Outpatient (CPO), and the Pharmacy Service Center (PSC).  SCOPE OF WORK AND DELIVERABLES Ohio Pharmacy Services requires prescription adjudication services for the purpose of reimbursing a broad network of pharmacies in circumstances in which Ohio Pharmacy Services is unable to supply or fill our customer’s prescription.  The network of pharmacies must include retail, specialty, and compounding pharmacies.  The retail pharmacies must be local to the customers of Ohio Pharmacy Services and able to provide same day filling of prescriptions.  The specialty pharmacy network must be sufficient to provide restricted distribution specialty medications and products.  The compounding pharmacy network must be sufficient to provide up to and including compounded sterile preparations.  The requested prescription adjudication services will primarily be used for immediate emergency prescription fills with duration and quantity restrictions and for specialty and compounded medications that Ohio Pharmacy Services is unable to procure or produce. On-line adjudication of prescription claims by contracted retail pharmacies utilizing a pharmacy claims adjudication service.  Provision of a methodology for auditing purposes that meet the requirements of State Accounting and for reports reflecting the facility’s prescription detail when requested. Electronic claims invoices.    Laws and Regulations The Contractor must perform the Work in compliance with all applicable laws and regulations, including: Provide all services within a secure system that complies with HIPAA and 45 CFR 164 Ohio Revised Code, Chapter 4729.80 compliant with all applicable rules and regulations regarding the handling of prescription data.   General Requirements   The Contractor must provide all Deliverables with established federal and state standards and guidelines, assuming all responsibility and liability for all services. The Contractor must provide services that assist local retail pharmacies in processing claims on 24 Hours / 7 Days basis. These services will include an override provision for emergency situations. The network of available local retail pharmacies should be an open network of retail pharmacies located throughout the entire State of Ohio. Contractor must provide services that assist compounding and specialty pharmacies in processing claims on 24/7 basis, including an override provision for emergency situations.  The Contractor must provide in their response their override procedures for override provisions in these emergency situations. The Contractors’ network should include pharmacies that specialize in compounding and specialty medications and must include access to medications with restricted distribution.  The Contractor must provide training to OPS staff that explains the Contractor’s billing process upon the contract award and if the Contractor implements any revisions or new processes. The Contractor must provide OPS with online access to the billing claims data. The Contractor must provide a customized report in a Microsoft Excel file format, with filtering capabilities within their system and can be sent to OPS. The Contractor must provide the customized reports must be sent to OPS on the 1st day of the month immediately following the prior month for which the data is reporting on. The Contractor must provide Prescription Data Elements for the billing and must include the following: Processing Group Name. Dispensing Pharmacy Name. Dispensing Pharmacy Street Address. Dispensing Pharmacy City. Dispensing Pharmacy State. Dispensing Pharmacy Zip Code. Dispensing Pharmacy Phone Number. Prescribing Physician’s Last Name. Prescribing Physician’s First Name. Processing Cardholder Number. Patient’s Last Name. Patient’s First Name. Patient’s Gender. Patient’s Birth Date. The National Drug Code (NDC) of the product dispensed, including the NDC of all ingredients of compounded preparations.        Drug name, dosage form, and strength of drug dispensed. Generic/Brand Code for drug dispensed. Refill Number. Prescription fill Date. Prescription Number. Metric Quantity Dispensed. Day's Supply of Prescription. Grand Total Dollar Amount Paid. Ingredient Cost Dollar Amount Paid. Dispensing Fee Dollar Amount Paid. Administrative Fee included with claim.   CENTRAL PHARMACY OUTPATIENT (CPO). CPO assists Community Mental Health Boards with the economic purchase and dispensing of psychotropic medications to clients meeting specific clinical and income eligibility criteria. CPO required services shall include, but not be limited to, the following:      The system must accommodate the following plan limits, a provision that will limit prescription fills to a maximum of a 10-day supply with no refill for psychotropic medications that are not controlled substances and to a maximum of a 30-day supply for psychotropic medications that are controlled substances.  Psychotropic medications will be identified by a formulary provided by CPO.  Exceptions to these limits would require prior authorization of an override from a CPO pharmacist. The Contractor must assure that a CPO phone number will appear on all retail screens for prior authorization use.  E. CENTRAL PHARMACY INPATIENT (CPI). CPI focuses on best practices for patient care within state, county or governmental inpatient settings. CPI offers competitively priced medications through consolidated purchasing, formulary management, medication monitoring, and coordinated care to ensure that health care dollars are spent wisely. CPI customers eligible to use the online adjudication services currently include 26 Department of Rehabilitation and Correction institutions and three (3) Department of Youth Services facilities. CPI required services must include, but not be limited to, the following:  The Contractor must provide a system with following plan limits, a provision that will limit prescription fills to a five day supply, or one unit of use item (i.e. one inhaler, one small tube of cream, etc.). Exceptions to this limit would require a prior authorization code, including a thirty (30) day prescription.  The Contractor must assure that a CPI phone number will appear on all retail screens for prior authorization use.    The Contractor will provide an override process for emergency situations. F.  BILLING REQUIREMENTS.   The Contractor must invoice the administrative fee for each adjudicated claim. The Contractor must submit a summary invoice to Ohio Pharmacy Services that provides the total cost for CPO services and the total cost for CPI services. This invoice should not contain any patient-specific or prescription-specific information. An additional statement for each operating unit of Ohio Pharmacy Services utilizing these services that must show all invoiced charges in detail.  Prescription Data Elements are listed section IV.B.10., shall be included in this statement. The Contractor must provide an additional statement for each operating unit of Ohio Pharmacy Services utilizing these services that must show an Account for Prescription must be generated for each pharmacy provider which includes the following information: Name of Pharmacy Provider. Remit Address for Pharmacy Providing Service. Phone number of Pharmacy Provider. The Contractor must provide a detail of claims reversed or adjustments made to payments. A processing fee reimbursement must be credited to the applicable pharmacy for claims billed in error or reversed.  The Contractor must not charge, bill, or invoice for an amount greater than the sum of 1) the amount paid to the dispensing pharmacy for a claim, plus 2) the contract awarded administrative fee per prescription that results from this RFP.   IMPLEMENTATION PLAN.  The Project Implementation Plan shall include a description of how the requirements of the Project will be implemented.  The State requires that the implementation plan for the proposed solution be developed by the Contractor and approved by the State. In its proposal, Contractors must submit its project implementation methodology and draft implementation plan which it proposes to use for implementation of the project.  The Contractor must meet with the State to review potential technical and logistical issues of the proposed implementation plan. The Contractor must provide a finalized implementation plan based on the feedback received from the State. To ensure a timely and satisfactory implementation, the Contractor and the State must jointly agree to a final implementation plan. The Contractor must indicate a commitment to assume responsibilities and execute Program requirements by six (6) months after Contract award. The implementation plan must include detail sufficient to give the State an understanding of how the Offeror’s knowledge and approach will: Manage the Project; Guide Project execution; Document planning assumptions and decisions; Facilitate communication among stakeholders; Define key management review as to content, scope, and schedule; and Provide a baseline for progress measurement and Project control.   TRANSITION PLAN.    The Offeror shall address the proposed transition process for ease of implementation of subsequent contractors should the need arise at the end of the Contract term. Staff Availability & Knowledge Transfer.  The Offeror will play an integral role in providing knowledgeable human resources during a transitional period to ensure uninterrupted operations and availability of the Information System.  Consultations and expertise are required in addition to supplied documentation.  Experts are required in the facilities, technical, conceptual and functional facets of the Information System. Documentation.  Documentation shall be made available to assist in the execution of a transition plan.  The Offeror is responsible for developing and maintaining documentation at all times during the Contract period.  All documentation will be made available to DMH upon DMH’s request.  The documentation shall include, but not be limited to:  user guides, program and system narratives, system flows and processing schedules, technical architecture & hardware specifications and the Disaster Recovery Plan. Application Data.  The Offeror is responsible for maintaining current and accurate data.  If required, this data will be made available to assist in the execution of a transition plan.  Testing.  The Offeror shall collaborate with DMH in the creation of a comprehensive transition test plan and the identification of test scenarios, particularly DMH-specific scenarios.  All facets of testing will require execution including self-contained system testing, user acceptance and integrated testing with DMH. In addition, the Offeror must be prepared to provide test data required for testing of DMH system changes. File Transfer Protocols.  The Offeror shall utilize existing secure file transfer protocols and parameters in exchanging data with DMH and its selected Offeror across approved network connection as defined in the Connectivity and Interface Requirements. Correspondence.  Electronic copies of correspondence not available through DMH imaging systems will be transferred to DMH at the termination of the Contract resulting from this RFP.   MINIMUM QUALIFICATIONS OF CONTRACTOR Offeror must demonstrate three previous projects in the previous five years. These projects must be of similar size, scope, and nature to the work in this RFP. Details of the similarities must be included. Contractor shall not be subject to an “unresolved” finding for recovery under Section 9.24 of Ohio Revised Code.

Agencia

Ohio Department of Mental Health - Financial Management

N° de solicitud

—

Tipo de aviso

Local Solicitation

NAICS

524292 — Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds

PSC

Q523 — Medical- Surgery

Valor estimado (inferido, no oficial)

—

Set-aside

—

Lugar de ejecución

OH

Publicada

25 de ago de 2026

Cierre

09 de sept de 2026

Última actualización

—

¿Calificás como pequeña empresa? El tope de facturación o empleados para el NAICS 524292 lo define la SBA y cambia con el tiempo — lo más seguro es confirmarlo ahí, no acá. Verificar en sba.gov ↗

GovBidder Connect no es una agencia gubernamental. Esta información se agrega de fuentes oficiales de dominio público y puede tener demoras o errores. Verificá los datos en la fuente oficial antes de actuar.