Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsFigure 9-2 outlines the components of the Team Noridian solution, their function, and how they add valueto the state of Iowa's Medicaid Program.SolutionComponenteCAMSHealth CareAdministrationPlatformRuleIT HealthCare RulesEngineExchange andAutomation ofCoreTechnologies(EXACT) SOAinfrastructureframeworkPitney BowesDOC1eCAMS WebPortalProposed System(State Implementation)State of WashingtonCOTSState of WashingtonCOTSState of Iowa (used forprocess automation)COTSState of WashingtonState of WashingtonFunctional Area CoveredThis is the core of the proposed system andaddresses the core functional requirements of thebusiness process areas, such as provider, member,and claims. The system is already being upgraded tomeet the HIPAA 5010 requirements and is technicallyICD10 compliant.RuleIT® provides out-of-the-box CMS-mandated rulesets for claims adjudication and a business dictionaryto configure state-specific policies and rules. It is aproven rules engine in a high-volume, high-throughputenvironment, such as the state of Washington, whichprocesses more than 80 million transactions annually.EXACT will manage the connectivity, and standardizethe exchange of data, between the new MMISmodules and heterogeneous systems both internaland external to the Department. EXACT's out-the-boxcapabilities fully support the automation andmanagement of interface services, including auditingand error tracking, alert and escalation, interfaceintegrity monitoring, and the automation of error andexception resolution, where applicableA Pitney Bowes product, DOC1, is used to generateon-demand and batch correspondence to providersand members from the system. The system in thestate of Washington has already integrated thisproduct with the rest of the system business areas sothat users can request the generation of letters to theproviders and members in near real time. In addition,the system uses an address validator component thatverifies the address of the entity (provider or member)down to the street level, resulting in improved dataquality and lower mail rejection.This provides a rich interactive user experience tothe provider community to interact with the Medicaidprogram in near real-time. The portal provides bothstatic and dynamic content. It also provides a singlepoint of access into the Medicaid program across thedifferent functional areas, such as pharmacy priorauthorizations, provider enrollment, and claimsubmission.The member portal also provides a self-servicemodel that allows access to both static information(such as benefits definition) and dynamic information(claims processed) to the member community in asecure manner.Key Highlights and Value to State of Iowa's MedicaidProgramThe eCAMS system provides comprehensive coverableof all business process areas and aligns with theMedicaid Information Technology Architecture (MITA)business architecture. eCAMS aligns with both MITA andSOA principles of being highly-configurable and flexible.The system provides visibility of ongoing key businessmetrics and allows for continuous process improvement.The solution has demonstrated success in improvingclaims and payment accuracy, as well as the turnaroundtime for changes – all of which has resulted in costsavings. For example, the implementation of a singleclaim edit resulted in an annual 6 million dollar savings inthe state of Washington.A health care focused rules engine provides theinfrastructure for the new MMIS to easily adapt to thechanging health care delivery landscape. It reduces risksof implementation and transition from a legacy system tothe next generation solution. With productionimplementations in two states, RuleIT comes preconfiguredwith hundreds of sample business rules foruse in Iowa. Through a combination of configurationparameters and rules engine changes, a full 80% ofchanges can be implemented without the need forprogramming changes or system releases.EXACT will be a key success factor for Team Noridian byproviding an adaptable, scalable, and technologyagnostic framework that supports the new MMIS'smodular yet interoperable design. With EXACT, manydifferent technologies can be incorporated and integratedwith the new MMIS and the Department. EXACT alsodeliver's "beyond ESB" benefits by providing aframework from which the Department can fully exploit itsIT assets and investments and enhance and extend theDepartment's business process automation.The use of street-level validation ensures improved dataquality, which improves fraud detection and preventionand, in turn, can potentially save the state of Iowa mailingand postage costs.Flexible template-driven letters allow Team Noridian andthe Department to rapidly adapt to changing programrequirements.eCAMS’ complete Web-based self-service portals forprovider and member has resulted in cost savings inother implementations, such as reducing paper volume inthe state of Michigan, and improved data quality andquicker adoption (provider verification in Michigan for40,000 providers completed in six months). The Iowaprovider community will benefit from using the Webbasedself-service screens thereby automating theirbusiness processes and larger providers will benefit fromavailability of real-time checks on claims and payments.The member community will have access to richinformation available through highly-interactive userexperience.9 | 4