Part 4 - Iowa Medicaid Enterprise

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RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsBE Member Management Requirements - MMIS A B C D EBE1.02.03BE1.03BE1.04BE1.05BE1.06BE1.07a. Member name and member number.b. Provider name and provider number.c. TCN and denial notice number.d. Date of service and date of NOD.e. Exception code.f. Written reason for denial.g. Same format as current ambulance NOD.Provide the capability to generate NODs for denials of selected servicessuch as therapy services, rehabilitation therapy service, claims foroccupational therapy, physical therapy and speech therapy.Support management of member information, including archives,reports, transaction and transaction error tracking.Generate notification when member information is received from externalsources to update member records.Receive and process member eligibility information from externalsources such as, IME‟s Integrated Eligibility System or Social SecurityAdministration (SSA‟s) state data exchange, for a given period of time;produce total and detail information that supports error correction andsynchronization. Apply reconciliation changes to master file. Produce afile of changed records to be sent to originating source.Archive member data sets and update transactions according to IMEprovided parameters.Provide member data to support case identification, tracking andreporting for the EPSDT services covered under Medicaid.Yes No SM 80YesYesYesYesYes No SM 100Yes No SM 120BE1.07.01 Provide the capability to meet the business requirements of EPSDT. Yes No SM 150BE1.07.02BE1.07.03BE1.07.04BE1.07.05Provide the capability to track screenings, referrals and treatments forEPSDT members.Identify all members eligible for EPSDT services within the benefit planadministration rules engine.Provide the capability for recording all case activity including, but notlimited to:a. Logs of notices.b. Recommended dates of service from the periodicity table.c. Actual dates of services.d. IME and contractor contacts.e. Case notes.Use the workflow management process to provide and log notices, trackservices provided and enter case notes for each eligible member in aprogram (such as EPSDT) and at a minimum, include processes listedbelow:a. Automatically generate notification letters or electroniccommunications, according to specifications set by IME. Identify thefamily head of household or foster care worker and generate screeningsletters and or electronic communications to this individual, even if thechild resides at a different address.b. Retrieve data from the MMIS claims and encounter data (if applicable)to compare to services recommended from the periodicity table.c. Provide for the inclusion of claims attachments.d. Automatically compare and report claims to the periodicity table, todetermine if the member received the health checkup examination andrelated services at the recommended intervals.YesYesYesYesYesYesYesYesYes No SM 80Section 9.1.1.1.2,Requirement #BE1.02.03Section 9.1.1.1.2,Requirement #BE1.03Section 9.1.1.1.2,Requirement #BE1.04Section 9.1.1.1.2,Requirement #BE1.05Section 9.1.1.1.2,Requirement #BE1.06Section 9.1.1.1.2,Requirement #BE1.07Section 9.1.1.1.2,Requirement #BE1.07.01Section 9.1.1.1.2,Requirement #BE1.07.02Section 9.1.1.1.2,Requirement #BE1.07.03Section 9.1.1.1.2,Requirement #BE1.07.04Section 9.1.1.1.2,Requirement #BE1.07.059.1.1.1 | 2
RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsBE Member Management Requirements - MMIS A B C D EBE1.08BE1.09BE1.09.01BE1.09.02BE1.09.03BE1.10BE1.11BE1.11.01BE1.11.02Provide an indicator to suppress generation of documents containingmember identification for confidential services or other reasons.Maintain indicators such as clinical or utilization and special needs statusfor such programs as lock-in, disease management, outcomes and highdollarcase management files.Provide the capability to maintain date-specific data necessary tosupport long term care claims processing, such as level of care (LOC),patient financial responsibility, admit and discharge dates, home-leavedays and hospital-leave days.Support the processing of nursing facility, Intermediate Care Facility forthe Mentally Retarded (ICF/MR), Home and Community Based Waiverand other long-term care (LTC) claims through the maintenance ofmember specific LTC data.Support the processing of nursing facility, ICF/MR, Home andCommunity Based Waiver and other long term care claims through themaintenance of provider specific certification and rate data.Maintain record and audit trail of a members requests for copies ofpersonal records (including time and date, source, type and status ofrequest).Maintain record and audit trail of errors during update processes,accounting for originating source and user.Provide the capability to produce daily audit trail reports and allowinquiries showing all member data updates applied to the membermanagement module.Provide the capability to maintain an audit trail to document date, timeand user who accessed a member record through the real-timeinterface.BE1.12 Allow authorized users to update member records online. Yes YesBE1.12.01BE1.13BE1.SS.01BE1.SS.02BE1.SS.03BE1.SS.04BE1.SS.05BE1.SS.07Provide the capability for authorized users to have online inquiry into themember module with access, at minimum, by case number, memberstate identification number (SID), social security number (SSN) andmember name or partial name.Support and track the identification of duplicate member records basedon state-defined criteria.Provide the capability to generate file of new and changed eligiblemembers to the contractor responsible for generating eligibility cards asdirected by IME including production on demand.Provide the capability to generate an alert when a member gives birth orwhen a pregnancy is terminated.Eligibility segments must be date driven and provide accurate eligibilityinformation at any point in history.Provide an online change-correction process, which allows the databaserecord to be modified according to users security access levels.Provide links between all modules, such that the user can easilynavigate with one “click” according to users security access levels.Provide the capability to maintain current and historical information, withinquiry and update capability, for authorized IME users, on MedicarePart A, B, C, D coverage, including but not limited to:YesYesYes No SM 50Yes No SM 80YesYesYes No SM 150Yes No SM 50YesYesYes No SM 100YesYesYes No SM 80Yes No SM 100Yes No SM 50YesYesYesYesYesYesYesYesYesYesSection 9.1.1.1.2,Requirement #BE1.08Section 9.1.1.1.2,Requirement #BE1.09Section 9.1.1.1.2,Requirement #BE1.09.01Section 9.1.1.1.2,Requirement #BE1.09.02Section 9.1.1.1.2,Requirement #BE1.09.03Section 9.1.1.1.2,Requirement #BE1.10Section 9.1.1.1.2,Requirement #BE1.11Section 9.1.1.1.2,Requirement #BE1.11.01Section 9.1.1.1.2,Requirement #BE1.11.02Section 9.1.1.1.2,Requirement #BE1.12Section 9.1.1.1.2,Requirement #BE1.12.01Section 9.1.1.1.2,Requirement #BE1.13Section 9.1.1.1.2,Requirement #BE1.SS.01Section 9.1.1.1.2,Requirement #BE1.SS.02Section 9.1.1.1.2,Requirement #BE1.SS.03Section 9.1.1.1.2,Requirement #BE1.SS.04Section 9.1.1.1.2,Requirement #BE1.SS.05Section 9.1.1.1.2,Requirement #BE1.SS.079.1.1.1 | 3
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Part 4 - Iowa Medicaid Enterprise

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