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 EBE2.SS.03BE2.SS.04BE2.SS.09BE2.SS.08BE3.01BE3.02BE3.03BE3.04Provide the capability to maintain a real time interface with the POS toverify member eligibility as directed by IME.Provide the capability to identify and report data exchange transactionsthat fail either fatal and or non-fatal update edits back to the originatingmodule and user area.Provide the capability to lock-in a member to a certain physician,hospital, pharmacy or all.Provide the capability to report on the number of members in lock-instatus, the reason for the lock-in, the number of unauthorized providersbilling for services during lock-in time segments.Provide eligibility status for date(s) queried in response to an eligibilityinquiry made through the MMIS. Track and monitor responses toqueries.Provide notification of third-party payers who must be billed prior toMedicaid in response to an eligibility inquiry made through the MMIS.Provide notice of participation in a managed care program in response toan eligibility inquiry made through the MMIS.Provide notification of program and service restrictions, such as lock-inor lock-out, in response to an eligibility inquiry made through the MMIS.BE3.05 Maintain record and audit trail of responses to eligibility inquiries. Yes YesBE4.01BE4.02BE4.SS.01BE4.SS.02BE4.SS.03BE5.01BE5.02BE5.03BE5.04BE5.05Support system transmission and receipt of all current version X12Neligibility verification transactions. System is required to support futurestandards through the life of the contract at no charge to the State ofIowa.Support production of X12N 270 transactions to query other payereligibility files and ability to process responses.Provide the capability to produce Health Insurance Portability andAccountability Act (HIPAA) certificates of creditable coverage on ascheduled and ad-hoc basis.Provide the capability to produce HIPAA privacy notices on a scheduledand ad hoc basis.Track disclosure of protected health Information (PHI) and have thecapability to indicate persons authorized to discuss PHI for a member.Identify and track potential Medicare buy-in members according to IMEand CMS-defined criteria.Transmit IME-identified buy-in member information for matching againstCMS-specified federal Medicare member database(s).Accept buy-in member response information from CMS-specified federalMedicare member database(s).Process change transactions to update buy-in member information.Identify and track errors or discrepancies between IME and federal buyinmember information.Provide buy-in member information for program or management useincluding:YesYesYesYesYesYesYes No SM 60YesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes No SM 80Yes No SM 120YesYesYes No SM 80YesYesSection 9.1.1.1.2,Requirement #BE2.SS.03Section 9.1.1.1.2,Requirement #BE2.SS.04Section 9.1.1.1.2,Requirement #BE2.SS.09Section 9.1.1.1.2,Requirement #BE2.SS.08Section 9.1.1.1.2,Requirement #BE3.01Section 9.1.1.1.2,Requirement #BE3.02Section 9.1.1.1.2,Requirement #BE3.03Section 9.1.1.1.2,Requirement #BE3.04Section 9.1.1.1.2,Requirement #BE3.05Section 9.1.1.1.2,Requirement #BE4.01Section 9.1.1.1.2,Requirement #BE4.02Section 9.1.1.1.2,Requirement #BE4.SS.01Section 9.1.1.1.2,Requirement #BE4.SS.02Section 9.1.1.1.2,Requirement #BE4.SS.03Section 9.1.1.1.2,Requirement #BE5.01Section 9.1.1.1.2,Requirement #BE5.02Section 9.1.1.1.2,Requirement #BE5.03Section 9.1.1.1.2,Requirement #BE5.04Section 9.1.1.1.2,Requirement #9.1.1.1 | 6
RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsBE Member Management Requirements - MMIS A B C D EBE5.06BE5.SS.01BE5.SS.02BE5.SS.03BE5.SS.04BE5.07BE5.07.01a. Transactions processed.b. Errors identified.c. Error correction status.d. Medicare premiums to be paid by member.Track buy-in exceptions for those members who are identified aseligible, but whose premiums have not been paid.Provide the capability to send an alert of all buy-in transactions that mayaffect eligibility status or cost shares for buy-in members.Provide the capability to generate buy-in premiums and provide theinformation required to support IME payment of premiums.Provide the capability to send a file to CMS of all buy-in deletions due toMedicaid and or Medicare eligibility termination or death and changes.Provide an alert and a weekly report of when Centers for Medicare andMedicaid Services (CMS) notifies the IME that another state has boughtinto Medicare for a member.Support automated data exchange process or processes, as specifiedby CMS, in order to identify and track Medicare Part D dual-eligible andMedicare Low-Income Subsidy (LIS) eligible members for the purposesof cost-avoidance on prescription drug claims and calculatingspenddown payments.Provide the capability to maintain an interface with CMS to assure thetimely accretion of Medicare eligible members for Part A and Part Bbenefit buy-in.BE.SS.01 Maintain historical date-specific spenddown information. Yes YesBE.SS.02BE.SS.03BE.SS.04BE.SS.05BE.SS.06Allow for providers to submit claims electronically for spenddownapplication for the member and family of the members.Allow for providers to submit inquiries concerning spenddownrequirements for a member.Allow members to view spenddown information on the web portalincluding claims that were submitted and used toward spenddown.Generate notice to provider and member of claims that were applied tospenddown and amount of unmet spenddown.Apply the amount of claims that are denied for unmet spenddown to thespenddown balance.BE.SS.07 Provide the capability to prevent duplicate use of claims for spenddown. Yes YesBE.SS.08BE.SS.9BE.SS.10Provide capability to manually deduct claims originally applied to unmetspenddown as directed by IME.Support edits which prevent payment of claims that were applied tospenddown in whole or part.Return spenddown met indicator (fund code) to eligibility system oncethe spenddown amount is met.YesYesYes No SM 60YesYesYesYesYes No SM 80YesYesYesYesYesYesYesYesYesYesYes No SM 120YesYesYes No SM 150Yes No SM 100Yes No SM 80BE5.05Section 9.1.1.1.2,Requirement #BE5.06Section 9.1.1.1.2,Requirement #BE5.SS.01Section 9.1.1.1.2,Requirement #BE5.SS.02Section 9.1.1.1.2,Requirement #BE5.SS.03Section 9.1.1.1.2,Requirement #BE5.SS.04Section 9.1.1.1.2,Requirement #BE5.07Section 9.1.1.1.2,Requirement #BE5.07.01Section 9.1.1.1.2,Requirement #BE.SS.01Section 9.1.1.1.2,Requirement #BE.SS.02Section 9.1.1.1.2,Requirement #BE.SS.03Section 9.1.1.1.2,Requirement #BE.SS.04Section 9.1.1.1.2,Requirement #BE.SS.05Section 9.1.1.1.2,Requirement #BE.SS.06Section 9.1.1.1.2,Requirement #BE.SS.07Section 9.1.1.1.2,Requirement #BE.SS.08Section 9.1.1.1.2,Requirement #BE.SS.9Section 9.1.1.1.2,Requirement #BE.SS.109.1.1.1 | 7
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Part 4 - Iowa Medicaid Enterprise

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