Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsBE Member Management Requirements - MMIS A B C D EBE.SS.11BE.SS.12BE.SS.13Ensure claims are applied to spenddown in the Medically Needy file on afirst in, first used basis.Allow claims for household members and or relatives of the member, tobe applied against the spenddown amount per Iowa rules.Provide online screens showing the Medically Needy spenddownamount, the amount of claims that have accumulated towards thespenddown amount, information for each certification period, the datespenddown is met and information about claims used to meetspenddown.YesYesYes No SM 80BE.SS.14 Provide a summary screen of the members certification history. Yes No SM 80BE.SS.15BE.SS.16Apply the unpaid portion of Medicare Crossover Claims to the MedicallyNeedy spenddown amount if the amount is greater than zero.Transmit the following information to the IME each time MMIS loads filetransfers from the external systems:a. Confirmation of the date each file is received and loaded.b. The number of files and or records that were successfully transmittedand posted.c. The number and detailed information of the records that wererejected.d. The rejection reason code for each record rejected.BE.SS.17 Reversals of claims should automatically adjust spenddown. Yes No SM 100BE.SS.18BE.SS.19Spenddown balances should be made available real-time to thepharmacy point-of-sale system and should be verified before claimsare paid.Process and maintain inputs and outputs including but not limited tothe following:Inputs:a. Data from the eligibility systems.b. Provider data.c. EPSDT data.d. Federal and state enrollment rules.e. Data entered and uploaded by professional service contractors.Outputs:a. Notices of Decision and appeal rights to members on deniedambulance claims and denied rehabilitation therapy service claims asdirected by the Department.b. Notices of Decision to members for denied and modified priorauthorizations.c. State Supplementary Assistance checks to the address on file foreach Residential Care Facility (RCF) member.d. Weekly file listing the state ID numbers, names, dates of service,amount paid and date paid of all Medicaid Members for whom aMedicare crossover claim has been paid, but for whom Medicareeligibility is not indicated on the eligibility record.e. Data entry and edit exception reports to the Department forreconciliation with eligibility data.f. Run a monthly report showing any possible duplicates that exist on theMMIS member eligibility file.g. Histories for inquiries with dates of service for which data has beenarchived.h. All IME specified reports.i. Data extracts for Medicaid Statistical Information System (MSIS),Payment Error Rate Measurement (PERM) and Office of InspectorGeneral (OIG) audits or any federal or state audits.YesYesYesYesYesYesYesYesYes No SM 120Section 9.1.1.1.2,Requirement #BE.SS.11Section 9.1.1.1.2,Requirement #BE.SS.12Section 9.1.1.1.2,Requirement #BE.SS.13Section 9.1.1.1.2,Requirement #BE.SS.14Section 9.1.1.1.2,Requirement #BE.SS.15Section 9.1.1.1.2,Requirement #BE.SS.16Section 9.1.1.1.2,Requirement #BE.SS.17Section 9.1.1.1.2,Requirement #BE.SS.18Section 9.1.1.1.2,Requirement #BE.SS.199.1.1.1 | 8