Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS Operations• A flexible benefit program structure to support FFS, MCO, waiver programs, personal care programsand others as needed by IME:• The configurable program structure administers FFS and managed care programs; programdefinitions include eligibility criteria for the program, covered services, service areas, servicerestriction, and cost sharing.• The configurable structure is derived from commercial health plan structures and carve-outservices and service areas within a benefit program. The plans within the benefit program providemultiple delivery modes and a la carte services.The centralized member data repository along with the configurable benefit program structure facilitatesthe maintenance of information on each member’s Medicaid benefits by IME, in support of claimspayment and other financial processes• An online, web-based eligibility system affords greater accessibility and includes Role Based AccessControl (RBAC) for granular security:• Member information can be accessed through online web screens as long as the user has propercredentials; information displayed to a user is restricted and based on security access.• Authorized providers are allowed to view online eligibility information of a member; the contentis limited to what is allowed under the EDI standard 271 HIPAA response.• Restrictions and audits are enforced on PHI data inquiries related to protected population.• Providers will have the flexibility to inquire on utilization tied to share of cost and will also havethe flexibility to view contribution information and prior authorization service utilization• eCAMS ensures HIPAA EDI, HIPAA screen compliance, and PHI are enforced and adhered toacross all of the eCAMS business process areas. This compliance is already implemented inWashington and Michigan projects.• Integrated on-demand and batch member correspondence generation features:• Users have the ability to generate letters, such as explanation of medical benefits (EOMB), lettersof creditable coverage, and EPSDT schedule reminders from the member business process area.• Users are afforded the flexibility to generate on-demand or batch processes for mailing; generatedletters are stored in electronic Document repository in an automated fashion for later referenceand to support audits.• Users also have the ability to retrieve all correspondence tied to a specific member from theonline member business process area.Proposed Solution Overview for eCAMS Member Business Process AreaFigure 9.1.1.1-2 depicts the proposed eCAMS member management business architecture along witheCAMS-supported member MITA business processes. The Figure identifies the member-dependentprocesses tied to the Claims, Managed Care, Prior Authorization (PA), TPL, Case Management,Reference, Provider, and Reporting business process areas. The figure also identifies some of the otherrequired external systems, identified in the RFP, such as eligibility, managed care enrollment broker,Medicare Buy-In, EDI switch vendors, TPL carriers, data warehouse, point-of-sale (POS), and TPLcontractor interactions.9.1.1.1 | 11