Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsBE2.01.01The eCAMS reference management module maintains all benefit plan creations, their co-existence withother benefit plans, priority and restrictions to different codes like procedure, diagnosis, claim types. Thebenefit plan assignment matrix is used by the member management module to assign benefit plans at themember level based on different data elements received in eligibility segments. eCAMS provides theflexibility to define specific table driven business rules for benefit plan effective dates, and to set them atthe benefit plan level. For example, the rule for the effective date of benefit plan A may be to set theeffective date as the first day of the following business month, while the effective date for benefit plan Bmay be a default date defined by IME.Figure 9.1.1.1-33 identifies multiple benefit coverage groups assigned for a member.Figure 9.1.1.1-33. eCAMS assigns benefit plan, including start and end dates, based on eligibility anddemographic factors.BE2.01.02eCAMS supports the creation and maintenance of different benefit plans using the reference businessprocess module via online screen functionality. Department defined business rules outline the benefitplans and their priority. The benefit plan definition includes the eligibility criteria for the plan, theservices covered, applicable plan premiums, the co-pay deductible, and excluded services.During the eligibility data intake process, eCAMS applies and associates benefit plans based on eligibilitycriteria defined for the member, whether for FFS, managed care benefit plans, or other defined plans.Whenever eCAMS receives eligibility and authorization data from multiple sources it uses benefit planrules for priority and co-existence to derive benefit plan assignments using the eligibility factors received.eCAMS applies Department-defined recipient aid category (RAC) hierarchies based on covered servicesas defined through procedure/revenue codes and taxonomy codes. The claims adjudication processutilizes the combination of RAC hierarchies and benefit plan assignments to determine which benefit planwill fund the claimed service.9.1.1.1 | 40