Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsFigure 9.1.1.1-34 depicts benefit planassignment in eCAMS using eligibility factorsreceived as part of eligibility files and definedbenefit plan rules.BE2.01.03The eCAMS reference administration has theflexibility to define benefit plans using DDEscreen functionality. When system receiveseligibility files from multiple sources it willprocess and assigns benefit plans at memberlevel based on eligibility and authorizationfactors. These different benefit plan segmentswill be linked to a member and will be used forclaims processing for that member for the dateof service received.The system assigns a unique member systemidentifier, called a member SID, to eachmember. All subsequent transactions andqueries for a member are associated to themember SID, after a detailed de-duplicationprocess. This enables the member's MedicaidID, and multiple benefit plan identifiers for thatmember, to be linked to the unique eCAMSmember identifier and avoid duplication ofmember records/data.Figure 9.1.1.1-34. eCAMS assigns multiplebenefit plans for a member based on eligibilityand authorization factors.BE2.01.04The eCAMS reference module has the flexibility for authorized users to seamlessly define and maintaindifferent benefit plans using benefit plan administration wizard. The defined benefit plans will havepriority, co-existing with other benefit plans and restriction like procedure, diagnosis, claim type, andprovider which will be used during claims processing.When eCAMS receives member eligibility information through the interface it will use the benefit plandefined in the reference module to assign these at the member level.When system processes claims for members it will use the benefit plan assigned at member level and willcheck the different restrictions defined at benefit plan level before paying.Figure 9.1.1.1-35 depicts DDE screen functionality for authorized users to define and maintain benefitplan details.9.1.1.1 | 41