Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsFigure 9.1.1.1-39. Benefit Plan Wizard. eCAMS provides and online wizard to walk authorized usersthrough the process of defining a benefit plan.BE2.02.03The eCAMS reference business process module supports the ability for authorized users to define andmaintain different benefit plans without programmer dependency. The benefit plan wizard allowsauthorized users to define different types of benefit plans such as Fee for Service or Managed Care. Thesystem also has the flexibility to define different restrictions at the benefit plan level such as service area,capacity, claim type, and cost sharing which will be used during claims processing. The results of thebenefit plan configuration process are stored in table driven rules for use in benefit plan assignments andclaims processing.BE2.02.04eCAMS maintains both active and historical record of benefit plan assignments for a member includingtheir dual eligibility information. Users can view both active and historical benefit plan details usingscreen functionality.BE2.03The eCAMS reference module provides online screen functionality for authorized users to definerestrictions/limitation for different benefit plans.During the eligibility 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. Thebenefit plan definition includes the eligibility criteria for the plan, the services covered, applicable planpremiums, the co-pay deductible, and excluded services. During claims processing, the system uses thelimitations and restrictions defined at benefit plan level for their adjudication.Figure 9.1.1.1-40 shows authorized users how to create different limitation for benefit plan which will beused during claims processing.9.1.1.1 | 45