Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationseCAMS associates all of the members comprising a case to one another. During the claims adjudicationprocess, the ability to determine if a claim belongs to a case where the head of household is enrolled as aspenddown client is available. Once identified, the payment amount of the claim can be applied againstthe spenddown amount of the case head.BE.SS.03eCAMS’ DDE screen functionality allows authorized providers to inquire spend down eligibilityinformation for a member. It also allows authorized providers to submit 270/271 for spenddown inquiries.BE.SS.04The eCAMS member portal has the flexibility to display member spenddown information; including claimsapplied towards spenddown, along with other member benefit related details using secured access privilege.BE.SS.05eCAMS’ framework supports the generation of letters of notice to providers and members of claims thatwere applied to spenddown based on scheduled trigger set by IME.BE.SS.06eCAMS deducts claims payments if the spenddown amount is not met by the member. Based on themember spenddown information, claims post edit 02235 - CLIENT PENDING SPENDDOWN REVIEW.The edit disposition is set to suspend ensuring the spenddown has been met.The eCAMS member record maintains spenddown information and tracks the spenddown balances of anindividual member.BE.SS.07The eCAMS adjudication engine has edits related to specific policies which are grouped in the rulesengine based on a logical grouping of those policies. For example, in eCAMS there is a set of duplicateclaims edits which could be configured to execute Department policies on exact and suspect duplicatesapplied to spend down for the same member.BE.SS.08eCAMS collects member spenddown amounts via eligibility interfaces. The spenddown amount is thenavailable for reduction during claims adjudication.eCAMS also supports adjustment processes whereby based on IME direction, Team Noridian canmanually flag the adjustment claim to be deducted from the original unmet spenddown. The adjustmentadjudication process will automatically deduct from the originally applied to unmet spenddown amount.BE.SS.9The claims adjudication module within eCAMS supports flexible editing of claims during adjudicationwhich prevents claims from being paid, in whole or part, during the period in which the client has not mettheir spenddown responsibility.The claims meeting these editing criteria can be marked as paid, but paid at zero, for service registry,similar to encounters where the services are registered as rendered but the payment amount is zero.BE.SS.10eCAMS returns a spenddown met indicator (fund code) to the eligibility system once the spenddownamount is met. The interface between the State eligibility system and eCAMS eligibility system is bidirectional in that both applications provide daily feeds to each other in order to stay in sync.9.1.1.1 | 57