Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsPR Provider Management Requirements - MMIS A B C D EPR1.12PR1.SS.02PR2.01PR2.02PR2.02.01PR2.03PR2.04PR2.04.01PR2.04.02PR2.05PR2.05.01PR2.06PR2.06.01PR2.06.02Provide for consistent provider naming conventions to differentiatebetween first names, last names and business or corporate names toallow flexible searches based on the provider name.Enrollment tracking process must be fully integrated with the MMIS andPoint-of-Sale (POS) so that information can be tracked from enrollmentrequest through provider enrollment without requiring duplicate entries insystems.Track and support the screening of applications and ongoing providerupdates for NPIs, state licenses and specialty board certification asappropriate. Review team visits when necessary and any other state andor federal requirement.Track and support any established provider review schedule to ensureproviders continue to meet program eligibility requirements.Maintain the capability to place a provider on either prepayment or postpayment review including the capability to identify whether the status isno review, prepayment review, post payment review, or both pre-andpostpayment review and include an indicator to identify the reason theprovider was placed on review.Verify provider eligibility in support of other system processes (e.g.,payment of claims).Capture Clinical Laboratory Improvement Amendments (CLIA)certification information and the specific procedures each laboratory isauthorized to cover. Link the information for use in claims adjudication.Receive updates to CLIA numbers and certification information. TheCLIA and certification information must be maintained by date segment,including an audit trail of the changes made.Use CLIA information from the national data site in the enrollmentprocess.Cross-reference license and sanction information with other state orfederal agencies.Provide the capability of matching providers based on a file ofsanctioned providers received from the appropriate state licensingauthority and other provider licensing boards, as well as other licensingand certification boards and flagging and updating the provider's recordfor termination.Generate notices to providers of expiring Medicaid agreements and orstate licenses.Automatically generate letters to providers requesting licensecertification renewal prior to end date of current certification or license asdirected by IME.Automatically generate an alert and a provider termination notice whenthe provider fails to respond within 30 days with updated license renewalinformation.PR2.06.03 Have the capability to edit the provider master file for license end date. Yes YesPR2.07Maintain multiple provider specific reimbursement rates with beginningand ending dates consistent with IME policy including but not limited to:a. Per Diem.b. Percentage of charges.c. Fee-for-Service (FFS).d. Ambulatory Payment Calculations (APC).e. Diagnosis Related Groups (DRG).f. Other.YesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes No SM 600YesYesYesYesYes No SM 40YesYesSection 9.1.2.1.2,Requirement #PR1.12Section 9.1.2.1.2,Requirement #PR1.SS.02Section 9.1.2.1.2,Requirement #PR2.01Section 9.1.2.1.2,Requirement #PR2.02Section 9.1.2.1.2,Requirement #PR2.02.01Section 9.1.2.1.2,Requirement #PR2.03Section 9.1.2.1.2,Requirement #PR2.04Section 9.1.2.1.2,Requirement #PR2.04.01Section 9.1.2.1.2,Requirement #PR2.04.02Section 9.1.2.1.2,Requirement #PR2.05Section 9.1.2.1.2,Requirement #PR2.05.01Section 9.1.2.1.2,Requirement #PR2.06Section 9.1.2.1.2,Requirement #PR2.06.01Section 9.1.2.1.2,Requirement #PR2.06.02Section 9.1.2.1.2,Requirement #PR2.06.03Section 9.1.2.1.2,Requirement #PR2.079.1.2.1 | 3