Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS Operationscredentials and allows authorized users to define which of these credentials must be provided for eachenrollment or re-enrollment activity. Examples of required credentials include:• Medical licenses• Specialty board certifications• General surgery certifications• American Board of Surgery or Surgical Critical Care• Specialty certifications, such as the CLIA certification for a laboratory• Trading Partner Agreement to conduct business using HIPAA transactions• State business licenses• Evidence of malpractice insurance• Additional credential requirements defined by IMEPrior to enrollment approval, the eCAMS wizard applies credentialing policy in real time as the providerenters enrollment information. All required credentials must be entered in order for the application to besubmitted. The wizard provides a lookup feature to ensure that the provider understands what must beprovided. The wizard notifies the provider if required credentials are missing.Once the provider’s enrollment is approved, the Credentialing Matrix is applied each time a change isrequested. The maintenance wizard provides the same functions as the enrollment wizard, advising theprovider of missing information in real time.eCAMS generates warning notices to providers in advance of the expiration of a required credential. Thisallows the provider to update the credential and avoid any lapse in active status.On a nightly basis, provider records are reviewed against the Credentialing Matrix; when missing orexpired credentials are found, the provider’s records are marked as inactive.Using the Credentialing Matrix, authorized users have the ability to implement new or revisedcredentialing requirements through a simple table change. The new credentialing requirement is effectiveas soon as the update is made. The enrollment unit begins by generating a communication that notifiesaffected providers of the new requirement and its effective date. The communication specifies the datewhen the credential must be provided if their enrollment is to remain valid. eCAMS automaticallychanges the status to “inactive” for providers who do not comply. This method limits inactivation tospecific taxonomies and programs for which the credential change is applicable. Other taxonomy/programcombinations for the provider remain active.RuleIT Rule ComposereCAMS uses the flexible and comprehensive RuleIT Rule Composer to define the enrollment rules foreach provider enrollment type and taxonomy (or PTSP). An enrollment type is a predefined generalcategory of provider. Authorized users will use the Rules Composer to define each step of the enrollmentprocess and the data elements required to complete that step for each enrollment type.The business rules developed in the decision management framework discussed above are deployed toproviders and enrollment unit staff in the form of wizards that govern the enrollment and maintenanceactivities for each type of enrollment. Once all of the business rules are defined, the authorized user willuse the Rules Composer to organize the enrollment path for each type of enrollment.Benefit and Feature SummaryTeam Noridian’s approach to the Provider Management business process area provides IME withsignificant benefits, as summarized in Figure 9.1.2.1-10.9.1.2.1 | 23