Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsCR Claims Receipt Requirements - MMIS A B C D ECR1.14.01CR1.14.02CR1.14.03CR1.16CR1.17CR1.17.01CR1.17.02CR1.18Provide the ability to tie the electronic claim to all related paper claimimages, attachments and adjustments that are submitted for the claim.Receive and process electronic attachments and apply them to one ormore claims based on IME rules.Provide the capability to accept attachments to any transactions (e.g.,claim, prior authorization, eligibility) and apply an attachment indicator inthe MMIS.Support testing of new provider claims submission systems by allowingproviders to submit electronic claims test files that are processedthrough the adjudication cycle without impact on system data.Identify any incomplete claim batches that fail to balance to controlcounts.Provide a return transmission that verifies the number of claims receivedand accepted.Maintain electronic data interchange (EDI) transmission logs of alltransactions (i.e., successful or failed).Provide and maintain the capability to process standard financialtransactions, including recoupments and payouts which cover more thanone claim and or service.CR1.SS.01 Accept pharmacy claims from the POS. Yes YesCR1.SS.02Provide the capability for authorized IME users to directly enter a claimonline when IME deems necessary.CR1.SS.03 Record time and date and user in the record for any online updates. Yes YesCR1.SS.04CR1.SS.05CR1.SS.06CR1.SS.07Provide the edit capability to check for correct provider number when theprovider submits the claim (e.g., at the front end).At a minimum, accept the following types of electronic claims: electronicbatch, individual electronic, DDE and paper claims converted toelectronic by an imaging process.Provide the capability to edit for potential duplicate services across allclaim types as defined by IME.Report all claim lines billed by a provider as a single claim, or HIPAAtransaction, by a provider, as a single claim document, to users andproviders.CR1.SS.08 Provide the ability to process all claims real-time. Yes YesCR1.SS.09CR1.SS.10Support a customized (reduced data requirements) online claimsubmission feature for waivered services, and other entities not coveredby HIPAA.Provide and maintain a data entry system that accepts and stores alldata elements deemed necessary by IME including but not limited to thefollowing:a. Provider type.b. Specialty.c. Sub-specialty.YesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes No SM 500YesYesSection 9.1.3.1.2,Requirement #CR1.14.01Section 9.1.3.1.2,Requirement #CR1.14.02Section 9.1.3.1.2,Requirement #CR1.14.03Section 9.1.3.1.2,Requirement #CR1.16Section 9.1.3.1.2,Requirement #CR1.17Section 9.1.3.1.2,Requirement #CR1.17.01Section 9.1.3.1.2,Requirement #CR1.17.02Section 9.1.3.1.2,Requirement #CR1.18Section 9.1.3.1.2,Requirement #CR1.SS.01Section 9.1.3.1.2,Requirement #CR1.SS.02Section 9.1.3.1.2,Requirement #CR1.SS.03Section 9.1.3.1.2,Requirement #CR1.SS.04Section 9.1.3.1.2,Requirement #CR1.SS.05Section 9.1.3.1.2,Requirement #CR1.SS.06Section 9.1.3.1.2,Requirement #CR1.SS.07Section 9.1.3.1.2,Requirement #CR1.SS.08Section 9.1.3.1.2,Requirement #CR1.SS.09Section 9.1.3.1.2,Requirement #CR1.SS.109.1.3.1 | 2