Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsCR1.06eCAMS contains a set of monitors and controls to track the claims and ensure proper balancing betweenthe inbound and outbound HIPAA EDI transactions. The controls employ automated and manualinterventions to ensure that none of the claims in a particular queue are dropped. For each of the claimstatuses, there are checkpoints set up to monitor that the claim is being handed off appropriately to thenext step.eCAMS also reconciles all processed claims and encounters through a series of data control reports. Thecontrol reports reconcile the EDI transactions received to the corresponding loaded claim records. EDIfile loading status, claim process status timelines, and claim type counts including encounters and batchcontrol numbers are some of the types of information used to ensure that all submitted claims areprocessed. Scheduled reports are generated for each of the aforementioned categories. Each of thesereports is stored over a specified period, distributed, or available on demand. This feature-rich componentallows authorized users to have online access to reports and permits local printing of an entire report orany portion of the report.Team Noridian’s solution provides an online dashboard feature to facilitate access to the operationsstatistics including the claims processing trends, suspend queue workloads, and aged claim status. Theoperations reports also identify the aged claims that have been in the system for more than 15, 30 and45 days. Team Noridian’s operations team investigates the reason for the delays and takes appropriateaction to resolve and release those claims. We will duly notify the Department for any action that requiresthe attention of Department. Figure 9.1.3.1-9 is a sample report for the loading process and highlights thevarious claim types and encounters being loaded. The report shows the invoice type and the status of eacharea. The status will serve as a checkpoint to reconcile the count of how many were entered into thesystem and the subsequent hand-off to the next step.Every claim entering the system is assigned a TCN which is an intelligent identifier. The first two digitsindicate the source of the claim such as EDI, paper etc. The scheduled reports group data by claim sourceto ensure that each claim is accounted for. For paper based claims, the data is reconciled with informationcollected within OnBase to ensure that all claims have been accounted for. Emdeon’s Transform outputfiles contain a list of each claim that was processed through the system. OnBase creates a verificationreport for each job that it processes. Within this verification report, OnBase keeps a count of all identifieddocuments as well as noting any unidentified records. These values are able to be compared to eCAMSand Transform reports to ensure all claims are reconciled from scanning to upload in the MMIS.9.1.3.1 | 15