Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsCR3.SS.01eCAMS provides the capability of front-end editing. This front-end edit is applicable to key claimparameters but not limited to the following: Member (checking for member enrollment), all types ofproviders (checking provider enrollment), revenue codes, prior authorization number (check priorauthorization number), revenue codes, diagnosis codes, procedure codes.Notifications will be sent to providers if the claim fails any of these edits. eCAMS audits all thetransactions and stores the log of all rejected claims.CR3.SS.02eCAMS has a separate Manage Trading Partner module. During the provider enrollment process, allproviders will be subject to trading partner registration. On successful registration, providers will be givenaccess to submit electronic HIPAA X12 transactions. On receipt of claims, EDI Services – EdifecsValidator validates the ISA sender ID and GS sender ID with the Manage Trading Partner module todetermine whether the submitter of a file is a valid trading partner of the submitted HIPAA X12transaction. If the validation is successful, the claim is sent through the remaining process and loaded intoMMIS. If the validation fails, the batch file is rejected and appropriate acknowledgments, such as TA1,997, and 999, are sent depending on the level (Interchange or Functional Group) of failure.CR3.SS.03eCAMS claim receipt business area has two types of system edits: X12 validation edits and system edits.• X12 validation edits are part of Edifecs and are used to validate files against SNIP Types. These editsare built into Edifecs and we can generate a report which provides the list of edits along with theirhistory and their effective dates.• System Edits are edits that come into picture when the claim either loaded or adjudicated. All theseedits are available through online screens and eCAMS supports the maintenance of edit codes throughonline screens and is configurable to support disposition codes, recycle counts, denial reason codesand their effective dates.The Edit Maintenance screen also has the flexibility to vary dispositions for single edit codes based oninvoice types and claim types. The hierarchy flows of edits are defined in RuleIT, while the pricing rulehierarchy for a given code is maintained through eCAMS online screens. Figure 9.1.3.1-30 depicts errorcode maintenance functionality. Audit trail of all modifications to these edits are captured in eCAMSdatabase. The audit trail also captures the user and time of modification to edits.9.1.3.1 | 38