Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsCA Claims Adjudication Requirements - MMIS A B C D ECA1.11.03CA1.12Provide the capability to track payments for each member in total and to limitpayments to any combination of benefit plans based on total services or an overalldollar ceiling as set by rules in the benefit plan administration rules engine.Identify and hierarchically assigns status and disposition of claims (i.e., suspend ordeny) that fail edits based on the edit disposition record.CA1.13 Identify and track all edits and audits posted to the claim in a processing period. Yes YesCA1.13.01CA1.13.02CA1.14CA1.SS.01CA1.SS.02CA1.SS.03CA1.SS.04Provide the capability to configure and apply all edits and audits with a rulesengine.Allow unlimited edits to any claim as defined by IME. Provide the capability to limitthe number of errors on a single claim before denying the claim.Provide and maintain for each error code, a resolution code, an override, force ordeny indicator and the date that the error was resolved, forced and or denied.Provide the ability to process a claims payment file daily, weekly and as specifiedby IME.Provide the capability to stamp the date, federal report code and state accountcode at the claim and line level of each claim.Apply edits to prevent payments for services covered under a waiver program to aMedicaid provider who does not have a provider agreement.Provide the ability to process a corrected claim through all edits and audits aftercorrections are applied to a rejected claim.Yes No SM 160YesYesYesYesYesYesYesYesYesYesYesYesYes No COTS 120CA1.SS.05 Provide the ability to store in the MMIS claims processed through the POS. Yes No SM 200CA2.01 Verify all fields defined as numeric contain only numeric data. Yes YesCA2.01.01Support claim adjudication based on HIPAA standard code sets in effect on thedate of service.CA2.02 Verify all fields defined as alphabetic contain only alphabetic data. Yes YesCA2.02.01Support claim adjudication based on HIPAA procedure modifiers in effect on thedate of service (i.e., the ability to bring in all modifiers and use a hierarchy definedby IME).CA2.03 Verify all dates are valid and reasonable. Yes YesCA2.04CA2.05CA2.06Verify all data items which can be obtained by mathematical manipulation of otherdata items, agree with the results of that manipulation.Verify all coded data items consist of valid codes (e.g., procedure codes, diagnosiscodes, service codes) that are within the valid code set under HIPAA Transactionsand Code Sets (TCS) and are covered by the state plan.Verify any data item that contains self-checking digits (e.g., member ID number,NPI number) passes the specified check-digit test.YesYesYesYesYes No SM 120YesYesYesYesYes No SM 320Section 9.1.3.2.2,Requirement #CA1.11.03Section 9.1.3.2.2,Requirement #CA1.12Section 9.1.3.2.2,Requirement #CA1.13Section 9.1.3.2.2,Requirement #CA1.13.01Section 9.1.3.2.2,Requirement #CA1.13.02Section 9.1.3.2.2,Requirement #CA1.14Section 9.1.3.2.2,Requirement #CA1.SS.01Section 9.1.3.2.2,Requirement #CA1.SS.02Section 9.1.3.2.2,Requirement #CA1.SS.03Section 9.1.3.2.2,Requirement #CA1.SS.04Section 9.1.3.2.2,Requirement #CA1.SS.05Section 9.1.3.2.2,Requirement #CA2.01Section 9.1.3.2.2,Requirement #CA2.01.01Section 9.1.3.2.2,Requirement #CA2.02Section 9.1.3.2.2,Requirement #CA2.02.01Section 9.1.3.2.2,Requirement #CA2.03Section 9.1.3.2.2,Requirement #CA2.04Section 9.1.3.2.2,Requirement #CA2.05Section 9.1.3.2.2,Requirement #CA2.069.1.3.2 | 2