SSB 1164

This bill relates to Medicaid program processes and oversight. _____ claims, provider rate changes, and claims tracking. The division defines “clean claim” for the purposes of the division. The bill directs the department of human services (DHS) to require that a Medicaid managed care organization (MCO) process and pay participating provider claims for each distinct provider type in accordance with the following: percent of clean claims shall be accurately paid or denied within calendar days, percent of clean claims shall be accurately paid or denied within calendar days, and 100 percent of clean claims shall be accurately paid or denied within calendar days, of receipt by the MCO. The date of receipt of the clean claim shall be based on the documented transmission date as reported by the clearinghouse or the MCO transmission system. Division I provides that an MCO shall have calendar days from receipt of notice from DHS of a change in a provider rate to accurately input the new rate into the MCO’s payment system and to reprocess and pay any affected claims. Division I requires an MCO to provide the MCO’s participating providers with the functionality to submit and track all claims, claim disputes, claim reconsiderations, and appeals on the MCO’s internet site to facilitate participation in an open and shared participating provider record. Division II of the bill relates to the use of uniform authorization criteria and a single credentialing verification organization by the Medicaid program. The division requires DHS to utilize a request for proposals process to procure the services of a single credentialing verification organization to be utilized by the state in credentialing and recredentialing providers for both the Medicaid managed care and fee-for-service payment and delivery systems. _____ as an Iowa Medicaid provider utilizing the credentialing verification system. DHS shall also contractually prohibit all MCOs from requiring additional credentialing information from a provider approved and enrolled by the department as an Iowa Medicaid provider in order to be a participating provider in the MCO’s provider network.