House Study Bill 169 - Introduced HOUSE FILE _____ BY (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON LUNDGREN) A BILL FOR An Act relating to Medicaid program processes and oversight. 1 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 2 TLSB 2169YC (5) 89 pf/rh

H.F. _____ DIVISION I 1 MEDICAID PROGRAM PROCESSES AND OVERSIGHT 2 Section 1. MEDICAID PROGRAM CLEAN CLAIMS —— PROVIDER RATE 3 CHANGES —— CLAIMS TRACKING. 4 1. For the purposes of this section, “clean claim” means 5 a claim that has no defect or impropriety including any 6 lack of required substantiating documentation or particular 7 circumstance requiring special treatment that prevents timely 8 payment of the claim. “Clean claim” does not include a claim 9 from a provider that is under investigation for fraud or abuse 10 or a claim under review for medical necessity. 11 2. a. The department of human services shall require 12 that Medicaid managed care organizations process and pay 13 participating provider claims for each distinct provider type 14 in accordance with the following: 15 (1) Ninety percent of clean claims shall be accurately 16 paid or denied within fourteen calendar days of receipt by the 17 Medicaid managed care organization. 18 (2) Ninety-five percent of clean claims shall be accurately 19 paid or denied within twenty-one calendar days of receipt by 20 the Medicaid managed care organization. 21 (3) One hundred percent of clean claims shall be accurately 22 paid or denied within thirty calendar days of receipt by the 23 Medicaid managed care organization. 24 b. The date of receipt of the clean claim shall be 25 based on the documented transmission date as reported by 26 the clearinghouse or the Medicaid managed care organization 27 transmission system. 28 3. A Medicaid managed care organization shall have 29 thirty calendar days from receipt of notice from the 30 department of human services of a change in a provider rate to 31 accurately input the new rate into the Medicaid managed care 32 organization’s payment system and to reprocess and pay any 33 affected claims. 34 4. A Medicaid managed care organization shall provide the 35 -1- LSB 2169YC (5) 89 pf/rh 1/ 4

H.F. _____ Medicaid managed care organization’s participating providers 1 with the functionality to submit and track all claims, claim 2 disputes, claim reconsiderations, and appeals on the Medicaid 3 managed care organization’s internet site to facilitate 4 participation in an open and shared participating provider 5 record. 6 DIVISION II 7 MEDICAID PROVIDER CREDENTIALING 8 Sec. 2. MEDICAID PROGRAM —— USE OF UNIFORM AUTHORIZATION 9 CRITERIA AND SINGLE CREDENTIALING VERIFICATION ORGANIZATION. 10 1. The department of human services shall utilize a request 11 for proposals process to procure the services of a single 12 credentialing verification organization to be utilized by 13 the state in credentialing and recredentialing providers for 14 both the Medicaid managed care and fee-for-service payment and 15 delivery systems. 16 2. The department shall contractually require all Medicaid 17 managed care organizations to accept verified information from 18 the single credentialing verification organization procured 19 by the state, and to approve as a participating provider any 20 provider approved and enrolled by the department as an Iowa 21 Medicaid provider utilizing the credentialing verification 22 system. 23 3. The department shall contractually prohibit all 24 Medicaid managed care organizations from requiring additional 25 credentialing information from a provider approved and enrolled 26 by the department as an Iowa Medicaid provider in order to 27 be a participating provider in the Medicaid managed care 28 organization’s provider network. 29 EXPLANATION 30 The inclusion of this explanation does not constitute agreement with 31 the explanation’s substance by the members of the general assembly. 32 This bill relates to Medicaid program processes and 33 oversight. 34 Division I of the bill relates to Medicaid program clean 35 -2- LSB 2169YC (5) 89 pf/rh 2/ 4

H.F. _____ claims, provider rate changes, and claims tracking. The 1 division defines “clean claim” for the purposes of the 2 division. The bill directs the department of human services 3 (DHS) to require that a Medicaid managed care organization 4 (MCO) process and pay participating provider claims for each 5 distinct provider type in accordance with the following: 90 6 percent of clean claims shall be accurately paid or denied 7 within 14 calendar days, 95 percent of clean claims shall be 8 accurately paid or denied within 21 calendar days, and 100 9 percent of clean claims shall be accurately paid or denied 10 within 30 calendar days, of receipt by the MCO. The date of 11 receipt of the clean claim shall be based on the documented 12 transmission date as reported by the clearinghouse or the MCO 13 transmission system. 14 Division I provides that an MCO shall have 30 calendar days 15 from receipt of notice from DHS of a change in a provider rate 16 to accurately input the new rate into the MCO’s payment system 17 and to reprocess and pay any affected claims. 18 Division I requires an MCO to provide the MCO’s 19 participating providers with the functionality to submit and 20 track all claims, claim disputes, claim reconsiderations, and 21 appeals on the MCO’s internet site to facilitate participation 22 in an open and shared participating provider record. 23 Division II of the bill relates to the use of uniform 24 authorization criteria and a single credentialing verification 25 organization by the Medicaid program. The division 26 requires DHS to utilize a request for proposals process to 27 procure the services of a single credentialing verification 28 organization to be utilized by the state in credentialing and 29 recredentialing providers for both the Medicaid managed care 30 and fee-for-service payment and delivery systems. DHS shall 31 contractually require all MCOs to accept verified information 32 from the single credentialing verification organization 33 procured by the state, and to approve as a participating 34 provider any provider approved and enrolled by the department 35 -3- LSB 2169YC (5) 89 pf/rh 3/ 4

H.F. _____ as an Iowa Medicaid provider utilizing the credentialing 1 verification system. DHS shall also contractually prohibit all 2 MCOs from requiring additional credentialing information from 3 a provider approved and enrolled by the department as an Iowa 4 Medicaid provider in order to be a participating provider in 5 the MCO’s provider network. 6 -4- LSB 2169YC (5) 89 pf/rh 4/ 4