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					                               IFMC Response to the Iowa Department of Human Services
                            Medical Services with Preferred Drug List - RFP #MED-04-034

Medical Support

A. Introduction

  The Iowa Foundation for Medical Care (IFMC) is dedicated to improving the health care
  for Medicaid members in the state of Iowa. IFMC has been the Medicare Peer Review
  Organization in Iowa and has served in that capacity since 1984. Prior to that, IFMC was
  the Medicare Professional Standards Review Organization for the state of Iowa from 1974
  through 1983. IFMC is the present contractor with the Iowa Department of Human
  Services (DHS) for the Medicaid Utilization and Quality Review programs.

  IFMC has enjoyed a cooperative and productive working relationship with DHS dating
  back to 1979. As a physician organization with over 2,000 members, IFMC has been
  performing many of the utilization review requirements specified in the current
  procurement for over fifteen (15) years. IFMC’s Medicaid management team has over
  fifty (50) years of combined experience with developing, implementing, and monitoring
  Medicaid utilization and quality improvement programs.

  IFMC understands the importance of improving the quality of care for Medicaid members
  by ensuring their care meets professionally recognized standards in hospitals, nursing
  facilities, other medical institutions, and home and community based settings. A strong
  quality and utilization management program protects the integrity of the Medicaid program
  by ensuring that Medicaid pays only for services and items that are reasonable, medically
  necessary, and provided in the most appropriate setting. For over ten (10) years, IFMC’s
  Medicaid Utilization Review Program has been successful in documenting savings for the
  State of Iowa. Each quarter, IFMC provides a cost savings report to DHS which
  consistently shows significant financial savings for the State compared to the cost of
  administering the program.

  Under its current contracts with DHS, IFMC is regularly asked to perform ad hoc programs
  and pilots. These include long term care assessments, disease management pilots, and
  many others. IFMC conducts research through consultation, surveys, best practices, report
  writing and the development of recommendations.

  IFMC understands that the medical support function includes policy development and
  consulting for specific service areas on behalf of DHS. As the medical services contractor,
  IFMC will have available the requisite medical and professional staff to meet DHS
  requests for professional advice for all areas of the program as well as recommendations on
  potential additions or changes to the existing coverage array for Medicaid.

  As with all other services components of this procurement, IFMC has proposed a risk-
  sharing arrangement with DHS that ties our revenue under the contract to our ability to
  meet specified performance measures. The specifics of this arrangement are discussed in
  our cost proposal.


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                             IFMC Response to the Iowa Department of Human Services
                          Medical Services with Preferred Drug List - RFP #MED-04-034

IFMC recognizes that DHS’ primary objectives for the medical support task include:
 providing assurance to DHS that Iowa Medicaid policy reflects current medical practice
   in the State
 providing DHS with appropriate medical and professional expertise to evaluate any
   requests for new or unusual services or treatment modalities.
 providing assurance to DHS that adequate medical or professional expertise is available
   to support administrative or court challenges to coverage decisions.
 providing assurance to DHS that decisions on individual service claims reflects current
   Iowa Medicaid policy.

IFMC has clearly met these objectives in its current Medicaid contract and will leverage its
specific Iowa Medicaid experience to extend this success to the medical support
component of the IME contract.

IFMC staff will review provider claims suspended for medical review and update the claim
record on the suspended claims file of the MMIS or POS system. At the request of DHS,
IFMC may update the provider files at the MMIS with new procedure codes or provider
types, or update prior approval indicators to reflect policy changes. IFMC staff may also
provide written instructions to the Provider Services contractor, POS contractor, or Core
MMIS contractor on DHS requested file updates. IFMC staff must consult with the
provider audit and rate setting contractor on the pharmacy State Maximum Allowable Cost
(SMAC) program.

As the medical services contractor, IFMC is committed to maintaining effective and useful
interfaces with external entities as required by the contract and as deemed necessary by
DHS. IFMC staff will have regular contact with individual providers regarding medical
policy questions and decisions on individual claims. In addition, IFMC may, on behalf of
DHS, send formal policy clarifications or updates to selected provider groups.

IFMC recognizes that the data sources for the medical support function include the DHS
policy and billing manuals for Medicaid along with procedure codes, prior authorization
requirements and pricing files, all residing on the MMIS and POS systems.

IFMC will work cooperatively with the MMIS and IME data warehouse vendor to obtain
necessary data to perform all medical support functions.




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                                 IFMC Response to the Iowa Department of Human Services
                              Medical Services with Preferred Drug List - RFP #MED-04-034


B. Contractor Responsibilities

IFMC is responding to RFP requirements by restating the number and text of the
requirement in sequence and writing a response immediately after the restated text. The
restated RFP number and text is displayed in italics and enclosed in a text frame.

The contractor responsibilities for the Medical Support function are:
1. Provide professional consultation services to DHS on requested changes to Medicaid services, whether
    from DHS or providers. This responsibility includes drafting proposed policy clarifications or new
    policy regarding services covered under the Medicaid program.

   Focused pattern of care studies are detailed investigations of certain aspects of care for
   specific clinical areas of interest. Examples of the clinical areas of interest include
   pregnancy, asthma, or immunizations. Examples of the focused aspects of care
   delivery include assessments of access to care, utilization of services, coordination of
   care, continuity of care, health education, or emergency services. Focused patterns of
   care studies contrast with random reviews of unrelated episodes or aspects of care.
   Comparison of managed care plan performance against specific performance standards
   can provide DHS with plan-specific baselines against which subsequent plan
   performance can be compared to measure improvement.

   IFMC has completed several clinical and non-clinical studies at the request of DHS.
   The studies have been requested based on legislative inquiries, new technology,
   exception to policy requests, and coverage issues. Examples of studies completed for
   DHS include:
    Acupuncture Study
    Home Infusion Therapy Study
    Durable Medical Equipment and Supplies Study
    Insulin Pump Study
    Nursing Facility Case Mix Study
    Iowa Medicaid Telemedicine Pilot Project

   At the time DHS determines the need for a clinical or non-clinical study, a meeting
   with the IFMC management team and DHS representatives will be held to discuss the
   project. Based on the study goals and objectives outlined by DHS, IFMC will identify
   the study team participants. The participants may include an epidemiologist, data
   analysts, certified professionals in healthcare quality, and registered nurses. A clinical
   focus study team will include a physician with expertise in the focus area. IFMC staff
   will complete a medical and scientific literature review as appropriate.

   If DHS requests a study to determine coverage policy for a new procedure or medical
   treatment, IFMC will obtain coverage information from other state Medicaid agencies,
   Medicare fiscal intermediaries, and commercial insurance companies as requested by
   DHS. IFMC could also identify and recommend coverage for specific clinical

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                                   IFMC Response to the Iowa Department of Human Services
                                Medical Services with Preferred Drug List - RFP #MED-04-034

     indications as supported in the medical literature. In addition, IFMC could gather cost
     and utilization information to assist DHS in determining the fiscal impact of covering a
     new service.

     For example, when DHS decided to add lung transplants to its list of covered organ
     transplant procedures, IFMC obtained specific cost information and determined the
     likely number of Medicaid members who may be candidates for this procedure. DHS
     utilized this information to establish its next fiscal year budget.

2.   Review individual service requests from providers for policy exceptions and provide a written request to
     the provider for information upon which to base recommendation to DHS.

     IFMC currently reviews individual service requests from providers for policy
     exceptions and provides a written request to the provider for information upon which to
     base a recommendation to DHS under its Medicaid contract through the exception
     process.

     Under current policy, exceptions to DHS’ rules may be granted in individual cases
     upon the director’s own initiative or upon written request. An exception to the DHS
     rules (also referred to as exception to policy) may be requested by a Medicaid member
     or their representative. DHS often refers exception to policy requests involving
     medical necessity decisions to IFMC for review. Requests for exceptions must be
     submitted in writing to the Bureau of Policy Analysis at DHS.

     The request for an exception currently includes the information located in the Iowa
     Administrative Code, 441-1.8(217). Exceptions are granted at the complete discretion
     of the director after consideration of all relevant factors, including IFMC’s review
     recommendations. IFMC generally receives two (2) types of exception to policy
     requests which require medical review: 1) organ transplant procedures not routinely
     covered by the Medicaid program; and 2) placement in out-of-state facilities that
     provide treatment for brain injury.

     Organ Transplant Exceptions

     If the exception is for an organ transplant procedure not routinely covered by the
     Medicaid program, DHS forwards the medical information submitted with the
     exception to policy request to IFMC. IFMC has an established panel of expert
     physician reviewers throughout the Midwest who specialize in performing the specific
     organ transplant procedures. IFMC identifies and recruits physician reviewers from
     those who express interest in the review process or through discussions with transplant
     center staff.

     An IFMC review coordinator will screen the case to determine if all pertinent medical
     information is available to complete the review. If additional information is needed,
     IFMC will communicate directly with the facility transplant coordinator or attending


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                                  IFMC Response to the Iowa Department of Human Services
                               Medical Services with Preferred Drug List - RFP #MED-04-034

     physician. Once all medical information is received, the review coordinator will
     identify the appropriate specialty physician reviewer, prepare a case summary, and mail
     all pertinent information to the physician to complete the review. Due to the short
     timeframes for review completion, IFMC will consider these reviews top priority and
     send the medical information to the physician via overnight mail. IFMC will not
     compromise the confidentiality of patient and provider-specific information by using
     facsimile transmissions. IFMC will prepare a written recommendation which will
     include the case summary and the physician reviewer’s medical rationale. IFMC will
     provide the written report to DHS within ten (10) working days following receipt of all
     necessary medical information.

     Out-of-State Placement Exceptions

     Exception to policy review for out-of-state rehabilitation facilities are completed
     according to the type of services and level of care requested. An IFMC review
     coordinator will complete telephonic review with staff from the out-of-state facility.
     IFMC review coordinators will utilize Acute Assessment and Services Criteria to
     determine medical necessity and appropriateness of the setting. If the IFMC review
     coordinator is unable to approve the case based on the established criteria, the case will
     be referred to a physician reviewer for determination. IFMC will prepare a written
     recommendation which will include the case summary and the physician reviewer’s
     medical rationale. IFMC will provide the written report to DHS within two (2)
     working days following receipt of all necessary medical information.

3.   Provide technical support to DHS in responding to program reviews and audits.

     IFMC regularly provides information to the State Auditor, helps the State prepare for
     CMS audits and waiver reviews including the current CMS waiver review. Under the
     IME procurement, IFMC will continue to provide technical support to DHS in
     responding to program reviews and audits.

4.   Provide professional support to Medicaid providers regarding policy, prior authorization or billing
     requirements. This support may be in the form of oral instruction or written communication and must be
     documented in a tracking system.

     IFMC will provide professional support to Medicaid providers regarding policy, prior
     authorization or billing requirements. This support may be in the form of oral
     instruction or written communication and will be documented in our tracking system.
     As the Medical Services contractor, IFMC will provide content regarding policy, prior
     authorization or billing requirements to the Provider Services vendor to coordinate and
     distribute.




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                                    IFMC Response to the Iowa Department of Human Services
                                 Medical Services with Preferred Drug List - RFP #MED-04-034


5.   Retain, either on staff or in a consulting capacity, medical and social service professionals. The
     consultants must be knowledgeable about the Iowa Medicaid program's policies and procedures
     regarding coverage and limitations. These consultants provide consultation, at a minimum, in the
     following areas:
           Anesthesiology                                           Optical
           Audiology                                                Optometry
           Cardiovascular, vascular, and thoracic surgery           Organ transplant services
           Child psychiatry                                         Orthodontics
           Chiropractic services                                    Pathology
           Dentistry                                                Pediatrics
           Geriatrics                                               Physical medicine
           Family practice                                          Plastic surgery
           Hematology                                               Podiatry
           Medical supplies and equipment                           Psychiatry
           Neurology                                                Psychology
           Obstetrics/gynecology                                    Radiology and nuclear medicine
           Occupational therapy                                     Rehabilitation
           Oncology                                                 Speech pathology
           Ophthalmology
     These consultants are available to provide consultation through the Medical Services contractor to DHS
     on matters relating to their particular profession. The scope of their work includes: policy development,
     coverage of specific services, medical necessity of services, member utilization review, and application of
     standards of the profession. The Medical Services contractor needs to provide DHS with the names and
     specialties of all consultants and notify DHS of changes to the roster.

     As the Medical Services contractor, IFMC will retain, either on staff or in a consulting
     capacity, medical and social service professionals who are knowledgeable about the
     Iowa Medicaid program's policies and procedures regarding coverage and limitations.
     IFMC currently has a network of consulting providers under its Medicaid contract with
     the State for retrospective case review and all other medical audits. These consultants
     are available to provide consultation through the Medical Services contractor to DHS
     on matters relating to their particular profession. The scope of their work includes:
     policy development, coverage of specific services, determination of medical necessity
     of services, member utilization review, and application of standards of the profession.
     As the Medical Services contractor, IFMC will regularly provide DHS with the names
     and specialties of all consultants and notify DHS of changes to the roster.

6.   The medical/professional staff and consultants support DHS in responding to appeals on prior
     authorizations or other denials of coverage, requests for exceptions to policy related to coverage of
     services, or other medical issues. The medical/professional staff or consultants, as appropriate, are
     required to attend appeal hearings and provide expert testimony in respect to their decisions on prior
     authorizations or other medical necessity cases. Medical/professional staff and consultants will also
     attend meetings with provider or other stakeholder groups, in support of DHS programs and as
     requested by DHS.

     Under our current contract with DHS, IFMC’s medical/professional staff and
     consultants support DHS in responding to appeals on prior authorizations or other
     denials of coverage, requests for exceptions to policy related to coverage of services, or


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                                  IFMC Response to the Iowa Department of Human Services
                               Medical Services with Preferred Drug List - RFP #MED-04-034

     other medical issues. The medical/professional staff or consultants, as appropriate,
     attend appeal hearings and provide expert testimony in respect to their decisions on
     prior authorizations or other medical necessity cases. IFMC’s medical/professional
     staff and consultants also attend meetings with provider or other stakeholder groups in
     support of DHS programs and as requested by DHS.

     A Medicaid member adversely affected by an IFMC denial and/or reconsideration
     decision has the right to appeal. IFMC describes the appeal rights, as explained in Iowa
     Administrative Code, 441 - Chapter 7, in all denial and reconsideration correspondence.
     Appeals must be submitted in writing to the Iowa Department of Inspections and
     Appeals (DIA).

     Under the current process, DIA notifies IFMC in writing when an appeal hearing is
     scheduled. Once IFMC is notified of the date and time an appeal is to be held,
     appropriate information from the review process will be submitted to the
     Administrative Law Judge identified on the DHS appeal notice, and to the appeal
     requestor. Each attachment within the packet of information will be labeled to facilitate
     referencing.

     The following information will be sent to the Administrative Law Judge and the appeal
     requestor:
      overview of the IFMC review process applicable to the case being appealed
      case summary
       copy of initial IFMC denial letter
       copy of reconsideration request
       copy of IFMC reconsideration outcome
       criteria and User’s Guide
       medical Record/Information

     Complete documentation is vital to the appeal process; it is the foundation upon which
     determinations are made and sustained. IFMC assembles complete case information
     for the Administrative Law Judge and the requestor, thereby reducing delays in the
     appeal process. IFMC management staff attend the administrative hearing which are
     usually held via teleconference and provide testimony regarding the review process.

7.   Manually review claims requiring a determination of medical necessity or appropriateness.

     Under the current contract for RHEP/Lock-in, IFMC manually reviews claims which
     require a determination of medical necessity or appropriateness. IFMC considers this
     requirement an extension of what IFMC is currently doing for the State under another
     contract.




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                                   IFMC Response to the Iowa Department of Human Services
                                Medical Services with Preferred Drug List - RFP #MED-04-034


8.   Manually price claims if no current fee or other payment exists for the service, consistent with Medicare
     or other applicable payment standards.

     IFMC manually prices claims if no current fee or other payment exists for the service,
     consistent with Medicare or other applicable payment standards. QualiTrac™ has a
     claim repricing program module that will be utilized to reprice claims if no current fee
     or other payment exists for the service.

     After making the determination of medical necessity or appropriateness, IFMC will
     assign a reimbursement value for the service or treatment code. The code,
     reimbursement value and the rationale will be documented in QualiTrac™. All
     documentation entries in QualiTrac™ are time and date stamped as well as the identity
     of the person doing the documentation.

     When that service or treatment code is encountered in the future, QualiTrac™ will have
     the documentation and history. In addition, reports or queries can be provided based on
     all reportable fields.

9.   Certify new outpatient hospital programs for appropriateness of Medicaid coverage and make
     recommendations to DHS regarding appropriateness of new programs; determine criteria to be used
     regarding coverage for new programs.

     IFMC will use criteria to certify new outpatient hospital programs. The certification
     process will be consistent with Iowa Administrative Code. IFMC has utilization
     management experience with each of the programs certified during the last two (2)
     years (i.e., cardiac rehabilitation, substance abuse, diabetic management, nutritional
     counseling and pulmonary rehabilitation). IFMC will build on our expertise in these
     programs to review the current process and develop recommendations for process
     changes if necessary.

10. Review all claims relating to hysterectomies, abortions, sterilization, private duty nursing, personal care
    and orthodontia.

     As the Medical Services contractor, IFMC will review all claims relating to
     hysterectomies, abortions, sterilization, private duty nursing, personal care and
     orthodontia. IFMC currently reviews hysterectomy claims under our current contract
     with DHS. Therefore, we would only need to expand this activity to include review of
     claims for abortions, sterilization, private duty nursing, personal care and orthodontia.
     All the systems are in place for such an expansion of services.




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                                   IFMC Response to the Iowa Department of Human Services
                                Medical Services with Preferred Drug List - RFP #MED-04-034


11. Prepare for DHS approval the CMS 64.96 Quarterly Report of Abortions, Hysterectomies and
    Sterilization, including supplemental worksheets relating to abortions not qualifying for Federal
    funding.

    IFMC will prepare for DHS approval the CMS 64.96 Quarterly Report of Abortions,
    Hysterectomies and Sterilization, including supplemental worksheets relating to
    abortions not qualifying for Federal funding. IFMC regularly assists DHS to compile
    data, issue reports and prepare for audits under its other contracts.

12. Communicate with the Medicare carrier regarding Medicare policy and notify DHS of Medicare policy
    changes that may affect Medicaid.

    As the Medical Services contractor, IFMC will need to communicate with the Medicare
    carrier regarding Medicare policy and notify DHS of Medicare policy changes that may
    affect Medicaid. IFMC has been a valued partner of DHS as the Medicare Quality
    Improvement Organization (QIO) for Iowa since 1984. IFMC’s Medicare QIO contract
    and regulations require that IFMC meets regularly with the Medicare Carrier to
    exchange information and data that will assist in each organization's efforts to promote
    high quality care and appropriate utilization of services. IFMC maintains a formal
    written agreement with the carrier which describes the administrative relationship
    between the organizations and specifies the type of information/data that will be shared.
    IFMC’s existing relationship with the Carrier provides unique advantages for DHS.

    IFMC meets with representatives from the Carrier on an ongoing basis. These
    meetings may be in-person or by teleconference. Topics discussed vary from meeting
    to meeting but generally focus on new Medicare rules/regulations that impact our work
    or on quality/utilization patterns seen during data analysis that may suggest a problem
    area needing further attention by either IFMC or the Carrier. The group also exchanges
    information about individual providers placed on a corrective action plan due to
    problems with their quality of care or inappropriate utilization. This collaborative
    exchange of information is similar to the interaction DHS expects between the various
    IME vendors. Our successful collaboration with the Carrier demonstrates IFMC’s
    ability to function in this type of environment.

    The existing relationship with the Carrier provides IFMC with "first hand" information
    about changes in Medicare payment/coverage rules that may have an impact on the
    Iowa Medicaid program. As a Medicare QIO, IFMC already has access to information
    about Medicare policy and future direction of the program. IFMC is also able to obtain
    information about future changes contemplated by Medicare before they are announced
    publicly. This "advance notice" would enable IFMC to share Medicare's plans with
    DHS early in the planning process, increasing the amount of time available to DHS to
    provide feedback to CMS about their plans and/or develop a Medicaid response to a
    new Medicare rule.



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                                  IFMC Response to the Iowa Department of Human Services
                               Medical Services with Preferred Drug List - RFP #MED-04-034

13. When appropriate, request from providers, medical records, operation reports, and documentation of
    medical necessity, invoices, or other information necessary for proper resolution of claims.

    When necessary, IFMC will request medical records, operation reports, and other
    documentation from providers necessary for proper resolution of claims. IFMC works
    with providers in this same capacity under our current contract with DHS.

    IFMC selects retrospective reviews monthly from the Medicaid claims data. IFMC
    produces reports identifying cases selected for reviews. These lists are sent to the
    appropriate contact person at each Iowa hospital. Hospitals have thirty (30) calendar
    days from the date of the request to photocopy and mail the requested medical records
    to IFMC. Medical records not received within (thirty) 30 days of the original request
    are denied. IFMC notifies the fiscal agent to recoup the hospital’s Medicaid
    reimbursement for cases where medical records are not received timely.

14. Provide support for the pharmaceutical case management program, as required by DHS. This includes
    advising on a provider eligibility process and training program, patient eligibility and notification
    process and billing process.

    IFMC professional medical staff will respond to questions regarding the pharmaceutical
    case management program. Information regarding inquiries including: 1) date, 2) time,
    3) type of inquery, and 4) response and follow-up action will be entered and tracked in
    QualiTrac™ and transferred to the Workflow Process Management (WPM) system.
    IFMC will provide DHS a summary report of inquiries received regarding the
    pharmacy case management program.

15. Maintain a tracking system to identify communication with providers, or other stakeholders over policy
    requests, billing procedures and appeals.

    IFMC, using QualiTrac™, will collect data regarding inquiries from providers and
    other stakeholders over policy, billing procedures and appeals. The QualiTrac™ call
    processing system will track contact date/time, caller identity, reason for the call, notes,
    and follow-up activity.

16. Conduct reviews of medical necessity for home health services claims and provide recommendations
    upon request of DHS.

    As the medical services contractor, IFMC will conduct reviews of medical necessity for
    home health services claims and provide recommendations upon request of DHS.
    IFMC has a long history with the State of providing utilization management services as
    the QIO for the State. IFMC currently conducts utilization review for DHS in the areas
    of: nursing home, waivers, ICF/MR, and psychiatric medical institution for children.




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                                     IFMC Response to the Iowa Department of Human Services
                                  Medical Services with Preferred Drug List - RFP #MED-04-034


   17. The Medical Support staff must confer with the Provider Audit and Rate Setting Contractor regarding
       the SMAC program and must review recommendations prior to implementation of any changes.

       As the medical services contractor, IFMC understands that it must confer with the
       provider audit and rate setting contractor regarding the SMAC program and must
       review recommendations prior to implementation of any changes. IFMC has a long
       tradition of working with multiple vendors and with many state agencies. IFMC will
       work with the provider audit and rate setting contractor to develop smooth and
       accountable processes regarding the SMAC program.

C. Required Reports

   The Medical Services contractor is required to provide the following reports for the Medical Support
   function:
   1. Quarterly report of all appeal hearings, including status, disposition of case and policy changes
       resulting from appeals.
   2. Monthly report of policy requests, including requestor, status, disposition of request and policy changes
       resulting from request.

   IFMC will provide the reports required under the Medical Services function. IFMC will
   work closely with DHS to determine the format and content of these reports, and any
   additional reports desired by DHS.

D. Performance Standards

   The performance standards for the medical support functions are provided below. As with
   many of the Operation Requirements of this RFP, IFMC proposes additional performance
   standards that we will meet in the performance of this contract. Please see our Cost
   Proposal for a full explanation of these additional standards and our proposal for a risk-
   sharing arrangement with DHS.




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                      IFMC Response to the Iowa Department of Human Services
                   Medical Services with Preferred Drug List - RFP #MED-04-034



                Performance Measures – 3.2.2.2 Medical Support

                               Minimum Standards

No.                                 Measure                                    %

1.    Screen claims appeals and review for accuracy, validity, and           100
      completeness within two (2) business days of receipt from
      provider.

2.    Notify the provider within three (3) business days of receipt of a     100
      claims appeal of incomplete or missing information.

3.    Send the final determination letter on a claims appeal to the          100
      provider within ten (10) business days of receipt of complete
      documentation.

4.    Process requests for exceptions to policy within ten (10) business     100
      days of receipt unless additional information is requested.

                   Additional/Supplemental At-Risk Measures

No.                                 Measure                                    %

1.    Review and price claims consistent with Medicare or other              100
      applicable payment standards within five (5) days of receipt.




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