Project Scope

The Division currently uses several different systems for reimbursement of services provided to clients. The unit cost reimbursement (UCR) systems are maintained by the state and reside on an IBM mainframe. These systems are not integrated, and there is no central system for storing client eligibility information. The goal of the IPRS project is to replace the existing UCR systems with one integrated system for processing and reporting all MH/DD/SAS and Medicaid claims. This will provide the Division with a significantly enhanced system that includes the following features:

Receiving claims using electronic data interchange (EDI)
Recipient Tracking and Eligibility
Provider Enrollment and Relations
Edits and Audits
Utilization Management (Prior Approval and Care Plans)
Claims Processing
Rates and Pricing
Budget Structures and Thresholds
Remittance and Financial
Monitoring and Reporting
Data Accessibility and Connectivity

Because the Division currently uses more than one UCR system, a single centralized system will streamline communications and activities to and from the Division. By using technologies made available during the IPRS project, the Division will gain greater control over information and better ensure the integrity of its data. By leveraging the Medicaid MMIS, which is being enhanced with multi-payer capabilities, the Division will obtain a well-established and secure system for claims processing and adjudication.

The primary objectives of the system development project are:

Provide an Integrated Payment and Reporting System to process and pay all Division and Medicaid claims through one system.
Use the claims processing engine of the North Carolina MMIS to process and pay claims for the Division of MH/DD/SA Services and leverage re-engineering efforts currently underway in the ITME project to provide multi-payer capabilities.
Define, design, and construct additional functionality required to meet the specific needs of DMH/DD/SAS.
Provide comprehensive training of the Integrated Payment and Reporting System to DMH/DD/SAS and two pilot sites.
Implement the IPRS at the two pilot sites identified by the Division and position the system for statewide implementation.

Business Benefits

Provides increased flexibility to implement unique policy and payment strategies for mental health, developmental disabilities, and substance abuse programs in a timely, cost effective way.

Establishes a central repository of recipient data across the Division's circle of services and programs.

Establishes a central repository of provider data across the Division's circle of services and programs.

Allows the state to more closely monitor the delivery of MH/DD/SA services, and to properly measure and track area program performance.

Reduces the potential for over-billing and duplicate payments for the same units of service.

Simplifies the claims filing practices for area programs and reduces the claims payment cycle time.