MMIS IV&V Project
Department of Health and Hospitals
“To-Be” MITA State Self-Assessment
August 10, 2009
1.0 Document Information 8
2.0 Executive Summary 8
3.0 Deliverable Description 11
4.0 Methodology 11
5.0 Concept of Operations and MITA Maturity Matrix 12
5.1 Concept of Operations 12
5.1.1 DHH To-Be Context diagram 12
5.1.2 Louisiana Medicaid Program Vision 13
5.1.2.1 Go Green 13
5.1.2.2 User Friendly 14
5.1.2.3 Web-Technology 14
5.1.2.4 Transparency 14
5.1.2.5 Access to Data 14
5.1.2.6 Disaster Response Plan 14
5.1.2.7 Improved Provider Oversight 15
5.1.2.8 Metrics 15
5.1.2.9 Enhanced Data Management 15
5.1.2.10 Business Process Re-Engineering 15
5.1.3 Louisiana Medicaid Program Mission and Goals 15
5.1.3.1 Mission 15
5.1.3.2 Goals 15
5.1.3.3 Drivers 16
5.1.4 Defined Qualities for Evaluation of Business Processes 16
5.2 MITA Maturity Model 17
5.2.1 Introduction 17
5.2.2 Deliverable Description 17
5.2.3 Background 17
5.2.4 Methodology 18
5.2.5 Findings 18
6.0 MITA “To-Be” Documentation 20
6.1 Member Management Overview 20
6.1.1 Business Process Improvements Identified During JADs 20
6.1.2 Determine Eligibility 22
6.1.2.1 Determine Eligibility “To-Be” Process Model 22
6.1.2.2 Determine Eligibility “To-Be” Business Capability Matrix 24
6.1.3 Disenroll Member 25
6.1.3.1 Disenroll Member “To-Be” Process Model 25
6.1.3.2 Disenroll Member “To-Be” Business Capability Matrix 26
6.1.4 Enroll Member 27
6.1.4.1 Enroll Member “To-Be” Process Model 27
6.1.4.2 Enroll Member “To-Be” Business Capability Matrix 28
6.1.5 Inquire Member Eligibility 29
6.1.5.1 Inquire Member Eligibility “To-Be” Process Model 29
6.1.5.2 Inquire Member Eligibility “To-Be” Business Capability Matrix 30
6.1.6 Manage Applicant and Member Communication 31
6.1.6.1 Manage Applicant and Member Communication “To-Be” Process Model 31
6.1.6.2 Manage Applicant and Member Communication “To-Be” Business Capability Matrix 32
6.1.7 Manage Member Grievance and Appeal 33
6.1.7.1 Manage Member Grievance and Appeal “To-Be” Process Model 33
6.1.7.2 Manage Member Grievance and Appeal “To-Be” Business Capability Matrix 34
6.1.8 Manage Member Information 35
6.1.8.1 Manage Member Information “To-Be” Process Model 35
6.1.8.2 Manage Member Information “To-Be” Business Capability Matrix 36
6.1.9 Perform Population and Member Outreach 37
6.1.9.1 Perform Population and Member Outreach “To-Be” Process Model 37
6.1.9.2 Perform Population and Member Outreach “To-Be” Business Capability Matrix 38
6.2 Provider Management Overview 39
6.2.1 Business Process Improvements Identified During “To- Be” Joint Application Design Session 39
6.2.2 Disenroll Provider 41
6.2.2.1 Disenroll Provider “To-Be” Process Model 41
6.2.2.2 Disenroll Provider “To-Be” Business Capability Matrix 43
6.2.3 Enroll Provider 44
6.2.3.1 Enroll Provider “To-Be” Process Model 44
6.2.3.2 Enroll Provider “To-Be” Business Capability Matrix 45
6.2.4 Inquire Provider 46
6.2.4.1 Inquire Provider Information “To-Be” Process Model 46
6.2.4.2 Inquire Provider Information “To-Be” Business Capability Matrix 47
6.2.5 Manage Provider Communication 48
6.2.5.1 Manage Provider Communication “To-Be” Process Model 48
6.2.5.2 Manage Provider Communication “To-Be” Business Capability Matrix 49
6.2.6 Manage Provider Grievance and Appeal 50
6.2.6.1 Manage Provider Grievance and Appeal “To-Be” Process Model 50
6.2.6.2 Manage Provider Grievance and Appeal “To-Be” Business Capability Matrix 51
6.2.7 Manage Provider Information 52
6.2.7.1 Manage Provider Information “To-Be” Process Model 52
6.2.7.2 Manage Provider Information “To-Be” Business Capability Matrix 53
6.2.8 Perform Provider Outreach 54
6.2.8.1 Perform Provider Outreach “To-Be” Process Model 54
6.2.8.2 Perform Provider Outreach “To-Be” Business Capability Matrix 56
6.3 Contractor Management Overview 57
6.3.1 Business Process Improvements Identified During JADs 57
6.3.2 Award Contract 59
6.3.2.1 Award Contract “To-Be” Process Model 59
6.3.2.3 Award Contract “To-Be” Business Capability Matrix 62
6.3.3 Manage Contract 63
6.3.3.1 Manage Contract “To-Be” Process Model 63
6.3.3.2 Manage Contract “To-Be” Business Capability Matrix 64
6.3.4 Close Out Contract 65
6.3.4.1 Close Out Contract “To-Be” Process Model 65
6.3.4.2 Close Out Contract “To-Be” Business Capability Matrix 66
6.3.5 Manage Contractor Information 67
6.3.5.1 Manage Contractor Information “To-Be” Process Model 67
6.3.5.2 Manage Contractor Information “To-Be” Business Capability Matrix 68
6.3.6 Manage Contractor Communication 69
6.3.6.1 Manage Contractor Communication “To-Be” Business Process Model 69
6.3.6.2 Manage Contractor Communication “To-Be” Business Capability Matrix 71
6.3.7 Support Contractor Grievance and Appeal 72
6.3.7.1 Support Contractor Grievance and Appeal “To-Be” Process Model 72
6.3.7.2 Support Contractor Grievance and Appeal “To-Be” Business Capability Matrix 73
6.3.8 Inquire Contractor Information 74
6.3.8.1 Inquire Contractor Information “To-Be” Process Model 74
6.3.8.3 Inquire Contractor Information “To-Be” Business Capability Matrix 75
6.4 Operations Management Overview 76
6.4.1 Business Process Improvements Identified During JADs 76
6.4.2 Authorize Referral 78
6.4.2.1 Authorize Referral “To-Be” Process Model 78
6.4.2.2 Authorize Referral “To-Be” Business Capability Matrix 81
6.4.3 Authorize Service 82
6.4.3.1 Authorize Service “To-Be” Process Model 82
6.4.3.2 Authorize Service “To-Be” Business Capability Matrix 83
6.4.4 Authorize Treatment Plan 84
6.4.4.1 Authorize Treatment Plan “To-Be” Process Model 84
6.4.4.2 Authorize Treatment Plan “To-Be” Business Capability Matrix 86
6.4.5 Apply Claim Attachment 87
6.4.5.1 Apply Claim Attachment “To-Be” Process Model 87
6.4.5.2 Apply Claim Attachment “To-Be” Business Capability Matrix 88
6.4.6 Apply Mass Adjustment 89
6.4.6.1 Apply Mass Adjustment “To-Be” Process Model 89
6.4.6.2 Apply Mass Adjustment “To-Be” Business Capability Matrix 90
6.4.7 Edit/Audit Claim-Encounter 91
6.4.7.1 Edit/Audit Claim-Encounter “To-Be” Process Model 91
6.4.7.2 Edit/Audit Claim-Encounter “To-Be” Business Capability Matrix 93
6.4.8 Price Claim – Value Encounter 94
6.4.8.1 Price Claim – Value Encounter “To-Be” Process Model 94
6.4.8.2 Price Claim – Value Encounter “To-Be” Business Capability Matrix 96
6.4.9 Prepare Coordination of Benefits (COB) 97
6.4.9.1 Prepare Coordination of Benefits (COB) “To-Be” Process Model 97
6.4.9.2 Prepare Coordination of Benefits (COB) “To-Be” Business Capability Matrix 99
6.4.10 Prepare Explanation of Benefits (EOB) 100
6.4.10.1 Prepare Explanation of Benefits (EOB) “To-Be” Process Model 100
6.4.10.2 Prepare Explanation of Benefits (EOB) “To-Be” Business Capability Matrix 101
6.4.11 Prepare Home and Community-Based Services (HCBS) Payment 102
6.4.11.1 Prepare HCBS Payment “To-Be” Process Model 102
6.4.11.2 Prepare HCBS Payment “To-Be” Business Capability Matrix 103
6.4.12 Prepare Premium EFT-Check 104
6.4.12.1 Prepare Premium EFT-Check “To-Be” Process Model 104
6.4.12.2 Prepare Premium EFT-Check “To-Be” Business Capability Matrix 105
6.4.13 Prepare Provider EFT-Check 106
6.4.13.1 Prepare Provider EFT-Check “To-Be” Process Model 106
6.4.13.2 Prepare Provider EFT-Check “To-Be” Business Capability Matrix 107
6.4.14 Prepare Remittance Advice-Encounter Report 108
6.4.14.1 Prepare Remittance Advice-Encounter Report “To-Be” Process Model 108
6.4.14.2 Prepare Remittance Advice-Encounter Report “To-Be” Business Capability Matrix 109
6.4.15 Prepare Capitation Premium Payment 110
6.4.15.1 Prepare Capitation Premium Payment “To-Be” Process Model 110
6.4.15.2 Prepare Capitation Premium Payment “To-Be” Business Capability Matrix 112
6.4.16 Prepare Health Insurance Premium Payment 113
6.4.16.1 Prepare Health Insurance Premium Payment “To-Be” Process Model 113
6.4.16.2 Prepare Health Insurance Premium Payment “To-Be” Business Capability Matrix 114
6.4.17 Prepare Medicare Premium Payments 115
6.4.17.1 Prepare Medicare Premium Payments “To-Be” Process Model 115
6.4.17.2 Prepare Medicare Premium Payments “To-Be” Business Capability Matrix 116
6.4.18 Inquire Payment Status 117
6.4.18.1 Inquire Payment Status “To-Be” Process Model 117
6.4.18.2 Inquire Payment Status “To-Be” Business Capability Matrix 118
6.4.19 Manage Payment Information 119
6.4.19.1 Manage Payment Information “To-Be” Process Model 119
6.4.19.2 Manage Payment Information “To-Be” Business Capability Matrix 120
6.4.20 Calculate Spend-Down Amount 121
6.4.20.1 Calculate Spend-Down Amount “To-Be” Process Model 121
6.4.20.2 Calculate Spend-Down Amount “To-Be” Business Capability Matrix 122
6.4.21 Prepare Member Premium Invoice 123
6.4.21.1 Prepare Member Premium Invoice “To-Be” Process Model 123
6.4.21.2 Prepare Member Premium Invoice “To-Be” Business Capability Matrix 124
6.4.22 Manage Drug Rebate 125
6.4.22.1 Manage Drug Rebate “To-Be” Process Model 125
6.4.22.2 Manage Drug Rebate “To-Be” Business Capability Matrix 126
6.4.23 Manage Estate Recoveries 127
6.4.23.1 Manage Estate Recoveries “To-Be” Process Model 127
6.4.23.2 Manage Estate Recoveries “To-Be” Business Capability Matrix 129
6.4.24 Manage Recoupment 130
6.4.24.1 Manage Recoupment “To-Be” Process Model 130
6.4.24.2 Manage Recoupment “To-Be” Business Capability Matrix 131
6.4.25 Manage Settlement 132
6.4.25.1 Manage Settlement “To-Be” Process Model 132
6.4.25.2 Manage Settlement “To-Be” Business Capability Matrix 133
6.4.26 Manage TPL Recovery 134
6.4.26.1 Manage TPL Recovery “To-Be” Process Model 134
6.4.26.2 Manage TPL Recovery “To-Be” Business Capability Matrix 135
6.5 Program Management Overview 136
6.5.1 Business Process Improvements Identified During JADs 136
6.5.2 Designate Approved Services/Drug Formulary 140
6.5.2.1 Designate Approved Services/Drug Formulary “To-Be” Process Model 140
6.5.2.2 Designate Approved Services/Drug Formulary “To-Be” Business Capability Matrix 142
6.5.3 Develop and Maintain Benefit Package 143
6.5.3.1 Develop and Maintain Benefit Package “To-Be” Process Model 143
6.5.3.2 Develop and Maintain Benefit Package “To-Be” Business Capability Matrix 145
6.5.4 Manage Rate Setting 146
6.5.4.1 Manage Rate Setting “To-Be” Process Model 146
6.5.4.2 Manage Rate Setting “To-Be” Business Capability Matrix 148
6.5.5 Develop Agency Goals and Initiatives 149
6.5.5.1 Develop Agency Goals and Initiatives “To-Be” Process Model 149
6.5.5.2 Develop Agency Goals and Initiatives “To-Be” Business Capability Matrix 150
6.5.6 Develop and Maintain Program Policy 151
6.5.6.1 Develop and Maintain Program Policy “To-Be” Process Model 151
6.5.6.2 Develop and Maintain Program Policy “To-Be” Business Capability Matrix 154
6.5.7 Maintain State Plan 155
6.5.7.1 Maintain State Plan “To-Be” Process Model 155
6.5.7.2 Maintain State Plan “To-Be” Business Capability Matrix 156
6.5.8 Formulate Budget 157
6.5.8.1 Formulate Budget “To-Be” Process Model 157
6.5.8.2 Formulate Budget “To-Be” Business Capability Matrix 158
6.5.9 Manage FFP 159
6.5.9.1 Manage FFP “To-Be” Process Model 159
6.5.9.2 Manage FFP “To-Be” Business Capability Matrix 161
6.5.10 Manage F-MAP 162
6.5.10.1 Manage F-MAP “To-Be” Process Model 162
6.5.10.3 Manage F-MAP “To-Be” Business Capability Matrix 163
6.5.11 Manage State Funds 164
6.5.11.1 Manage State Funds “To-Be” Process Model 164
6.5.11.3 Manage State Funds “To-Be” Business Capability Matrix 165
6.5.12 Manage 1099’s 166
6.5.12.1 Manage 1099’s “To-Be” Process Model 166
6.5.12.2 Manage 1099’s “To-Be” Business Capability Matrix 168
6.5.13 Perform Accounting Functions 169
6.5.13.1 Perform Accounting Functions “To-Be” Process Model 169
6.5.13.2 Perform Accounting Functions “To-Be” Business Capability Matrix 170
6.5.14 Develop and Manage Performance Measures and Reports 171
6.5.14.1 Develop and Manage Performance Measures and Reports “To-Be” Process Model 171
6.5.14.2 Develop and Manage Performance Measures and Reports “To-Be” Business Capability Matrix 172
6.5.15 Monitor Performance and Business Activity 173
6.5.15.1 Monitor Performance and Business Activity “To-Be” Process Model 173
6.5.15.2 Monitor Performance and Business Activity “To-Be” Business Capability Matrix 174
6.5.16 Generate Financial and Program Analysis Report 175
6.5.16.1 Generate Financial and Program Analysis Report “To-Be” Process Model 175
6.5.16.3 Generate Financial and Program Analysis Report “To-Be” Business Capability Matrix 176
6.5.17 Maintain Benefits-Reference Information 177
6.5.17.1 Maintain Benefits-Reference Information “To-Be” Process Model 177
6.5.17.2 Maintain Benefits-Reference Information “To-Be” Business Capability Matrix 179
6.5.18 Manage Program Information 180
6.5.18.1 Manage Program Information “To-Be” Process Model 180
6.5.18.2 Manage Program Information “To-Be” Business Capability Matrix 181
6.6 Program Integrity Management Overview 182
6.6.1 Business Process Improvements Identified During JADs 182
6.6.2 Identify Candidate Case 183
6.6.2.1 Identify Candidate Case “To-Be” Process Model 183
6.6.2.2 Identify Candidate Case “To-Be” Business Capability Matrix 185
6.6.3 Manage the Case 186
6.6.3.1 Manage the Case “To-Be” Process Model 186
6.6.3.3 Manage the Case “To-Be” Business Capability Matrix 189
6.7 Care Management Overview 190
6.7.1 Business Process Improvements Identified During JADs 190
6.7.2 Establish Case 192
6.7.2.1 Establish Case “To-Be” Process Model 192
6.7.2.2 Establish Case “To-Be” Business Capability Matrix 193
6.7.3 Manage Case 194
6.7.3.1 Manage Case “To-Be” Process Model 194
6.7.3.2 Manage Case “To-Be” Business Capability Matrix 195
6.7.4 Manage Registry 196
6.7.4.1 Manage Registry “To-Be” Process Model 196
6.7.4.2 Manage Registry “To-Be” Business Capability Matrix 197
6.8 Business Relationship Management Overview 198
6.8.1 Business Process Improvements Identified During JADs 198
6.8.2 Establish Business Relationship 199
6.8.2.1 Establish Business Relationship “To-Be” Process Model 199
6.8.2.2 Establish Business Relationship “To-Be” Business Capability Matrix 201
6.8.3 Manage Business Relationship Communication 202
6.8.3.1 Manage Business Relationship Communication “To-Be” Process Model 202
6.8.3.2 Manage Business Relationship Communication “To-Be” Business Capability Matrix 203
6.8.4 Manage Business Relationship 204
6.8.4.1 Manage Business Relationship “To-Be” Process Model 204
6.8.4.2 Manage Business Relationship “To-Be” Business Capability Matrix 205
6.8.5 Terminate Business Relationship 206
6.8.5.1 Terminate Business Relationship “To-Be” Process Model 206
6.8.5.2 Terminate Business Relationship “To-Be” Business Capability Matrix 207
1.0 Document Information
Revision # / Revision Date / Section(s) Revised / Revision Description1.0 / 7/23/2009 / Initial Submission
2.0 Executive Summary
An assessment was conducted of the current Medicaid business processes through a series of “As Is” Joint Application Design (JAD) sessions. Current Medicaid business functions were cross-referenced to the MITA business areas and Medicaid staff was assigned to attend JAD sessions related to their job responsibilities or expertise. The result of the “As-Is” JADs was to document Medicaid’s current business processes and workflows. This effort formed the foundation for a common understanding of the business processes across sections and the basis for identifying future changes that should be explored.
To support the “To-Be” JAD processes, work sessions were conducted with the Medicaid Director and Deputy Directors to define a “To-Be” vision for Medicaid. The following table provides an overview of that vision across several categories of improvements.
LA MITA Vision / Global Improvements from “To Be” JAD Sessions /Go Green: Paperless Business Processes / · Allow electronic applications and electronic approvals/signatures
· Allow imaged or scanned documents to be accessible online and eliminate passing of paper between offices/staff
· Support real-time prior authorizations
User Friendly / · Provide automation that allows staff to work in a more efficient and effective manner
· Provide easier public access to information with appropriate safeguards, such as web portals
· Allow real-time updates and access to information across systems/agencies
· Provide more visual support while entering data(for example, populate fields with words rather than codes)
· Provide single sign-on across applications
· Support automated generation of letters and notices (allow for free-form text to be added)
· Maintain keys (e.g., member name, member number) from panel to panel or function to function
Web-Technology / · Provide expanded web portals supporting more efficient provider and beneficiary services
· Support electronic forms of communication
· Provide web based systems and/or presentations
· Allow direct entry of data or inquiry by clients, providers, and other stakeholders (with appropriate security access)
· Accept electronic applications or enrollment documents to be entered online or uploaded for processing
· Provide scan and attach capabilities for attachments
· Support use of electronic signatures (Incoming and outgoing)
Transparency / · Allow real-time searches for data across systems and programs for inquiry and data verification purposes
· Support the sharing of data across systems (for example, real-time inquiry of data in other systems)
· Support maintenance/storage of data in only one system but used by all. Eliminate redundant entry of data (no data to be entered twice)
· Provide decision support system and data warehouse that has all current data in the decision support system (10 years worth) converted into new warehouse
· Support real-time exchange of data between systems (including systems internal to DHH – e.g., vital records; licensing/certification information)
· Maintain one electronic record (e.g., case record, provider record) that can be viewed and/or updated by persons with appropriate security
Enhance and Support Current and Future Systems / · Reduce prior authorization turnaround time and improve quality of medical reviews,
· Support real-time editing of data as it is entered
· Support electronic attachments
· Automate as much as possible; warnings on recipients about to reach service level limits
· Support one-stop enrollment centers/“Neighborhood Place”
· Support Coordinated Care Networks (CCN) as well as all other Medicaid reform efforts
· Allow collection and storage of encounter data
· Provide the ability to support the use of COTS applications
Access to Data / · Improve searches of data across systems and shorten time to research and retrieve accurate data
· Support role-based authentication and access to functions/panels
· Maintain automated history of letters and notices generated including standard and free-form text
Improved Oversight / Reporting / · Maintain enhanced provider profiles
· Maintain performance statistics related to contracts monitoring and level of care reviews
· Maintain accurate and historical provider contact information and common ownership information
· Provide real-time links to licensure/certification information
· Maintain audit trail of changes made, person making the change, and when changes made
· Monitor system activity and act on security incidents
· Support improved analysis for decision-making
· Maintain history of data (No enforced timeline for deletion of history)
Metrics / · Identify and analyze program trends, pattern, and directions
· Support management of program funds
· Produce program data necessary to satisfy Federal Medicaid reporting requirements, monitor utilization, and assess quality of care provided to participants
· Support generation of ad hoc reports by users with limited need for programming staff
· Support timed generation of standard reports by system (support both electronic and paper formats)
Other / · Support performance based compensation
· Support outcome driven measures
· Increased monitoring to ensure standard of care across Louisiana by similar providers / services
· Support both manual and automated workflows
· Support real-time, online claims processing
· Provide electronic tracking of required actions and generate alerts/notifications to users
· Support automated processing of records without user interaction to extent possible
During the “To-Be” JADs, the vision as outlined by the Medicaid Executive Management team, was shared and used as a guide to facilitate a review of the “As-Is” workflows to identify areas where the processes could be modified using increased automation, standardized process, or implementation of centralized processes for the “To-Be” Medicaid environment. The capture of information to complete the Business Continuity Models (BCMs) for each of the “To-Be” Business Processes was also facilitated during the JADs.