Stateself-Assessmenttobesummaryreport

kentuckycabinetforhealthandfamilyservices

divisionformedicaidservices

kentuckymmisprocurement2012

Medicaidinformationtechnologyarchitecture

stateself-assessmenttobesummaryreport

Deliverable7

November 23, 2012

Version2.0

Preparedby:

7926JonesBranchDrive,Suite330

McLean,VA22102

(480)423-8184

/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

RevisionHistory

VersionNumber / Date / Reviewer / Comments
V1.0 / 7/06/2012 / Fred Hinds
V1.01 / 11/13/2012 / Fred Hinds
V2.0 / 11/23/2012 / Nancy Ferguson / Reviewed and accepted changes

TableofContents

1Executive Summary

1.1Overview

1.2Summary of Findings

2MITA State Self Assessment process

2.1Description of the MITA SS-A Process

2.2Cognosante Methodology

2.3Executive Goals and Objectives

2.3.1Kentucky Medicaid Mission

2.3.2Kentucky Medicaid Vision

2.3.3Kentucky Medicaid Values

2.3.4Kentucky Medicaid Guiding Principles

2.3.5Kentucky Goals and Objectives

3External Drivers of Change

3.1Patient Protection and Affordable Care Act (ACA)

3.2Impact of the Seven Conditions and Standards on MITA Maturity Goals

3.2.1Overview

3.2.2Summary of 7C&S Impacts

3.2.3Impacts on Business Relationship Management Processes

3.2.4Impacts on Care Management Processes

3.2.5Impacts on Contractor Management Processes

3.2.6Impacts on Member Management Processes

3.2.7Impacts on Operations Management Processes

3.2.8Impacts on Program Integrity Management Processes

3.2.9Impacts on Program Management Processes

3.2.10Impacts on Provider Management Processes

4To Be Maturity Changes

5Results of the MITA Business Process Assessment

5.1Overview

5.2Business Relationship Management

5.2.1Overview of Business Relationship Management

5.2.2Business Relationship To Be Summary

5.2.3Business Relationship Management Process To Be Summaries

5.3Care Management

5.3.1Overview of Care Management

5.3.2Care Management To Be Summary

5.3.3Care Management Process To Be Summaries

5.4Contractor Management

5.4.1Overview of Contractor Management

5.4.2Contractor Management To Be Summary

5.4.3Contractor Management Process To Be Summaries

5.5Member Management

5.5.1Overview of Member Management

5.5.2Member Management To Be Summary

5.5.3Member Management Process To Be Summaries

5.6Operations Management

5.6.1Overview of Operations Management

5.6.2Operations Management To Be Summary

5.6.3Operations Management Process To Be Summaries

5.7Program Integrity Management

5.7.1Overview of Program Integrity Management

5.7.2Program Integrity Management To Be Summary

5.7.3Program Integrity Management Process To Be Summaries

5.8Program Management

5.8.1Overview of Program Management

5.8.2Program Management To Be Summary

5.8.3Program Management Process To Be Summaries

5.9Provider Management

5.9.1Overview of Provider Management

5.9.2Provider Management To Be Summary

5.9.3Provider Management Process To Be Summaries

Appendix A: cms mita maturity capability table

Appendix B: Completed MITA Business process Templates

ListofFiguresandTables

Figure 1: Medicaid Enterprise To Be MITA Maturity Levels

Figure 2: Line of Sight Diagram

Figure 3: Business Relationship Management

Figure 4: Care Management

Figure 5: Contractor Management

Figure 6: Member Management

Figure 7: Operations Management

Figure 8: Program Integrity Management

Figure 9: Program Management

Figure 10: Provider Management

Table 1: MITA Maturity Levels

Table 2: ACA Impacts on Manage Medicaid Population Health

Table 3: ACA Impacts on Eligibility Determination

Table 4: ACA Impacts on Eligibility Determination

Table 5: ACA Impacts on Audit Claim/Encounter

Table 6: ACA Impacts on Manage Recovery Process

Table 7: ACA Impacts on Benefit Packages

Table 8: ACA Impacts on Monitoring Performance and Business Activity

Table 9: ACA Impacts on Case Identification

Table 10: ACA Impacts on Managing Cases

Table 11: ACA Impacts on Provider Enrollment

Table 12: 7C&S Impact Summary

Table 13: 7C&S Impact Legend

Table 14: 7C&S Impact Assessment

Table 15: Business Relationship Management Detailed Results

Table 16: Care Management Detailed Results

Table 17: Contractor Management Detailed Results

Table 18: Member Management Detailed Results

Table 19: Operations Management Detailed Results

Table 20: Program Integrity Management Detailed Results

Table 21: Program Management Detailed Results

Table 22: Provider Management Detailed Results

Table 23: 2012 To Be Goal Revisions

Table 24: Business Relationship Management Process To Be Summaries

Table 25: Care Management Process To Be Summaries

Table 26: Contractor Management Process To Be Summaries

Table 27: Member Management Process To Be Summaries

Table 28: Operations Management Process To Be Summaries

Table 29: Program Integrity Management Process To Be Summaries

Table 30: Program Management Process To Be Summaries

Table 31: Provider Management Process To Be Summaries

Table 32: CMS MITA Maturity Capability Table

ListofAcronyms

Thefollowingacronymsareusedthroughoutthisdocument:

Acronym / Definition
7C&S / Seven Conditions and Standards
ACA / Affordable Care Act, also known as Patient Protection and Affordable Care Act
ACH / Automated Clearing House
AMA / American Medical Association
APD / Advanced Planning Document
AVRS / Auto Voice Response System
BA / Business Architecture
BCCTP / Breast and Cervical Cancer Treatment Program
BCM / Business Capabilities Matrix
BP / Business Process as defined by the Medicaid Information Technology Architecture (MITA)
BRM / Business Relationship Management
CAQH / Council for Affordable Quality Healthcare
CFR / Code of Federal Regulations
CHFS / Cabinet for Health and Family Services
CM / Care Management
CMS / Centers for Medicaid & Medicare Services
COB / Coordination of Benefits
COTS / Commercial off-the-shelf
DCBS / Department of Community Based Services
DFWAIP / Department of Fraud, Waste, Abuse Identification and Prevention
DMS / Division for Medicaid Services
EA / Enterprise Architecture
EDI / Electronic Data Interchange
EFT / Electronic Funds Transfer
eMARS / Electronic Management and Administrative Reporting System
EPSDT / EarlyandPeriodicScreening,Diagnosis,andTreatment
FA / Fiscal Agent
FFP / Federal Financial Participation
FFS / Fee-for-service
FPL / Federal Poverty Level
FTP / File Transfer Protocol
FMAP / Federal Medical Assistance Percentage
GOPM / Governor’s Office for Policy and Management
HBE / Health Benefit Exchange
HIE / Health Information Exchange
HIPAA / Health Information Portability and Accountability Act of 1996
HIX / Health Insurance Exchange
HL7 / Health Level 7
IA / Information Architecture
ICD-10 / International Classification of Diseases and Related Health Problems, Tenth Revision
ICN / Internal Control Number
ID / Identification
KAMES / Kentucky Automated Management and Eligibility System
KenPAC / Kentucky Patient Access and Care
KHIE / Kentucky Health Information Exchange
KPI / Key Performance Indicators
KY / Kentucky
MCO / Managed Care Organization
MITA / Medicaid Information Technology Architecture
MMIS / Medicaid Management Information System
NCCI / National Correct Coding Initiative
NCPDP / National Council for Prescription Drug Program
NPI / National Provider Identifier
NPPES / National Plan and Provider Enumeration System
OATS / Office of Administrative and Technology Services
OM / Operations Management
PA / Prior Authorization
PCCM / Primary Care Case Manager
PDF / Portable Document Format
PE / Presumptive Eligibility
PG / Program Management
PI / Program Integrity
POS / Point of sale/service
PR / Provider Management
PSA / Public Service Announcement
RA / Remittance Advice
RAC / Recovery Audit Contractor
RFP / Request for Proposal
SLA / Service Level Agreements
SMDL / State Medicaid Director Letter
SNAP / Supplemental Nutrition Assistance Program
SOA / Service Oriented Architecture
SSA / Social Security Administration
SS-A / State Self-Assessment as defined by the Medicaid Information Technology Architecture (MITA)
SUR / Surveillance and Utilization Review
TA / Technology Architecture
TANF / Temporary Assistance to Needy Families
TPL / Third Party Liability
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

1ExecutiveSummary

1.1Overview

CognosanteisundercontracttotheKentuckyCabinetforHealthandFamilyServices(CHFS)toprovideconsultingservicesfortheKentuckyMedicaidManagementInformationSystem(MMIS)Procurement.Aspartofthatworkeffort,CognosanteiscontractedtocompletetheMedicaidInformationTechnologyArchitecture(MITA)StateSelf-Assessment(SS-A).CognosantesubmitsthisupdatedToBeAssessmentdeliverableinaccordancewithTakeoverandReplacementProjectAmendment1.

TheamendmentrequiredanexaminationofthepreviouslyproducedMITASS-AdocumentandadeterminationregardingtheimpactoftherecentKentuckyenhancementstotheAsIsmaturitylevelsandareviewoftheimpactsthattheAffordableCareAct(ACA)andCMSEnhancedFundingRequirements,SevenConditionsandStandards(7C&S)willhaveontheToBeMITAmaturitylevelgoals.ThisdocumentwillpresenttheresultsoftheexaminationoftheToBeassessmentoffuturegoals,objectives,opportunities,andchallenges.AdditionaldocumentswillincludeaGapAnalysisandaTransitionPlan.TheTransitionPlanwillhighlightaplantotransitionfromthecurrentMMISarchitecturetofuturebusinessandtechnologyneedsandservices.

Section2providesadescriptionofthe MITA assessmentprocessemployedbyCognosanteandpresentsKentuckyMedicaid’sgoalsandobjectivesastheyrelatetoMITA.

Section3discussesthetwomajorexternaldriversofchange,theACAandthe7C&S.ThesectionprovidesthedetailsofthereviewoftheACAand7C&SwithindividualMITAbusinessprocesscapabilities.ACAandthe7C&Srequiredare-evaluationofthetechnicalrequirementsneededtosupporttheKentuckyMedicaidprogram.

Section4containstheassessmentresults.ThissectionprovidesdetailsonthecurrentlevelsofmaturityofeachKentuckyCHFSbusinessprocessascomparedtotheMITAmaturitylevelsalongwithKentucky’sToBegoals.

The original AsIsassessmentbyKentucky was completed in 2008. The To Be assessment was completed in 2010. Both assessments were performed using the v2.0 Business Capability Matrix(BCM) and reflected amaturitydeterminationbasedonv2.0capabilityinformation. The current To Be assessment was conducted usingthev2.01BCMandmaturitydeterminationsarebasedonv2.01capabilityinformation.Asaresultofthisversiongap,thechangestocapabilitystatementsrequiredsomeAsIsmaturitylevelstoberevisedtoreflectthe latest MITA maturity levels.

Inthis2012 assessment,Cognosantereviewedthepreviousassessment.Sincethattime,the Centers for Medicaid & Medicare Services (CMS)approvedrevisionstotheMITABCM. Theseupdates included changes and additions tothecapabilitystatements driving MITAmaturityleveldeterminations.Asaresult,theBCMcomponentof the MITAFrameworkmovedfrom v2.0 to v2.01.

The intent of the SS-A update is to identify MITA capabilities that will need to be improved in order to meet CMS requirements and the future needs of the Kentucky Medicaid.These requirements will be reviewed for possible inclusion into the MMIS Procurement Project RFP.

The Office of Administrative and Technology Services (OATS) will be leading the effort on the SS-A update to MITA v3.0.

1.2SummaryofFindings

Figure 1 below provides a summary of the Kentucky Medicaid Enterprise To Be maturity levels for all eight business areas. Each of these business areas is discussed fully in Section 5,Results of the MITA Business Process Assessment, and includes detailed discussion of the factors affecting assignment of MITA Maturity Levels.

Figure 1: Medicaid Enterprise To Be MITA Maturity Levels

TheupdateoftheexistingMITASS-Afocusedon:

ChangestotheMedicaidEnterprisesincethelastassessment
TheshifttowardsincreaseduseofManagedCareOrganizations(MCOs)
TheimpactstotheMITAbusinessprocessesfromthe ACA
TheimpactstotheMITAbusinessprocessesfromthe7C&S

ThefirstpartofthereviewfocusedonthechangestotheMedicaidEnterprisesincetheinitialassessments.Thesechangeswereincorporatedintothedetailedbusinessprocessdocuments.Severalofthenotablechangeswere:

Eliminationofthe Kentucky Patient Access and Care (KenPAC) program
LimitedImplementationofthe Kentucky Health Information Exchange (KHIE)
Improvementstothewebportalfunctionality

TheshifttoManagedCareonlyslightlyaffectstheMITAcapabilities.WhiletheContractorManagementprocessesmaybeusedmorefrequently,thechangedoesnotresultinMITAcapabilitychanges.TheProgramManagementareabusinessprocesseswillbeutilizedtooverseetheeffectivenessofthecareprovidedbytheMCOs.

The ACAisprimarilydrivingpolicychangesandprogramexpansion.ExamplesofACArequirementsimpactingtheMedicaidEnterpriseare:

Programpolicychangessuchasexpandedbenefits(e.g.,tobaccocessation,obesityeducationandoutreach)
Expandedenrollmentincreasingeligibilityto133%ofthe FederalPovertyLevel(FPL)
IntegrationandinteroperabilitywiththeHealth Insurance Exchange (HIX), referred to as the Health Benefit Exchange (HBE) in Kentucky,includingtheshareduseofeligibilitydeterminationmodules
CompliancewiththeNationalCorrectCodingInitiative(NCCI),whichKentuckyhasalreadyimplementedtoolstoensurecompliance

The7C&ShasthelargestimpactontheMITAcapabilities.The7C&Saddressmanyofthearchitecturalrequirements(interfacesandopenarchitecture)andbusinessresults(timelines,efficiency,and cost-effectiveness)areasdetailedintheMITAcapabilities.Thefollowinglistrepresentsahighlevelviewoftheitemsinthe7C&SthatdirectlyimpactMITAcapabilities:

Architecturerequirementssuchasmodularity,useofaseparaterulesengine,openinterfaces,andinteroperability
Businessresultsrequirementstoensureefficientandeffectiveoperations
ServiceLevelAgreement(SLA)andKeyPerformanceIndicator(KPI)requirementstotightlymonitorcontractors(bothadministrativeandhealthservices)
Requireduseofindustrystandards(Health Insurance Portability and Accountability Act (HIPAA)andMITAstandards)

2MITAStateSelfAssessmentprocess

2.1DescriptionoftheMITASS-AProcess

MITAisintendedtoprovideStateswithaninformationarchitecturethattheycanuseasaframeworkforimprovingMedicaidandexchangingdatathroughouttheenterprise,includingandamongbeneficiaries,vendorsandservicesproviders,stateandfederalMedicaidagencies,andotheragenciesandprogramswhicharesupportedbyfederalmatchingfunds.WhileMedicaidagenciesrelysubstantiallyontechnologytoperformtheirwork,MITAenvisionschangesthatwillenabletheMedicaidbusinessprocessestodrivethetechnologicalchangesoverthenextdecade.MITAalsoenvisionsthatmanyofthesebusinessprocessesmightbesimilaramongthevariousMedicaidagencies,andthatsomeeconomiesofscalemightbegainediftheseprocessescanbemodeledandsharedamongstates.ThegoalofMITAisto:

“EstablishanationalframeworkofenablingtechnologiesandprocessesthatsupportimprovedprogramadministrationfortheMedicaidenterpriseandforstakeholdersdedicatedtoimprovinghealthcareoutcomesandadministrativeproceduresforMedicaidbeneficiaries.”

CMSestablishedtheMITAframework,whichelaboratedontheMITAvision.ThatframeworkadaptedthebestpracticesintheindustrytomeettheuniquerequirementsofMedicaid.TheframeworkdetailedthatMITAwouldincludeaBusinessArchitecture(BA),anInformationArchitecture(IA),andaTechnicalArchitecture(TA)thatwouldworkinconcerttodefineandimprovetheadministrationofMedicaidEnterprises.

TheBusinessArchitecturewouldincludeallofthebusinessprocessesdefinedbytheMedicaidagencyandestablishamaturitylevelforeachofthem.TheInformationArchitecturewoulddefinethedataandstandardsnecessarytoconductthesebusinessoperations.Finally,theTechnicalArchitecturewouldestablishfundamentalconceptsoftechnology,suchasinteroperability,modularity,andflexibility,withoutnamingspecifictechnologyplatformsorsystems.TheTechnicalArchitectureisstillinearlystagesofdevelopment,buttheInformationArchitecture(IA)hasalmostnostructureintheFramework2.01.ThisassessmentonlycoverstheBusinessArchitecture.

ThedevelopmentoftheIAiscurrentlytakingplaceatHealthLevelSeven(HL7),whereallofthebusinessprocessesarebeingmodeled.AlloftheconceptsintheframeworkallowindividualMedicaidagenciestheoptionsandflexibilitytopursuetheirownEnterpriseArchitecture(EA),whilestilladheringtothebasicprinciplesthatmovetheentityforwardonthecontinuumtomorematurecapabilitiesthatbettermeettheestablishedgoalsandobjectives.

FundamentaltoimplementationoftheMITAconceptistherequirementforeachStatetoconductaSS-A.WithinthisSS-A,eachStateistocarefullyandhonestlylookatitscurrentbusinessprocessestoestablishwhichonespertaintoitsMedicaidoperationsandwhatmaturitylevelthatbusinessprocessis—theAsIsstate.TheMITAmaturitylevelsarespecifictoeachbusinessprocess,butcanbesummarizedinthefollowingtable:

Table1:MITAMaturityLevels

DefinitionofStateMedicaidLevelsofMaturity
Level1 / Level2 / Level3 / Level4 / Level5
AgencyfocusesonmeetingcompliancethresholdsforStateandFederalregulations,primarilytargetingaccurateenrollmentofprogrameligiblesandtimelyandaccuratepaymentofclaimsforappropriateservices. / Agencyfocusesoncostmanagementandimprovingqualityofandaccesstocarewithinstructuresdesignedtomanagecosts(e.g.,managedcare,catastrophiccaremanagement,anddiseasemanagement).Focusonmanagingcostsleadstoprograminnovations. / Agencyfocusesonadoptingnationalstandards,collaboratingwithotheragenciesindevelopingreusablebusinessprocesses,andpromotingone-stop-shopsolutionsforprovidersandconsumers.Agencyencouragesintrastatedataexchange. / Agencybenefitsfromwidespreadandsecureaccesstoclinicaldataandfocusesonimprovementofhealthcareoutcomes,empoweringbeneficiariesandproviderstakeholders,measuringobjectivesquantitatively,andensuringoverallprogramimprovement. / Agencyfocusesonfinetuningandoptimizingprogrammanagement,planningandevaluationsinceithasbenefitedfromnational(andinternational)interoperabilityandpreviouslynotedimprovementsthatmaximizeautomationofroutineoperations.

OncetheAsIsstate isdetermined,theSS-ArequirestheStatetoconsiderwhereitwouldliketobeoverthenextperiodoftime.ThattimeperiodisdeterminedbytheState,butcanbethenearfuture,oramoredistantgoalof5to10yearsinthefuture.ThisistheToBematuritylevelforeachbusinessprocess.BetweentheAsIsandtheToBeareissuesthatmustbeaddressedbeforetheStatecanprogresstothehighermaturity.ThoseissuesrepresenttheGaps.AsaStatedefinesitToBematuritylevel,itmayalsoelaborateonfunctionalityitwouldneedtoaccomplishthatmaturity.Thatmayrepresentbothbusinessprocessandtechnicalrequirementstoachievethatgoal.ThisprocessisbestillustratedbyafictitiousexamplethatisnotrelatedtoKentuckyoranyotherspecificState:

TheStateofAtlantiscurrentlyusesapaperapplicationforitsEnrollProviderbusinessprocess.ThisisconsideredtheAsIsstateoftheBP.Thatapplicationisreviewedmanuallybyanindividual,andproviderinformationisvalidatedviaphonecalls.ThisprocessisMITAmaturityLevel1asitisprimarilymanual.Atlantishasdeterminedthatintwoyearsitwouldliketoreceiveallofitsproviderapplicationsviaawebportalandautomatetheenrollmentwithenrollmentrules.ThisisconsideredtheToBestateoftheBP.ThismovestheprocesstoMITAmaturityLevel2asitincorporatesmoreelectronicprocessesandautomatestheapprovalprocessforalargepercentageofproviders.Additionally,withinfiveyears,AtlantiswouldliketomovetoanationaldatabankforproviderenrollmenttobeabletoseethatprovidersfromotherStatesareenrolledandthereforeeligibletoparticipateinAtlantisMedicaid.ThisprocesswouldmovetoaMITALevel3becauseitincorporatesstandardsforenrollmentandsharesdataacrossStatelineswithinastandardizeddatabank.

AsAtlantisplansitsprogressionfortwoyearsandthenfiveyears,someissuesremain.Itmustfirstdevelopawebportalandmustthenencourageproviderstouseitforenrollment.ItmustrewriteStaterulestoallowaproviderapplicationwithoutapapersignaturepage.ValidationofStatelicensuremustbeconductedthroughaninterfacetotheBoardofLicensure,andvalidationofthesocialsecurity/taxidentifiermustpassthroughaninterfacefromtheSocialSecurityAdministration(SSA).TheNationalProviderIdentifier(NPI)mustbevalidatedbyaquerytotheNationalPlanandProviderEnumerationSystem(NPPES).Oncethesevalidationshaveoccurred,thesystemmustapplybusinessrules,writtenbyAtlantis,tograntapprovaltotheprovider.BeforeaprovidercanbeenrolledthroughaNationalStandardizedEnrollmentSystem,thatsystemmustbedeveloped,tested,andvettedthroughanumberofStates.TheseissuesrepresenttheGapportionoftheMITASS-A.Somegapswillinvolvenewtechnology(webportaldevelopmentandinterfacecreation),whileotherswillinvolvechangestobusinessprocesses(rewritingStaterules,writingtherulesforapplicationacceptance,providingprovideroutreach,etc.).

TheMITASS-Aconsistsof:

AnassessmentoftheAsIsbusinessprocesses
AnassessmentoftheToBebusinessprocesses
TheGapsidentifiedtoachievingthedesiredToBeobjectives
ATransitionPlantooutliningthepathtosatisfyingthegaps

TheTransitionPlanoutliningthepathforwardisdevelopedwiththeCommonwealthandremainsalivingdocument.Eachbusinessprocesswillhaveitsowncurrentstate,issueslist,andrequirementsforthefuturethatmustbeaddressed,prioritizedandplanned.TheMITAframeworkprovidestheinstructions,buttheCommonwealthofKentuckymustdesignitsownroadmap.Throughoutthecourseofthejourney,differentissueswillbecomemoreimportantandwilljumptheprioritylist,newFederalandStatelawswilldemandmoreimmediateattention,andtechnologyitselfwillcontinuetoevolve.ThegoalofMITAistoestablishabaselinefromwhichtoplan,revisetheplan,andmoveforward.Priortoanyadvancedplanningdocument(APD)development,theStateisstronglyadvisedtocompleteits MITASS-A.ThisbaselinewillprovidevaluableinformationtotheState,whichenablesthedevelopmentofamorecomprehensiveAPD.ThefollowingfigurerepresentshowtheMITASS-AfitsintotheState’soverallplanforMMISimprovement.ItisreferredtoastheLineofSightbecauseitreferenceshoweachphaseoftheprocessmovesforwardtothenextphase.

Figure2:LineofSightDiagram

2.2CognosanteMethodology

AMITASS-Ahingesondeterminingtheexecutivevisionforthefuture,establishingtheinterestedstakeholders,capturingthecurrentlevelofbusinessprocesseswithintheenterprise,andenvisioningthecapabilitiesofanMMISasitisenhancedovertime.WhileMITAestablishesaframework,thatframeworkonlyservestoinitiatethediscussion.Cognosantereviewedtheexistinggoalsforthefuture.ThecurrentgoalsarerepresentedinSection2.3below.TheestablishedgoalsweremappedagainsttheMITAgoalsandobjectives,andformedthebasisforalldiscussionswithCHFSprogramstaff.

Becausethescheduleforthisengagementwasaggressive,CognosanteusedtheoriginalKentuckyMITAFramework2.0materialasafoundationwithitseightbusinessareasand79businessprocesses,asthebaseline.TheoriginalmaterialwasreviewedandplacedinastandardizedtemplatesbasedonMITAFramework2.01.AreviewofrecentchangestotheMMIS,legislationsuchastheACA,andCMSrequirementswasconductedandanyupdatesandnewfindingswereaddedtothetemplates.Thedetailedtemplateswereusedasthebasisforthefinaldeliverables.Thesecompletedtemplateswillbedeliveredinasoftcopybecauseofthelengthandtheneedtobeabletosearchthedocumentselectronically.ThisprocessassuredthatallMITAbusinessareasandprocesseswouldbeaddressed.

2.3ExecutiveGoalsandObjectives

2.3.1KentuckyMedicaidMission

Owingtotheunbridledspiritofitsworkforce,themissionofKentuckyMedicaidistoprovideinnovativeopportunitiestoitsmembersthatwillpromotehealthylifestyles,personalaccountability,andresponsibleprogramgovernanceforahealthierKentucky.

2.3.2KentuckyMedicaidVision

KentuckyenvisionsservingasanationalmodelforachievingexcellenceinMedicaidbyincreasingthequalityofbenefitservices,transformingcaremanagement,updatingrelevanttechnology,providingsupportforanoutstandingworkforce,andpreventing,detecting,andreducingfraud,waste,andabuse.

2.3.3KentuckyMedicaidValues

Respect–forallpersonswithwhomwecomeincontact

Integrity–inallofourtransactionsanddealingswithoneanotherandthepublic

Competency–ineachtaskweperform

Collaboration–inmakingdecisionsthatimpactothers

Accountability–forourdecisionsandactions

Excellence–inallthatweendeavortoachieve

Commitment–tooneanother,ourmembersandourproviders

2.3.4KentuckyMedicaidGuidingPrinciples

Dotherightthing,therightway,thefirsttime.
Alldecisionsmustpassthethreewaytest:

Isitlegal?
Isitethical?
Isitmoral?

Qualityserviceisthemosteffectiveservice.
KentuckyGoalsandObjectives

TheKentuckyMedicaidmissionseekstoaccomplishthefollowingfivegoals:

IntegratecaredeliverysystemsandprovidersforenhancedaccessandservicetoMedicaidmembers.
Redesignthebehavioralhealthcaredeliverysystem.
Increaseemphasisonprimarycare.

Developmechanismstoutilizeavailableresourcestomostappropriatelymeettheneedsofmembers.
TailorservicestomeettheindividualneedsbydevelopingvaryingbenefitpackagesdesignedtoaddressthedifferentpopulationscoveredbytheMedicaidprogramandtoestablishmeaningfulbenefitsbasedonbestpractices.
EnsurethatMedicaidisthepayeroflastresortbyestablishingan"optout"optionforthoseMedicaidmemberswhohaveaccesstoprivateinsurancecoverageandtocreateafinancialincentiveforthemtochoosethatoption.
Utilizelessonslearnedandbestpracticesthroughproven,traditionalinsuranceandbusinessmodelsandintegrateintotheMedicaidprogram.
EncourageMedicaidmemberstobepersonallyresponsiblefortheirownhealthcare.
DesignDiseaseandCareManagementprogramstoimprovethehealthofindividualswithspecificchronicconditions.
InitiateahealthliteracyprogramtomaketheMedicaideligiblemoreinformedabouthealth,healthcareandservices.
RedesigntheMedicaidprograminfrastructuretoutilizeandmaximizeappropriatebusinesspractices.
EnhancementofcostconsciousactivitiesperformedbytheMMIS.
Exploregrantopportunitieswithvariousfoundationsforprogramplanning,educationandresearch.
Providethorough,thoughtfuleducationalmaterialsandresourcestomembersandproviderstoassistandenrichtheirparticipationintheMedicaidprogram.
Developamodelofbestpracticesthatwillsupportprovidersandhelpempowermemberstolivehealthierlives.

3ExternalDriversofChange

WhiletheCommonwealthofKentuckyoperatesandmanagesitsownMedicaidprogram,CMSandfederallegislationplayamajorroleindeterminingprogrampoliciesanddirection.Theseexternaldriversrequireadditionalsystemcapabilities,funding,andCommonwealthresources.

3.1PatientProtectionandAffordableCareAct(ACA)

TheACAcontainsmanybroadprovisionsthatchangethewayhealthcareisdeliveredandthewayhealthinsuranceispurchased.SeveraloftheseprovisionsimpacttheMedicaidprogramsuchasexpandedeligibility,providerenrollment,andtheestablishmentofthe HBEthatwill interfacewiththe MedicaidEnterprise when making an eligibilitydetermination.

TheMITABusinessProcesseslistedbelowwillbeimpactedinsomemannerbytheimplementationofACA.

CM03–ManageMedicaidPopulationHealth

Table2:ACAImpactsonManageMedicaidPopulationHealth

ACASection / Requirement
4004 / Educationandoutreachcampaignregardingpreventivebenefitsandobesityrelatedcare.
4108 / Providesincentiveforstatesforpreventionofchronicdiseasesandhealthierlifestyles.

ME01–DetermineEligibility

Table3:ACAImpactsonEligibilityDetermination

ACASection / Requirement
2001 / Section2001oftheACAcreatesaneweligibilitycategoryentitled“newlyeligible”forindividualswithincomesbelow133%ofFPL.
2001 / Statesmustcreateandmaintainbenchmarkplans.

TheHBE willbetakinginapplicationsanddeterminingMedicaideligibilitybasedonincomerequirements.TheHBE mayalsobesharingtheeligibilitydeterminationservicesusedbyMedicaidandotherstateagencies.

ME02–EnrollMember

Newmemberswillbeaddedbasedonexpandedeligibilityrequirementsas determinedthroughtheHBE eligibility determination and enrollmentprocesses.Thenecessaryinterfaceswillneedtobedevelopedtosupportthose processes.

ME08–PerformPopulationandMemberOutreach

Table4:ACAImpactsonEligibilityDetermination

ACASection / Requirement
4004 / Educationandoutreachcampaignregardingpreventivebenefitsandobesity-relatedcare.

OM07–AuditClaim/Encounter

Table5:ACAImpactsonAuditClaim/Encounter

ACASection / Requirement
6507 / RequirescompliancewithNationalCorrectCodingInitiative (NCCI).

OM16–PrepareHealthInsurancePremiumPayment

OM21–PrepareMemberPremiumInvoice

Intheseprocesses,theCommonwealthiscoveringthemember’sshareofthepremiumformedicalcoverage.The premium billing, collections, and reconciliation processesfor member premiums maybehandledthroughtheHBE process/system/vendordependingontheCommonwealth’ssolution.The Division for Medicaid Services (DMS)couldrealizesomegainsinefficiencybyeliminatingamanualMedicaid processandincorporatingitintotheHBE.

OM20–CalculateSpendDownAmount

TheSpendDownprocesstypicallycoversclientswithincomesslightlyhigherthanMedicaideligibilitylimits.Inthesecases,theHBE willofferincreasinghealthcaresubsidiesforhealthinsurancecoverageleadinguptofullMedicaidcoverage.TheparticipantswouldlikelyqualifyforcoveragewhichmayeliminatetheneedfortheSpendDownprocess.

OM26–ManageRecovery

Table6:ACAImpactsonManageRecoveryProcess

ACASection / Requirement
6411 / TheACArequiresthecontractingofaRecoveryAuditContractor(RAC).
6506 / Thisprovisionextendstheperiodoftimeforrecoverytooneyearfromthetimeofdiscovery.

PG02–DevelopandMaintainBenefitPackage

Table7:ACAImpactsonBenefitPackages

ACASection / Requirement
2001 / Statesmustcreateandmaintainbenchmarkplansaswellasthe“newlyeligible”benefitcategory.
2001 / Beginningin2014,benchmarkandbenchmark-equivalentplansmustbeginprovidingatleastessentialhealthbenefits,asdescribedinSection1302(b).
(SeeStateMedicaidDirectorLetter(SMDL)#10-013.)
2401 / Increasedeligibility(150%FPL)forpersonalcareattendantservicesfordisabledbeneficiaries.
2502 / StateMedicaidprogramsmustcoverbarbiturates,benzodiazepines,andtobaccocessationproducts.
Eliminationofexclusionofcoverageofcertaindrugs.
4107 / RequiresthattobaccocessationprogramsforpregnantwomenbecoveredbyMedicaid.

PG17–MonitorPerformanceandBusinessActivity

Table8:ACAImpactsonMonitoringPerformanceandBusinessActivity

ACASection / Requirement
2001 / StatesmustreporttoCMSonMedicaidenrollees,disaggregatedbychildren,parents,non-pregnantchildlessadults,disabledindividuals,elderlyindividuals,orothercategoriesrequiredbytheSecretary.

PI01–IdentifyCandidateCase

Table9:ACAImpactsonCaseIdentification

ACASection / Requirement
6411 / TheACArequiresthecontractingofaRecoveryAuditContractor(RAC).

PI02–ManageCase

Table10:ACAImpactsonManagingCases

ACASection / Requirement
6411 / TheACArequiresthecontractingofaRecoveryAuditContractor(RAC).

PM01–EnrollProvider

Table11:ACAImpactsonProviderEnrollment

ACASection / Requirement
6401 / TheACArequiresadditionalscreeningofproviders.Theadditionalscreeningrequirementswillcheckforpotentialfraud,wasteandabuse.Therequirementincludesfingerprinting,criminalbackgroundchecks,andrandomsitevisits.
6402 / ThisprovisionrequirestheNPIforproviderenrollmentintheMedicaidprogram.
6403 / TheNationalPractitionerDatabasemustbeusedintheenrollingofproviders.StatesmustconvertfromtheHealthIntegrityandProtectionDatabasetotheNationalPractitionerDatabase.

3.2ImpactoftheSevenConditionsandStandardsonMITAMaturityGoals

3.2.1Overview

DMScompletedaMITASS-Av2.01in2008,aspartoftheplanningprocessrequiredbyCMS.InApril2011,CMSreleasedtheEnhancedFundingRequirements:SevenConditionsandStandards(7C&S),listedbelow:

ModularityStandard–Requirestheuseofamodular,flexibleapproachtosystemsdevelopmentincludingtheuseofopeninterfacesandexposedapplicationprogramminginterfaces;theseparationofbusinessrulesfromcoreprogramming;andtheavailabilityofbusinessrulesinbothhumanandmachinereadableformats.

MITACondition–RequiresstatestoaligntoandadvanceincreasinglyinMITAmaturityforbusiness,architecture,anddata.

IndustryStandardsCondition–Statesmustensurealignmentwith,andincorporationof,industrystandards,suchasHealthInsurancePortabilityandAccountabilityAct(HIPAA)security,privacy,andtransactionstandards.

LeverageCondition–Statesolutionsshouldprovidesharing,leverage,andreuseofMedicaidtechnologiesandsystemswithinandamongstates.

BusinessResultsCondition–Systemsshouldsupportaccurateandtimelyprocessingofclaims(includingclaimsofeligibility),adjudications,andeffectivecommunicationswithproviders,beneficiaries,andthepublic.

ReportingCondition–Solutionsshouldproducetransactiondata,reports,andperformanceinformationthatwouldcontributetoprogramevaluation,continuousimprovementinbusinessoperations,andtransparencyandaccountability.

InteroperabilityCondition–SystemsmustensureseamlesscoordinationandintegrationwiththeKentucky HBEandallowinteroperabilityamongotherstateagenciesandcommunityorganizationsprovidingoutreachandenrollmentassistanceservices.

ItisDMS’intenttoprocureanewsysteminordertomeetthe7C&Sandqualifyfortheenhancedfundingoftheprogram.

Ananalysiswasdonetocomparethedetailsofthe7C&StotheMITAcapabilitiestodeterminewhichMITAcapabilitieswillbeimpacted.TheresultoftheanalysiswillbetoelevatetheMITAToBegoalstoalignwiththeobjectivescontainedintheSevenConditionsandStandards.

Therecentreleaseofthe7C&Srequiresnewdesignanddevelopmentefforts,includingtotalMMISreplacements,toaddresscompliancewiththesestandardsandconditionsinordertoreceivedenhancedfederalfundingforMedicaidtechnologyinvestments.DMSunderstandsthatachievingfullcompliancewiththesestandardswilltaketime,andwillnotbeasimpletask.

3.2.2Summaryof7C&SImpacts

Ahigh-levelsummaryofthe7C&SassessmentresultsislistedinTable 12.Thesearethecomponentsofthe7C&SthathadmultipleimpactsofMITAbusinessprocesscapabilityToBelevels.

Table12:7C&SImpactSummary

Condition/Standard / KeyelementsimpactingtheMITAcapabilities
ModularityStandard /

Useofaseparaterulesengine
UseofexposedservicesandService Oriented Architecture (SOA)

MITACondition / TherewerenodirectimpactstotheMITAbusinesscapabilitiesidentified.
IndustryStandardsCondition /

UseofHIPAAtransactionstandards
ConformancewithCMSissuedindustrystandards

LeverageCondition /

ReuseofMedicaidtechnologies

BusinessResultsCondition /

Eliminationofmanualtaskstoprovideeffectiveandefficientbusinessprocesses
Increasingthedegreeofautomation
Includingperformancestandardsincontracts

ReportingCondition /

Allowingaccesstodataforprogramevaluation

InteroperabilityCondition /

Seamlesscoordinationandinteroperabilitywithothersystems
Useofopeninterfaces

Table 14: 7C&S Impact Assessmentbelowprovidesahigh-levelpictureoftheareasimpacted.Table 13: 7C&S Impact Legendprovidesakeytothetable.

Table13:7C&SImpactLegend

Key / Description
High / Themajorityofthebusinessprocesses(>66%)haddirectimpactsfromthe7C&Srequirements.
Moderate / Asignificantnumber(33-66%)oftheprocesseshaddirectimpactsfromthe7C&Srequirements.
Minimal / Lessthan33%oftheprocesseshaddirectimpactsfromthe7C&Srequirements.
None / Noneoftheprocesseshaddirectimpactsfromthe7C&Srequirements.
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

Table14:7C&SImpactAssessment

BusinessArea / ModularityStandard / MITACondition / IndustryStandardsCondition / LeverageCondition / BusinessResultsCondition / ReportingCondition / InteroperabilityCondition
BusinessRelationshipManagement / Moderate / None / High / Minimal / Minimal / None / Minimal
CareManagement / Moderate / None / Moderate / None / High / Minimal / Minimal
ContractorManagement / Minimal / None / Moderate / Minimal / High / Moderate / None
MemberManagement / High / None / Minimal / None / High / Moderate / Moderate
OperationsManagement / High / None / Minimal / None / High / High / High
ProgramIntegrityManagement / Moderate / None / None / None / High / None / None
ProgramManagement / Moderate / None / Moderate / None / High / Moderate / Moderate
ProviderManagement / Moderate / None / Minimal / None / High / Moderate / Minimal
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

3.2.3ImpactsonBusinessRelationshipManagementProcesses

TheinteractionoftheSevenConditionsontheBusinessRelationshipManagementprocessisprimarilyintheIndustryStandardsConditionandModularityStandardareas.TheemphasisinthisareaistowardsadoptingMITAandHIPAAstandardsaswellasstandardinterfacesandreusableservices.

TheprimaryconditionsandstandardsthatimpactMITAToBecapabilitiesfortheBusinessRelationshipManagementBusinessAreaincludethefollowing:

UseofaseparateRulesEnginetoautomatebusinessrules
AdoptionofHIPAAstandardtransactions
AdoptionofMITAdatastandardsandinterfaces
UseofSOAservicestocreatereusableservices
Useofautomationtoimproveprocessingtimeandefficiency

/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

Table15:BusinessRelationshipManagementDetailedResults

BusinessProcess / KentuckyMITACapabilityGap / Condition/Standard / ActiontoMeetMITAToBeand7C&S
BR01 / EstablishBusinessRelationship / Lackofdataaccuracyandcompleteness,lackofprocessintegration,andmanualprocessingnegativelyimpactstheaccuracyoftheprocess. / ModularityStandard / ImplementaseparateRulesEnginetoautomateprocesses
BR01 / EstablishBusinessRelationship / InternaldatastandardshavebeenimplementedandHIPAAstandardsfortransactionsareinuse. / IndustryStandardCondition / AdoptMITAdatastandardsandinterfaces
BR01 / EstablishBusinessRelationship / Theprocessconformstoregulationsandfacilitatescostmanagementandongoingqualityimprovement. / LeverageCondition / UseofSOAserviceswillcreatereusableservices.
TheprocessisenhancedoverLevel2andalsosupportsimprovedprogrammanagement,meetsMITAdefinitions,andsupportstheshifttosharedbusinessservices.
BR01 / EstablishBusinessRelationship / Theprocessisamixtureofautomationandmanualinterventionbecauseoftheneedtointerfacebetweenmanydifferentstakeholdersanddatasources(internalandexternaltotheenterprise). / InteroperabilityCondition / UseMITAstandardstomakesysteminteroperablewithothersystems.
TheprocessisprimarilyautomatedwiththeuseofMITAstandardsandstepsareinternallyinteroperable.
BR02 / ManageBusinessRelationship / ThebusinessprocessissupportedbyproprietaryElectronic Data Interchange (EDI)andnon-standardizeddataandformatfrommultiplesources. / IndustryStandardCondition / InternaldatastandardshavebeenimplementedandHIPAAstandardsfortransactionsareinuse.
BR02 / ManageBusinessRelationship / Manualcommunicationandprocessingarenottimely. / IndustryStandardCondition / Someuseofelectronicinterchange,automationofsomesteps,andinternal(andHIPAA)datastandardshaveincreasedcoordinationandconsistency,thusimprovingend-to-endtimeframesforcommunicationandprocessing.
BR03 / TerminateBusinessRelationship / Theprocessrequiresupto30days. / BusinessResultsCondition / Improveprocesstimetoaverage10daysorless
BR03 / TerminateBusinessRelationship / Manualoperationresultsinsubjectiveselectionofdatatobeused. / BusinessResultsCondition / Implementstandards
BR03 / TerminateBusinessRelationship / Theprocessreliesprimarilyonmanualactivities. / BusinessResultsCondition / Implementautomationtoimproveefficiency
BR04 / ManageBusinessRelationshipCommunication / ThebusinessprocessissupportedbyproprietaryEDIandnon-standardizeddataandformatfrommultiplesources. / IndustryStandardCondition / AdoptHIPAAstandardsfortransactions
BR04 / ManageBusinessRelationshipCommunication / Thereislackofdataaccuracyandcompleteness. / IndustryStandardCondition / UseofHIPAAdataexchangestandards,andincreaseduseofautomationreducesinaccuracies
BR04 / ManageBusinessRelationshipCommunication / Thereislackofdataaccuracyandcompleteness. / ModularityStandard / Internalstandardizationofdata,useofHIPAAdataexchangestandards,andincreaseduseofautomationreducesinaccuracies
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

3.2.4ImpactsonCareManagementProcesses

TheinteractionoftheSevenConditionsontheCareManagementprocessisprimarilyintheBusinessResultsarea.MedicaidEnterpriseemphasisisbeginningtoturn“outward”inthatmoreprogramstodealwiththehealthofthegeneralpopulation,andeffortsatdiseasepreventionandeducationarebecomingmoreimportant.Theprocessestoachievethisresultarestillintheirearlystages.Thedevelopmentandincreasedmaturityoftheprocessesmustbeaddressedinordertoincreaseeffectiveness.CloselyfollowingthisconditionarethoseofIndustryStandardsandModularity(especiallyintheareaofaRulesEngine).AsotherStatesdevelopeffectiveprograms,itwillbeimperativethattheCommonwealthfollowsuccessfulexamples.Thismeansamethodofchangingprocessingrules,andbeingabletoimplementthesechangesandprogramsasquicklyaspossible.

TheprimaryconditionsandstandardsthatimpactMITAToBecapabilitiesfortheCareManagementBusinessAreaincludethefollowing:

UseofaseparateRulesEnginetoautomatebusinessprocesses
Designinteroperablesystemstoimprovedataaccessandefficiency
Automateprocessestoimproveefficiency
CoordinatestandardsofcarewithotherCommonwealthagencies
Strategiestoimprovehealthofidentifiedgroupsmustbepublished
ExpansionandadherencetoHIEstandardsandpracticeswillimprovethisprocess

/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

Table16:CareManagementDetailedResults

BusinessProcess / KentuckyMITACapabilityGap / Condition/Standard / ActiontoMeetMITAToBeand7C&S
CM01 / EstablishCase / Theprocessisamixtureofautomationandmanualinterventionbecauseoftheneedtointerfacebetweenmanydifferentstakeholdersanddatasources(internalandexternaltotheenterprise). / ModularityStandard / Separaterulesenginecouldbeusedtoenhancetheprocess.
TheprocessisprimarilyautomatedwiththeuseofMITAstandardsandstepsareinternallyinteroperable.
CM01 / EstablishCase / Processusesmanualmethodtoestablishgroups,andisill-defined / BusinessResultsCondition / Automatetaskstoimproveefficiencyandeffectiveness
CM02 / ManageCase / Manualprocessesidentifyservicesoractionstobeperformedandpointsforintervention.Opportunitiesforimprovementsexistatmanypointsintheprocess. / BusinessResultsCondition / Automateprocessestoimproveefficiency.
CM03 / ManageMedicaidPopulationHealth / Thebusinessprocessconsistsprimarilyofmanual,paperbasedsteps.Manualcompilationofdataisrequired. / BusinessResultsCondition / Automatetaskstoimproveefficiencyandeffectiveness
CM03 / ManageMedicaidPopulationHealth / Usingcensus,vitalstatisticsandotherdatasources,informationshouldbedistributedtotargetedgroups / InteroperabilityCondition / ProposedsystemsneedtosupportinteroperabilitywithHIE,publichealthagencies,andotherhumanserviceprograms.
CM04 / ManageRegistry / ProcesspromotesconnectionwithhealthcareorganizationsandotherStateswithrespecttomanagingtheexchangeofinformation / IndustryStandardCondition / ExpansionandadherencetoHIEstandardsandpracticeswillimprovethisprocess
CM04 / ManageRegistry / Currentregistryisgrowingandexpandingconnectivity / BusinessResultsCondition / ExpandKHIEaccesstoincludeallhealthcareproviders
CM04 / ManageRegistry / Processincludesmanagementoflaboratoryinformation,claiminformationfromMedicaid,hospitalsandhealthcarepractitioners / InteroperabilityCondition / Exchangeofinformationbetweeninvolvedpartiesiscriticaltotheprocess
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

3.2.5ImpactsonContractorManagementProcesses

ContractorManagementisalabor-intensiveactivity.Theprocessesareveryspecializedandmanual.The BusinessResultsconditioniskeyinthisarea.Efficienciesmustbefoundintheportionsoftheprocessthatarecommontotheprocessacrossoccurrences(suchastheevaluationofRFPresponses,publishingofresultsoftheawardprocess,etc.).AlsoimpactingthesemanagementprocessareIndustryStandardsandReporting.TheCommonwealthisseekingtobeawareofactivityinotherStatesandacrossagencieswithresultsofContractorManagementactivities.AndtheproperreportingofcontractoractivitiesiscriticaltomaintainFederalreportingstandardsandregulations.

TheprimaryconditionsandstandardsthatimpactMITAToBecapabilitiesfortheContractorManagementBusinessAreaincludethefollowing:

Improvingtheefficiencyoftheprocessbyutilizingmoreautomation
Producingreliableandaccurateresults
Improvingelectroniccommunications
Publishingtheresultsandmakingthemavailableforinquiry
Increasecentralizedtrackingandautomation

/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

Table17:ContractorManagementDetailedResults

BusinessProcess / KentuckyMITACapabilityGap / Condition/Standard / ActiontoMeetMITAToBeand7C&S
CO01 / ProduceAdministrativeorHealthServicesRFP / Contractdataarecentralizedandmaintainedelectronically.Thereiscoordinationbetweenagencies.Requirementstrackingandmaintenancearecentralized. / IndustryStandardCondition / Centralizedcontractdatashouldutilizeautomationwherepossible.MITAstandardsneedtobeintegratedintotheRFPprocess.Improvecoordinationbetweenagenciestoeliminateduplicationofcontractedservices.
CO01 / ProduceAdministrativeorHealthServicesRFP / CompletedRFPsareavailableforresponsebypotentialvendors / ReportingCondition / PublishcompletedRFPsinvariousformats
CO01 / ProduceAdministrativeorHealthServicesRFP / ManualmeansareprimarilyusedtocreateRFPs / LeverageCondition / CompleteRFPsutilizingcurrentMITAstandardsthatserveasmodelsforadditionalRFPs
CO02 / AwardAdministrativeorHealthServicesContract / Theprocesscomplieswithstateandfederalregulationshowever;manualprocessesadverselyaffectcosteffectiveness. / BusinessResultsCondition / Utilizedefineddataandcontentstandards;centralizationreducesprocesscostsandallowsstafftoshiftsomeattentiontocostmanagementandongoingqualityimprovement.
CO02 / AwardAdministrativeorHealthServicesContract / Proposalinformationisreceivedandverifiedinvariousmethods / ReportingCondition / Resultsoftheproposalprocessshouldbepublishedandavailableforinquiry
CO03 / ManageAdministrativeorHealthServicesContract / Monitoringtoolsareusedtotrackadherencetocontractrequirements / ModularityStandard / Useofaseparaterulesenginewouldfacilitatecontractmonitoring(especiallyadministrative)
CO05 / ManageContractorInformation / Updatestothecontractormasterfilearemadefrommanydifferentfaxandpapersources.Staffmembersrelyuponmanualandsubjectivevalidationmethods. / BusinessResultsCondition / Processshould userequeststhatarestandardizedandautomatedwhichincreasestheefficiencyandaccuracy
CO06 / ManageContractorCommunication / Processisprimarilymanualusingelectronicformsofcommunication / BusinessResultsCondition / Inquiriesshould bereceivedandprocessedbycentralizedcontractmonitoringgroup
CO06 / ManageContractorCommunication / Informationregardingpotentialchangesandcontractactivitiesisdistributed / ReportingCondition / Communicationstargetingprospectivevendorsmustbemadeavailable
CO07 / PerformContractorOutreach / Staffmanuallyverifies thattheinformationisaccurate. / ReportingCondition / Electroniccommunicationsshould havebuilt-inverificationsofaccuracy.
CO07 / PerformContractorOutreach / Informationfortheoutreachismanuallyaccessed.Thisaddstothetimerequirementsforthisprocess. / BusinessResultsCondition / Someinformationfortheprocessshould be accessibleelectronically.Thisreducesthetimerequirementsforlaunchingtheoutreach.
CO08 / SupportContractorGrievanceandAppeal / Processispaper-based(andincludesdocumentsrequiredtobepaper),andmaytakeanextendedperiodoftimetocomplete / BusinessResultsCondition / IncorporateautomationtoolssuchasdocumentimagingandWorkflow.
CO08 / SupportContractorGrievanceandAppeal / Stateagenciesarestandardizingandcentralizingsomeoftheadministrationofthisprocess / IndustryStandardCondition / Increasingtheconsistencybetweenstateswillimprovetheprocess
CO09 / InquireContractorInformation / InquiriesarereceivedandprocessedasrequiredbyOpenRecordlawrequirements / BusinessResultsCondition / Implement automated processes to improve efficiencies
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

3.2.6ImpactsonMemberManagementProcesses

MemberManagementisoneoftheprimaryareasoffocusintheMedicaidEnterprisesystem.Manyoftheactivitieswithinthemanagementprocessarematureandpredictable,makingthemexcellentcandidatesforautomation.Withthisinmind,Modularity(withaflexible,easilyuser-modifiedRulesEngine)willallowimprovementstotheBusinessResultscondition.Muchofthebasicdecision-making(particularlyinearlyprocesseswithintheMemberManagementprocessflow)canbeaccomplishedbeforemanualprocessesareinvolved.AstheMedicaidEnterprisesystemsevolve,theinteractionbetweenCareManagement(withtheemphasisoneducatingandincreasingthehealthofthegeneralpopulation)andMemberManagementwillbecomemorecritical.Interoperabilitybetweenthesesystemsandprogramswillbecomeevenmoreimportanttothesuccessoftheefforts.

TheprimaryconditionsandstandardsthatimpactMITAToBecapabilitiesfortheMemberManagementBusinessAreaincludethefollowing:

UseofaseparateRulesEnginetoautomatebusinessprocesses
Improvebusinessresultsbyreducingmanualprocesses
Adoptingnationalstandardinterfacesanddata
Developingopeninterfaceswithbotheligibilitysourcesandeligibilityusers

/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

Table18:MemberManagementDetailedResults

BusinessProcess / KentuckyMITACapabilityGap / Condition/Standard / ActiontoMeetMITAToBeand7C&S
ME01 / DetermineEligibility / Decisionsonprogramsandlevelsofeligibilityareinitiallydeterminedbyhard-codedsystemrules / ModularityStandard / Implement a separaterulesengineto eliminate hard-coding of rules
ME01 / DetermineEligibility / Processisacombinationofautomatedandmanualprocesses;manualstepsarenotefficient / BusinessResultsCondition / Implement a system thatmakesrules-baseddecisionstodeterminetheprogramforwhichanindividualmayqualify;completionoftheprocessisacollaborativeactivity
ME01 / DetermineEligibility / Processrequirestheinteractionofsystemsforvariousstakeholders.
WorkersinremoteofficesuseKAMEStoprocessinitialapplicationdata / InteroperabilityCondition / Develop web tools so that applicantsmaycompleteandsubmitelectronicapplicationsfromanylocationthathasinternetaccess;create a uniformapplicationprocessformultipleprograms,includingMedicaid.
ME02 / EnrollMember / Decisionsonprogramsandlevelsofeligibilityareinitiallydeterminedbysystemrules / ModularityStandard / Implement a separaterulesenginewouldenhanceprocess
ME02 / EnrollMember / Thesystemmakesrules-baseddecisionstodeterminetheprogramforwhichanindividualqualifies;completionoftheprocessisacollaborativeactivity / BusinessResultsCondition / Processisacombinationofautomatedandmanualprocesses;manualstepsarenotefficient,RulesEnginewouldautomatesomeoftheprocess.
ME02 / EnrollMember / Processrequirestheinteractionofsystemsforvariousstakeholders.
WorkersinremoteofficesuseKAMEStoprocessapplicationdata. / InteroperabilityCondition / Ensurethatopeninterfacesareestablishedandmaintained.
ME03 / DisenrollMember / Decisionsonprogramsandlevelsofeligibilityareinitiallydeterminedbysystemrules / ModularityStandard / Separatebusinessrulesfromcoreprogramming.
ME03 / DisenrollMember / Theprocessisprimarilymanual.Disenrollmentinformationismanuallyenteredandautomaticallyupdatestotheeligibility/enrollmentdatastore. / BusinessResultsCondition / Automate the process where possible with some datastillmanuallyentered.Automate the application of business rules to increase overallefficiency.
ME03 / DisenrollMember / Processrequirestheinteractionofsystemsforvariousstakeholders.
WorkersinremoteofficesuseKAMEStoprocessapplicationdata. / InteroperabilityCondition / Automate the disenrollment of membersbasedonStatebusinessrulesorFederalregulations.Membersshouldalsobe automatically disenrolledfromWaiverandManagedCareprograms if program rules require it.
ME04 / InquireMemberEligibility / Requestsarereceivedinvariousformats,primarilyelectronictransactions / ModularityStandard / Implement standard SOA based services to make the process modular and standardized across the enterprise.
ME04 / InquireMemberEligibility / Processisacombinationofseveralinquirytechnologiesandsystems.AutomatedinquiriescurrentlyuseHIPAAtransactionsandAVRSfunctionality. / InteroperabilityCondition / Convert the processtoexposedservicesusingopeninterfaces
ME05 / ManageApplicantandMemberCommunication / Requestsarereceivedinvariousformats,primarilyelectronictransactions / ModularityStandard / Implementelectroniccommunicationmethodstomergeinquiriesintoasinglestreamandmaintainelectroniccopiesofcommunications.
ME05 / ManageApplicantandMemberCommunication / Mostinquiriesareresearchedmanually,leadingtoinconsistentresultsandefficiency / BusinessResultsCondition / Implementautomatedtoolsforworkflowmanagementtostreamlineresponseprocess.
ME06 / ManageMemberGrievanceandAppeal / Thisisanall-manualprocess.GrievancesandappealsarefiledviafaxandUSPS.Confidentialdocumentsaretransferredbycertifiedmail. / BusinessResultsCondition / Documentsshouldbescannedandthecasefileautomatedandsharedamongcaseworkers.
ME06 / ManageMemberGrievanceandAppeal / Nostandardsbeyondgeneralrequirementsforestablishingacase. / IndustryStandardCondition / EstablishlocaldocumentationstandardsandworktowardsMITAstandards
ME07 / ManageMemberInformation / Amember’sdatastorerecordwillincludealleligibilityandenrollmentspans,andsupportflexibleadministrationofbenefitsfrommultipleprogramssothatamembermayreceiveacustomizedsetofservices / ReportingCondition / Enablethedatastoretobeusedtoprovideinformationandstatisticsforavarietyofmember-relatedactivities
ME07 / ManageMemberInformation / ThisprocessisassociatedwithmanyotherprocesseswhichutilizeMemberInformation / ModularityStandard / Developopeninterfacesandexposestandardservices
ME08 / PerformPopulationandMemberOutreach / Processislabor-intensive;highcostsreducefrequencyofoutreach. / BusinessResultsCondition / Useautomationtoimproveresultsintargetingpopulationsneedingoutreachandeducation.
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

3.2.7ImpactsonOperationsManagementProcesses

TheOperationsManagementprocessesoftheMedicaidEnterprise(bothautomatedandmanualactivities)aretheheartoftheenterprise.Theseprocessedpayclaimsandgeneratecapitationpayments.Thesuccessoftheprocessesreliesonefficientandeffectiveoperations.Withthatinmind,evaluationandimprovementoftheBusinessResultsderivedfromtheseactivitiesisthemostcritical.Evenslightimprovementsaremagnifiedduetothehighvolumeoftransactionsprocessed,andindividualsserved.CloselytiedtothisconditionistheModularityofthesystem.Theabilitytoreplaceunder-performingmodules(suchasaRulesEngineorProviderEnrollmentfunction)willallowthecontinualimprovementoftheenterprise.OtherconditionsthatareandwillbecomeevenmorecriticalareReportingandInteroperability.Thestatisticsconcerningprocessing,plusinformationdealingwiththememberpopulationmustbeusedtoidentifyareaswhereimprovementsarerequired.Andasothernon-Stateagencies(includingFederalprogramssuchasaHealthInsuranceExchangemandate,andaHealthInformationeffort)willmaketheabilitytocommunicateandshareinformationacrossagenciesextremelyimportant.

TheprimaryconditionsandstandardsthatimpactMITAToBecapabilitiesfortheOperationsManagementBusinessAreaincludethefollowing:

ImplementtheuseofaRulesEnginetoseparatetheprocessingrulesfromthecoresystem
Implementexposedservicestobetterfacilitatethedataflowbetweensystems(e.g.,priorauthorizations,TPL,Coordination of Benefits (COB),Treatmentplans,andpremiumpayments)
IntegratewithothersystemsforseamlessinteractionwithHIEandHBE functions
Utilizationofworkflowtoolstoautomateprocessesandimprovebusinessresults

/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

Table19:OperationsManagementDetailedResults

BusinessProcess / KentuckyMITACapabilityGap / Condition/Standard / ActiontoMeetMITAToBeand7C&S
OM02 / AuthorizeService / ManualprocessesareusedbytheCommonwealthforauthorizationforFFSclaimsneedingpreapprovalorpostapproval / BusinessResultsCondition / Implementautomationtobemoreeffectiveandefficient
OM02 / AuthorizeService / TheAuthorizeServicerequestmaytakemanydays.
Accessingthedatarequiredtomakethedecisionmaytakedays. / ModularityStandard / ImplementaseparateRulesEnginetoautomateprocesses
OM02 / AuthorizeService / Authorizationofserviceiscommunicatedtootherhealthcareagenciesandparticipants / InteroperabilityCondition / Improvetheexchangeofdatabyautomatingtheapproval/denialnotifications.
OM03 / AuthorizeTreatmentPlan / AuthorizeTreatmentPlanrequestsaremanuallyvalidatedagainststatespecificbusinessrules. / ModularityStandard / ImplementaseparateRulesEnginetoautomateprocesses
OM03 / AuthorizeTreatmentPlan / ManualprocessesareusedbytheCommonwealthforauthorizationoftreatmentplansneedingpreapprovalorpostapproval(forauditpurposes) / BusinessResultsCondition / Improveautomationinthetreatmentplanapprovalprocess
OM03 / AuthorizeTreatmentPlan / Authorizationofthetreatmentplaniscommunicatedtotheappropriatehealthcareagencyandparticipants / InteroperabilityCondition / Supportinteroperabilitywithothersystemsintheexchangeoftreatmentplandata
OM04 / ApplyClaimAttachment / ManualprocessesareusedbytheCommonwealthinordertoassociateanattachmentwithapriorclaim / BusinessResultsCondition / Improveautomationintheattachmentprocesstoimproveefficiency
OM04 / ApplyClaimAttachment / Manualmatchesandreviewsresultininconsistencyanderrors. / ModularityStandard / ImplementaseparateRulesEnginetoautomateprocessestoevaluateattachment
OM04 / ApplyClaimAttachment / Adoptionofstandardsandprotocolsbaseduponlegislation / IndustryStandardCondition / Implementindustrystandardsforattachments
OM05 / ApplyMassAdjustment / ManualprocessesareusedbytheCommonwealthinordertocommunicatewiththeFAandprocessthemassadjustments / BusinessResultsCondition / Developmoreefficientandeffectiveprocesses
OM05 / ApplyMassAdjustment / Agencystaffmanuallyproducereportstoidentifytheclaimsaffectedbytheadjustment. / InteroperabilityCondition / Claimsaffectedbythemassadjustmentshouldbeidentifiedthroughanautomatedapplication
OM06 / EditClaim/Encounter / Automationofbusinessrules / ModularityStandard / SeparateRulesEnginewouldremovebusinessrulesfromcoreprogramming
OM06 / EditClaim/Encounter / E2EprocessworksinconjunctionwithMCOstoprocess/editclaimsandencounters / InteroperabilityCondition / Theresultofprocessingandeditsmustbecommunicatedtoallparticipantsinthehealthcarecycle
OM07 / AuditClaim/Encounter / Businessrulesarepartofcoresystem / ModularityStandard / SeparateRulesEnginewouldremovebusinessrulesfromcoreprogramming
OM07 / AuditClaim/Encounter / Systemverifiesthatservicesrequiringauthorizationhaveapproval,clinicalappropriateness,andpaymentintegrity / InteroperabilityCondition / Theresultoftheauditmustbecommunicatedtoallparticipantsinthehealthcarecycle,alongwithreturnedclaims/encountersifappropriate
OM11 / PrepareCOB / InformationisexchangedwithTPLvendor,HealthManagementSystems(HMS),inordertocoordinatethirdpartyrecoveries / InteroperabilityCondition / ImplementstandardservicesfordatainteractionswithTPLvendor
OM12 / PrepareEOB / Arandomsampleofservicesiscreatedforevaluation / ModularityStandard / Rulesandprocessingshouldbeseparate
OM13 / PrepareHomeandCommunityBasedServicesPayment / Dataiscollectedbybothmanualandautomatedprocesses / BusinessResultsCondition / Processneedstobemoreefficientandwell-defined
OM15 / PrepareCapitationPremiumPayment / Paymentsarecalculatedbaseduponstandardratesandprovidercontracts / ModularityStandard / Rulesforcalculationsshouldutilizeseparaterulesengine
OM16 / PrepareHealthInsurancePremiumPayment / Paymentsareidentifiedandcalculated / BusinessResultsCondition / Processneedsincreasedautomationtobemoreeffectiveandefficient
OM17 / PrepareMedicarePremiumPayment / Paymentsareidentifiedandcalculated / ModularityStandard / Rulesengineshouldbeseparate
OM17 / PrepareMedicarePremiumPayment / DataisexchangedwithSSAandCMS / InteroperabilityCondition / Communicationwithpublichealthagenciesshouldbeseamlessusingstandardinterfaces
OM18 / InquirePaymentStatus / Systemprocessestransactionsandcreatesaresponse / ModularityStandard / Rulesengineshouldbeseparate
OM19 / ManagePaymentInformation / Systemmanagesalloperationalaspectsofthedatastore / ModularityStandard / Rulesengineshouldbeseparate
OM19 / ManagePaymentInformation / Providesdatatootherbusinessprocesses / ReportingCondition / Accuratedatashouldbemaintainedandexposedtoauthorizedprocesseswithintheorganization
OM20 / CalculateSpendDownAmount / Systemmanagesspenddownrules / ModularityStandard / Rulesengineshouldbeseparate
OM21 / PrepareMemberPremiumInvoice / Premiumamountsarecalculatedbaseduponavarietyoffactors / ModularityStandard / Implementaseparaterulesengine
OM21 / PrepareMemberPremiumInvoice / CalculationprocessismanualandreliesofdataexternaltoMMIS / BusinessResultsCondition / Automatethecalculationprocess,possiblyintegratewiththeHBE
OM21 / PrepareMemberPremiumInvoice / Invoicesarecreatedmanually / ReportingCondition / Makeinvoiceinformationavailabletoothersystems
OM22 / ManageDrugRebate / Systemcalculatesamountsforrebateforeachmanufacturerusinginternalrules / ModularityStandard / Separate the business rules from the hard-coded system
OM23 / ManageEstateRecovery / Processusesnon-standarddataandcommunicationavenues / BusinessResultsCondition / Standardize the data and communication avenues to make the process more efficient
OM24 / ManageRecoupment / Processusesnon-standarddataandcommunicationavenues / IndustryStandardCondition / Implement the use ofstandarddata and communication avenues
OM26 / ManageRecovery / Processusesnon-standarddataandcommunicationavenues / IndustryStandardCondition / Usestandardizeddatafordataexchangeandreduceadministrativeburden
/ Version 2.0
Page 1
/ Kentucky MMIS Procurement 2012
MITA SS-A To Be Summary Report

3.2.8ImpactsonProgramIntegrityManagementProcesses