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Establish Business Relationship

Standards Management

Description

The Establish Business Relationship business process encompasses activities undertaken by the State Medicaid Agency (SMA) to enter into business partner relationships. Agreements are between state agency and its partners, including collaboration amongst intrastate agencies, the interstate and federal agencies. It contains functionality for interoperability, establishment of inter-agency service agreements, identification of the types of information exchanged, and security and privacy requirements. These include Trading Partner Agreements (TPA), Service Level Agreements (SLA), and Memoranda of Understanding (MOU) with other agencies; Electronic Data Interchange (EDI) agreements with providers, Managed Care Organizations (MCOs), and others; and Centers for Medicare & Medicaid Services (CMS), other federal agencies, and Regional Health Information Organizations (RHIO).

Business Process Template

Trigger events
Environment-based
  • Request made for business relationship (e.g., EDI, email, mail, facsimile, telephone).
  • Identification of the need for a business relationship (e.g., new policy, new program).
Interaction-based

None published

Results
  • The SMA agrees upon Business Relationship with business partner.
  • Defined communication protocols for data exchange.
  • Alert to send notification to business partner of agreement.
  • Established agreement between business partners (e.g., TPA, SLA, MOU).
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive request for business relationship from partner.
  • 2. Conduct collection of agreement information with other party.
  • 3. Validate information submitted is correct and as complete as possible. Information complies with syntax criteria and requestor completes all required fields.
  • 4. Validate that the provided information is authentic.
  • 5. Decide determination for establishment of relationship. If no agreement, go to step 9.
  • 6. Establish terms of the business relationship (e.g., TPA, SLA, MOU).
  • 7. Establish Key Performance Indicator (KPI).
  • 8. Establish payment agreements.
  • 9. Establish data exchange requirements.
  • 10. Establish authentication protocol.
  • 11. Establish security protocol.
  • 12. Establish privacy requirements.
  • 13. Agreement on business relationship.
  • 14. END: Send alert to notify business partner of agreement.
Predecessor processes
Successor processes
Shared data
  • Business Partner data store including service agreement information
  • Contractor data store including contract information
Constraints

Federal and state policies and regulations will constrain these agreements.

Failures
  • Parties are unable to agree on terms of relationship.
Performance measures
  • Time to complete business process = within __ days
  • Accuracy with which edits are applied = ___%
  • Consistency of decisions and disposition = ___%
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Business Relationship Management BPT.pdf, pages 1-2.

Business Capability Model (10 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

Is the process primarily manual or automatic?
  1. LEVEL 1The process consists primarily of manual activity to accomplish tasks.
  2. LEVEL 2Uses a mix of manual and automatic processes to gather, record, communicate, and distribute information to SMA leadership, other state agencies, and participating providers regarding the business relationship. Uses some electronic information interchange agreements and includes HIPAA requirements for information exchange.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate. All trading partners sign electronic information interchange agreements.
  4. LEVEL 4SMA automates process to the full extent possible across the interstate.
  5. LEVEL 5SMA automates process to the full extent possible across the nation.
Does State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2SMA applies a mix of HIPAA and state-specific standards. SMA has a methodology to assist them in developing business relationships and their associated manual and electronic documentation.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information SMA defines in the Service Level Agreement (SLA) with trading partner.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange of information SMA defines in the SLA with trading partner.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information SMA defines in the SLA with trading partner.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks. SMA has informal agreements with business partners.
  2. LEVEL 2SMA uses business agreements with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
  3. LEVEL 3SMA uses a formal SLA with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
  4. LEVEL 4SMA uses a SLA with other interstate agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. LEVEL 5SMA uses a SLA with agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.

Business Capability Quality: Timeliness of Process

How timely is this end-to-end process?
  1. LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation). The process can require many weeks due to the need to customize each agreement.
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. Process completes in a shorter timeframe than at Level 1.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. The process can complete in ten (10) business days or less.
  4. LEVEL 4Information is available in near real time. SMA has interstate interoperability. The process can complete in five (5) business days or less.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and federal agencies. Results are almost immediate.

Business Capability Quality: Data Access and Accuracy

How accurate is the information in the process?
  1. LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making. Information Accuracy and consistency in the agreements have a low rating.
  2. LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Business agreements result in higher accuracy in the terms and conditions. Accuracy is higher than at Level 1.
  3. LEVEL 3Automation of information collection increases the reliability of SMA internal information. External sources of information use MITA Framework and industry standards for information exchange. Decision-making is automatic using standardized business rules definitions. Accessibility is 99% or higher.
  4. LEVEL 4Automation of information collection increases the reliability of SMA internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange with interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accessibility is 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework and industry standards for information exchange with national agencies. Decision-making is automatic using national standardized business rules definitions. Accessibility is 99% or higher.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. Exchange of agreement information dependent on postal or other hard copy delivery services.
  2. LEVEL 2The process uses on-line access to agreements. Business partners request modifications via email. SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
  3. LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. SMA uses a standardized SLA. SMA uses electronic document communication standards to make modifications. Accessibility takes less than 60 seconds.
  4. LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3.
  5. LEVEL 5SMA obtains information easily and exchanges with national agencies and entities. Accessibility is greater than Level 4.

Business Capability Quality: Cost Effectiveness

What is the cost of the process compared to the benefits of the results?
  1. LEVEL 1High relative cost due to low number of automatic, standardized tasks The process meets state budget. Cost effectiveness may not be measured.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2. The process demonstrates the improvement value projected by SMA.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange. SMA increases cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.

Business Capability Quality: Effort to Perform; Efficiency

How efficient is the process?
  1. LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3Adoption of standardized agreements and MITA Framework, industry standards and information exchange with intrastate agencies and entities improve efficiency to 95% or higher.
  4. LEVEL 4Adoption of standardized agreements and MITA Framework, industry standards and information exchange with interstate agencies and entities improve efficiency to 98% or higher.
  5. LEVEL 5Adoption of standardized agreements and MITA Framework, industry standards and information exchange with national agencies and entities improve efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

How accurate are the results of the process?
  1. LEVEL 1Manual processes result in greater opportunity for human error. Contractual agreements meet state policy and legal requirements but SMA does not adopt standards for accuracy. Accuracy is low.
  2. LEVEL 2Automation and standardized business rules definitions results in uniform terms and conditions reducing errors and improving accuracy above Level 2.
  3. LEVEL 3Adoption of standardized business rules definitions and MITA Framework, industry standards and information exchange with intrastate agencies and entities improve accuracy to 99% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 99% or higher.

Business Capability Quality: Utility or Value to Stakeholders

Does the business process satisfy stakeholders?
  1. LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Business Relationship Management BCM.pdf, pages 1-7.

Other Business Relationship Management processes

Manage Business Relationship CommunicationManage Business Relationship InformationTerminate Business Relationship