CM
Establish Case
Case Management
Description
The Care Management, Establish Case business process uses criteria and rules to: • Identify target members for specific programs. • Assign a care manager. • Assess the member’s needs. • Select a program. • Establish a treatment plan. • Identify and confirm provider. • Prepare information for communication. This business process may establish a case for one individual, a family or a target population such as: • Medicaid Waiver program case management - Home and Community-Based Services (HCBS) - Other • Disease management • Catastrophic cases • Early Periodic Screening, Diagnosis, and Treatment (EPSDT) • Vaccines for children and adults • Population management This business process may initiate a case from claim processing indicators such as: • Several claims for an individual member over a time interval. • New claims close to discharge date. • Claims containing one of the with the following: - Place of Service - Certain Places of Service - Discharge Date - Admit Date - PWK - Attachments containing lab results, treatment plans, etc. - NTE - Notes containing discharge plans, goals, treatment plan - EPSDT Referral Claim - Claims containing certain types of the following information: ✓ Principle Diagnosis ✓ Admitting Diagnosis ✓ Patient Reason for Visit ✓ Other Diagnosis Information ✓ Principle Procedure ✓ Other Procedure ✓ Condition Info ✓ Treatment Code - Prescription drug claim - CLIA certification - Home Health claim - Test Result Different criteria and rules, relationships, and information define each type of health care case and require different types of external investigation. The Health Information Exchange (HIE) provides health information and clinical records for member and care coordination with provider and other agencies.
Business Process Template
Trigger events
Environment-based
- Periodic review to scan for new cases is due.
- Request to look into a specific case.
Interaction-based
- An alert triggered by other events, such as a targeted diagnosis or referral generated from information submitted on a claim.
- Receive enrollment of member from Enroll Member business process.
- Receive information to establish a case (e.g., Electronic Data Interchange (EDI)).
Results
- List of members associated with cases and programs.
- Assessment of the needs of the member for care management.
- Treatment Plan for member.
- Associated Providers List.
- Case file information.
- Communications information for providers and members.
- Alert to notify member of care management case.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Identify candidates for new cases with specific criteria (e.g., patient characteristics, medical conditions, location, or age).
- 2. Identify information requirements and parameters to include such items as periods of time, data elements, and data relationships.
- 3. Identify new case(s) for care management based on requirements and parameters.
- 4. Create case record for each new case.
- 5. Assign care manager.
- 6. Care manager reviews health and clinical information from Health Information Exchange (HIE).
- 7. Assess the needs of the member for care management.
- 8. Based on needs, determine which program(s) is appropriate for the member.
- 9. Based on needs, establish treatment (care) plan that identifies the services the member needs to receive, the types of providers, the care setting, frequency, and expected results.
- 10. Based on the treatment plan, select providers to deliver the services, contact and confirm availability, record decisions.
- 11. Record care management determination and related information.
- 12. END: Send alert to notify member of care management case.
Predecessor processes
- Receive Inbound Transaction
- Enroll Member
- Manage Applicant and Member Communication
- Manage Member Grievance and Appeal
- Identify Utilization Anomalies
Successor processes
- Send Outbound Transaction
- Manage Case Information
- Manage Applicant and Member Communication
- Authorize Treatment Plan
- Manage Treatment Plan and Outcomes
Shared data
- Member data store including demographics
- Health Information Exchange (HIE) data store including health information, clinical record and clinical information
- Enterprise Master Patient Index (EMPI) for single and complete view of patient information
- Provider data store including provider network information
- Health Benefits data store including programs and services Information
Constraints
States and programs within States use different criteria to establish cases. Diseases included in Disease Management differ from state to state. States define and treat catastrophic cases differently. States will conform to required Affordable Care Act requirements for EPSDT and immunizations case management.
Failures
- Details of the case are inconsistent with criteria; discontinued case.
Performance measures
- Time required to establish a case.
- Effectiveness of selection criteria in determining real cases.
Source: CMS MITA 3.0 Business Process Template, Care Management BPT.pdf, pages 1-4.
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?
- LEVEL 1The process consists primarily of manual activity to accomplish tasks.
- LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks.
- LEVEL 3SMA automates process to the full extent possible within the intrastate and targets members for assessments, treatment plans and outcome tracking, and disease management. SMA exchanges clinical information within a state Health Information Exchange (HIE).
- LEVEL 4SMA automates process to the full extent possible within the region and targets members for assessments, treatment plans and outcome tracking, and disease management. SMA exchanges clinical information via a regional Health Information Exchange (HIE).
- LEVEL 5SMA automates process to the full extent possible nationally and targets members for assessments, treatment plans and outcome tracking, and disease management. SMA exchanges clinical information nationally via the Nationwide Health Information Network (NwHIN).
Does the State Medicaid Agency use standards in the process?
- LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
- LEVEL 2SMA applies a mix of HIPAA and state-specific standards.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for state Health Information Exchange (HIE).
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange of information to a regional Health Information Exchange (HIE).
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information via the NwHIN.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
- LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks. The process consists primarily of manual processes (e.g. telephone contacts, facsimile, letters) to gather and share information between social service agencies, physician offices and other provider types to establish cases.
- LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions. Permits authorized users to access other information bases and retrieve pertinent information about the member (i.e. eligibility, claims history) improving over Level 1.
- LEVEL 3SMA collaborates with other intrastate agencies, and entities and the Regional Health Information Organization (RHIO) to adopt national standards, and to develop and share reusable business services.
- LEVEL 4SMA collaborates with other regional agencies, and entities, and the RHIO to adopt national standards, and to develop and share reusable processes including clinical information shared via a regional Health Information Exchange (HIE).
- LEVEL 5SMA collaborates with national agencies, and entities, and the RHIO for national (and international) interoperability improvements that maximize automation of routine operations shared across the NwHIN.
Business Capability Quality: Timeliness of Process
How timely is this end-to-end process?
- LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
- LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
- LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2. Process completes, on the average, within seven (7) business days.
- LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has regional Health Information Exchange (HIE) interoperability, which further improves timeliness over Level 3.
- LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies via NwHIN. Most processes execute at the point of service. Results are almost immediate.
Business Capability Quality: Data Access and Accuracy
How accurate is the information in the process?
- 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.
- LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
- LEVEL 3Automation of information collection increases the reliability of a state Health Information Exchange (HIE)’s internal information. External sources of information use MITA Framework for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy is 99% or higher.
- LEVEL 4Automation of information collection increases the reliability of the regional SMA internal and external sources of information. SMA adopts MITA Framework for information exchange by regional Health Information Exchanges (HIE). Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
- LEVEL 5SMA adopts MITA Framework for national information exchange. Decision-making is automatic using national standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information in the process?
- LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
- LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
- LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities from a Health Information Exchange (HIE) based on MITA Framework. Accessibility information takes no more than three (3) seconds.
- LEVEL 4SMA obtains information easily and exchanges with regional agencies from an interstate regional Health Information Exchange (HIE) and entities. Accessibility takes no more than three (3) seconds.
- LEVEL 5SMA obtains information easily and exchanges with national agencies. Accessibility takes no more than three (3) seconds.
Business Capability Quality: Cost Effectiveness
What is the cost to perform the process compared to the benefits of the results?
- LEVEL 1High relative cost due to low number of automatic, standardized tasks.
- LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for state Health Information Exchange (HIE) further improving cost effectiveness ratio over Level 2.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate and regional Health Information Exchange (HIE) exchange improving cost effectiveness ratio over Level 3.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information via the NwHIN improving cost effectiveness ratio over level 4.
Business Capability Quality: Effort to Perform; Efficiency
How efficient is the process?
- 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.
- LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate Health Information Exchange (HIE) and entities improving efficiency to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate regional Health Information Exchange (HIE) and entities improving efficiency to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with the NwHIN improving efficiency to 98% or higher.
Business Capability Quality: Accuracy of Process Results
How accurate are the results of the process?
- LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
- LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate Health Information Exchange (HIE) and entities improving accuracy to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate regional Health Information Exchange (HIE) and entities improving accuracy to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with the NwHIN improving accuracy to 98% or higher.
Business Capability Quality: Utility or Value to Stakeholders
Does the business process satisfy stakeholders?
- LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
- LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies Health Information Exchange (HIE) and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate regional Health Information Exchange (HIE) and entities improving stakeholder satisfaction to 95% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with the NwHIN improving stakeholder satisfaction to 98% or higher.
Source: CMS MITA 3.0 Business Capability Model, Care Management BCM.pdf, pages 1-7.