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Inquire Contractor Information

Contractor Information Management

Description

The Inquire Contractor Information business process receives requests for contract (e.g., managed care, at-risk mental health or dental care, Primary Care Physician (PCP)) verification from authorized providers, programs or business associates, performs the inquiry, and prepares the response for the Send Outbound Transaction.

Business Process Template

Trigger events
Environment-based

None published

Interaction-based
  • Receive contract verification request from Receive Inbound Transaction.
Results
  • Contract verification response sent to requestor.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive contract verification request.
  • 2. Validate information submitted is correct and as complete as possible. Information complies with syntax criteria and requestor has completed all required fields.
  • 3. Validate that the provided information is authentic.
  • 4. Agency logs contract verification request.
  • 5. Determine request status as initial or duplicate.
  • 6. Query contractor data store for requested information.
  • 7. Agency logs contract verification response.
  • 8. END: Send contract verification response to requestor.
Predecessor processes
  • Receive Inbound Transaction
Successor processes
Shared data
  • Contractor data store including contract information
Constraints

The State Medicaid Agency (SMA) determines what information to share.

Failures
  • The SMA is unable to find contractor information.
  • The SMA is unable to respond to a request.
  • Validation failed.
  • Requestor provides incomplete information (e.g., missing required information elements).
Performance measures
  • Time to verify Contractor information and generate response information: e.g., Real Time response = within __ seconds, Batch Response = within __ hours
  • Response Accuracy = ___%
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Contractor Management BPT.pdf, pages 2-4.

Business Capability Model (12 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. The inquirer contacts SMA by telephone, facsimile, or mail and receives responses via the same modes.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. Agencies provide web portals for inquiries and responses. Inquirers have access under the state mandatory requirements for access to public information regarding the contractor and contract.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate. SMA integrates web portals to improve access to Contractor information.
  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 the 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.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.
What information does the inquiry and response convey?
  1. LEVEL 1Inquiries include the following: Does this entity have a current contract? What services does the contract cover? What is the end date of the contract?
  2. LEVEL 2Requestor may make inquiry via web on contractor name, address, start and end date, major services provided, and contact information.
  3. LEVEL 3SMA adopts MITA Framework messages and other nationally recognized standards for the exchange of information.
  4. LEVEL 4SMA adopts MITA Framework messages and other nationally recognized standards for interstate information exchange.
  5. LEVEL 5SMA adopts MITA Framework messages and other nationally recognized standards for national exchange of information.
How formalized is the process?
  1. LEVEL 1The process is informal and inconsistent.
  2. LEVEL 2The process is formal across state agencies with proper reviews to ensure correctness and legality. SMA keeps accurate logs of all inquiries.
  3. LEVEL 3SMA adopts automatic workflow within the intrastate to ensure accuracy and proper reviews. SMA stores and transfers relevant inquiry documents electronically.
  4. LEVEL 4SMA adopts automatic workflow across the interstate to ensure accuracy and proper reviews.
  5. LEVEL 5SMA adopts automatic workflow across the nation to ensure accuracy and proper reviews.
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.
  2. LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
  3. LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
  4. LEVEL 4SMA collaborates with other interstate agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. LEVEL 5SMA collaborates 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 the 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). SMA answers inquiries within three (3) to seven (7) business days.
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2.
  4. LEVEL 4Information is available in near real time. SMA has interstate interoperability, which further improves timeliness over Level 3.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. 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?
  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.
  2. 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.
  3. LEVEL 3Automation of information collection increases the reliability of SMA’s internal information. External sources of information use MITA Framework for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy rating is at 99% or higher.
  4. LEVEL 4Automation of information collection increases the reliability of SMA’s internal and external sources of information. SMA adopts MITA Framework for information exchange by interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
  5. 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?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. Access to information is available only during business hours.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1. The web portal is accessible according to a schedule. Web portal is functional beyond the normal hours of the business day.
  3. LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is almost 24 hours per day, excepting during maintenance windows.
  4. LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is almost 24 hours per day, excepting during maintenance windows.
  5. LEVEL 5SMA obtains information easily and exchanges with national agencies and entities. Accessibility is almost 24 hours per day, excepting during maintenance windows.

Business Capability Quality: Cost Effectiveness

What is the cost to support the process to the value of its results?
  1. LEVEL 1High relative cost due to low number of automatic, standardized tasks.
  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.
  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 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

What is accuracy of the results of the process?
  1. LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 98% 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, Contractor Management BCM.pdf, pages 7-13.

Other Contractor Management processes

Award ContractClose Out ContractManage ContractManage Contractor CommunicationManage Contractor Grievance and AppealManage Contractor InformationPerform Contractor OutreachProduce Solicitation