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Manage Contractor Grievance and Appeal

Contractor Support

Description

The Manage Contractor Grievance and Appeal business process handles contractor (e.g., managed care, at-risk mental health or dental care, primary care physician) appeals* of adverse decisions or communications of a grievance. The Manage Contractor Communication business process initiates a grievance or appeal. The State Medicaid Agency (SMA) logs and tracks the grievance or appeal; it triages to appropriate reviewers; it researches it; it may request additional information; it schedules and conducts a hearing in accordance with legal requirements; and it makes a ruling based upon the evidence presented. Staff documents and distributes results of the hearings, and adds relevant documents to the contractor’s information. Agency formally notifies contractor of the decision. This business process supports the Manage Performance Measures business process by providing information about the types of grievances and appeals it handles; grievance and appeals issues; parties that file or are the target of the grievances and appeals; and the dispositions. This information used to discern program improvement opportunities, which may reduce the issues that give rise to grievances and appeals. Based on the appeal business process, if a contractor wins an appeal that impacts or clarifies a Medicaid State Plan, health plan, or health benefit this process sends that information to Maintain State Plan, Manage Health Plan Information or Manage Health Benefit Information business processes to modify the relevant policy or procedure. Disposition could result in legislative change requirements that will be communicated to lawmakers. NOTE: States may define grievance and appeal differently, perhaps because of state laws. *This business process supports grievances and appeals for both prospective and current contractors. A non-enrolled contractor can file a grievance or appeal, for example, when agency does not award a contract to contractor. Protests received from prospective contractors are addressed in the Award Contract business process

Business Process Template

Trigger events
Environment-based
  • Receive grievance or appeal alert from Manage Contractor Information business process.
  • Receive grievance or appeal alert from Award Contract business process.
Interaction-based

None published

Results
  • Alert to send notification of final disposition of grievance or appeal to the contractor.
  • If applicable, alert sent to Establish Compliance Incident business process for further investigation.
  • If applicable, alert sent to Maintain State Plan business process to modify the relevant policy or procedure.
  • If applicable, alert sent to Manage Health Plan Information business process to modify the relevant policy or procedure.
  • If applicable, alert sent to Manage Health Benefit Information business process to modify the relevant policy or procedure.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive grievance or appeal.
  • 2. Agency logs grievance or appeal.
  • 3. Validate information submitted is correct and as complete as possible. Information complies with syntax criteria and submitter has completed all required fields.
  • 4. Validate that the provided information is authentic.
  • 5. If appropriate, request additional documentation.
  • 6. Determine status as initial, second, expedited or other status as designated by the state.
  • 7. Triage to appropriate personnel for review.
  • 8. Perform research and analysis.
  • 9. If appropriate, schedule hearing within required time limit.
  • 10. If appropriate, conduct hearing within required time limit.
  • 11. Determine disposition.
  • 12. If applicable, send alert to Establish Compliance Incident business process for further investigation.
  • 13. If applicable, alert sent to Maintain State Plan business process to modify the relevant policy or procedure.
  • 14. If applicable, alert sent to Manage Health Plan Information business process to modify the relevant policy or procedure.
  • 15. If applicable, alert sent to Manage Health Benefit Information business process to modify the relevant policy or procedure.
  • 16. END: Send alert to notify contractor of disposition determination. NOTE: Some of the above steps may be iterative and a grievance or appeals case may take many months to finalize.
Predecessor processes
Successor processes
Shared data
  • Contractor data store including provider network and contract information
  • Grievance and Appeal data store including case history information
  • Claims data store including claims and premium Information
Constraints

States have different requirements for evidence and the process for conducting the grievance/appeals cases. They have different rules for assigning outcome status and state specific consequences.

Failures
  • Grievance and appeal supporting documentation is incomplete.
  • The SMA cannot schedule or conduct hearing in the required period.
  • Contractor withdraws grievance or appeal.
  • Unable to process grievance or appeal per federal or state law.
Performance measures
  • Time to complete process: normal grievance/appeal = __days; second appeal = __ days; expedited appeal = __hours
  • Accuracy of decisions = __%
  • Consistency of decisions and disposition = __%
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Contractor Management BPT.pdf, pages 8-11.

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 process is entirely paper based, which results in cumbersome document management and process inefficiencies.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. The process conducts some of its activities electronically, except where federal and state regulations require paper documents. SMA is able to scan documents for capturing electronic information.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate. The process conducts the majority of its activities electronically, except where federal and state regulations require paper documents. SMA is able to scan documents for capturing electronic 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.
How central is the grievance and appeals process?
  1. LEVEL 1Disparate programs file, manage, and resolve grievances and appeals from contractors. This contributes to inconsistent application of relevant laws and administrative policies inhibiting performance monitoring. Contractors have difficulty finding the right door for filing grievances and appeals.
  2. LEVEL 2Agencies begin to centralize or standardize the administration of the process to achieve economies of scale, thereby increasing coordination and improving consistency of application of business rules and appeals disposed. SMA clearly identifies the policy and procedures for filing grievances and appeals. SMA establishes a Review Board to review cases.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards within intrastate further increases coordination and reuse of standardized grievance & appeal business services. SMA standardizes the process across the intrastate.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards within interstate further increases coordination and reuse of standardized Grievance & Appeal business services. SMA standardizes the process across the interstate.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards within national further increases coordination and reuse of standardized Grievance & Appeal business services. SMA standardizes the process across the nation.
How does the State Medicaid Agency manage the process?
  1. LEVEL 1SMA follows guidelines for opening, documenting, and resolving the case.
  2. LEVEL 2SMA establishes a formal Management Plan.
  3. LEVEL 3SMA administers the process is as part of SMA and manages it using a comprehensive Management Plan.
  4. LEVEL 4SMA administers the process as part of SMA and manages it using a comprehensive Management Plan across the interstate.
  5. LEVEL 5SMA administers the process as part of SMA and manages it using a comprehensive Management Plan 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 nationally recognized 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.
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 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).Cases typically require months to complete. Duration of process is 180 business days or longer.
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. Duration of process is 100 business days or less.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Duration of process is 45 business days or less.
  4. LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. 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 2Nationally recognized standards 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 and industry standards 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 and industry standards for information exchange with 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 and industry standards for information exchange with national agencies. Decision-making is automatic using national standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information required for the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually. Contractors have difficulty accessing program business rules to discern the merit of their grievance or appeal.
  2. LEVEL 2SMA stores information in disparate systems. Contractors have limited access to program business rules to discern whether their grievances or appeals have merit. 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. Contractors can electronically access program business rules to discern whether their grievances or appeals have merit. Accessibility is greater than Level 2.
  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 to perform the process compared to the benefits 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. Cases may require months to complete.
  2. LEVEL 2Automation and state standards increase productivity allowing for more time on improving process and working on exceptions. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities. The process is consistent, orderly, and allows staff to spend even more time on quality outcomes and process improvement. Efficiency improves 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

How accurate are 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 support business activity monitoring of performance measures, which in turn provide information needed for process improvements. SMA improves accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities. The process collects information about the types of grievance and appeal it handles. SMA uses this information to discern program improvement opportunities that may reduce the issues that give rise to grievances and appeals. Accuracy improves 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 that resolves cases in a shorter period. 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 28-36.

Other Contractor Management processes

Award ContractClose Out ContractInquire Contractor InformationManage ContractManage Contractor CommunicationManage Contractor InformationPerform Contractor OutreachProduce Solicitation