CO
Manage Contractor Information
Contractor Information Management
Description
The Manage Contractor Information business process is responsible for managing all operational aspects of the Contractor (e.g., managed care, at-risk mental health or dental care, primary care physician, Recovery Audit Contractor (RAC)) data store. This business process receives a request for addition, deletion, or modification to Contractor information, validates the request, and applies the instruction. NOTE: Requires billing agents, clearinghouses, or other alternate payees (as defined by the Secretary) to register with Medicaid agency.
Business Process Template
Trigger events
Environment-based
- Receive request to create, inquire, delete, or modify contractor information from authorized individuals via email, mail, facsimile, telephone or web.
- Receive request to verify contractor information from authorized external parties.
Interaction-based
None published
Results
- The State Medicaid Agency (SMA) creates, inquires on, deletes, or modifies contractor information.
- Alert sent to notify Health Insurance Marketplace of provider network modification information.
- Alert sent to notify insurance affordability program of provider network modification.
- Alert to Manage Contractor Communication business process to notify contractor of relevant modifications.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive request from authorized individuals or agencies to create, inquire, delete or modify contractor information.
- 2. Agency logs request for contractor information.
- 3. Validate information submitted is correct and as complete as possible. Information complies with syntax criteria and requestor has completed all required fields.
- 4. Validate authorization of requestor to acquire contactor information.
- 5. Find appropriate contractor.
- 6. Create, inquire, delete or modify relevant contractor information.
- 7. Send alert to notify Health Insurance Marketplace of provider network modification.
- 8. Send alert to notify insurance affordability program of provider network modification.
- 9. Send alert to Manage Contractor Communication business process to notify provider of relevant modifications.
- 10. END: The SMA creates, inquires on, deletes, or modifies contractor information.
Predecessor processes
Successor processes
Shared data
- Contractor data store including contract information
Constraints
Information requirements and data structures for the contractor data store may differ from state to state.
Failures
- The SMA cannot find contractor information.
- The SMA cannot respond to a request (e.g., cannot change tax ID because it would change the contracted entity).
- Validation failed (e.g., address is not a legal address).
- Contract provides incomplete information (e.g., missing required information elements).
Performance measures
- Timeliness to complete process = within __ days
- Accuracy with which changes are applied = ___%
- Consistency of decisions and disposition = ___%
- Error rate = __% or less
Source: CMS MITA 3.0 Business Process Template, Contractor Management BPT.pdf, pages 1-2.
Business Capability Model (11 questions)
Each capability question defines five maturity levels, from Level 1 through Level 5.
Business Capability Descriptions
Is the process manual or automatic?
- LEVEL 1The process consists primarily of manual activity to accomplish tasks. Staff receives instructions to update the contractor master file from many sources via paper and facsimile.
- 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. SMA produces audit trail of decisions 100% of the time.
- LEVEL 4SMA automates process to the full extent possible across the interstate.
- LEVEL 5SMA automates process to the full extent possible across the nation.
How is the information regarding the Contractor information validated?
- LEVEL 1Validation is manual and subjective.
- LEVEL 2Validation is consistent and based on business rules definitions.
- LEVEL 3SMA adopts MITA Framework, industry standards, and national standards within the intrastate that use standardized business rules definitions for consistent validation.
- LEVEL 4SMA adopts MITA Framework, industry standards, and national standards across the interstate that use regional standardized business rules definitions for consistent validation.
- LEVEL 5SMA adopts MITA Framework, industry standards, and national standards across the nation that uses national standardized business rules definitions for consistent validation.
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 intrastate exchange of information.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange.
- 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?
- LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
- LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
- LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
- LEVEL 4SMA collaborates with other interstate agencies and entities to adopt national standards, and to develop and share reusable processes.
- 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?
- LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation). Maintenance of contract files, contract amendment, and related documents is a manual process.
- LEVEL 2Process timeliness improves through use of automation. SMA scans and stores contracts, amendments, and relevant documents. 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.
- LEVEL 4Information is available in near real time. SMA has interstate 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. 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 SMA’s internal information. External sources of information use MITA Framework for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy is 98% or higher.
- 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 is 98% or higher.
- LEVEL 5SMA adopts MITA Framework for national information exchange. Decision-making is automatic using national standardized business rules definitions. Accuracy is 98% 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 based on MITA Framework and industry standards. Accessibility is greater than Level 2.
- LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3.
- 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?
- 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 further improving cost effectiveness ratio over Level 2.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange. SMA increases cost effectiveness ratio over Level 3.
- 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?
- 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 agencies and entities improving efficiency to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher.
- 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?
- 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 agencies and entities improving accuracy to 90% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher.
- 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?
- 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 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 agencies and entities improving stakeholder satisfaction to 95% or higher.
- 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 1-7.