Perform Contractor Outreach

Contractor Support

Description

The Perform Contractor Outreach business process is responsible for sending information such as public health alerts, new programs, and/or modifications in the Medicaid Program policies and procedures. For prospective contractors (e.g., managed care, at-risk mental health or dental care, primary care physician), States Medicaid Agency (SMA) develops contractor outreach information for prospective contractors identified by analyzing Medicaid business needs. For currently enrolled contractors, information may relate to public health alerts, public service announcements, and other objectives. The SMA communicates contractor outreach information by a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). The SMA produces, distributes, tracks, and archives all contractor outreach communications according to state rules.

Business Process Template

Trigger events

Environment-based

Executive Management decision to: o Fill gaps in health care service and administrative coverage. o Solicit updated/new administrative and technical functions. o Introduce new programs requiring new types of health or administrative service. o Change to existing policies and procedures. o Respond to critical need in a specific target population. o Identify new populations in need of service (e.g., new immigrant communities).
State transition-based trigger events: o Alert received from Manage Health Plan Information business process of addition or modification. o Alert received from Manage Health Benefit Information business process of addition or modification.

Interaction-based

None published

Results

Agency produces outreach communications (e.g., mailing brochure, web page, email, kiosk, radio, billboard, and TV advertisements) and distributes to targeted contractors. Agency may also conduct face-to-face meetings.
Tracking information as needed for measuring performance and business activity monitoring.

Business process steps

1. START: Receive request for outreach materials or communication.
2. Target population identified and defined by analyzing information, performance measures, feedback from community, and policy directives.
3. Approve, deny, or modify decisions to develop outreach communications.
4. Determine content and method of communication (e.g., email, mail, publication, mobile device, facsimile, telephone, web or EDI.
5. Determine performance measures.
6. Prepare content that is linguistically, culturally, and competency appropriate for the communication in agreed upon format.
7. Review and approve communication.
8. Generate communication in agreed upon format.
9. Agency logs communication message.
10. END: Evaluate the efficacy of the communication (e.g., customer satisfaction, first time resolution rate)

Predecessor processes

Successor processes

Shared data

Contractor data store including provider network information
Plan data store including policy information
Health Benefits data store including benefit package and benefits information
Performance Measures data store including agency’s objectives (e.g., Consumer
Assessment of Healthcare Providers and Systems (CAPHS) and Healthcare
Effectiveness Data and Information Set (HEDIS) information)

Constraints

Communications and information packages will address the needs of the targeted population. Materials will be linguistically and culturally appropriate, legally compliant, appropriate to the targeted group, and meet financial guidelines (re: cost to produce and distribute). Other constraints may be agency priority, availability of resources, and accuracy of contractor contact information. Contractor may have communication barriers such as lack of internet or phone access. Contractor is unable to access needed or requested information.

Failures

Unable to identify target population based on desired criteria.
Management denies permission for outreach activity.
The SMA cancels health plan or health benefit.
Delivery failures due to erroneous contact information.

Performance measures

Time to complete process of developing outreach materials = __days
Accuracy of outreach materials = __%
Successful delivery rate to targeted individuals = __%
Effectiveness of the communication - Outreach results in achieving specified goals

Source: CMS MITA 3.0 Business Process Template, Contractor Management BPT.pdf, pages 6-8.

Business Capability Model (12 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. SMA conducts the process via mail, in person, and telephone for individual communications; and flyers, radio, TV, newspapers, and publications for public media. SMA is not targeting contractor populations.
LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. SMA conducts process via a web portal for existing contractors. SMA targets populations to receive communications via mail, in person and telephone for individual communications; and flyers, radio, TV, newspapers, and publications public media.
LEVEL 3SMA automates process to the full extent possible within the intrastate. The process is electronic. Audience downloads, saves or prints publications. SMA also uses publications the law requires to post solicitations. Portal includes usability features or functions that accommodate the needs of persons with disabilities, including those who use assistive technology.
LEVEL 4SMA automates process to the full extent possible across the interstate.
LEVEL 5SMA automates process to the full extent possible across the nation.

Is communication linguistically, culturally, and competency appropriate?

LEVEL 1Functionally, linguistically, culturally, and competency appropriate outreach and education materials are lacking because they are difficult and costly to produce.
LEVEL 2Outreach material is functionally, linguistically, culturally, and competency appropriate, but at great expense. SMA limits outreach material by state defined parameters (e.g., only two (2) languages used).
LEVEL 3SMA automates process to the full extent possible across the intrastate. Use of electronic communications makes provision of functionally, linguistically, culturally, and competency appropriate outreach material more cost-effective.
LEVEL 4SMA automates process to the full extent possible across the interstate.
LEVEL 5SMA automates process to the full extent possible across the nation.

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 clinical and interstate information exchange.
LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.

How formalized is the process?

LEVEL 1The process is informal and inconsistent.
LEVEL 2The process is formal across SMA with proper reviews to ensure correctness and legality. SMA keeps accurate logs of all outreach initiatives.
LEVEL 3SMA adopts automatic workflow within intrastate to ensure accuracy and proper reviews. SMA stores and transfers relevant inquiry documents electronically.
LEVEL 4SMA adopts automatic workflow within interstate to ensure accuracy and proper reviews.
LEVEL 5SMA adopts automatic workflow within nation to ensure accuracy and proper reviews.

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 including clinical information.
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 process End-to-End?

LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation). Timeliness depends on the type of outreach. It is ad hoc in nature. Outreach activity duration is relatively lengthy.
LEVEL 2Process timeliness improves through use of automation and web portal distribution of information. Timeliness exceeds legal requirements.
LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. SMA releases alerts and information immediately. Timeliness exceeds Level 2.
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.
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 and industry standards for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy is 95% or higher.
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 is 95% or higher.
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 is 95% 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 nationally recognized 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 its 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. SMA launches outreach to a general audience but is unable to align content with targeted audience negatively affecting accuracy.
LEVEL 2Automation and standardized business rules definitions reduce errors. Capability to match outreach with target audience improves the accuracy of the process. SMA improves accuracy above Level 1.
LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities. SMA uses methods to target outreach to contractors that met specific needs. Accuracy is 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

How satisfied are the stakeholders with the process?

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 20-28.

Other Contractor Management processes

Award Contract Close Out Contract Inquire Contractor Information Manage Contract Manage Contractor Communication Manage Contractor Grievance and Appeal Manage Contractor Information Produce Solicitation