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Determine Provider Eligibility

Provider Enrollment

Description

The Determine Provider Eligibility business process collects enrollment application from Health Care Provider, or collects re-enrollment or revalidation information from existing Provider. The business process verifies syntax and semantic of information, checks status tracking (e.g., initial, modification, duplicate, cancelation), requests additional information when necessary, determines screening level (i.e., limited, moderate or high), verifies applicant information with external entities, collects application fees, and notifies Health Care Provider or Provider of enrollment eligibility determination (e.g., accepted, denied, or suspended). Determine Provider Eligibility business process sends enrollment determination alert signals to subscribing business processes Enroll Provider and Manage Provider Communication. Determine Provider Eligibility sends alert signal to Manage Accounts Receivable Funds business process to collect application fee. The Determine Provider Eligibility business process works in conjunction with Medicare and the processing of dual eligibles. Medicare agency conducts provider screening activities, application fee collection, and revalidation for those providers who are dual eligible. Determine Provider Eligibility business process is responsible for the provider screening activities, application fee collection, and revalidation for only Medicaid providers. NOTE: External contractors such as quality assurance and credentialing verification services may perform some of these steps.

Business Process Template

Trigger events
Environment-based
  • Receive the following from either a Health Care Provider or existing Provider: o Requester completes enrollment application information (e.g., Provider name, Provider address, Provider National Provider Identifier (NPI), etc.). o Requestor resubmits enrollment application information. o Requestor modifies or cancels application. o Disenrolled Provider submits re-enrollment application information. o Requestor submits additional information in support of an enrollment application.
  • Periodic review is due or receipt of request to: o Determine revalidation of credentials. Revalidation takes place every five (5) years except for Durable Medical Equipment Prosthetic, Orthotics & Supplies which is every three (3) years; revalidation also requires an application fee. o Monitor sanctions applied to a Provider. o Assist in program integrity review.
Interaction-based

None published

Results
  • Agency accepts, denies, or suspends the requestor’s application.
  • Agency notifies the requestor of enrollment eligibility (i.e., accepted, denied or suspended).
  • Alert sent to Enroll Provider business process to assign contracting parameters; establish payment rates and other activities for eligible requestor.
  • Alert sent to Manage Accounts Receivable Funds business process to collect application fee.
  • If applicable, alert sent to Disenroll Provider business process to remove provider from services.
  • Alert sent to notify provider via Manage Provider Communication business process of enrollment eligibility determination.
  • If applicable, alert sent to notify Medicare of both dual eligible and regular Medicaid providers information.
  • Tracking information as needed for measuring performance and business
  • activity monitoring.
Business process steps
  • 1. START: Health Care Provider completes and submits an enrollment application or existing Provider submits enrollment application for revalidation.
  • 2. Requestor identifies Office of the National Coordinator for Health Information Technology (ONC) Authorized Testing and Certification Body (ATCB) certification for electronic health record incentive.
  • 3. Requestor identifies if they are currently participating in Medicare or Children’s Health Insurance Program (CHIP). If yes, skip to step 14.
  • 4. Requestor selects application fee payment option including designation of hardship or exclusions from payment.
  • 5. Requestor provides appropriate payment information.
  • 6. Receive enrollment application and other pertinent enrollment communication information.
  • 7. Validate application syntax/semantic conformance. a. END: If validation fails, business process stops (see Failures).
  • 8. If necessary, request missing information from requestor. Go step 14.
  • 9. Determine submission status by querying the Provider data store. Application status may be initial, resubmitted with modification, or duplicate. a. If resubmitted application, message contains only updated information and process may skip irrelevant steps below. b. END: If duplicate application, produce result messages and stop business process (see Failures). c. Other communications may be requests to cancel application, and to deactivate or reactivate enrollment.
  • 10. Determine applicant type/Provider taxonomy (e.g., primary, rendering, pay to, billing, or other).
  • 11. Determine designated categorical risk (e.g., limited, moderate, or high) based on provider/supplier’s category.
  • 12. Assess categorical risk to determine appropriate required screening level. a. Limited Risk includes: i. Verification of any provider/supplier-specific requirements established by Medicare ii. License verifications (may include licensure checks across state) iii. Database Checks (to verify Social Security Number (SSN), the National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, an Office of the Inspector General (OIG) exclusion; taxpayer identification number; tax delinquency; death of individual practitioner, owner, authorized official, delegated official, or supervising physician) b. Moderate Risk includes: i. Inclusion of Limited Risk screening ii. Unscheduled or Unannounced Site Visits c. High Risk includes: i. Inclusion of Moderate Risk screening ii. Criminal Background Check iii. Fingerprinting
  • 13. Conduct screening based on required screening level with automated transactions except where manual verification if necessary.
  • 14. Determine enrollment eligibility (e.g., accepted, denied, or suspended) based on federal and state rules.
  • 15. Determine if there are enrollment caps due to moratoriums issued. If yes, skip to step 19.
  • 16. If Medicaid accepts enrollment application, send alert to Enroll Provider business process to assign contracting parameters, establish payment rates, and other activities for eligible requestor.
  • 17. Alert sent to Manage Accounts Receivable Funds business process to collect application fee.
  • 18. If Medicaid denies the enrollment application for existing Provider, send alert to Disenroll Provider business process to remove provider from services.
  • 19. If applicable, send alert to notify Medicare of both dual eligible and regular Medicaid providers information.
  • 20. END: Send enrollment eligibility determination to Manage Provider Communication business process to send relevant information to requestor.
  • Alternate Business Process Path: Determine Provider Eligibility business process results in a denial or suspension of an enrollment eligibility request for reasons such as: - Requestor fails to meet screening requirements. - Requestor fails to meet state enrollment requirements. - National Plan and Provider Enumeration System (NPPES) or any other national enumeration systems cannot enumerate Health Care Provider.
Predecessor processes
  • Receive Inbound Transaction
Successor processes
Shared data
  • Centers for Medicare & Medicaid Services (CMS) Medicare Dual Eligible Provider data store
  • Provider data store including application information (NPI, Provider demographics, Provider taxonomy)
  • NPI and Provider demographics exchanged with the National Plan and Provider Enumeration System (NPPES) and any other national enumeration systems
  • Provider sanction information from: - The OIG or the General Accounting Office (GAO) sanction lists of individuals, vendors, and/or suppliers excluded from participation in Medicare, Medicaid, and other federally funded Sate programs from databases such as the List of Excluded Individuals/Entities (LEIE) and the Excluded Parties List System (EPLS). - State Provider Licensing Authority - Healthcare Integrity and Protection Data Bank (HIPDB) data store - National Practitioner Databank (NPDB) - State Prescription Monitoring Program (PMP)
  • Tax identifiers: Employer ID Number (EIN), Social Security Number (SSN), Taxpayer Identification Number (TIN) from applicant and verified with tax identifier verification sources and any other information required for Form 1099 production
  • Disclosure information including: - Information on ownership and control - Information related to business transactions - Information on persons convicted of crimes - Disclosure by providers and State Medicaid agencies.
  • Multiple office locations, pay to addresses, business associates, and key contract personnel
  • CMS caps and limits moratorium information
  • Insurance Affordability Program data store including eligibility and enrollment information
Constraints

The Provider application process will accommodate the full range of Provider types, organizations, specialties, different types of applicants (e.g., the primary Provider, billing agent, pay-to entity), and care settings (e.g., solo office practice, group practice, rural health clinic); as well as, appropriate applications (e.g., New, Modification, Cancellation, Update). Different business rules may apply to each of these different types. Affiliations - Managed Care Organization (MCO) or subpart relationship.

Failures
  • Duplicate or cancelled applications.
  • Failure to validate application edits.
  • Requires additional information to process application.
Performance measures
  • Time to complete Enrollment process = within __ days
  • Accuracy with which edits are applied = ___%
  • Consistency of decisions and disposition = ___%
  • Error rate = __% or less Provider Enrollment Variations Type Subtypes Information Institutional Provider The Institutional Provider application will accommodate a range of institutional Provider types (e.g., inpatient, nursing home, day care), different types of applicants (e.g., the primary Provider, billing agent, pay-to entity), and care settings (e.g., outpatient, emergency room, assisted living). NPI, entity type, taxonomy, type of facility, bed size, equipment, type of institutional services, ownership, trading partner information, billing and payment information, tax code, Diagnosis Related Group (DRG) or other payment type Individual Provider The Individual Billing Provider application will accommodate a range of professional billing Provider types (e.g., Physician, Osteopath, Podiatrist, Chiropractor, Clinic, Lab, Radiology, other). NPI, entity type, taxonomy, affiliation, location, trading partner information, billing and payment information Individual Rendering Provider The Individual Rendering Provider application will accommodate a range of professional rendering Provider types (e.g. Physician, Osteopath, Podiatrist, Chiropractor, Clinic, Lab,

Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 24-30.

Business Capability Model (15 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

Does enrollment process meet state and federal regulations or policies?
  1. LEVEL 1Meets state and federal requirements for processing applications timely and accurately.
  2. LEVEL 2SMA exceeds state and federal requirements for processing applications timely and accurately.
  3. LEVEL 3SMA exceeds state and federal requirements for processing provider enrollment applications timely and accurately including includes one-stop collaboration across SMA including dual-eligibility with Medicare and CHIP as well as enhancing background check and screening by level of risk with federal agencies.
  4. LEVEL 4SMA exceeds state and federal requirements for processing provider enrollment applications timely and accurately. SMA collaborates with federal agencies for regional validation of background information and screening by level of risk in near-real time enrollment based on taxonomy.
  5. LEVEL 5SMA exceeds state and federal requirements for processing provider enrollment applications timely and accurately. SMA uses federated registries that identify providers across the country, who qualify to serve special populations or are disqualified based on criminal activity.
Is the process primarily manual or automatic?
  1. LEVEL 1The process consists primarily of manual activity to receive and process paper enrollments provider submits via mail.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish process paper and web-based applications.
  3. LEVEL 3The enrollment application process is fully automatic to the extent possible within the intrastate. SMA receives a majority of Provider applications online. SMA produces audit trail of determination results 100% of the time.
  4. LEVEL 4The enrollment application process is fully automatic to the extent possible within the region.
  5. LEVEL 5The enrollment application process is fully automatic to the 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, standard enrollment application interfaces, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, standard enrollment application interfaces, and other nationally recognized standards for regional exchange of information.
  5. LEVEL 5SMA adopts MITA Framework, standard enrollment application interfaces, and other nationally recognized standards for national exchange of information.
Does the State Medicaid Agency use required screening requirements?
  1. LEVEL 1SMA uses state-specific screening requirements.
  2. LEVEL 2SMA uses a mix of federal screening and state-specific requirements
  3. LEVEL 3SMA adopts all federal screening requirements for low, medium and high risk providers within the intrastate.
  4. LEVEL 4SMA adopts all federal screening requirements for low, medium and high risk providers within the region.
  5. LEVEL 5SMA adopts all federal screening requirements for low, medium and high risk providers across the nation.
What provider identifier is used?
  1. LEVEL 1SMA uses local identifier the state assigns to provider.
  2. LEVEL 2SMA cross-references National Provider Identifier (NPI) to state identification.
  3. LEVEL 3The NPI is the identification of record for all health care providers. SMA enumerates atypical providers differently. SMA retains legacy identifiers for some business purposes, but newly enrolled providers use national identifiers.
  4. LEVEL 4SMA widely uses the NPI for those providers that are required to do so. SMA uses atypical provider identification within the region.
  5. LEVEL 5SMA widely uses the NPI for those providers that are required to do so. SMA uses atypical provider identification across the nation.
How does the State Medicaid Agency verify credentials (e.g., college degree, license, certification, NPI, Employer Identification Number (EIN), Social Security Number (SSN))?
  1. LEVEL 1SMA manually validates information. Staff contact external and internal document verification sources via telephone, facsimile, mail. Decisions on information verifications take three (3) to seven (7) business days. Validation is manual and subjective.
  2. LEVEL 2Many application information validations are automatic SSN, address, birth certificate, etc.). Validation is consistent and based on business rules
  3. LEVEL 3SMA adopts MITA Framework, enrollment application standard messages, and national standards within the intrastate that use standardized business rules definitions for consistent validation.
  4. LEVEL 4SMA adopts MITA Framework, enrollment application standard interfaces, and national standards across the interstate region that use a regional standardized business rules definitions for consistent validation.
  5. LEVEL 5SMA adopts MITA Framework, enrollment application standard messages, and national standards across the nation that use a national standardized business rules definitions for consistent validation.
Is there a process for revalidation of credentials?
  1. LEVEL 1SMA re-enrolls providers as needed. SMA revalidates credentials manually.
  2. LEVEL 2SMA re-enrolls providers periodically and revalidates credentials via a mix of manual and automatic processes (consistent with enrollment process).
  3. LEVEL 3SMA revalidates credentials automatically within the intrastate and staff receive alerts when adverse results occur (e.g., provider license is terminated; provider is added to a criminal investigation list).
  4. LEVEL 4SMA revalidates credentials automatically across the interstate region and staff receives alerts when adverse results occur.
  5. LEVEL 5SMA revalidates credentials automatically across the nation and staff receives alerts when adverse results occur.
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. Information is verified manually using telephone, facsimile and mail.
  2. LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions for information verification with credentialing organization and identification sources
  3. LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services for information verification.
  4. LEVEL 4SMA collaborates with other regional agencies and entities to adopt national standards, and to develop and share reusable enrollment application processes for information verification.
  5. LEVEL 5SMA collaborates with national agencies and entities for national (and international) interoperability improvements that maximize automation of routine enrollment application 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). Average end-to-end process is completed in 30-60 business days.
  2. LEVEL 2Process timeliness improves through use of automation. Average end-to-end process completes in 15-30 business days
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of enrollment application information sharing, standards, and regional information exchange hubs. Turnaround time on application decision for 85% or higher of enrollments is no more than 24 hours. Exceptions may be those requiring extensive credentialing or site visits. SMA distributes eligibility determination notice of appeal rights within 15 minutes or less 100% of the time.
  4. LEVEL 4Enrollment application information and verification is available in near real time. SMA has regional interoperability. Turnaround time on application decision for 95% or higher of enrollments is no more than four (4) hours.
  5. LEVEL 5Enrollment application information is available in real time. Enrollment application 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 enrollment application and verification information collection increases the reliability of SMA’s internal information. External sources of enrollment application and verification information use MITA Framework and industry standards for information exchange and verification. Decision-making is automatic using standardized business rules definitions. Accuracy rating is at 99% or higher.
  4. LEVEL 4Automation of enrollment application and verification information collection increases the reliability of regional sources of information. SMA adopts MITA Framework and industry standards for information exchange and verification by regional 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 national enrollment application and verification information exchange and verification. 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?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
  3. LEVEL 3SMA obtains enrollment application and verification information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. System produces enrollment reports showing status of entire Medicaid population in graphical format for management use. Accessibility is greater than Level 2.
  4. LEVEL 4SMA obtains enrollment application and verification information easily and exchanges with regional agencies and entities. Accessibility is greater than Level 3.
  5. LEVEL 5SMA obtains enrollment application and verification 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?
  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, enrollment application and verification standard interfaces, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, enrollment application and verification standard messages, and other nationally recognized standards for regional information exchange improving cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts MITA Framework, enrollment application and verification standard messages, 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 and enrollment application and verification standard messages with intrastate agencies and entities improving efficiency to 99%.
  4. LEVEL 4SMA adopts MITA Framework and enrollment application and verification standard messages with by regional agencies and entities improving efficiency to 99%.
  5. LEVEL 5SMA adopts MITA Framework and enrollment application and verification standard messages with national agencies and entities improving efficiency to 99%.

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 improve accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework and enrollment application and verification standard messages with intrastate agencies and entities improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework and enrollment application and verification standard messages with regional agencies and entities improving accuracy to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework and enrollment application and verification standard messages 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 and enrollment application and verification standard messages 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 and enrollment application and verification standard messages with regional agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts MITA Framework and enrollment application and verification standard messages with national agencies and entities improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Eligibility and Enrollment Management BCM.pdf, pages 33-42.

Other Eligibility and Enrollment Management processes

Determine Member EligibilityDisenroll MemberDisenroll ProviderEnroll MemberEnroll ProviderInquire Member EligibilityInquire Provider Information