Disenroll Provider

Provider Enrollment

Description

The Disenroll Provider business process is responsible for managing disenrollment in the Medicaid Program. This business process covers the activity of disenrollment including the tracking of disenrollment requests and validation that the disenrollment meets state’s rules. Medicaid sends notifications to affected parties (e.g., provider, contractor, business partners) as well as alerts to other business processes to discontinue business activities.

Business Process Template

Trigger events

Environment-based

Receive request to disenroll provider.
Receive information from Medicare/Medicaid Sanction, National Practitioner Databank (NPDB), Healthcare Integrity and Protection Data Bank (HIPDB), or state licensing boards.
Receive information about a provider’s death, retirement, or disability.

Interaction-based

Receive disenrollment from insurance affordability program.
Receive disenrollment from Determine Provider Eligibility business process within ineligible information.
Receive disenrollment from Manage Compliance Incident Information business process for continued failure to make payments.
Receive disenrollment from Manage Provider Information business process from provider request.
Receive disenrollment from Manage Contractor Information business process from contractor request.
Receive alert from Determine Adverse Action Incident business process to remove provider from services.
Receive alert from Close Out Contract business process to remove provider from services.

Results

Agency disenrolls Provider or contractor from participation in Medicaid Program.
Alert sent to notify provider via Manage Provider Communication business process of disenrollment information.
Alert sent to notify contractor via Manage Contractor Communication business process of disenrollment.
Alert sent to notify Medicare/Medicaid Sanction, National Practitioner Data Bank (NPDB), Healthcare Integrity and Protection Data Bank (HIPDB), and state licensing boards via Manage Business Relationship Communication business process of disenrollment information.
If applicable, alert sent to Manage Contractor Payment to stop payment arrangement.
Alert sent to Close Out Contract business process with disenrollment information.
Alert sent to Apply Mass Adjustment business process to associate members with alternate provider or contractor.
Alert sent to notify Health Insurance Marketplace of provider disenrollment information.
Tracking information as needed for measuring performance and business activity monitoring.

Business process steps

1. START: Receive disenrollment request or relevant information.
2. Validate authenticity of the requestor to have authorization to request disenrollment.
3. Determine disenrollment request or information processing status by querying the Provider data store. Application status may be one of the following: initial, resubmitted with modification, or duplicate. a. If resubmitted application, message contains only updated information and process may skip irrelevant steps below. b. 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.
4. Verify the disenrollment information.
5. Validate that the disenrollment request meets state rules.
6. Remove provider or contractor from Medicaid participation.
7. Send alert to notify Medicare/Medicaid Sanction, NPDB, HIPDB, and state licensing boards via Manage Business Relationship Communication business process of disenrollment information.
8. If applicable, send alert to Manage Contractor Payment business process to stop payment arrangement.
9. Send alert to Close Out Contract business process with disenrollment information.
10. Send alert to Apply Mass Adjustment business process to associate members with alternate provider or contractor.
11. Send alert to notify provider via Manage Provider Communication business process of disenrollment information.
12. Send alert to notify contractor via Manage Contractor Communication business process of disenrollment.
13. Send alert to notify other insurance affordability programs of the disenrollment from Medicaid.
14. Send alert to notify Health Insurance Marketplace of provider disenrollment information.
15. END: Agency removes Provider or contractor from participation in Medicaid services.

Predecessor processes

Successor processes

Manage Provider Communication
Manage Provider Information
Manage Contractor Communications
Manage Contractor Information
Manage Business Relationship Communication
Manage Contractor Payment
Close Out Contract
Apply Mass Adjustment

Shared data

Provider data store including provider network and contact information (e.g., NPI, provider demographics, provider taxonomy)
NPI and provider demographics exchanged with National Plan and Provider
Enumeration System (NPPES)
Provider sanction information such as: a. The Office of Inspector General or the General Accounting Office (OIG/GAO) sanction lists of individuals, vendors, and/or suppliers that are excluded from participation in Medicare, Medicaid, and other federally funded state programs b. State Provider Licensing Authority c. HIPDB d. NPDB
Tax identifiers: Employer ID Number (EIN), Social Security Number (SSN), Taxpayer
Identification Number (TIN) from applicant and verified with tax identifier verification sources
Insurance Affordability Program data store including eligibility and enrollment information

Constraints

The Provider disenrollment 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 different types of application (e.g., New, Modification, Cancellation, Update). Different business rules will apply to each of these different types.

Failures

Duplicate disenrollment requests.
Requirement for additional information to process disenrollment.

Performance measures

Time to complete Disenrollment process = within __ days
Accuracy with which edits are applied = ___%
Consistency of decisions and disposition = ___%
Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 35-38.

Business Capability Model (10 questions)

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

Business Capability Descriptions

Is the process primarily manual or automatic?

LEVEL 1The process consists primarily of manual activity to accomplish tasks.
LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks
LEVEL 3SMA fully automates the provider disenrollment process within the intrastate. SMA shares Provider Network information with Health Insurance Marketplace (HIX). SMA produces audit trail of disenrollment decision 100% of the time.
LEVEL 4SMA fully automates the provider disenrollment within the region. SMA shares Provider Network information with Health Insurance Marketplace (HIX). SMA shares Meaningful Electronic Health Record information with the Registration and Attestation (R&A) System.
LEVEL 5SMA fully automates the provider disenrollment process across the nation. SMA shares Provider Network information with Health Insurance Marketplace (HIX). SMA shares Meaningful Electronic Health Record information with the R&A System.

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, standard provider disenrollment interfaces, and other nationally recognized provider disenrollment standards for intrastate exchange of provider disenrollment information.
LEVEL 4SMA adopts MITA Framework, standard provider disenrollment interfaces, and other nationally recognized provider disenrollment standards for regional exchange of provider disenrollment information.
LEVEL 5SMA adopts MITA Framework, standard provider disenrollment interfaces, and other nationally recognized provider disenrollment standards for national exchange of provider disenrollment 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 provider disenrollment standards as well as develop and share reusable business services.
LEVEL 4SMA collaborates with other regional agencies and entities to adopt national provider disenrollment standards as well as develop and share reusable provider disenrollment processes including clinical information.
LEVEL 5SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine provider disenrollment operations.

Business Capability Quality: Timeliness of Process

How timely is the 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). Process completes within ten (10) business days or more.
LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. Process completes within five (5) business days or less
LEVEL 3Timeliness improves via state and federal collaboration, use of provider disenrollment information sharing, standards, and regional information exchange hubs. Process completes in 24 hours or less.
LEVEL 4Provider disenrollment information is available in near real time. Provider disenrollment processes ensure immediate action, response, and results. SMA has regional interoperability, which further improves timeliness over Level 3.
LEVEL 5Provider disenrollment information is available in real time. Provider disenrollment processes improve further through connectivity with other States and with federal agencies. Most provider disenrollment 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 3SMA automates the collection of provider disenrollment increasing the reliability of SMA’s internal information. External sources of provider disenrollment 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.
LEVEL 4SMA automates the collection of provider disenrollment information increasing the reliability of regional sources of information. SMA adopts MITA Framework and provider disenrollment standards for information exchange with regional agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
LEVEL 5SMA adopts MITA Framework and industry standards 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 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 provider disenrollment 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 provider disenrollment information easily and exchanges with regional agencies and entities. Accessibility is greater than Level 3.
LEVEL 5SMA obtains provider disenrollment 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, provider disenrollment standard messages, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
LEVEL 4SMA adopts MITA Framework, provider disenrollment standard messages, and other nationally recognized provider disenrollment standards for regional information exchange improving cost effectiveness ratio over Level 3.
LEVEL 5SMA adopts MITA Framework, provider disenrollment standard interfaces, and other nationally recognized standards for national (and international) information exchange of provider disenrollment information improving 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 and provider disenrollment standard messages with intrastate agencies and entities improving efficiency to 95% or higher.
LEVEL 4SMA adopts MITA Framework and provider disenrollment standard messages with regional agencies and entities improving efficiency to 98% or higher.
LEVEL 5SMA adopts MITA Framework and provider disenrollment standard messages 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 and provider disenrollment standard messages with intrastate agencies and entities improving accuracy to 90% or higher.
LEVEL 4SMA adopts MITA Framework and provider disenrollment standard messages with regional SMA and entities improving accuracy to 98% or higher.
LEVEL 5SMA adopts MITA Framework and provider disenrollment 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?

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 and provider disenrollment standard messages 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 and provider disenrollment standard messages with regional agencies and entities improving stakeholder satisfaction to 95% or higher.
LEVEL 5SMA adopts MITA Framework and provider disenrollment 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 50-57.

Other Eligibility and Enrollment Management processes

Determine Member Eligibility Determine Provider Eligibility Disenroll Member Enroll Member Enroll Provider Inquire Member Eligibility Inquire Provider Information