MES Certification Navigator
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Enroll Provider

Provider Enrollment

Description

The Enroll Provider business process is responsible for enrolling providers into Medicaid that includes: • Determination of contracting parameters (e.g., Provider taxonomy, type, category of service that the Provider can bill). • Establishment of payment rates and funding sources, taking into consideration service area, incentives or discounts. • Alert sent to Manage Contract business process to negotiate contracts. • Supporting receipt and verification of program contractor’s Provider enrollment roster information (e.g., from Managed Care Organization (MCO) and Home and Community-Based Services (HCBS)). • Alert sent to Manage Provider Information business process to load initial and modified enrollment information, including Providers contracted with program contractors into the Provider data store. • Alert sent to Manage Provider Information business process to provide timely and accurate notification, or to make enrollment information required for operations available to all parties and affiliated business processes, including: - Alert sent to Prepare Provider Payment business process for capitation and premium payments. - To prepare Provider Electronic Funds Transfer (EFT) or check with the Manage Accounts Payable Disbursement business process. - The appropriate communications and outreach processes for follow-up with the affected parties, including informing parties of their procedural rights. • Periodic review is due or receipt of request to: - Negotiate payment rates. - Notify Provider of enrollment determination. Enroll Provider business process supports receipt and verification of program contractor’s Provider enrollment roster information (e.g., name, identification, contract information, type, specialty and services) from Managed Care Organization (MCO) and HCBS organizations.

Business Process Template

Trigger events
Environment-based
  • Periodic review is due or receipt of to: o Renegotiate payment rates. o Reevaluate enrollment based criteria such as performance measures, or triggered by date such as anniversary date based on Medicaid policy to verify information based on a contractual duration (e.g. year or months).
  • Receive program enrollment or disenrollment information from Medicaid or CHIP.
  • Receive request for provider’s enrollment roster information.
Interaction-based
  • Receive newly eligible Provider from Determine Provider Eligibility business process.
  • Receive newly eligibility contractor from Award Contract business process.
  • Receive alert from Manage Performance Measures to revalidate provider.
Results
  • Enrolled, re-enrolled, suspended, or denied enrollment of provider or contractor into programs.
  • If applicable, alert sent to notify provider via Manage Provider Communication business process of enrollment determination.
  • If applicable, alert sent to notify contractor via Manage Contractor Communication business process of enrollment determination.
  • If applicable, alert sent to Manage Contractor Payment for payment arrangement.
  • Alert sent to Perform Provider Outreach to send relevant state policy information.
  • Alert sent to Manage Contract business process to negotiate contract.
  • If applicable, send response for Provider enrollment roster information.
  • Alert sent to notify Health Insurance Marketplace of provider enrollment
  • information.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Determine contracting parameters (e.g., Provider taxonomy, categories of service for which the Provider can bill), eligible Provider types, payment types, contract terms and maximums, member enrollment levels, panel size, and any contractor specific benefit packages and procedures.
  • 2. Assign any identifiers used internally.
  • 3. Determine if there are enrollment limits due to moratoriums issued. If yes, skip to step 9.
  • 4. Assign to programs and determine rates: Includes identifying type of rate (e.g., negotiated, Medicare, percent of charges, case management fee, other via look-ups in the reference and benefit repositories).
  • 5. If applicable, send alert to Manage Contractor Payment business process for payment arrangement.
  • 6. Send alert to Perform Provider Outreach business process to send relevant state policy information.
  • 7. Send alert to Manage Contract business process to negotiate contract.
  • 8. If applicable, send alert to notify contractor via Manage Contractor Communication business process of enrollment determination.
  • 9. If applicable, provide response to request for Provider enrollment roster information.
  • 10. Send alert to notify Health Insurance Marketplace of provider enrollment information.
  • 11. END: Send alert to notify provider via Manage Provider Communication business process of enrollment determination.
Predecessor processes
Successor processes
Shared data
  • Provider data store including: - Provider demographics - Provider network - Contract information - Type - Specialty - Enrolled Program - Jurisdiction - Payment Information - Provider taxonomy - Service Location Information - Category of Service - Services - Limitations - Business Arrangement
  • Contractor data store including provider network information
  • Plan data store including health benefit and fees information
  • Moratorium data store including Caps and Limits information
  • Health Insurance Marketplace including provider enrollment information
Constraints

The Provider enrollment 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 applications (e.g., New, Modification, Cancellation, Update). Different business rules may apply to each of these different types. Affiliations - MCO or subpart relationship.

Failures
  • Lack of applicable rates.
  • Provider meets caps or limits moratorium.
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, DRG or other payment type Individual Provider The Individual Billing Provider application will accommodate a range of professional billing

Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 30-35.

Business Capability Model (12 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 applications enrollment timely and accurately including one-stop collaboration across SMA.
  4. LEVEL 4SMA fully automates the enrollment process within the region.
  5. LEVEL 5SMA fully automates the enrollment process across the nation.
Is the process primarily manual or automatic?
  1. LEVEL 1The process consists primarily of manual paper-based activity to accomplish tasks.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate. SMA adopts MITA Framework, enrollment standard messages, and national standards within the intrastate that use standardized business rules definitions for consistent enrollment Provider Network information is shared with Health Insurance Marketplace (HIX). SMA produces audit trail of enrollment decision 100% of the time.
  4. LEVEL 4SMA automates the enrollment process to the extent possible within the region. SMA adopts MITA Framework, enrollment standard messages, and national standards within the region that use a regional standardized business rules definitions for consistent enrollment Provider Network information is shared with Health Insurance Marketplace (HIX). SMA shares Meaningful Electronic Health Record information with the Registration and Attestation (R&A) System.
  5. LEVEL 5SMA automates the enrollment process to the extent possible across the nation. SMA adopts MITA Framework, enrollment standard messages, and national standards nationally that use a national standardized business rules definitions for consistent enrollment Provider Network information is shared with Health Insurance Marketplace (HIX). SMA shares Meaningful Electronic Health Record information with the R&A System.
How does the applicant complete and submit the application?
  1. LEVEL 1Applicant completes application on paper and submits via facsimile, in person, or mail.
  2. LEVEL 2Applicant may use state standardized paper application but also has choices of data entry at government offices and kiosks. Electronic submissions are available and used.
  3. LEVEL 3Applicants may complete and submit nationally standardized electronic application from any location that has internet access. Multiple intrastate programs, including Medicaid, Medicare, and CHIP conduct dual-eligibility determination.
  4. LEVEL 4SMA shares business services across interstate.
  5. LEVEL 5SMA shares business services 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 interfaces, and other nationally recognized enrollment standards for intrastate enrollment assignment and exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, standard enrollment interfaces, and other nationally recognized enrollment standards for clinical and regional exchange of enrollment assignment information.
  5. LEVEL 5SMA adopts MITA Framework, standard enrollment interfaces, and other nationally recognized enrollment standards for national exchange of enrollment assignment 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 regional agencies and entities to adopt national standards and to develop and share reusable enrollment assignment processes including clinical information.
  5. LEVEL 5SMA collaborates with national agencies and entities for national (and international) interoperability improvements that maximize automation of routine enrollment assignment 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).
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of enrollment assignment information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2.
  4. LEVEL 4Enrollment assignment information is available in near real time. SMA has regional interoperability, which further improves timeliness over Level 3.
  5. LEVEL 5Enrollment assignment information 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 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 3SMA automatically collects enrollment assignment information increasing the reliability of SMA’s internal information. External sources of enrollment assignment 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 4SMA automatically collects enrollment assignment information increasing the reliability of regional sources of information. SMA adopts MITA Framework and industry standards or information exchange by regional agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
  5. LEVEL 5SMA uses 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?
  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 assignment information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Enrollment reports on the status of entire Medicaid population in graphical format for management use. Accessibility is greater than Level 2.
  4. LEVEL 4SMA obtains enrollment assignment information easily and exchanges with regional agencies and entities. Accessibility is greater than Level 3.
  5. LEVEL 5SMA obtains enrollment assignment 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 assignment standard messages, and other nationally recognized enrollment assignment standards further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, enrollment assignment standard messages, and other nationally recognized enrollment assignment standards for regional information exchange improving cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts MITA Framework, enrollment assignment standard messages, and other nationally recognized enrollment assignment 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 assignment standard messages with intrastate agencies and entities improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework and enrollment assignment standard messages with regional agencies and entities improving efficiency to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework and enrollment assignment 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?
  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 assignment standard messages with intrastate agencies and entities improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework and enrollment assignment standard messages with regional agencies and entities improving accuracy to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework and enrollment assignment 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 assignment 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 assignment standard messages with regional agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts MITA Framework and enrollment assignment 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 42-50.

Other Eligibility and Enrollment Management processes

Determine Member EligibilityDetermine Provider EligibilityDisenroll MemberDisenroll ProviderEnroll MemberInquire Member EligibilityInquire Provider Information