MES Certification Navigator
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Inquire Member Eligibility

Member Enrollment

Description

The Inquire Member Eligibility business process receives requests for eligibility verification from Health Insurance Marketplace, authorized providers, programs or business associates; performs the inquiry; and prepares the Eligibility, Coverage or Benefit Information response. The response information includes but is not limited to benefit status, explanation of benefits, coverage, effective dates, and amount for co-insurance, co-pays, deductibles, exclusions and limitations. The information may include details about the Medicaid health plans, health benefits, and the provider(s) from which the member may receive covered services. NOTE: This business process does not include Member requests for eligibility verification. Member initiated requests are handled by the Manage Member Information and or Manage Applicant and Member Communication business processes.

Business Process Template

Trigger events
Environment-based

None published

Interaction-based
  • Receive eligibility inquiry from the Health Insurance Marketplace via ANSI X12 Health Care Eligibility Benefit Inquiry and Response (270/271) 270 Inquiry transaction using the Council for Affordable Healthcare (CAQH®) Committee on Operating Rules for Information Exchange (CORE®) Phase 1 and 2 Rules.
  • Receive eligibility inquiry from the provider via ANSI X12 Health Care Eligibility Benefit Inquiry and Response (270/271) 270 inquiry transaction using CAQH CORE Rules.
  • Receive eligibility inquiry from the pharmacist via National Council for Prescription Drug Programs (NCPDP) Retail Pharmacy Eligibility transaction.
  • Receive eligibility inquiry via Automated Voice Response System (AVRS) or other commonly available electronic means.
Results
  • Response sent to Health Insurance Marketplace via ANSI X12 Health Care Eligibility Benefit Inquiry and Response (270/271) 271 Response transaction using CAQH CORE Rules.
  • Response sent to provider via ANSI X12 Health Care Eligibility Benefit Inquiry and Response (270/271) 271 Response transaction using CAQH CORE Rules.
  • If applicable, response sent to AVRS or other commonly available electronic means with eligibility information.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive eligibility verification request.
  • 2. Agency logs eligibility verification request.
  • 3. Validate requester’s authorization to receive requested information.
  • 4. Find requested member’s eligibility information.
  • 5. Agency logs response.
  • 6. If applicable, send response to AVRS with eligibility information.
  • 7. END: Send response to requestor via ANSI X12 Health Care Eligibility Benefit Inquiry and Response (270/271) 271 Response transaction using CAQH CORE Rules.
Predecessor processes
  • Receive Inbound Transaction
Successor processes
  • Send Outbound Transaction
Shared data
  • Member data store including demographics, eligibility and enrollment information
Constraints

Eligibility verification request can ask for verification at the categorical, health plan, provider, or health benefit level per X12 Health Care Eligibility Benefit Inquiry and Response (270/271) 270 Inquiry depending on trading partner agreements. Agency must use Council for Affordable Healthcare (CAQH®) Committee on Operating Rules for Information Exchange (CORE®) Phase 1 and 2 Rules in addition to other HIPAA compliant inquiry methods.

Failures
  • Unauthorized requestor cannot receive requested information at the level asked (e.g., eligibility for mental health program); however, requester may receive more general information such as verification of eligibility for health plan or health benefit coverage. NOTE: Responses that a member is not eligible or is not active are not failures to process the request.
Performance measures
  • Time to verify eligibility and generate response: e.g., Real Time response = within __ seconds, Batch Response = within __ hours
  • Response Accuracy = ___%
  • Error rate = __% or less
  • Usage of CORE certified response = ____ % of the time

Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 22-24.

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 automated?
  1. LEVEL 1The process consists primarily of manual activity to accomplish tasks.
  2. LEVEL 2SMA uses a mix of manual and automated processes to accomplish tasks.
  3. LEVEL 3SMA automates the inquire member eligibility process through use of shared enrollment service to maximum extent possible with CHIP and the Marketplace.
  4. LEVEL 4SMA automates the inquire member eligibility process through use of shared enrollment service integrated with CHIP and Marketplace.
  5. LEVEL 5SMA automates the inquire member eligibility process through use of shared enrollment service and is fully integrated with CHIP and Marketplace.
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, industry standards (e.g., HIPAA, Affordable Care Act) and other nationally recognized standards for intrastate exchange of member eligibility information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards (e.g., HIPAA, Affordable Care Act) and other nationally recognized standards for interstate exchange of member eligibility information and actively participates in the ongoing development of related standards.
  5. LEVEL 5SMA adopts MITA Framework, industry standards e.g., HIPAA, Affordable Care Act), and other nationally recognized standards for national exchange of member elgibility information, actively participates in the ongoing development of standards, and works with other States and federal agencies to develop and adopt standards related to eligibility inquiry process.
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 2The agency collaborates with other agencies and entities to adopt HIPAA standards and EDI transactions
  3. LEVEL 3SMA collaborates with insurance affordability programs to develop and implement common eligibility inquiry standards.
  4. LEVEL 4SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage the eligibility inquiry process.
  5. LEVEL 5SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage the eligibility inquiry process. The SMA works with state and national data sources, the Marketplace, and CHIP agency to establish data exchanges and supporting activities with programs in other States.

Business Capability Quality: Timeliness of Process

How timely is the end-to-end process?
  1. LEVEL 1SMA sometimes meets threshold or mandated requirements for timeliness (e.g., the process achieves results within the time specified by law, or regulation). Eligibility inquiries may take multiple business days.
  2. LEVEL 2SMA improves timeliness through use of automation. Timeliness always meets legal requirements. SMA completes eligibility inquiries in less than two (2) business day.
  3. LEVEL 3SMA improves timeliness through use of automation. Timeliness always meets legal requirements. SMA completes eligibility inquiries in one (1) business day.
  4. LEVEL 4SMA improves timeliness through use of automation. Timeliness always meets legal requirements. Information is available in near real time.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other regions, States and with federal agencies. Most processes execute at the point of service. Timeliness improves over Level 4.

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 adopts MITA Framework and industry standards for eligibillity inquiries. Decision-making is automatic using business rule engines Accuracy is 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework and industry standards for eligibillity inquiries. Decision-making is automatic using business rule engines. Accuracy is 95% or higher.
  5. LEVEL 5SMA uses Marketplace, MITA Framework, and national standards for eligibility inquiries. Decision-making is automatic using business rule engines. Accuracy is 98% 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. Systems experience extended scheduled and unscheduled downtime
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1. Systems experience extended scheduled and unscheduled downtime
  3. LEVEL 3SMA easily obtains and uses information from Marketplace and CHIP agency based on MITA Framework and industry standards. Accessibility is greater than Level 2.
  4. LEVEL 4SMA easily obtains and uses information from Marketplace and CHIP agency based on MITA Framework and industry standards. Accessibility is greater than Level 3.
  5. LEVEL 5SMA easily obtains and uses information from Marketplace and CHIP agency based on MITA Framework and industry standards. 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 automated, standardized tasks.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, increasing cost effectiveness ratio over Level 1
  3. LEVEL 3SMA adopts Marketplace, MITA Framework, and intrastate standard messages and other nationally recognized standards further increasing cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts Marketplace, MITA Framework, regional standard messages and other nationally recognized standards for information exchange increasing cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts Marketplace, MITA Framework, industry standards, and other nationally recognized standards for national 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 agency performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts shared enrollment services improving efficiency to 90% or higher.
  4. LEVEL 4SMA adopts shared enrollment services improving efficiency to 95% or higher.
  5. LEVEL 5SMA uses shared enrollment services 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 results in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and business rules reduce error and improve accuracy above Level 1
  3. LEVEL 3SMA adopts standard messages for interacting with other state agencies and entities, improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts standard messages for interacting with agencies and entities across some states improving accuracy to 95% or higher.
  5. LEVEL 5SMA adopts standard messages for interacting with agencies and entities across all states improving accuracy to 98% or higher.

Business Capability Quality: Utility or Value to Stakeholders

How satisfied are the 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 standard messages for interacting with other state agencies and entities, improving stakeholder satisfaction to 80% or higher.
  4. LEVEL 4SMA adopts standard messages for interacting with agencies and entities across some states, improving stakeholder satisfaction to 90% or higher.
  5. LEVEL 5SMA adopts standard messages for interacting with agencies and entities across all states, improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Eligibility and Enrollment Management BCM.pdf, pages 27-33.

Other Eligibility and Enrollment Management processes

Determine Member EligibilityDetermine Provider EligibilityDisenroll MemberDisenroll ProviderEnroll MemberEnroll ProviderInquire Provider Information