EE
Inquire Provider Information
Provider Enrollment
Description
The Inquire Provider Information business process receives requests for provider enrollment verification from authorized providers, programs or business associates; performs the inquiry, and prepares the response information for the Send Outbound Transaction.
Business Process Template
Trigger events
Environment-based
- Receive provider enrollment verification request from Receive Inbound Transaction.
Interaction-based
- Receive eligibility inquiry via Automated Voice Response System (AVRS).
Results
- Provider enrollment verification response that may include information such as enrollment start/end dates, provider type, and specific specialties provided.
- If applicable, response sent with eligibility inquiry information via AVRS.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive provider enrollment verification information from Receive Inbound Transaction.
- 2. Agency logs enrollment verification request.
- 3. Validate requestor’s authorization to receive requested information.
- 4. Find requested provider’s enrollment verification information.
- 5. Agency logs response.
- 6. If applicable, send eligibility inquiry response via AVRS.
- 7. END: Send response to requestor via Send Outbound Transaction.
Predecessor processes
- Receive Inbound Transaction
Successor processes
- Send Outbound Transaction
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
Constraints
States determine what information share and who can access what requested information.
Failures
- Process unable to process the provider information verification request.
- Unauthorized requester cannot receive requested information.
Performance measures
- Time to verify provider information and generate response information: e.g., Real Time response = within __ seconds, Batch Response = within __ hours
- Response Accuracy = ___%
- Error rate = __% or less
Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 38-40.
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. SMA receives most requests via telephone, facsimile, or mail.
- LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. SMA submits response via automatic voice response system, web portal, Electronic Data Interchange (EDI) transaction, personal computer, terminal connection or within batch response parameters.
- LEVEL 3The inquire provider process is fully automatic to the extent possible within the intrastate.
- LEVEL 4The inquire provider process is fully automatic to the extent possible within the region.
- LEVEL 5The inquire provider process is fully automatic to the 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 nationally recognized and state-specific standards.
- LEVEL 3SMA adopts MITA Framework, provider inquiry standard messages, and other nationally recognized provider inquiry standards for intrastate exchange of provider enrollment information.
- LEVEL 4SMA adopts MITA Framework, provider inquiry standard messages, and other nationally recognized provider inquiry standards for clinical and regional exchange of provider enrollment information.
- LEVEL 5SMA adopts MITA Framework, provider inquiry standard messages, and other nationally recognized provider inquiry standards or national exchange of provider enrollment 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 EDI transactions.
- LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national provider inquiry standards as well as develop and share reusable business services.
- LEVEL 4SMA collaborates with other regional agencies and entities to adopt provider inquiry national standards as well as develop and share reusable provider inquiry processes including clinical information.
- LEVEL 5SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine provider inquiry operations.
Business Capability Quality: Timeliness of Process
How timely is the end-to-end inquiry process?
- LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
- LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements
- LEVEL 3Timeliness improves via state and federal collaboration, use of provider inquiry information sharing, standards, and regional information exchange hubs. Timeliness is ten (10) seconds or less.
- LEVEL 4Information Provider enrollment information is available in near real time. Provider inquiry processes that use clinical provider inquiry information result in immediate action, response, and results. SMA has regional interoperability, which further improves timeliness over Level 3.
- LEVEL 5Provider enrollment information is available in real time. Provider inquiry processes improve further through connectivity with other States and with federal agencies. Most provider inquiry 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 inquiry information increasing the reliability of SMA’s internal information. External sources of provider inquiry information use MITA Framework and industry standards for information verification submission. Decision-making is automatic using a statewide provider inquiry standardized business rules definitions. Accuracy rating is at 99% or higher.
- LEVEL 4SMA automates the collection of provider inquiry information increasing the reliability of regional sources of information. SMA adopts MITA Framework and industry standards for information exchange verification by 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 provider inquiry standards for national information verification submission. 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 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.
- LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 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
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, 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, Eligibility and Enrollment Management BCM.pdf, pages 57-63.