Inquire Payment Status

Payment and Reporting

Description

The Inquire Payment Status business process begins with receiving an Accredited Standards Committee (ASC) X12 276 Health Care Claim Status Request transaction or a request for information received through other means such as email, paper, telephone, facsimile, web, or Automated Voice Response (AVR). The business process handles the request for the status of a specified claim(s), retrieves information from the claims payment history, and generates the response information. In addition, the business process formats the information into the ASC X12 277 Health Care Information Status Notification transaction, or other mechanism for responding, via the media used to communicate the inquiry, and sends claim status response via the Send Outbound Transaction.

Business Process Template

Trigger events

Environment-based

Receive status request via email, mail, mobile device, facsimile, telephone, or web.

Interaction-based

Receive status request via ASC X12 276 Health Care Claim Status Request transaction.

Results

Requester received claims status information.
If applicable, response sent via ASC X12 277 Health Care Information Status Notification transactions to requester.
If applicable, alert sent to submitter via ASC X12 TA1 Interchange Acknowledgment, 997 Functional Acknowledgment, 999 Implementation Acknowledgment, and/or the 824 Application Advice transaction(s) per Trading Partner Agreement (TPA).
Tracking information as needed for measuring performance and business activity monitoring.

Business process steps

1. START: Receive claim status request. a. If applicable, alert sent to submitter via ASC X12 TA1 Interchange Acknowledgment, 997 Functional Acknowledgment, 999 Implementation Acknowledgment, and/or the 824 Application Advice transaction(s) per Trading Partner Agreement (TPA). END: Business process ends.
2. Agency logs claim status request.
3. Validate requester has authorization to receive requested information.
4. Inquire the payment status information to obtain required requested data elements (e.g., member birth date, member last and first name, member ID, claim service date, internal control number, medical record number).
5. Generate claim status response.
6. If applicable, provide claim status response via ASC X12 277 Health Care Information Status Notification transactions to requester.
7. END: If applicable, receive alert from submitter via ASC X12 TA1 Interchange Acknowledgment, 997 Functional Acknowledgment, 999 Implementation Acknowledgment, and/or the 824 Application Advice transaction(s) per Trading Partner Agreement (TPA).

Predecessor processes

Successor processes

Send Outbound Transaction

Shared data

Claim data store including payment information

Constraints

Payment Status Inquiry and Response will conform to the format and content in accordance with federal and state-specific requirements, e.g., using HIPAA Transaction Standard Companion Guide that may differ based on situational fields determined by state policy.

Failures

The State Medicaid Agency (SMA) does not receive the claim Payment Status Inquiry submission.

Performance measures

Time to complete the process: e.g., Real Time response = within __ seconds, Batch Response = within __ hours
Accuracy with which payment status rules are applied = __%
Consistency with which payment status rules are applied = __%
Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Operations Management BPT.pdf, pages 2-4.

Business Capability Model (11 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 paper-based activity to accomplish tasks. SMA associates inquiry with a specific claim document.
LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. Automated Voice Response systems, direct data entry, web enabled direct data entry, point of service devices for electronic claim status responses, and submission of HIPAA Accredited Standards Committee (ASC) X12 transactions.
LEVEL 3SMA automates process to the full extent possible within the intrastate.
LEVEL 4SMA automates process to the full extent possible across the interstate.
LEVEL 5SMA automates process to the full 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 HIPAA and state-specific standards.
LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for payment status and interstate information exchange.
LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.

How integrated is the process?

LEVEL 1Depending on the type of claim, providers should contact different portions of the organization (e.g. provider call center, pharmacy call center, waiver programs).
LEVEL 2SMA begins to centralize the process providing a more central point of access for all types of claims.
LEVEL 3SMA fully integrates the process to the extent possible across the intrastate.
LEVEL 4SMA fully integrates the process to the extent possible across the interstate.
LEVEL 5SMA fully integrates the process to the extent possible across the nation.

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 standards, and to develop and share reusable business services.
LEVEL 4SMA collaborates with other interstate agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
LEVEL 5SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine 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 in two (2) business days.
LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. Process completes in one (1) business day or less.
LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2.
LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has interstate interoperability, which further improves timeliness over Level 3.
LEVEL 5Information 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?

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 3Automation of information collection increases the reliability of SMA’s internal information. External sources of 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 4Automation of information collection increases the reliability of SMA’s internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange with interstate 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 information exchange with national agencies. 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, Operations Management BCM.pdf, pages 6-13.

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