OM
Manage Data
Payment and Reporting
Description
The Manage Data business process is responsible for the preparation of the data sets and delivery to federal agencies (e.g., Centers for Medicare & Medicaid Services (CMS), Social Security Administration (SSA).) Information exchange may include extraction of Medicaid and CHIP Business Information and Solutions (MACBIS) information needs (i.e., fee-for-services, managed care, eligibility and provider information). The Manage Data business process includes activity to extract the information, transform to the required format, encrypt for security, and load the electronic file to the target destination. The uses for the information include: • Research and evaluation of health care activities. • Staff can forecast the utilization and expenditures for a program. • Staff can analyze policy alternatives. • State and federal agencies can respond to congressional inquiries. • Matches to other health related databases.
Business Process Template
Trigger events
Environment-based
- Periodic (e.g., quarterly) timetable for information is due.
- Receive request for information.
Interaction-based
None published
Results
- Information message sent to target destination.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive time event or request to initiate Manage Data business process.
- 2. Extract required information from source data stores.
- 3. Transform information to meet business and technical needs of target destination.
- 4. Apply necessary encryption algorithms for security.
- 5. END: Send message with information to the target destination.
Predecessor processes
- NOTE: Many MITA Framework business processes collect data for extraction of information and send to target destination. The following are the business processes that manage primary data stores.
- Manage Case Information
- Manage Contractor Information
- Manage Member Information
- Manage Provider Information
- Manage Budget Information
- Manage Accounts Receivable Information
- Manage Accounts Payable Information
- Generate Financial Report
- Process Claim
- Process Encounter
- Generate Remittance Advice
- Manage Compliance Incident Information
- Maintain State Plan
- Manage Health Plan Information
- Manage Health Benefit Information
- Manage Performance Measures
- Manage Reference Information
Successor processes
- Send Outbound Transaction
Shared data
- Claims data store including claims, encounters, adjudication, and historical information
- Care management data store including treatment plan, outcomes, and authorization information
- Plan data store including Medicaid State Plan, health plan, health benefits, reference, performance measures, and benchmarks information
- Compliance Incident data store including anomalies and adverse action information
- Member data store including demographics, eligibility determination, enrollment, grievance and appeals, communication, and outreach information
- Provider data store including provider network, eligibility determination, enrollment, grievance and appeals, communication, and outreach information
- Contractor data store including provider network, enrollment, grievance and appeals, communication, and outreach information
- Financial data store including accounts payable and accounts receivable information
Constraints
The Manage Data business process will adhere to the federal requirements for submission of information to federal agency.
Failures
- Requested information is not available for extraction.
- Transformation does not meet the federal requirements for submission.
- Information message does not meet the target destination submission requirements.
Performance measures
- Time to complete the process: e.g., Real Time response = within ___seconds, Batch Response = within ___ hours
- Accuracy with which the State Medicaid Agency (SMA) applies rules =___%
- Consistency with which the SMA applies rules =___%
- Error rate =___% or less
Source: CMS MITA 3.0 Business Process Template, Operations Management BPT.pdf, pages 18-20.
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 1SMA has no automatic activity to accomplish Extract, Transform and Load (ETL) tasks.
- LEVEL 2SMA uses a mix of manual and automatic ETL processes to accomplish tasks.
- LEVEL 3SMA automates ETL process to the full extent possible within the intrastate.
- LEVEL 4SMA automates process to the full extent possible, across the interstate. SMA includes clinical information in the process.
- 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 industry 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 clinical and interstate information exchange.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of 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 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).
- LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements
- 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 2Industry 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 industry standards for information exchange. 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 uses industry standards for information exchange with interstate agencies. Accuracy rating is at 99% or higher.
- LEVEL 5SMA uses industry standards for information exchange with national agencies. 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 industry standards increase accessibility over Level 1.
- LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on 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 18-24.