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Submit Electronic Attachment

Claims Adjudication

Description

The Submit Electronic Attachment business process begins with receiving attachment information that either a payer requests (solicited) or a provider submits (unsolicited). The solicited attachment information can be in response to requests for more information from the following business processes for example: Process Claim, Process Encounter, Authorize Service, Authorize Treatment Plan, and Manage Estate Recovery. The business process links attachment information to the associated applicable transaction (e.g., claim, prior authorization, treatment plan) or suspends for a predetermined time set by state specific business rules, after which the business process purges information. The business process validates the successfully associated attachment information using application-level edits, determining whether the information provides the additional information necessary to adjudicate (i.e., approve, suspend or deny) the transaction.

Business Process Template

Trigger events
Environment-based
  • Periodic timetable to associate suspended attachment information with subsequently received transactions.
Interaction-based
  • Receive claim via Accredited Standards Committee (ASC) X12 837 Health Care Claim transaction.
  • Receive Retail Pharmacy Claim Transaction (National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard).
  • Receive ASC X12 277 Health Care Information Status Notification requesting additional information.
  • Receive ASC X12 278 Health Care Servicer Review Information transaction.
Results
  • The State Medicaid Agency (SMA) accepts and associates attachment information with the appropriate transaction (e.g., claim, prior authorization, treatment plan, etc.).
  • If applicable, the SMA rejects attachment information as invalid.
  • If applicable, the SMA suspends attachment information awaiting the receipt of a matching transaction.
  • If applicable, the SMA purges attachment after duration of predetermined time.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive attachment information.
  • 2. Validate attachment provides all required information.
  • 3. Associate attachment information with applicable transaction.
  • 4. Validate application level edits such as provider, member, and benefit information, and association with transaction.
  • 5. Determine whether the attachment supplies the additional information as required by state business rules.
  • 6. If applicable, reject attachment information as invalid. END: Business process stops.
  • 7. If applicable, suspend attachment information awaiting the receipt of a matching transaction. END: Business process stops.
  • 8. If applicable, purge attachment after duration of predetermined time. END: Business process stops.
  • 9. END: The SMA accepts and associates attachment information with the appropriate transaction.
Predecessor processes
Successor processes
Shared data
  • Claims data store with transaction information
  • Provider data store with provider network information
  • Member data store with demographic information
  • Care Management data store with authorization information
  • Financial data store including accounts receivable information
Constraints

The attachment information will conform to the format and content in accordance with national standards and state-specific rule-reporting requirements, e.g., using HIPAA Transaction Standard Companion Guide, and contain valid required information content based on several criterion (e.g., type of claim, type of service, provider type, and member demographic). The attachment will be consistent with the associated original transaction per state rules, and will contain the correct information for this business process to execute.

Failures
  • Quality of the image too bad to render as usable.
  • Cannot locate applicable transaction (i.e., claim, prior authorization).
  • Attachment is missing required information.
Performance measures
  • Time to complete the process: Real Time response = within __ seconds, Batch Response = within __ hours
  • Accuracy with which the SMA applies and associates attachments rules = __%
  • Number of attachments = __% of total claims. (Processing a higher percentage of claims attachments may indicate that a state is able to utilize more clinical information when determining whether a claim meets state payment rules)
  • Error rate of correctly re-associating attachment information = __% or less

Source: CMS MITA 3.0 Business Process Template, Operations Management BPT.pdf, pages 21-25.

Business Capability Model (13 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

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.
  4. LEVEL 4SMA automates process to the full extent possible across the interstate.
  5. LEVEL 5SMA automates process to the full extent possible across the nation.
How is clinical information requested and received when this information is required to process a transaction (claim, service authorization request, treatment plan) or for other processes?
  1. LEVEL 1SMA requests medical and dental records via telephone or mail and responder delivers copies in paper format (including X-rays) via mail certified mail and facsimile.
  2. LEVEL 2SMA receives a mix of paper and electronic attachments and returns a mix of electronic and paper formats.
  3. LEVEL 3SMA receives the majority of transactions and attachments electronically. SMA continues to accept paper attachments from a small number of providers who still submit paper transactions.
  4. LEVEL 4SMA no longer requires attachments because the payer has direct access to the clinical information stored in the Health Information Exchange (HIE).
  5. LEVEL 5Through the Nationwide Health Information Network (NwHIN), SMA can view clinical information stored in Clinical information in any location in the country. Attachments are no longer necessary.
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, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.
Does the clinical information accompany the transaction?
  1. LEVEL 1Submitter sends paper attachments (i.e., clinical records) separately from the transaction, and then SMA matches the two (2) documents, requiring manual intervention.
  2. LEVEL 2SMA automatically matches electronic attachments to corresponding claim. SMA may scan paper attachments, but still associate them manually with the applicable transaction.
  3. LEVEL 3SMA requires electronic attachments for electronically submitted transactions, and they accompany the transaction.
  4. LEVEL 4Maturity level is not applicable.
  5. LEVEL 5Maturity level is not applicable.
Are validation activities manual or automatic?
  1. LEVEL 1Validation that the attachment provides the necessary information is a primarily manual process.
  2. LEVEL 2Some validation is automatic.
  3. LEVEL 3The implementation of the process as a service per industry standard interface requirements allows automatic validation of attachments.
  4. LEVEL 4SMA automates process to the full extent possible across the interstate.
  5. LEVEL 5SMA automates process to the full extent possible across the nation.
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 interstate agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. 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?
  1. LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation). It requires 30 or more business days for receipt of the requested records and associating them with the transaction.
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. SMA may scan paper attachments, reducing the distribution time within SMA. It requires 24 hours or less to receive clinical attachment and associate with correct transaction.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional Health Information Exchange (HIE). Timeliness exceeds Level 2.
  4. 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.
  5. 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?
  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 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 is 99.9% or higher.
  4. 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 is 99.9% or higher.
  5. 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 is 99.9% 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. Accessing clinical records generally requires 48 or more hours.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1. SMA accesses clinical records in one (1) hour or less.
  3. 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.
  4. LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3.
  5. 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?
  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, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange. SMA increases cost effectiveness ratio over Level 3.
  5. 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?
  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, industry standards and information exchange with intrastate agencies and entities improving efficiency to 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 90% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 90% 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, industry standards and information exchange with intrastate agencies and entities improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher.
  5. 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?
  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, 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.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. 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 46-54.

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