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Prepare REOMB

Compliance Management

Description

The Prepare REOMB business process is responsible for the creation of Recipient Explanation of Medicaid Benefits (REOMB) for detecting payment problems. The State Medicaid Agency (SMA) sends the REOMB to randomly selected members of Medicaid services. It gives information on the Medicaid services paid on behalf of the member. The communication includes the provider's name, the date(s) of services, and the payment amount(s). Instructions on the communication tell the member what to do if the provider did not actually perform any of the listed services billed directly to him/her by the provider. NOTE: This business process does not include the handling of returned information.

Business Process Template

Trigger events
Environment-based
  • Periodic timetable is due for generation of the REOMB sample information.
Interaction-based

None published

Results
  • Member receives REOMB.
  • Alert sent with REOMB notification to member via Manage Applicant and Member Communication business process with REOMB information.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Timetable for scheduled REOMB generation.
  • 2. Identify member selection using random sampling methodology.
  • 3. Review sample selection information.
  • 4. Prepare REOMB for each select member.
  • 5. END: Send alert to member via Manage Applicant and Member Communication business process with REOMB information.
Predecessor processes
  • None
Successor processes
  • Manage Applicant and Member Communication
Shared data
  • Member data store including demographics information
  • Claims data store including payment information
Constraints

The policies and business rules for preparing the REOMB sample information differ by state. The SMA will provide the REOMB or letters to the members within 45 days of payment of claims.

Failures
  • This business process has no failure modes that prevent the process from going to completion.
Performance measures
  • Time to complete process: e.g., Batch Responses = within __ hours
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Performance Management BPT.pdf, pages 12-13.

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?
  1. LEVEL 1The process consists primarily of manual paper-based activity to accomplish tasks. SMA identifies the samples and generates Recipient Explanation of Medical Benefits (REOMB) manually. Distribution is via the mail.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. SMA uses sampling enhancements to target selected populations.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate. SMA may integrate the REOMB with Personal Health Records (PHR). When SMA uses PHR, it enhances the sampling process to target selected populations. SMA generates EOBs automatically that are available via web portal.
  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.
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.
If sampling is used, what sampling algorithm is used?
  1. LEVEL 1SMA complies with federal regulations to produce random samples of REOMB monthly.
  2. LEVEL 2SMA enhances the sampling process to target selected populations.
  3. LEVEL 3In addition to the targeted populations, SMA generates the sampling dynamically based on provider billing patterns and Surveillance Utilization Review System results.
  4. LEVEL 4Maturity level is not applicable.
  5. LEVEL 5Maturity level is not applicable.
Is communication linguistically, culturally, and competency appropriate?
  1. LEVEL 1Functionally, linguistically, culturally, and competency appropriate outreach and education materials are lacking because they are difficult and costly to produce.
  2. LEVEL 2Outreach material is functionally, linguistically, culturally, and competency appropriate, but at great expense. SMA limits outreach material by state defined parameters (e.g., only two (2) languages used).
  3. LEVEL 3SMA automates process to the full extent possible across the intrastate. Use of electronic communications makes provision of functionally, linguistically, culturally, and competency appropriate outreach material more cost-effective.
  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).
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. 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. Members can review data online and report on a questionable service through a web interface Accuracy rating is at 99% 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. Members have direct access to Personal Health Records. Accuracy rating is at 99% 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 rating is at 99% or higher.

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. Effectiveness is 50% or below, associated with responses to the REOMB that lead to program savings.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1. Flexibility in targeting REOMB over manually identifying the sample improves effectiveness of responses to 75% or better.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.Integration with Personal Health Record may increase effectiveness to 85% or better.
  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. The member returns REOMB electronically or responds to REOMB on the web portal improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher.
  5. 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?
  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 99% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 99% 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, Performance Management BCM.pdf, pages 29-35.

Other Performance Management processes

Determine Adverse Action IncidentEstablish Compliance IncidentIdentify Utilization AnomaliesManage Compliance Incident Information