PL
Manage Reference Information
Health Benefit Administration
CMS names this process two ways. The Business Process Template and the framework's business architecture index use the name above; the Business Capability Model (Appendix D) publishes it as Maintain Reference Information.
Description
The Manage Reference Information business process is responsible for all operations aspects for the creation, modification, and deletions of reference code information. The Process Claim business process additions or adjustments trigger this business process. Additional triggers for Manage Reference Information business process include the addition of a new health plan or benefit, or the modification to an existing program due to the passage of new state or federal legislation, or budgetary modifications. The business process includes revising code information (e.g., Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT), National Drug Code (NDC)), and/or revenue codes. Business process also adds rates associated with those codes and updates existing rates. The business process updates and adds information from the Manage Member Information and Manage Provider Information business processes as well as drug formulary, health plan and health benefit information. Designate Approved Services and Drug Formulary The Designate Approved Services and Drug Formulary activity is responsible for review of new and/or modified service codes (e.g., HCPCS, International Classification of Diseases (ICD) or NDC) for possible inclusion in various Medicaid Benefit programs. The State Medicaid Agency (SMA) may include or exclude certain services and drugs in each benefit package. Internal or external team(s) of medical, policy, and rates staff review service, supply, a inclusion or exclusion of codes to various benefit plans. The review team is responsible for reviewing any legislation to determine scope of care requirements that the SMA will meet. Review includes the identification of any modifications or additions needed for regulations, policies, and or Medicaid State Plan in order to accommodate the inclusion or exclusion of service/drug codes. The review team is also responsible for the defining coverage criteria and establishing any limitations or authorization requirements for approved codes.
Business Process Template
Trigger events
Environment-based
- Addition or modification to health plan or health benefit as directed by state or federal legislation or budgetary modifications.
- Receive revised reference code set by industry standards organization.
- Annual, bi-annual, quarterly or other review of newly established or modified service codes and National Drug Codes as published by maintainers of medical codes.
Interaction-based
- Receive new or modification of reference information from Process Claim business process.
- Receive new or modification of health plan information from Manage Health Plan Information business process.
- Receive new or modification of health benefits information from Manage Health Benefit Information business process.
Results
- Addition or modification of reference code set elements.
- Alert sent to notify provider and contractor of reference code addition or modification.
- Approved services and drug formularies established and defined.
- The SMA approved or denied service codes and NDC codes for inclusion or exclusion in one or more Medicaid Health Plan.
- Alert sent to notify impacted member of approved services and drug formulary.
- Alert sent to Manage Rate Setting business process to establish rates for approved services and drug formulas.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive addition or modification of reference information.
- 2. Review addition or modification to determine impact to coverage requirements based on current benefit programs.
- 3. Add or update codes or rates, including pre- and post-verification for accuracy.
- 4. Add or update member benefits, including pre- and post-verification for accuracy.
- 5. Add or update drug formulary information, including pre- and post-verification for accuracy.
- 6. Add or update program under which services are available.
- 7. END: Send alert to notify provider and contractor of reference code addition or modification.
- Designate Approved Services and Drug Formulary
- 1. START: Receive addition or modification of codes information.
- 2. Review new or modified coding to determine impact to coverage requirements based on current benefit programs.
- 3. Approve addition or elimination of services or NDC.
- 4. Determine coverage policies.
- 5. Review and identify modifications to Medicaid State Plan.
- 6. Review and identify modifications to regulations.
- 7. Recommend modifications to the State Medicaid Enterprise.
- 8. END: Send alert to notify provider, contractor, and impacted member of approved services and drug formulary.
Predecessor processes
Successor processes
- Process Claim
- Process Encounter
- Manage Rate Setting
- Manage Provider Communication
- Manage Contractor Communication
- Manage Applicant and Member Communication
- Manage Data
Shared data
- Reference data store including code set, drug formulary, and service code formulary information
- Member data store including health benefits information
- Provider data store including provider network information
- Contractor data store including provider network information
- Health Benefit data store including benefit and rate information
Constraints
The SMA will maintain the Reference data store according to federal and state-specific policies and procedures, and comply with any code authority requirements. The SMA establishes service and drug formularies. Policies and procedures may differ from state to state.
Failures
- The review does not take place prior to the effective date of the codes.
Performance measures
- Time to complete process: e.g., Real Time response = within __ seconds, Batch Response = within __ days
- Accuracy of decisions = ___%
- Consistency of decisions and disposition = ___%
- Error rate = __% or less
Source: CMS MITA 3.0 Business Process Template, Plan Management BPT.pdf, pages 13-16.
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 paper-based activity to accomplish tasks.
- LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. SMA uses business intelligence tools to analyze data to support maintenance of the reference information.
- 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 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 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 this 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 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, Plan Management BCM.pdf, pages 40-46.