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Manage Provider Communication

Provider Support

Description

The Manage Provider Communication business process receives requests for information, provides publications, and assistance from prospective and current providers’ communications (e.g., inquiries related to eligibility of provider, covered services, reimbursement, enrollment requirements). The State Medicaid Agency (SMA) may communicate information using a variety of methods such as email, mail, publication, mobile device, facsimile, telephone, web or Electronic Data Interchange (EDI). This business process includes the log, research, development, approval and delivery of routine or ad hoc messages. NOTE: Manage Provider Communication business process handles inquiry from prospective and current providers by providing assistance and responses to individual entities (i.e., bi-directional communication). Also included are scheduled communications such as program memorandum, notifications of pending expired provider eligibility, or formal program notifications such as the disposition of appeals. The Perform Provider Outreach business process targets both prospective and current provider populations for distribution of information about programs, policies, and health care issues.

Business Process Template

Trigger events
Environment-based
  • Receive inquiry from current or prospective provider.
  • Receive request to send information packages such as provider enrollment applications and/or billing instructions.
  • Receive request for assistance, such as a request for training or modify in provider information.
  • Periodic timetable (e.g. hours, monthly, and quarterly) is due to send information. For example, SMA sends communications within 24 hours of new provider enrollment or periodic publications such as newsletters.
Interaction-based
  • Receive requests from other business processes to develop and produce communications for providers such as notifications from Enroll Provider business process.
  • Receive inquiries originating from customer help desk through Manage Provider Information business process.
Results
  • Current or prospective provider receives appropriate assistance, communications, appointment, and/or information packages.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive request for communication.
  • 2. Validate information submitted is correct and as complete as possible. Information complies with syntax criteria and requestor has completed all required fields.
  • 3. Validate that the provided information is authentic.
  • 4. Agency logs request for communication.
  • 5. Determine content and method of communication (e.g., email, mail, publication, mobile device, facsimile, telephone, web, or EDI.
  • 6. Determine performance measures.
  • 7. Prepare content that is linguistically, culturally, and competency appropriate for the communication in agreed upon format.
  • 8. Review and approve communication.
  • 9. Generate communication in agreed upon format.
  • 10. Agency logs communication message.
  • 11. END: Evaluate the efficacy of the communication (e.g., customer satisfaction, first time resolution rate).
Predecessor processes
Successor processes
Shared data
  • Provider data store including provider network, contract, and grievance information
  • Plan data store including policy information
  • Health Benefit data store including benefit package and benefit information
  • Ancillary Communication Tracking Systems: Customer Relationship Management (CRM), Help Desk Log, Protected Health Information (PHI) disclosure log, etc.
Constraints

Communications requested will vary by state, depending on programs supported and type of provider requesting information. Provider may have communication barriers such as lack of internet or phone access. Provider is unable to access required or requested information.

Failures
  • SMA is unable to provide linguistically, culturally, or competency appropriate information.
  • Delivery failures due to erroneous contact information or lack of contact information.
Performance measures
  • Time to complete response: By phone __ minutes; by email ___ hours; by mail __days
  • Accuracy of communications = __%
  • Communications successfully delivered = __%

Source: CMS MITA 3.0 Business Process Template, Provider Management BPT.pdf, pages 6-8.

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 activity to accomplish tasks. SMA conducts this process primarily via paper, facsimile, and telephone.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks. The process increases the use of electronic methods. SMA accepts inquiries that provider responds to online or by telephone.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate including communication delivery by email, paper, mobile devices, Automatic Voice Response System (AVRS), telephone, facsimile, web portal or Electronic Data Interchange (EDI) transaction. Portal includes usability features or functions that accommodate the needs of persons with disabilities, including those who use assistive technology.
  4. LEVEL 4SMA automates process to the full extent possible within the region.
  5. LEVEL 5SMA automates process to the full extent possible across the nation.
Is communication linguistically, culturally, and competency appropriate?
  1. LEVEL 1Functionally, linguistically, culturally, and competency appropriate communications are lacking because they are difficult and costly to produce.
  2. LEVEL 2Communication 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 communications more cost-effective.
  4. LEVEL 4SMA automates process to the full extent possible within the region.
  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. SMA establishes a formal Communications Management Plan.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate state exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for regional exchange of information.
  5. 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?
  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 EDI transactions.
  3. LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share services.
  4. LEVEL 4SMA collaborates with other regional state agencies and entities to adopt national standards, and to develop and processes including clinical information.
  5. LEVEL 5SMA collaborates with federal agencies and entities for national (and international) interoperability 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).Requests may take multiple business days.
  2. LEVEL 2Process timeliness improves through use of automation. Providers have access to self-services via a web portal resolving their inquiries themselves. SMA answers most requests in 24 hours or less. Multiple web portals may exist as providers may work with multiple agencies. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. SMA responds to most common inquiries in real-time. Exceptions may require 24 hours or less. SMA integrates web portals so providers have consistent way of communicating.
  4. LEVEL 4Information is available in near real time. SMA has regional 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 rating is at 99% or higher.
  4. LEVEL 4Automation of information collection increases the reliability of regional agencies’ internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange by regional agencies. Decision-making is automatic using regional standardized business rules definitions. 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.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1
  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 regional 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 the 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 regional information exchange improving 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 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional 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 process results?
  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 regional 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 regional 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, Provider Management.pdf, pages 14-21.

Other Provider Management processes

Manage Provider Grievance and AppealManage Provider InformationPerform Provider OutreachTerminate Provider