Manage Provider Information

Provider Information Management

Description

The Manage Provider Information business process is responsible for managing all operational aspects of the Provider data store, which is the source of comprehensive information about prospective and contracted providers and their interactions with the State Medicaid Agency (SMA). The Provider data store is the SMA Source of Record (SOR) for provider demographic, business, credentialing, enumeration, performance profiles, payment processing, and tax information. The data store includes contractual terms (e.g., the services the provider is to provide) related performance measures, and the reimbursement rates for those services. In addition, the Provider data store contains records about and tracks the processing of provider enrollment applications, credentialing and enumeration verification, and all communications with or about the provider, including provider verification requests and responses, and interactions related to any grievance/appeal. The Provider data store may store records or pointers to records for services requested and services provided, performance, utilization, and program integrity reviews, and participation in member care management. Business processes that generate prospective or contracted provider information send requests to the Member data store to add, delete, or modify information. The Provider data store validates information upload requests, applies instructions, and tracks activity. The Provider data store provides access to provider records to applications and staff via batch record transfers, responses to queries, and subscription services.

Business Process Template

Trigger events

Environment-based

Receive request to create, inquire, delete, or modify provider information from authorized individuals via email, mail, facsimile, telephone or web.
Receive request to verify provider information from authorized external parties.

Interaction-based

None published

Results

The SMA creates, inquires on, modifies or deletes provider information.
Alert sent to notify Health Insurance Marketplace of provider network modification information.
Alert sent to notify insurance affordability program (i.e., Medicare, CHIP and Basic Health Program) of provider network modification.
Alert sent to Manage Provider Communication to notify provider of relevant modifications.
Tracking information as needed for measuring performance and business activity monitoring.

Business process steps

1. START: Receive request from authorized individuals or agencies to create, inquire, delete or modify provider information.
2. Agency logs request for provider information.
3. Validate information submitted is correct and as complete as possible. Information complies with syntax criteria and requestor has completed all required fields.
4. Validate the authorization by requestor to acquire provider information.
5. Find appropriate provider.
6. Create, inquire, delete or modify relevant provider information.
7. Send alert to notify Health Insurance Marketplace of provider network modification.
8. Send alert to notify insurance affordability program of provider network modification.
9. Send alert to Manage Provider Communication to notify provider of relevant modifications
10. END: The SMA creates, inquires on, deletes, or modifies provider information.

Predecessor processes

Successor processes

Shared data

Provider data store including provider network, contract, demographics, application, eligibility, enrollment, grievance, appeals and communications information
Financial data store including payment information
Plan data store including policy information
Health Benefit data store including benefit program and benefit information
Claims data store including claim status and claims payment information
Care Management data store including case management, health record, and clinical data information
Business Activity data store including performance information

Constraints

State-specific workflows determine which processes load and access the Provider data store and by which interactions and messages (e.g., query/response, batch uploads, publish and subscribe, etc.), the information content and how they will structure data store records, as well as determine how to validate the incoming information prior to updating the Provider data store. Archive information in accordance with state and federal record retention requirements.

Failures

Requestor has no authorization to the provider information.
Unable to find requested Provider.
Provider information is not available for inquiry.

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, Provider Management BPT.pdf, pages 1-3.

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?

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
LEVEL 3SMA automates process to the full extent possible within the intrastate and stores the enhanced provider background and screening information as well as application fees within the state. Provider Network information is shared with Health Insurance Marketplace (HIX). SMA produces audit trail of decision 100% of the time.
LEVEL 4SMA automates process to the full extent possible across the interstate and stores the enhanced provider background and screening information as well as application fees within the region. Provider Network information is shared with Health Insurance Marketplace (HIX).
LEVEL 5SMA automates process to the full extent possible across the nation. This process uses and stores the enhanced provider background and screening information as well as application fees in a federal repository. Provider Network information is shared with Health Insurance Marketplace (HIX).

How does the State Medicaid Agency validate application information?

LEVEL 1SMA manually validates information. Staff contacts external and internal document verification sources via telephone, facsimile, mail. Decisions on information verifications take multiple business days. Validation is manual and subjective.
LEVEL 2Many application information validations are automatic (Social Security Number (SSN), address, birth certificate, etc.). Validation is consistent and based on business rules.
LEVEL 3SMA adopts MITA Framework, industry standards, and national standards within the intrastate that use standardized business rules definitions for consistent validation within the state.
LEVEL 4SMA adopts MITA Framework, industry standards, and national standards across the interstate that use regional standardized business rules definitions for consistent validation within the region.
LEVEL 5SMA adopts MITA Framework, industry standards, and national standards across the nation that use national standardized business rules definitions for consistent validation.

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 of information on a regional basis.
LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information mandated by federal standards.

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 regional agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
LEVEL 5SMA collaborates with federal 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). Manual and semi-automatic steps delay updates; updates take from one week to one month. Notifications are inconsistent in regards to time, and in general, are not timely (i.e., five (5) or more business days later than the update).
LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. On the average, updates occur daily (within 24 hours). Notifications are available on the day of the modification
LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional Health Insurance Marketplace (HIX). Timeliness exceeds Level 2.
LEVEL 4Information is available in near real time. SMA has regional 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 regional 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.
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 regional 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. Requires numerous data entry staff to key new and updated information, and reconcile duplicates and data inconsistencies
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 regional information exchange improving 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 regional 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 regional 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 regional 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, Provider Management.pdf, pages 1-8.

Other Provider Management processes

Manage Provider Communication Manage Provider Grievance and Appeal Perform Provider Outreach Terminate Provider