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Terminate Provider

Provider Information Management

Description

The Terminate Provider business process is responsible for the termination of provider agreement to participate in the Medicaid Program. The basis for termination can be: • Centers for Medicare & Medicaid Services (CMS) and the State Medicaid Agency (SMA) terminate a provider agreement if an individual provider: - Is not in substantial compliance with the requirements of participation, regardless of whether immediate jeopardy is present; - Provider does not meet the eligibility criteria for continuation of payment as set forth in 42 CFR 488.412(a)(1). • CMS and the state may terminate a facility's provider agreement if a facility: - Is not in substantial compliance with the requirements of participation, regardless of whether immediate jeopardy is present; or - Facility fails to submit an acceptable Corrective Action Plan (CAP) within the timeframe specified by CMS or the SMA. • CMS and the SMA terminate a facility's provider agreement if a facility: - Fails to relinquish control to the temporary manager, if CMS or the SMA imposes that remedy; or - Facility does not meet the eligibility criteria for continuation of payment as set forth in 42 CFR 488.412(a)(1). The effect of termination of the provider agreement ends: (1) payment to the facility, and (2) any alternative remedy.

Business Process Template

Trigger events
Environment-based
  • Receive request to terminate provider.
  • Receive notification of termination of provider from insurance affordability program.
Interaction-based
  • Receive alert from Determine Adverse Action Incident business process to cease activities with provider.
Results
  • Removal of provider or contractor from participation in Medicaid Program.
  • Alert sent to notify provider via Manage Provider Communication business process of termination proceedings.
  • If applicable, alert sent to notify contractor via Manage Contractor Communication business process of termination proceedings.
  • If applicable, alert sent to notify public via Perform Population and Member Outreach business process of termination proceedings.
  • Alert sent to notify business partners via Manage Business Relationship Communication business process of provider termination.
  • Alert sent to notify Health Insurance Marketplace of provider termination information.
  • Alert sent to notify insurance affordability program of provider termination information.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive request to terminate provider.
  • 2. Review determination of noncompliance and investigation materials.
  • 3. Send alert to notify provider via Manage Provider Communication business process of termination proceedings.
  • 4. If applicable, send alert to notify contractor via Manage Contractor Communication business process of termination proceedings.
  • 5. If applicable, send alert to notify public via Perform Population and Member Outreach business process of termination proceedings.
  • 6. Conduct communications and investigations within required timeframes.
  • 7. If provider had implemented systems and processes to ensure that the likelihood of further violation is remote, and there is adequate evidence that the provider is in compliance with the requirements, the SMA rescinds the termination action and puts the provider back into compliance.
  • 8. If provider has not implemented systems and processes to avoid further violations, terminate the provider.
  • 9. Send alert to notify business partners via Manage Business Relationship Communication of provider termination.
  • 10. Send alert to notify Health Insurance Marketplace of provider termination information.
  • 11. Send alert to notify insurance affordability program of provider termination information.
  • 12. END: Remove provider or contractor from participation in Medicaid Program.
Predecessor processes
Successor processes
Shared data
  • Provider data store including provider network and contract information
  • Business Activity data store including performance information
  • Compliance Management data store including compliance incident information
  • Insurance Affordability Program data store including eligibility and enrollment information
Constraints

Before terminating a provider agreement, CMS and the SMA will notify the facility and the public: (1) At least two (2) calendar days before the effective date of termination for a facility with immediate jeopardy deficiencies; and (2) At least 15 calendar days before the effective date of termination for a facility with non-immediate jeopardy deficiencies that constitute noncompliance.

Failures
  • Unable to find requested Provider.
  • Provider information is not available for inquiry.
Performance measures
  • Time to complete termination process = within __ days
  • Consistency of decisions and disposition = ___%
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Provider Management BPT.pdf, pages 3-6.

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?
  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 and stores the provider termination information within the state. SMA automates process to the full extent possible within the intrastate. SMA shares Provider Network information with Health Insurance Marketplace (HIX). SMA produces audit trail of termination decision 100% of the time.
  4. LEVEL 4SMA automates process to the full extent possible and stores the provider termination information for the region. SMA automates process to the full extent possible across the interstate. SMA shares Provider Network information with Health Insurance Marketplace (HIX).
  5. LEVEL 5SMA automates process to the full extent possible This process uses and stores the provider termination information in a federal repository. SMA automates process to the full extent possible across the nation. SMA shares Provider Network information with Health Insurance Marketplace (HIX).
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 automates process to the full extent possible and stores the provider background and screening termination information within the state. SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA automates process to the full extent possible and stores the provider background and screening termination information for the region standard messages and other nationally recognized standards for clinical and interstate information exchange.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and national standards for consistent validation at a federal level and stored in a federal repository standard messages 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 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 regional agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. 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?
  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 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 SMA’s 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 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 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 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 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 8-14.

Other Provider Management processes

Manage Provider CommunicationManage Provider Grievance and AppealManage Provider InformationPerform Provider Outreach