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Department of Health Care ServicesCA-MMISConcept of Operations (COO)

March 7, 2014Version 2.0

Table of ContentsPreface.......................................................................................6

Executive Policies.........................................................................................6Professional Responsibility...........................................................................6Revision History............................................................................................6

1. Introduction.......................................................................101.1 Business Architecture (BA) – Alignment to MITA...............................11

1.1.1 Business Architecture Artifacts.............................................121.1.2 Business Process Model (BPM)...........................................131.1.3 MITA Maturity Model (MMM)................................................151.1.4 Business Capability Matrix (BCM)........................................15

1.2 Document Assumptions......................................................................161.3 Document Scope................................................................................171.4 Document Constraints........................................................................181.5 Referenced Documents......................................................................191.6 Definitions...........................................................................................21

2. CA-MMIS Actors Catalog..................................................303. As-Is CA-MMIS.................................................................32

3.1 As-Is CA-MMIS Business Processes.................................................333.2 As-Is CA-MMIS Context Diagram.......................................................35

3.2.1 Business Associates.............................................................393.3 As-Is CA-MMIS COO..........................................................................40

3.3.1 As-Is CA-MMIS COO – Inbound/Outbound Transactions....404. To-Be CA-MMIS................................................................57

4.1 The CA-MMIS Health Enterprise System Information Exchange and Access Environment...........................................................574.2 To-Be CA-MMIS COO........................................................................594.3 To-Be Environment of CA-MMIS Business Process Implementation in System Replacement Project........................................614.4 Transition from As-Is to To-Be............................................................62

4.4.1 Effectiveness – Increase Business Maturity.........................634.4.2 Effectiveness – Improved Performance Standards..............66

4.5 Compliance.........................................................................................664.5.1 Security and Confidentiality..................................................664.5.2 System Security and Privacy................................................664.5.3 Other Standards for Compliance..........................................67

4.6 Critical Business Processes...............................................................67

Concept of Operations 2

4.7 Business Architecture – Assumptions, Constraints, and Risks.....................................................................................................67

Appendices..............................................................................81A. CA-MMIS Actors Catalog........................................................................81B. CA-MMIS Business Process Maturity Level.........................................123C. Actor Primary Interactions with CA-MMIS Business Process.....................................................................................................133D. Medi-Cal Enterprise..............................................................................142E. Planned Releases Roadmap................................................................143


List of TablesTable 1: Explanation of Global Definitions................................................16

Table 2: Referenced Documents..............................................................19

Table 3: Definitions...................................................................................21

Table 4: CA-MMIS Primary Entities..........................................................37

Table 5: CA-MMIS Business Associates..................................................40

Table 6: As-Is CA-MMIS COO Table (Care Management).......................41

Table 7: As-Is CA-MMIS COO Table (Contractor Management)..............42

Table 8: As-Is CA-MMIS COO Table (Financial Management)................43

Table 9: As-Is CA-MMIS COO Table (Member Eligibility and Enrollment Management)...........................................................................................47

Table 10: As-Is CA-MMIS COO Table (Member Management)...............47

Table 11: As-Is CA-MMIS COO Table (Operations Management)...........48

Table 12: As-Is CA-MMIS COO Table (Plan Management).....................50

Table 13: As-Is CA-MMIS COO Table (Provider Eligibility Management) 52

Table 14: As-Is COO Table (Performance Management).........................55

Table 15: As-Is COO Table (Provider Management)................................56

Table 16: Release 1 Business Functionality.............................................61

Table 17: Quality Attributes to Measure Business Process......................64

Table 18: Template for Business Capability Matrix (BCM).......................65

Table 19: Business Architecture - Assumptions, Constraints, and Risks. 68

Table 20: CA-MMIS Actors Catalog..........................................................81

Table 21: CA-MMIS As-Is and To-Be Maturity Levels............................123

Table 22: CA-MMIS Primary Actor Interactions with Business Processes................................................................................................................133

List of FiguresFigure 1: Relationship Between MITA Business Architecture Artifacts.....13

Figure 2: Business Process Model Components......................................14


Figure 3: Business Processes and Business Capabilities........................16

Figure 4: Actors Catalog Diagram............................................................31

Figure 5: As-Is CA-MMIS Business Processes.........................................34

Figure 6: As-Is CA-MMIS Context Diagram..............................................36

Figure 7: The CA-MMIS Health Enterprise System Exchange and Access Environment.............................................................................................58

Figure 8: To-Be COO Diagram (CA-MMIS HE System)...........................60

Figure 9: As-Is and To-Be CA-MMIS Transformation Characteristics......62

Figure 10: COO (Business Architecture Transition)..................................63

Figure 11: MITA Maturity Level.................................................................65

Figure 12: Medi-Cal Enterprise...............................................................142

Figure 13: Roadmap for Releases 1 – 5.................................................143


Preface

Executive Policies

The Project Policies document, which is stored in the Process Library document folder on the California Medicaid Management Information System (CA-MMIS) SharePoint site, contains policies that apply directly to the CA-MMIS System Replacement Project and tasks to develop, maintain, convert, or re-engineer computer software and services. The Project Policies document is applicable to subcontractors and vendors by including a requirement in the applicable contract, Statement of Work, or task order.

Professional Responsibility

The project management team has a responsibility to maintain ethical and professional conduct in the management of projects. This obligation includes producing quality products or services within the project’s scope, with consideration to time and cost. Cooperation and good faith are the professional responsibility of stakeholders.

Revision History

Version Date Description Author

0.01 9/17/2012 Initial draft of COO Alok Kumar, Bonnie Lam

0.02 9/20/2012 Revised draft Leyla Avila

0.03 9/26/2012 QM initial review of COO document

Sharisse Baltikauskas

0.04 9/27/2012-9/28/2012

Update based on QM initial review

Alok Kumar, Barbara Jones, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh

0.05 10/3/2012-10/5/2012

Update based on DHCS comments

Alok Kumar, Barbara Jones, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh

0.06 10/09/2012 EPMO Review Tanya Sachdeva

0.07 10/11/2012 QM Review Sharisse Baltikauskas



0.08 10/12/2012-10/14/2012

Update based on QM review Denise Walsh, Bonnie Lam

0.09 10/15/2012 Final QM Review Sharisse Baltikauskas

0.10 10/15/2012 Updated Figures 4 & 14 and removed “PA” from Definitions Table

Bonnie Lam, Denise Walsh

0.11 10/29/2012 Updated based on additional findings from DHCS’ final review.

Alok Kumar, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh

0.12 11/7/2012 QM Review for resubmission Sharisse Baltikauskas

0.13 11/08/2012 Updated based on QM review of responses to DHCS’ final review.

Denise Walsh

0.14 11/09/2012 Final QM Review for resubmission

Sharisse Baltikauskas

1.00 11/20/2012 DHCS approved Tanya Sachdeva

1.01 10/16/2013 – 12/03/2013

Updated document according to CR issued by DHCS.

Updated document throughout to align with list of 66 BPs in scope for CA-MMIS versus previous list of 39 BPs.

Added CDA and CDSS to Actors Catalog and diagram.

Removed Appendix D (Business Improvements/Operational Scenarios).

Removed Tables 4 and 16-19.

Added new section titled “Business Architecture – Alignment to MITA.”

Added new section titled “Business Architecture – Assumptions, Constraints, and Risks.”

Alok Kumar, Barbara Jones, Denise Walsh, Jeff Strand, Lisa Cruz

1.02 12/04/2013 Accepted track changes and distributed draft for peer review.

Denise Walsh



1.03 12/04/2013 Incorporated peer review comments.

Updated Terms/Acronyms table.

Added File Maintenance and Service Delivery to Actors Catalog.

Updated Appendix D according to internal SME review comments.

Denise Walsh, Lisa Cruz, Alok Kumar, John Hunziker, Barbara Jones, Jeff Strand, John Stewart

1.04 12/10/2013 Accepted track changes and prepared document for submission to DHCS for informal review.

Denise Walsh

1.05 01/09/2014 Deleted the “Configuration of This Document” statement, as it is no longer applicable to CA-MMIS deliverables.

Added a new section titled “Critical Business Processes.”

Deleted Appendix D.

Deleted Figure 1 and the preceding paragraph.

Modified Figure 9 so it only includes Business Architecture details.

Removed Information and Technical Architecture details from Figure 11.

Added explanation regarding the difference between sections 1.2/1.4 and section 4.6 (now 4.7).

Updated the Actor UMD to CAAS per DHCS directive. This change was effective January 1, 2014.

Expanded the descriptions of the impacts listed in the Actors Catalog.

Alok Kumar, Denise Walsh, Barbara Jones

1.06 01/27/2014 Updated CAAS to CAASD.

Added SBP161 (67th BP in-scope for CA-MMIS) to applicable tables and figures.

Updated based on CRF received from DHCS for Version 1.05.

Alok Kumar, Denise Walsh



1.07 02/06/2014 Added a discussion of the modified agile approach.

Added Appendix E (Roadmap for Releases).

Alok Kumar, John Stewart, Denise Walsh

1.08 02/11/2014 Updated Actor Impacts table. Added statement before Table 19 for clarity.

General formatting cleanup.

Prepare document for final submission.

Alok Kumar, Barbara Jones, Denise Walsh

1.09 03/04/2014 Updated the definition of “stakeholder” throughout document, based on feedback received from the DHCS Transition Team.

Denise Walsh

2.0 03/07/2014 DHCS Approval Deirdre Smith


1. Introduction

A COO is an abstract model that describes how an organization intends to operate to achieve its goals and objectives and meet the Federal Seven Conditions and Standards to achieve Enhanced Federal Financial Participation funding. It provides a structure that helps organizations document their As-Is (current) operations and define the To-Be (future) transformations. The COO helps frame the vision and showcase the target To-Be environment, independent of technology. It is a well-thought-out vision of the future with actors and other stakeholder interactions in mind. The COO also satisfies Standard 2: Medicaid Information Technology Architecture (MITA) Condition of Centers for Medicare & Medicaid Services (CMS) Enhanced Funding Requirements.

As part of the State Self-Assessment (SS-A), the Office of HIPAA Compliance (OHC) developed an Enterprise Medi-Cal COO that included business processes within Medi-Cal. The CA-MMIS COO (i.e., this document) is a part of the Enterprise Medi-Cal COO, and it covers the business processes in scope for the CA-MMIS System Replacement Project.

The COO supports the furtherance of the Department of Health Care Services (DHCS) goals and objectives as identified in the California Department of Health Care Services Strategic Plan (2013-2017) and its mission “… to provide Californians with access to affordable, high-quality health care, including medical, dental, mental health, substance use treatment services, and long-term care.”

The goals for the State of California in the CA-MMIS System Replacement Project are:

1. Achieve a Medicaid Management Information System (MMIS) that moves the State Medi-Cal program administration higher in the MITA maturity model.

2. Exhibit the interoperability and reusability required by MITA.3. Create an environment for integrating the business and information technology (IT)

environments to improve the management of the Medi-Cal Program.4. Provide a solid platform for future growth with scalable architecture that can grow and

change with the Medi-Cal Program.5. Support DHCS’ move toward Health Information Exchange (HIE)/Health Information

Technologies (HIT) to support improved outcomes and quality services for Medi-Cal members.

6. Support enhanced fraud detection and prevention strategies.7. Align CA-MMIS with current industry MITA and Service Oriented Architecture (SOA)

guidelines.8. Meet current federal regulation for reporting in compliance with Health Information

Portability and Accountability Act (HIPAA).9. Provide easier access for the Provider community to submit and correct claim

documents and retrieve status information, help and billing information electronically.10. Rapid response to change in terms of adaptability and flexible user functionality.

Each change in a law or regulation often means multiple changes to system software. A major goal of this replacement effort is to reduce the time and cost associated with future system enhancements

11. Meet the Seven Conditions and Standards to qualify for Enhanced Federal Financial Participation (FFP).


12. Technology that supports DHCS programs into the future, in such a manner that business requirements drive enhancements rather than system limitations driving business decisions.

13. Effective management of Medicaid with a system that supports data analysis, performance measurement, and planning. It also requires the ability to share data with providers and other stakeholders.

14. Rules-based configuration through Business Rules Management Systems (BRMSs) that allows authorized users to update business rules in response to changing legislative requirements, regulatory policy, and evolutions in Medicaid and the health care industry.

15. A system that interfaces with other systems in a seamless framework that supports coordination with providers and other stakeholders.

16. A system that supports web-based self-service for provider/pharmacist processing needs.

17. A system that supports multi-payer capability – California, like most states, has several programs that have business requirements almost identical to Medicaid. In addition, members move in and out of these programs as their financial circumstances change.

18. A system that meets the above-listed goals without substantially increasing operating costs.

The COO documents the As-Is operations and the To-Be vision of the future for CA-MMIS. It helps DHCS determine business improvements and changes to the current operations and processes to achieve the long term vision of moving the State Medi-Cal program administration higher in the MITA Maturity Model (MMM).

The COO is produced early in the requirements analysis process of the CA-MMIS System Replacement Project to describe what the system will do (not how it will do it) and why (rationale). It sets the foundation for developing the Business Process Template (BPT) and is used for the Requirements Elicitation sessions.

The COO is updated in each System Replacement release to reflect corrections and approved changes. It is also maintained during system operations and maintenance of the CA-MMIS Health Enterprise (HE) System and thereby serves as a future “As-Is” view. Once the COO is approved and baselined, it is governed by the CA-MMIS Architecture/MITA Workgroup for management of future updates. Changes to the number of business processes in scope for CA-MMIS are governed by the Change Control Board (CCB).

The COO is also aligned to The Open Group Architecture Framework (TOGAF) Phase B – Business Architecture which has been adopted as the framework to elaborate the architecture for CA-MMIS System Replacement.

1.1 Business Architecture (BA) – Alignment to MITA

The CA-MMIS System Replacement Project allows for MITA business capability improvement for impacted business processes. The MITA Framework defines a future in which health care stakeholders (e.g., policy makers, public health and oversight


agencies, taxpayers, consumers, and providers) participate in achieving the objectives of improving health outcomes of the population served in a timely and accountable way. Stakeholders are able to apply for health assistance and receive an eligibility determination in real-time. Stakeholders benefit from improvements in information sharing and exchange that enable caregivers, payers, and members to view appropriate clinical information immediately and use this information to make appropriate health care decisions. Providers and payers are able to focus on their primary functions of care giving, benefit plan monitoring, and evaluation as most of the administrative burden of information capture, processing, and reporting are obsolete with the usage of direct messaging between data exchange partners.

1.1.1 Business Architecture Artifacts

The BA is a conceptual construct comprised of models, matrices, and templates. These components are derived from a variety of industry standards because no single methodology exists that meets the scope of MITA.

The BA provides the foundation for defining a vision for improvements in Medicaid program operations that result in better outcomes for the stakeholders. The BA contains models of typical Medicaid Business Processes and describes how these processes can improve over time. This allows states to use the BA to assess their own current business capabilities and determine future targets for improvement.

The BA is comprised of the following artifacts:

1. COO2. Business Process Model (BPM)3. Business Capability Matrix (BCM)

The BA is comprised of the following tool:

1. MMM


The following diagram describes the relationships among the various BA components (artifacts). This diagram helps determine the dependencies (incoming as well as outgoing) for the BA artifacts and other tasks, activities, and related artifacts such as the SS-A and MITA Roadmap.

Figure 1: Relationship Between MITA Business Architecture Artifacts

The following sections describe the MITA artifacts and tool that comprise the BA.

1.1.2 Business Process Model (BPM)

The MITA BPM presents a hierarchy of Medicaid Business Processes organized into categories of Business Areas that are high-level groupings of Business Processes, which share common focus and information.

The BPM offers a hierarchy of business areas and sub-tier business areas that lead to the individual Business Process at the lowest level included in the model. The State BPM addresses each of the MITA BPMs and adds some state-specific processes. The State has described, sub-divided, and provided definitions of these state-specific processes


unique from the hierarchy presented in the BPM. The BPM for CA-MMIS is the subset of processes that the State has identified through its SS-A.

The Business Process is defined as a series of activities that are triggered by one or more events and result in one or more results. The Business Processes contained in the MITA BPM and the state-specific BPM are described in a standard template that captures the Trigger, Result, and Business Logic. The Trigger is the initiating event. It is defined in terms of data or a time/schedule. The Result is the output of the process. It is described as data produced by the Business Process. Business Logic is defined by the individual steps/activities. The following figure illustrates the components of the Business Process.

Figure 2: Business Process Model Components

OHC provides the Business Processes and their descriptions or variances to the CMS MITA 3.0 Business Processes for DHCS. CMS provided the actual BPMs that include triggers and other model elements. Xerox is responsible for incorporating those models into the overall architecture design guidelines. Xerox develops the To-Be BPM for the business processes defined for CA-MMIS in the COO. The To-Be BPMs are updated in each release and as needed to reflect corrections and approved changes. Each CA-MMIS Business Process is represented both as a narrative as well as in a Business Process Model and Notation (BPMN) diagram. BPMN is a flowchart based notation for defining business processes and is a visual language for describing “process logic” in a diagram.

Individual BPMs and BPMN diagrams are being developed for each BP through several collaborative sessions with DHCS.


1.1.3 MITA Maturity Model (MMM)

The purpose of the MMM is to serve as a reference model for defining the business capabilities as described in the BCM. The BCM is discussed further in the following section. The MMM establishes boundaries and measures to use in determining whether a business capability definition is clear and concise. The MMM is used as a tool to illustrate how Business Processes are planned to mature over time from a current level to a future level.

The scope of the MMM is to define the maturity levels (1 through 5) using business capability quality and technical capability quality attributes. The SS-A helps determine the current maturity level (As-Is) of Medicaid business operations and sets the groundwork to establish a To-Be vision for the evolution of the State Medicaid Program’s MITA maturity level over time.

Recognizing that Business Processes form the core activities of the Medicaid Program, and in keeping with the guiding principle that MITA “represents a business-driven enterprise transformation,” the SS-A draws primarily on the BA component of the MITA Framework. The SS-A sets forth specific objectives for reaching a higher maturity level in each Business Process identified in the MITA Framework; the actual steps needed to achieve these objectives are developed as part of the transition planning process.

The MMM is a MITA tool; therefore, an artifact is neither developed nor subject to an update cycle.

1.1.4 Business Capability Matrix (BCM)

The BCM is created from several sources – the BPM, the MMM, and the State’s As-Is and To-Be Medi-Cal Business Processes for the CA-MMIS. Applying the MMM to each Business Process yields the BCM, which shows how the Business Process matures over time. The BCM assigns a Level 1 through 5 to each Business Process.

The following figure is an extension of the figure “Business Process Model Components” from the BPM section above and shows how the BPM is the focus of the BCM.


Figure 3: Business Processes and Business Capabilities

BCM details will be captured by the State in their BCM artifact to gauge the maturity levels obtained by each of the business process.

1.2 Document Assumptions

The following assumptions pertain specifically to this document. For assumptions related to business processes, refer to Section 4.7, Business Architecture – Assumptions, Constraints, and Risks.

1. The colors and varying shades on the various figures/diagrams throughout the COO document are primarily for aesthetic purposes, unless stated in the legend or associated section. For example, the two different shades of the “To-Be Context Diagram” are representative of the MITA Business Areas and HE components as stated in the legend.

2. To clarify important terms that are used throughout the COO, refer to the table below. It is critical for readers to understand the concept of these terms and how they relate to each other in order to gain a foundational and complete understanding of the COO. For consistency, these terms also appear in the Definitions table.

Table 1: Explanation of Global Definitions

Term Explanation

Actor Refers to a specific user group, organization, or system that interacts with CA-MMIS directly or indirectly. These actors belong to one of the three categories (i.e., DHCS, Xerox, and External entities).

“DHCS actors” refer to user groups, agencies, and divisions within DHCS.

“Xerox actors” refer to user groups, teams, and departments within Xerox.

“External actors” refer to Federal agencies, other State agencies, counties and other ancillary groups, submitters and other intermediaries, providers, and members.

CA-MMIS Business Process

Refers to CA-MMIS business processes that are derived from the Medi-Cal Business Processes in the SS-A. Currently, there are 67 CA-MMIS business processes out of the 141 Medi-Cal business processes.


Term Explanation

Medi-Cal Business Process

Refers to the DHCS Enterprise Medi-Cal business processes that are identified in the SS-A performed by OHC in June, 2013. Currently, there are 141 Medi-Cal business processes. The Medi-Cal business processes are aligned to the MITA business processes by the MITA 2.0 and 3.0 crosswalk developed by DHCS. This crosswalk illustrates the mapping of MITA 2.0 to MITA 3.0, including the Medi-Cal Business Areas, Business Categories, and Business Processes.

The crosswalk is available on SharePoint using the link/path below:

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/DHCS%20MITA%20Business%20Processes%202.0%20to%203.0%20Crosswalk%20Catalog.xlsx

CA-MMIS System Replacement > Draft Deliverables and Work Products > Workgroup: SR-Architecture/MITA > Topic: Business Architecture > DHCS MITA Business Processes 2.0 to 3.0 Crosswalk Catalog

MITA Business Process Refers to the MITA 3.0 business processes that are defined by CMS under the BA.

Stakeholder The term “stakeholder” in this document refers to one or more Actors performing in a common role [or common set of roles], who are impacted by the transition from the Legacy CA-MMIS System to the CA-MMIS Health Enterprise System, or who need to be kept informed of its progress, from the broadest perspective.

“Internal stakeholders” refer to DHCS and Xerox, and are trained by Xerox Operations Training Department (OTD).

“External stakeholders” refer to providers, provider associations, ancillary groups (health plans, counties, etc.), intermediaries (vendors, clearinghouses, CMS, etc.), members, and the public. The Provider Outreach and Education (O&E) Department conducts the outreach activities to these external stakeholders.

1.3 Document Scope

The purpose of this COO is to document the current state of CA-MMIS, the Medicaid Enterprise vision of the future as it relates to the CA-MMIS HE System, and describe the impact of planned improvements on stakeholders, information exchanges, Medicaid operations, and health care outcomes. It satisfies the requirements for a MITA COO as described within the MITA Business Architecture.

This COO includes Medi-Cal business processes for which DHCS has contracted Xerox to provide support for the CA-MMIS System Replacement Project. Medi-Cal business processes that meet at least one of the following criteria are considered in-scope for this deliverable:

1. Medi-Cal business processes that use CA-MMIS to support the business operation, regardless of whether the operation is performed by DHCS, Xerox, or Shared (e.g., Manage Drug Rebate).

2. Medi-Cal business processes which CA-MMIS interfaces with, links with, or provides/consumes a service [e.g., Service to obtain eligibility information from the Medi-Cal Eligibility Data System (MEDS)].

The COO is not a requirements document. It is not to be considered as a roadmap, implementation plan, or transition plan, as it does not contain the steps involved in




planning for the transition from the current state to the future. The COO does not prescribe or limit the approach or technologies that may be used to reach the vision of moving the State Medi-Cal program administration higher in the MMM.

The COO includes the following major sections:

1. CA-MMIS Actors: a list of actors (with brief description) who interact with CA-MMIS directly or indirectly and their impacts.

2. As-Is (Current State) CA-MMIS: identifies in-scope Medi-Cal business processes for CA-MMIS, primary actors, and actor interactions with the CA-MMIS business processes. It also includes the As-Is Context Diagram and the As-Is COO Diagram.To-Be (Future State) CA-MMIS: defines the HE transfer systems and business module/function where in-scope MITA business processes will be implemented, as well as the As-Is and To-Be business maturity levels to depict the desired transition based on the SS-A. It also includes the To-Be Context Diagram and the To-Be COO Diagram.

1.4 Document Constraints

The business processes identified for each release of the CA-MMIS System Replacement Project are subject to change during requirement validations. This document identifies current business processes by release and transfer system, as known at the time of publication.

For constraints specific to each business process, refer to Section 4.7, Business Architecture – Assumptions, Constraints, and Risks.


1.5 Referenced Documents

The following table displays a list of documents referenced in this COO.

Table 2: Referenced Documents

Referenced Document

Document Location Version # and Date

CA-MMIS System Replacement – Architecture Plan

Xerox Link: https://cammis.sp.acs-inc.com/sites/lib/Deliverable%20Library/Architecture%20Plan.docx

Version 3.08

July 2, 2013

DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/lib/Deliverable%20Library/Architecture%20Plan.docx

SharePoint Navigation Path: CA-MMIS Home > Deliverables > Deliverables Library > Del ID : DPP.0003 Architecture Plan > Architecture Plan

California Department of Health Care Services Strategic Plan

http://www.dhcs.ca.gov/Documents/DHCS%20Strategic%20Plan.pdf October 2008

DHCS Division Descriptions

http://www.dhcs.ca.gov/Documents/DHCS%20Division%20Descriptions%20May%202012.pdf

May 2012

Enhanced Funding Requirements: Seven Conditions and Standards – Medicaid IT Supplement (MITS-11-01-v1.0)

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/EFR-Seven-Conditions-and-Standards.pdf

Version 1.0

April 2011

Medi-Cal Enterprise Business Process Diagram

Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/COO%20-%20Medi-Cal%20Enterprise%20Business%20Process%20Diagram.vsd

August 29, 2013

DHCS Link : https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/COO%20-%20Medi-Cal%20Enterprise%20Business%20Process%20Diagram.vsd

SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Draft Deliverables and Work Products > Workgroup : SR-Architecture > Project Phase: Phase I > COO-Medi-Cal Enterprise Business Process Diagram

CA-MMIS MITA Workgroup SS-

Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip

Version 1.3


https://cammis.sp.acs-inc.com/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip

https://cammis.sp.acs-inc.com/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/COO%20-%20Medi-Cal%20Enterprise%20Business%20Process%20Diagram.vsd



https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/COO%20-%20Medi-Cal%20Enterprise%20Business%20Process%20Diagram.vsd

https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/COO%20-%20Medi-Cal%20Enterprise%20Business%20Process%20Diagram.vsd





http://www.dhcs.ca.gov/Documents/DHCS%20Strategic%20Plan.pdf

https://cammis-sp.psd.dhs.ca.gov/sites/lib/Deliverable%20Library/Architecture%20Plan.docx

https://cammis-sp.psd.dhs.ca.gov/sites/lib/Deliverable%20Library/Architecture%20Plan.docx

https://cammis.sp.acs-inc.com/sites/lib/Deliverable%20Library/Architecture%20Plan.docx

https://cammis.sp.acs-inc.com/sites/lib/Deliverable%20Library/Architecture%20Plan.docx

Referenced Document


A based on MITA 2.0

May 30, 2008DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip

SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites> System Replacement > Documents > Reference > Category : Architecture > Med-Cal_MITA_SS-A Based on MITA 2.0

Medi-Cal MITA SS-A Interim Report (Medi-Cal business processes and maturity level ratings) based on MITA 3.0

Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx

August 6, 2013

DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx

SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Draft Deliverables and Work Products > Workgroup : SR-Architecture/MITA > Topic: Concept of Operations > State BP Ratings 20130806

MITA 3.0 Framework

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Medicaid-Information-Technology-Architecture-MITA.html

Version 3.0

February 2012

MITA 3.0, Part I Business Architecture, Chapter 2 - Concept of Operations

Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf

Version 3.0

February 2012

DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf

SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Reference > Category : Standards > more… > Part I Chapter 2 Concept of Operations 3.0

MITA 3.0, Part I Business Architecture, Appendix A - Concept of Operations Details

Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf

Version 3.0

February 2012

DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf

SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Reference > Category : Standards > more… > Part I Appendix A Concept of Operations Details 3.0

MITA Workgroup Charter

Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf

December 7, 2012

DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf

SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Draft Deliverables and Work Products > Workgroup : SR-Architecture/MITA > Topic: Charter > Scanned Approved Charter MITA Architecture WG


https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf

https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf

https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf

https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf

https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf

https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf

https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf



https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx

https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx

https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip

https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip

Referenced Document


Risks Log Xerox Link: https://cammis.sp.acs-inc.com/cammis/Lists/Risks/O_P_Risks.aspx

Not Applicable

DHCS Link: https://cammis-sp.psd.dhs.ca.gov/cammis/Lists/Risks/O_P_Risks.aspx

SharePoint Navigation Path: CA-MMIS Home > Risks

1.6 Definitions

This section lists glossary terms and acronyms specifically applicable to this document.

Table 3: Definitions

Term/Acronym Explanation/Expansion

A&I Audits & Investigations

A/R Accounts Receivable

AB Assembly Bill

ACA Affordable Care Act

ACMS Automated Collection Management System

Actor Refers to a specific user group, organization, or system that interacts with CA-MMIS directly or indirectly. These actors belong to one of the three categories (i.e., DHCS, Xerox, and External entities).

“DHCS actors” refer to user groups, agencies, and divisions within DHCS. “Xerox actors” refer to user groups, teams, and departments within Xerox.

“External actors” refer to Federal agencies, other State agencies, counties and other ancillary groups, submitters and other intermediaries, and members.

AD DHCS Administration Division

ADA Americans with Disabilities Act

ADM Administration Division

AEVS Automated Eligibility Verification System

AIIHI American Indian Infant Health Initiative

AVRS Automated Voice Response System

BA Business Architecture which describes the needs and goals of the State and presents a collective vision of the future


https://cammis-sp.psd.dhs.ca.gov/cammis/Lists/Risks/O_P_Risks.aspx

https://cammis.sp.acs-inc.com/cammis/Lists/Risks/O_P_Risks.aspx


BCM Business Capability Matrix. The BCM scale of 1 to 5 assesses the degree of automation, standardization, and integration, with Level 5 representing the highest level of maturity

BCMP Business Change Management Plan

BIC Beneficiary Identification Card

BPM Business Process Model

BPMN Business Process Model and Notation

BPT Business Process Template

BRMS Business Rules Management System

BWARD Benefits & Waiver Analysis Division

CAASD Clinical Assurance and Administrative Support Division

CAH Critical Access Hospital

CalMEND California Mental Health Care Management Program

CalSORH California State Office of Rural Health

CA-MMIS California Medicaid Management Information System


Refers to CA-MMIS business processes that are derived from the Medi-Cal Business Processes in the SS-A. Currently, there are 67 CA-MMIS business processes out of the 141 Medi-Cal business processes.

CA-MMIS Health Enterprise System

The name of the CA-MMIS Replacement System once it has been fully implemented in CA-MMIS Replacement System Project

CA-MMIS Replacement System

The name of the approach being designed, developed, and implemented in response to the requirements specified in DHCS Requests for Proposal (RFP) 08-85022.

CAQH Council for Affordable Quality Healthcare

CCB Change Control Board

CCS California Children’s Services

CDA California Department of Aging

CDPH California Department of Public Health

CEAP California Enterprise Architecture Program

CFR Code of Federal Regulations

CHDP Child Health & Disability Prevention Program



CMS Centers for Medicare & Medicaid Services

CMS-DHCS Children’s Medical Services Branch of DHCS

CMSP County Medical Services Program

COHS County Organized Health System

COO Concept of Operations

CORE Committee on Operating Rules for Information Exchange

COTS Commercial Off-The-Shelf. COTS products are not modified and are implemented and integrated as part of the overall system. However, they can be configured to meet CA-MMIS requirements.

CRDD Capitation Rates Development Division

CSC California Children’s Services

CTA California Technology Agency

DHCS Department of Health Care Services

DMC Dental Managed Care Plan

DMC Drug Medi-Cal

DMH Department of Mental Health

DOF Department of Finance

DOJ Department of Justice

DPHP Designated Public Hospital Project

DRAMS Drug Rebate Analysis & Management System

DRG Diagnostic Related Group

DRU Drug Rebate Unit

DSH Department of State Hospitals

DUR Drug Use Review

EDI Electronic Data Interchange

EDU Encounter Data Unit

EFT Electronic Funds Transfer

ERA Electronic Remittance Advice

FAU Financial Analysis Unit



FDB First Data Bank

FFB Fiscal Forecasting Branch

FFP Federal Financial Participation

FFS Fee For Service

FFSRDD Fee-For-Service Rates Development Division

FI Fiscal Intermediary

FIPS Federal Information Processing Standards

FISMA Federal Information Security Management Act

FLEX Medicare Rural Hospital Flexibility

FMB Financial Management Branch

FPACT Family Planning, Access, Care, and Treatment. Family PACT is a program that provides no-cost family planning services to low-income men and women, including teens. Many doctors and clinics throughout California are part of the Family PACT program.

FTB Franchise Tax Board

GHPP Genetically Handicapped Persons Program

HAM Health Administration Manual

HCBS Home & Community Based Services

HCPCS Healthcare Common Procedure Coding System

HE Health Enterprise

HHS Department of Health and Human Services

HIE Health Information Exchange

HIPAA Health Insurance Portability and Accountability Act of 1996

HIPP Health Insurance Premium Payment

HIT Health Information Technologies

HITECH Health Information Technology for Economic and Clinical Health Act of 1996

HIX Health Insurance Exchange

HUCDS Hospital/Uninsured Care Demonstration Section

IH Indian Health



IRS Internal Revenue Service

ISO International Organization for Standardization

IT Information Technology

ITSD Information Technology Services Division

KDE Key Data Entry

LEA Local Educational Agency

LGA Legislative & Governmental Affairs

LGBT Lesbian, Gay, Bisexual & Transgender

LIHP Low Income Health Program Division

LTCD Long Term Care Division

MAR Management Administrative Reports

MC Medi-Cal Consultant

MCED Medi-Cal Eligibility Division

MCO Managed Care Organization

MCP Managed Care Plan

MCP Managed Care Plan

MDSD Medi-Cal Dental Services Division

MedCCC Medi-Cal Claims Customer Service Office

Medi-Cal The name of the California Medicaid program serving low-income families, seniors, persons with disabilities, children in foster care, pregnant women, and certain low-income adults. It is jointly administered by DHCS and CMS, with many services implemented at the local level mainly by the counties of California.

Medi-Cal Business Process

Refers to the DHCS Enterprise Medi-Cal business processes that are identified in the SS-A performed by OHC. Currently, there are 151 Medi-Cal business processes. The Medi-Cal business processes are aligned to the MITA business processes by the MITA 2.0 and 3.0 crosswalk developed by DHCS. This crosswalk illustrates the mapping of MITA 2.0 to MITA 3.0, including the Medi-Cal Business Areas, Business Categories, and Business Processes.

MEDS Medi-Cal Eligibility Data System

MEDS Medi-Cal Eligibility Data System

MHP Mental Health Plan



MITA Medicaid Information Technology Architecture

MITA Business Process

Refers to the MITA 3.0 business processes that are defined by CMS under the Business Architecture.

MITA Condition One of the Seven Conditions and Standards of CMS’ Enhanced Funding Requirements. This condition requires the State to align to and advance increasingly in MITA maturity for business, architecture, and data. The State is required to develop a COO and BPM to satisfy this condition.

MITA Maturity Level The five levels of maturity and the measurable qualities that each level should demonstrate for the particular business process. The MITA Maturity Model tool is used to determine how a business can mature over time and advance to each level.

MMA Medicare Modernization Act

MMCD Medi-Cal Managed Care Division

MMIS Medicaid Management Information System

MMM MITA Maturity Model

MPSG Medical Professional Service Group

MRB Medical Review Branch

MSPS Medi-Cal Supplemental Payment Section

NIST National Institute of Standards and Technology

NOA Notice of Action

O&E Provider Outreach and Education Department

OCR Office of Civil Rights

OCR Optical Character Recognition

OFP Office of Family Planning

OHC Office of HIPAA Compliance

OHIT Office of Health Information Technology

OIL Operating Instruction Letter

OLS Office of Legal Services

OMB Office of Management and Budget

OMCP Office of Medi-Cal Procurement

OMH Office of Multicultural Health



OPA Office of Public Affairs

OTD Xerox Operations Training Department

OWH Office of Women’s Health

PA Prior Authorization

PAVE Provider Application Verification and Enrollment

PBD Pharmacy Benefits Division

PBM OS+ Pharmacy Benefit Management Open System

PC Pharmacy Consultant

PED Provider Enrollment Division

PHP Prepaid Health Plan

PIU Provider Integrity Unit

PMF Provider Master File

POB Program Operations Branch

PRHD Primary & Rural Health Division

PRU Provider Review Unit

PUBS Publications

QAF Quality Assurance Fee

R&C Research and Correspondence

RAD Remittance Advice Details

RAIS Rebate Accounting and Information System

RFA Requests For Application

RFP Requests For Proposal

RHSD Rural Health Services Development

RSA Rational Software Architect

SAM State Administrative Manual

SAMW Seasonal Agricultural and Migratory Workers Program

SAR Service Authorization Request

SCD Systems of Care for Children and Adults Division



SCO State Controller’s Office

SDN Software Development Notice

Seven Conditions and Standards

Conditions and standards that must be met by the states in order for Medicaid technology investments to be eligible for the enhanced match funding. The seven conditions and standards are: Modularity Standard, MITA Condition, Industry Standards Condition, Leverage Condition, Business Results Condition, Reporting Condition, and Interoperability Condition.

SG System’s Group

SHIP Small Rural Hospital Improvement Program

SIMM State Information Management Manual

SLA Service Level Agreement

SMA State Medicaid Agency

SmartPA© Automated authorization tool for pharmacy claims

SMH Specialty Mental Health

SMSB Statewide Medical Services Branch

SNFD Safety Net Financing Division

SOA Service Oriented Architecture

SPBU Small Provider Billing Unit

SPCP Office of Selective Provider Contracting Program

SS-A State Self-Assessment

Stakeholder Refers to one or more Actors performing in a common role [or common set of roles], who are impacted by the transition from the Legacy CA-MMIS System to the CA-MMIS Health Enterprise System, or who need to be kept informed of its progress, from the broadest perspective. “Internal stakeholders” refer to DHCS and Xerox, and are trained by Xerox Operations Training Department (OTD). “External stakeholders” refer to providers, provider associations, ancillary groups (health plans, counties, etc.), intermediaries (vendors, clearinghouses, CMS, etc.), members, and the public. The Provider Outreach and Education (O&E) Department conducts the outreach activities to these external stakeholders.

SUDS Substance Use Disorder Services

SURS Surveillance and Utilization Review Subsystem

TAR Treatment Authorization Request

TOGAF The Open Group Architecture Framework



TPL Third Party Liability

TPLRD Third Party Liability and Recovery Division

Transfer Systems The Xerox baselined products HE, PBM OS+, Drug Rebate Analysis & Management System (DRAMS), SmartPA©, and Medical Authorization, are termed “transfer systems” and are different from the Commercial Off-The-Shelf (COTS) products such as the Isaac Blaze Rules Engine. Xerox transfer systems are to be configured, customized, and enhanced to meet State requirements. At the end of System Replacement, when the transfer systems have been successfully customized and implemented, the resulting strategy is the CA-MMIS HE System for the State of California.

TSC Telephone Service Center

UMD Utilization Management Division


2. CA-MMIS Actors Catalog

An Actor is a person or entity external to the system being specified (e.g., another system, a piece of hardware), who interacts with the system to accomplish tasks. Actors correspond to different user roles (not names or formal Human Resources titles) that use the system. Actors are distinguished by the ways in which they interact with the system. Factors that distinguish actors include common responsibilities, skill levels, work activities, and modes of interaction with the system. An individual may serve in the role of one or more actors (e.g., a call center manager may play the role of customer service manager and claims manager), whereas other actors may have distinct operational scenarios for their interactions with the system.

The Primary Actor is the actor that initiates the system request and interacts with the system to accomplish a goal. Other involved actors do not directly interact with the system, but have an influence on, or are influenced by, the system.

A list of Actors who interact with CA-MMIS directly or indirectly can be found in the CA-MMIS Actors Catalog in Appendix A. The impact(s) to each of the Actors in each System Replacement Release are also provided in Appendix A. The Actors Catalog is available as part of the “Business Architecture – Actors Catalog” within the TOGAF Business Architecture domain developed using Rational Software Architect (RSA).

The Actors Catalog Diagram below summarizes the actors listed in the CA-MMIS Actors Catalog (Appendix A) and the entity type (DHCS, Xerox, or External) that they belong to. Actors who are not part of DHCS or Xerox are categorized as “External” entity type in the CA-MMIS Actors Catalog and Diagram. The Diagram uses the Aliases, instead of the formal Actor Name, from the CA-MMIS Actors Catalog. The CA-MMIS Actors Catalog and Diagram are used as a starting point for the Stakeholder Analysis deliverable, the BPT, and the BPMN diagrams.

Note: As indicated in the Assumptions section of this document, the term “stakeholders” in this document refers to one or more Actors performing in a common role [or common set of roles], who are impacted by the transition from the Legacy CA-MMIS System to the CA-MMIS Health Enterprise System, or who need to be kept informed of its progress, from the broadest perspective. “Internal stakeholders” refers to DHCS and Xerox, and are trained by Xerox OTD. “External stakeholders” refers to providers, provider associations, ancillary groups (health plans, counties, etc.), intermediaries (vendors, clearinghouses, CMS, etc.), Medi-Cal beneficiaries, and the public. The Provider O&E Department conducts the outreach activities to these external stakeholders.


https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents_1/index.html

Figure 4: Actors Catalog Diagram


3. As-Is CA-MMIS

The CA-MMIS system has been developed under federal guidelines for the development and operation of California Medicaid processing and information retrieval. As a federally certified system, CA‐MMIS receives 90 percent federal funding for development, 75 percent federal funding for systems operation, and 50 percent for claims payments on most federal/state covered services. CA‐MMIS processes Medi-Cal claims other than Dental.

Medi‐Cal is California’s Medicaid program and it is administered by DHCS. Medi‐Cal is intended to provide Federal and State financial assistance for the health and medical care of the needy by providing health care coverage for low‐income families, aged, blind, and disabled persons, and individuals whose income and resources are insufficient to meet the costs of necessary medical services.

The Medi-Cal MITA SS-A created in 2008 showed process redundancy within the Medi-Cal program (e.g., provider enrollment is performed nine different ways within the Medi-Cal program). The assessment of Medi-Cal’s business capabilities measured using the MITA 2.0 BCM showed the highest level of capability of Medi-Cal business processes was a level 3, with the majority of Medi-Cal business processes achieving a maturity level of 2 or under. Many systems, interfaces, and data sets integral to Medi-Cal program operations are not able to share data in a timely and automated manner. Manual processing of claims still occurs. Multiple proprietary repositories may support a single business area, and these repositories supporting one business area may not be able to share data effectively with other interdependent business areas. The lack of automated interfaces within and between business areas is a common aspect of the Medi-Cal current view found in the 2008 Medi-Cal MITA SS-A.

The information presented in this section is based on the Medi-Cal MITA SS-A, which was created in June, 2013 based on MITA 3.0. Refer to Section 4.4.1 for MITA Maturity Level descriptions.


3.1 As-Is CA-MMIS Business Processes

The As-Is Enterprise Medi-Cal business processes include CA-MMIS specific business processes. The As-Is Medi-Cal Enterprise includes Tier 1 Medi-Cal Business Areas and Tier 2 Medi-Cal Business Categories, as well as CA-MMIS related business processes that are derived from the number of Medi-Cal specific business processes that are required by MITA 3.0. For a diagram of the Medi-Cal Enterprise, refer to Appendix F.

The following diagram contains the As-Is CA-MMIS Business Areas and associated Business Processes, based on MITA 3.0. Each business process is denoted as either Xerox, DHCS, or Shared, depending on which entity performs the business process.


MITA Business Process: Refers to the MITA 3.0 business processes that are defined by CMS under the Business Architecture.

Medi-Cal Business Process: Refers to the DHCS Enterprise Medi-Cal business processes that are identified in the SS-A performed by OHC. Currently, there are 141 Medi-Cal business processes. The Medi-Cal business processes are aligned to the MITA business processes by the MITA 2.0 and 3.0 crosswalk developed by DHCS. This crosswalk illustrates the mapping of MITA 2.0 to MITA 3.0, including the Medi-Cal Business Areas, Business Categories, and Business Processes.

CA-MMIS Business Process: Refers to CA-MMIS business processes that are derived from the Medi-Cal Business Processes in the SS-A. Currently, there are 67 CA-MMIS business processes out of the 141 Medi-Cal business processes.

Figure 5: As-Is CA-MMIS Business Processes


3.2 As-Is CA-MMIS Context Diagram

The As-Is CA-MMIS Context Diagram presents a current-state conceptual view of the external entities with which CA-MMIS interacts. The Context Diagram shows CA-MMIS as a whole, with inputs and outputs at a high level between the external entities and CA-MMIS. It is the intent of the As-Is Context Diagram to provide readers an understanding of the environment in which CA-MMIS is used.

The primary purpose of the CA-MMIS system is to process medical claims to support the State of California’s health care programs, particularly the Medi-Cal program. As such, the primary entities identified in the As-Is CA-MMIS Context Diagram directly interface with CA-MMIS due to claims-related and care management transactions. Business associates are not considered primary entities. A more elaborate description of business associates is discussed later in this section.

External entities are conceptual groupings of individuals or organizations based on the role the entities have with CA-MMIS (Refer to Entity Type in the CA-MMIS Actors Catalog in Appendix A). While the CA-MMIS Actors Catalog has a large number of entities involved, the context diagram depicted below shows the primary external entities that directly exchange information with CA-MMIS and the type of information they exchange with CA-MMIS.

To view the As-Is CA-MMIS Context Diagram with specific inbound and outbound transactions of each primary entity, along with its respective description, refer to the tables below.


Figure 6: As-Is CA-MMIS Context Diagram


Table 4: CA-MMIS Primary Entities

Actor Name Description Inbound Interaction to CA-MMIS

Outbound Interaction from CA-MMIS

Inbound & Outbound Interaction to/from CA-MMIS

Provider Refers to individuals or organizations enrolled by the Medi-Cal program to provide certain services to Medi-Cal members. Includes doctors, hospitals, nursing homes, pharmacies, or durable medical supplies retailers.

Part of the Medi-Cal Actor Catalog that functions as a subset of the Provider actor group are the Child Health and Disability Prevention Program (CHDP) Provider, which renders medical services specifically to members under the CHDP program and the Pharmacy Provider, which dispenses drugs to members and submits pharmacy claims.

Claims - refers to the claim forms submitted in order to receive payment for the services they rendered or items they dispensed to members.

Inquiries/Responses - refers to a general type of Inbound and Outbound information that is exchanged between Providers and CA-MMIS. For instance, inquiry and response on Provider eligibility status or claims payment.

Enrollments - refers to the information sent by Providers in order to become eligible for Medi-Cal and other State programs.

Eligibilities - refers to Provider and Member eligibility criteria and status that are necessary to adjudicate claims accurately. This information is sent out by CA-MMIS to give providers the ability to know if they will be paid for seeing the member.

Payment Information - refers to statements sent to providers to notify them of claims that have been received and processed. It also indicates if the claim has been approved, suspended, or denied. If necessary, this creates a point to start an appeal.

Enrollments - in response to information received from Providers, CA-MMIS sends out information regarding the enrollment.

Laboratory Services - refers to the information that Providers initiate by requesting lab service reservations and verification of frequency limits prior to performing procedures. Conversely, CA-MMIS conducts outbound transactions in response to the inbound information that providers requested.

Prior Authorizations (PA) – refers to the information sent by Providers to authorize a service or procedure for the member. CA-MMIS adjudicates the prior authorization request and provides the response.

Member Refers to beneficiaries of Medi-Cal and other State related programs; specifically, individuals or families who have met eligibility requirements to be enrolled in the Medi-Cal program.

N/A N/A Beneficiary Identification Card (BIC) - refers to the identification card that allows providers to determine Members’ eligibility and enrollment status to the Medi-Cal program.





Managed Care Organization (MCO)

Refers to entities that manage commercial Medicaid programs. They submit encounters which report services provided to members. Medi-Cal Managed Care Health Plans have their own doctors, specialists, clinics, pharmacies, and hospitals.

Encounters - refers to the claim forms submitted by MCOs in order to receive reimbursement for the services and/or items they paid for on behalf of Medi-Cal Members. These claims include encounter details that describe the types of service rendered to Members.

Networks – indicates providers authorized to perform services on behalf of the MCO in support of approved Members.

N/A N/A

Medicare and Other Payers

Medicare submits crossover claims to Medi-Cal. “Other Payers” refers to those payers that are responsible in covering Medi-Cal members’ health care costs. This group includes private payers or other third party payers.

Claims - refers to the claim forms submitted in order to receive payment for the services that their eligible Providers rendered and/or the items they dispensed to Medi-Cal Members.

N/A Inquiries/Responses - refers to general types of Inbound and Outbound information that are exchanged between Medicare and/or Other Payers and CA-MMIS (e.g., inquiry and response on claims status).

CMS Refers to an agency of the U.S. Department of Health and Human Services (HHS). CMS is the federal agency which administers Medicare, Medicaid, and the Children’s Health Insurance Program. CMS also provides information for health professionals, regional governments, and consumers.

Policies and Regulations - refers to legislative mandates that CA-MMIS needs to adhere to in order to receive funding, remain in compliance, and avoid costly penalties.

Reports – refers to quantitative and/or qualitative information generated from Medi-Cal and other related State programs that are audited, monitored, and controlled by CMS.

Inquiries/Responses - refers to general types of Inbound and Outbound information that are exchanged between CMS and CA-MMIS (e.g., inquiry and response on Medi-Cal Drug Rebate’s CMS-64 quarterly reports).





DHCS and Other State Agencies

Refers to the DHCS and other State agencies that report to CMS. DHCS is the single state agency responsible for administration of the Medi‐Cal, County Medical Services Program (CMSP), California Children’s Services (CCS), Genetically Handicapped Persons Program (GHPP), and CHDP programs. It also has responsibility for the administration of other health‐related programs. An example of Other State Agencies mentioned in the CA-MMIS Actors Catalog is the Department of Justice (DOJ). DOJ primarily works together with DHCS to monitor illegal activities.

Policies and Regulations - refers to legislative mandates that DHCS and Other State Agencies need to adhere to in order to receive funding, remain in compliance, and avoid costly penalties.

Reports – refers to quantitative and/or qualitative information that is generated from Medi-Cal and other related State programs that are required and requested by CMS. These reports are also audited, monitored, and controlled by CMS or state agencies.

Payment Data and Claims Reference Files – refers to the data sent from CA-MMIS to DHCS and State divisions. This includes Claims Payment information sent to the State Controller’s Office (SCO).

Inquiries/Responses - refers to general types of Inbound and Outbound information that are exchanged between CMS and DHCS and/or Other State Agencies (e.g., inquiry and response on a report that presents data on illegal activities related to fraudulent health care providers).

3.2.1 Business Associates

The CA-MMIS Actors Catalog includes external entities that are not primary entities. These are considered Business Associates and are excluded from the As-Is Context Diagram.

According to the U.S. HHS and 45 Code of Federal Regulations (CFR) 160.103, a “business associate” is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. The types of functions or activities that may make a person or entity a business associate include payment or health care operations activities, as well as other functions or activities regulated by the Administrative Simplification Rules. Business associate functions and activities include: claims processing or administration; data analysis, processing or administration; utilization review; quality assurance; billing; benefit management; practice management; and re-pricing. Business associate services refers to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, and financial.

The CA-MMIS Actors Catalog identifies several business associates that are involved with the primary entities mentioned above. The Business Associates for CA-MMIS are defined in the following table.


Table 5: CA-MMIS Business Associates

Actor Name Description

First Data Bank (FDB) Provides formulary data updates. Note that the formulary file refers to a CA‐MMIS table identifying the drugs or medical supplies, and rates, acceptable for billing under the Medi‐Cal system. These files are established by Title 22, California Code of Regulations.

Maximus Performs enrollment and disenrollment of Managed Care Plan (MCP) members. Also referred to as “MCP Eligibility.”

Drug Manufacturers/Labelers Receives drug rebate invoices and submits rebates to DHCS. These entities are contracted with CMS and DHCS on drug rebate.

Submitters Sends claims to CA-MMIS on behalf of providers. Also known as “Clearinghouses.”

3.3 As-Is CA-MMIS COO

The As-Is CA-MMIS COO illustrates the information exchanged between CA-MMIS and the external entities (i.e., “DHCS” and “External” under the CA-MMIS Actors Catalog). The external entities consist of the primary entities identified in the As-Is CA-MMIS Context Diagram and the business associates.

3.3.1 As-Is CA-MMIS COO – Inbound/Outbound Transactions

This section discusses the operational view of the inbound and outbound transactions that are exchanged between CA-MMIS and the external entities as it exists at present. These transactions are specific to CA-MMIS business areas and processes that interface with Providers, MCOs, Medicare and Other Payers, CMS, DHCS and Other State Agencies, and Business Associates.

Inbound Interaction to CA-MMIS refers to the information that CA-MMIS receives, while Outbound Interaction from CA-MMIS refers to the information that CA-MMIS sends out to the specific Actors identified. There are instances where CA-MMIS receives and sends out the same information, and this scenario is categorized as Inbound/Outbound Interaction.

Note: For a more elaborate description of these external entity groups, refer to the previous Section , As-Is CA-MMIS Context Diagram.


3.3.1.1 Care Management

Table 6: As-Is CA-MMIS COO Table (Care Management)

CA-MMIS Business Category


PROVIDERS DHCS & OTHER STATE AGENCIES

Inbound Interaction to CA-MMIS


Inbound/ Outbound Interaction




Authorization Determination

Authorize CCS/GHPP Services

Receive Service Authorization Request (SAR)

Send adjudicated SAR response

N/A Receive SAR review result from CMSNet

Send SAR for review to CMSNet

Send SAR utilization data

N/A

Medi-Cal Treatment Authorization Requests (TARs)

Receive TAR

Send adjudicated TAR response

N/A Receive TAR review result from Pharmacy/Medi-Cal Consultant

Send TAR for review to Pharmacy/Medi-Cal Consultant

Send TAR utilization data

N/A

Case Management

Authorize Treatment Plan

Receive treatment plan

Send authorized treatment plan

N/A N/A N/A N/A

Establish Case

Receive Medi-Cal Case

N/A N/A Create a Medi-Cal Case

N/A N/A

Establish CCS/GHPP Case

Receive CCS/GHPP Case

N/A N/A Create a CCS/GHPP Case

N/A N/A

Manage Case Information

Receive Medi-Cal Case details

N/A N/A N/A N/A Retrieve and work a Medi-Cal Case

Manage CCS/GHPP Case

Receive CCS/GHPP Case details

N/A N/A N/A N/A Retrieve and work a CCS/GHPP Case




PROVIDERS DHCS & OTHER STATE AGENCIES







Perform Screening and Assessment

Receive TAR or claim for processing and perform clinical screening.

Send adjudicated TAR response or adjudicated claim response

N/A N/A N/A N/A

Manage Treatment Plan and Outcomes

N/A N/A N/A Receive electronic records

N/A N/A

State Specific Reserve Service

Receive reservation requests

N/A N/A N/A N/A N/A

3.3.1.2 Contractor Management

Table 7: As-Is CA-MMIS COO Table (Contractor Management)



DHCS & OTHER AGENCIES BUSINESS ASSOCIATES







Contractor Support

Manage Medi-Cal Contractor Communication

N/A Communicate information to DHCS

N/A N/A Post documentation and communications to SharePoint

N/A

Contract Management

Manage CA-MMIS Fiscal Intermediary (FI) Contract

Communication information from DHCS

N/A Receive FI Letters and send response letters

N/A N/A N/A


3.3.1.3 Financial Management

Table 8: As-Is CA-MMIS COO Table (Financial Management)



PROVIDERS MCO CMS DHCS & OTHER AGENCIES



Inbound/Outbound Interaction





Accounts Payable Management

Manage 1099 N/A N/A Receive & send 1099 information

N/A Send 1099 reports

Receive 1099 information

Send 1099 information

Manage Incentive Payment

Receive incentive payment request

Process incentive payment and send payment information

N/A N/A N/A Receive incentive payment request

Send incentive payment information

Manage Medi-Cal Accounts Payable Information

N/A N/A N/A N/A N/A Receive warrant numbers for Medi-Cal payments

Send Accounts Payable (A/P) information

Manage Medi-Cal Payable Disbursement

N/A Weekly Check write from CA-MMIS

N/A N/A Send Weekly Check

Write data to SCO

Receive Provider disbursement transactions

Send Provider disbursement payment information












Manage Contractor Payment

N/A Send payment request to Financial Management Branch (FMB)

N/A N/A N/A Send payment request to FMB

Send Contract Management / payment reports from CA-MMIS

Manage Medicare Premium Payment

Store Medicare buy-in Premium Payment information

N/A N/A N/A N/A N/A Executed by DHCS Third Party Liability and Recovery Division (TPLRD)

Manage Health Insurance Premium Payments

Store Medicare buy-in Premium Payment information

N/A N/A N/A N/A N/A Executed by DHCS TPLRD

Accounts Receivable Management

Manage Cost Reports Settlement

N/A N/A N/A N/A N/A Receive Accounts Receivable (A/R) recoupment transaction information

Send Provider payment information

Manage Drug Rebate N/A N/A N/A Receive MCO information for drug rebate

Send CMS reports for drug rebate information

Receive drug claims data

Send drug rebate information












Manage Medi-Cal Accounts Receivable Funds

N/A N/A N/A N/A Receive funds information to determine provider payments (no budget process)

Send check-write information

Manage Medi-Cal Accounts Receivable Information

N/A N/A N/A N/A N/A Receive A/R transaction initiation request

Send A/R transaction reports

Manage Overpayment Recoupment

N/A N/A N/A N/A N/A Appeals process overpayment / recoupment

Create Provider recoupment transactions

Manage TPL Recovery

N/A Send Third Party Liability (TPL) letters

N/A N/A N/A N/A Send TPL analysis results, recoupment transaction information

Manage Estate Recovery

Store data in the Automated Collection Management System (ACMS)

N/A Store Vital Records Data in CAMMIS Member Subsystem (MEDS)

N/A N/A N/A Overseen by DHCS TPLRD












State Specific Manage Member Health Care Reimbursement

CA-MMIS is used to validate Medi- Cal member/provider eligibility and Service coverage for medical services

N/A N/A N/A N/A CA-MMIS is used to validate Medi- Cal member/provider eligibility and service coverage for medical services

Member Reimbursement checks are distributed by the State Controller’s Office

Fiscal Management

Manage State Funds N/A N/A N/A N/A N/A N/A Send Contract Management/payment

reports from CA-MMIS

Formulate Medi-Cal Budget


N/A N/A N/A N/A Weekly Check write from CA-MMIS

Generate Medi-Cal Budget Estimates Financial Report


N/A N/A N/A N/A Weekly Check write from CA-MMIS


3.3.1.4 Member Eligibility and Enrollment Management

Table 9: As-Is CA-MMIS COO Table (Member Eligibility and Enrollment Management)



PROVIDERS




Member Enrollment

Inquire Medi-Cal Eligibility

Receive member eligibility Inquiry transactions

Send member eligibility response

N/A

3.3.1.5 Member Management

Table 10: As-Is CA-MMIS COO Table (Member Management)



PROVIDERS DHCS & OTHER AGENCIES






Member Support Management

Manage Medi-Cal Applicant and Member Communication

N/A N/A Receive request for TAR in the Field Office

Receive Notice of Action (NOA) letter from Consultants.

NOA letters are printed and mailed out.


3.3.1.6 Operations Management

Table 11: As-Is CA-MMIS COO Table (Operations Management)



PROVIDERS MCO MEDICARE & OTHER PAYERS

DHCS & OTHER AGENCIES








Claims Adjudication

Submit Medi-Cal Claim Attachment

Receive claim attachments

N/A N/A N/A N/A N/A N/A

Apply Medi-Cal Mass Adjustment

N/A N/A N/A N/A Receive mass adjustment changes

N/A N/A

Process Medi-Cal Claim

Receive Medi-Cal Claim

Send Medi-Cal claim adjudication response

N/A Receive Crossover claims

Receive policy changes to process Medi-Cal claims

N/A N/A

Payment and Reporting

Generate Medical Remittance Advice

N/A Send medical remittance advice details (RAD)

N/A N/A N/A Send medical remittance advice information

N/A

Inquire Medi-Cal Payment Status

Receive Medi-Cal Payment request

Send Medi-Cal payment inquiry response

N/A N/A N/A N/A N/A




PROVIDERS MCO MEDICARE & OTHER PAYERS









Manage Data N/A N/A N/A N/A Receive reference data [FDB, Healthcare Common Procedure Coding System (HCPCS), etc.]

N/A Retrieve data; Update data

Process Encounter

Process Managed Care Encounter

N/A N/A Receive Managed Care encounter data

N/A N/A Send Manage Care Encounter reports

N/A


3.3.1.7 Plan Management

Table 12: As-Is CA-MMIS COO Table (Plan Management)



CMS DHCS & OTHER AGENCIES







Plan Administration

Maintain Program Policy

N/A N/A N/A FI Letter requesting updates to program policy

N/A N/A

Health Plan Administration

Manage Medi-Cal Program Information

Define policies; initiate tasks to update policies

N/A N/A Define policies; initiate tasks to update policies in CA-MMIS

Update Provider bulletin Web page

N/A

Develop and Manage Performance Measures

N/A N/A N/A N/A Generate/send performance measure reports

N/A

Health Benefits Administration

Maintain Benefits-Reference Information

Define policies; Initiate tasks to update policies in CA-MMIS

N/A N/A Receive policies; Initiate tasks to update policies in CA-MMIS

N/A N/A

Manage Benefit Information

N/A N/A N/A Receive policies; initiate tasks to update policies in CA-MMIS

N/A N/A

Manage Drug Formulary

N/A N/A N/A Receive policies; initiate tasks to update Formulary File and associated tables

N/A N/A




CMS DHCS & OTHER AGENCIES







Manage Rate Setting

N/A N/A N/A Receive policies; initiate tasks to update policies in CA-MMIS

N/A N/A


3.3.1.8 Provider Eligibility Management

Table 13: As-Is CA-MMIS COO Table (Provider Eligibility Management)



Provider DHCS & OTHER AGENCIES







Provider Enrollment

Enroll Medi-Cal Provider

Submit enrollment applications (out-of-state Providers)

Send approval/denial letter (out-of-state Providers)

N/A N/A N/A N/A

Inquire Medi-Cal Provider Information

N/A N/A Receive/send inquiry transactions

N/A N/A Receive/send inquiry transactions

Determine Medi-Cal Provider Eligibility

N/A N/A N/A Provider Enrollment Division determines the enrollment of providers

N/A N/A

Determine Provider Eligibility for Incentive Program

N/A N/A N/A CA-MMIS Provider Subsystem: Verifies authorized Medi-Cal providers and includes provider data in the Provider Master File (PMF).

N/A N/A

Determine CHDP

N/A N/A N/A Provider Enrollment Division

N/A N/A











Provider Eligibility

determines the enrollment of CHDP providers

Enroll Drug Medi-Cal Provider

N/A N/A Providers are able to access member eligibility through Automated Eligibility Verification System (AEVS), MC Web site etc.

Drug Medi-Cal PMF is sent to CA-MMIS to add as a “Other Intermediary” into the Medi-Cal PMF.

N/A N/A

Enroll Mental Health Provider

N/A N/A Providers are able to access member eligibility through AEVES, Medi-Cal Web site, etc.

Mental Health PMF is sent to CA-MMIS to add as a “Other Intermediary” into the Medi-Cal PMF

N/A N/A

Enroll Dental Provider


Enroll CCS Provider

N/A N/A N/A CMSNet is considered to be part of CA-MMIS and stores provider approvals for CCS and CHDP as well as authorized treatment request for CCS and GHPP

N/A N/A











Enroll CHDP Provider

N/A N/A N/A CA-MMIS CHDP Subsystem: Stores CHDP provider enrollment information that is accessed during CHDP claims processing.

N/A N/A

Disenroll Medi-Cal Provider

N/A N/A N/A CA-MMIS Provider Subsystem: Verifies authorized Medi-Cal providers and includes provider data in the PMF. Provider is not removed from the Medi-Cal PMF. Status changes to inactive or their enrollment is end-dated.

N/A N/A

Disenroll Dental Provider


3.3.1.9 Performance Management

Table 14: As-Is COO Table (Performance Management)





Inbound Interaction to CA-MMIS Outbound Interaction from CA-MMIS


Compliance Management Determine Adverse

Action IncidentReceive information to add Providers to Suspect Hold; receive TPL cases

Send Suspect Hold reports & Audits & Investigations (A&I) transaction information

N/A

Identify Utilization Anomalies N/A Send utilization data and reports N/A

Establish Compliance Incident N/A Send utilization data and reports N/A

Manage Compliance Incident Information N/A Send utilization data and reports N/A

Prepare Beneficiary Confirmation Letters N/A Send utilization data and reports N/A

3.3.1.10 Provider Management

Table 15: As-Is COO Table (Provider Management)



PROVIDERS MCO







Provider Information Management

Manage Medi-Cal Provider Information

Receive Provider data update

N/A N/A Receive network provider data

N/A N/A




PROVIDERS MCO







Provider Support

Manage Medi-Cal Provider Communication

N/A Publish provider communications

N/A N/A N/A N/A

Perform Medi-Cal Provider Outreach

N/A Provides support & training

N/A N/A N/A N/A

Perform Family Planning, Access, Care, and Treatment (FPACT) Provider Outreach

N/A Provides FPACT training

N/A N/A N/A N/A

Manage Medi-Cal Fee-for-Service (FFS) Provider Grievance & Appeal

Receives appeals & grievance

Send Claims appeals adjudication information

N/A N/A N/A N/A


4. To-Be CA-MMIS

In the future, Medi-Cal business processes are expected to be more automated, standardized, unified, and timely. Stakeholders are not required to access the Medi-Cal program through numerous, disparate channels, and they benefit from new agency interfaces that feature capabilities supporting “single point of entry” or “no wrong door” concepts. In addition, Member, Provider, claims, and other repositories operate in an integrated architecture, transmitting standardized data real-time through shared technology services throughout the Medi-Cal program and other state and federal agencies and programs. The coordination improves the Medi-Cal program’s cost-effectiveness and significantly enhances the value to its key stakeholders.

4.1 The CA-MMIS Health Enterprise System Information Exchange and Access Environment

The To-Be Context Diagram purposely conveys a setting where the CA-MMIS Health Enterprise System’s business transformation is realized in a new and dynamic enterprise environment with the Member’s relationship central to the enterprise.

The To-Be Context Diagram displays the direct interaction between the primary entities and CA-MMIS. The role of the business associates that is evident in the As-Is Context Diagram scenario diminishes on its corresponding To-Be scenario. Due to technological advancement, particularly the HE components that are scheduled to be implemented in CA-MMIS, the primary entities are able to exchange and access information easily. The transactions that are exchanged between the primary entities and CA-MMIS are not limited as compared to the transactions in the As-Is state. This high level of technological sophistication supports operational efficiency and productivity by minimizing administrative costs and the number of processes necessary in order to retrieve and/or send information with key entities.

To illustrate the overall business transformation of CA-MMIS in relation to the Member-centric structure of California’s health system, refer to the following figure.


Figure 7: The CA-MMIS Health Enterprise System Exchange and Access Environment


4.2 To-Be CA-MMIS COO

The SS-A conducted by DHCS in June, 2013 was used to formulate the To-Be CA-MMIS Context and COO Diagram. The To-Be view includes consolidated interfaces with program stakeholders instead of multiple program access routes and interfaces. Also, the To-Be vision includes consolidated data repositories and consolidation of business areas and improved coordination between programs and business processes. This leads to higher maturity levels and shows improvement and transformation of the business processes over time. Through the technological advancement that HE brings, the As-Is CA-MMIS business processes are able to align to higher MITA maturity levels and transition into the MITA-driven To-Be CA-MMIS business processes.

To view the To-Be COO Diagram (CA-MMIS HE System), refer to the diagram below.

Concept of Operations


Figure 8: To-Be COO Diagram (CA-MMIS HE System)

4.3 To-Be Environment of CA-MMIS Business Process Implementation in System Replacement Project

In the first quarter of 2014, DHCS and Xerox agreed to replace the phased approach with a modified agile approach. The CA-MMIS System Replacement Project will be now implemented in five distinct releases, with each release building on the prior release. The roadmap for the planned releases is provided in Appendix E.

Details for each release will be documented as the scope of each release is finalized.

The following table provides the business functionality being planned for implementation in Release 1.

Table 16: Release 1 Business Functionality

# Business Functionality

1 Development of the framework to retrieve Member Eligibility data (HIPAA X12 270/271 transactions requests/responses from FAME/MEDS

2 Development of the framework for making To-Be systems as the system of record for all Reference Data and integration with Legacy

3 Development of the framework for making To-Be systems as the system of record for all Formulary data and integration with Legacy

4 Development of the framework for managing rate settings

5 Development of the framework for managing benefit plans

6 Provider Enrollment/Disenrollment functionality; integration with Provider Master Files and PAVE, along with Provider maintenance and inquiry

7 Building the framework for determining Medi-Cal Provider eligibility, including incentive program

8 Integration of Legacy RAIS invoices with To-Be Rebate Web to allow manufacturers and labelers to view their invoices

9 Provider Outreach and Communication Management through correspondences and contact management, and publications to upload static information such as manuals, bulletins, and FAQs

10 Management of Medi-Cal Program information

11 Management of Program Policy

12 HE Portal integration to access Legacy IHO/MCM Case information

13 HE Portal integration to access Legacy Grievance & Appeal information


4.4 Transition from As-Is to To-Be

The current state (As-Is) of the DHCS CA-MMIS is:

Multiple program access routes and interfaces for stakeholders Disparate state repositories Limited coordination between business areas Multiple variants for business area processes

The future vision (To-Be) for DHCS CA-MMIS includes but is not limited to:

Consolidated interfaces with program stakeholders Consolidated data repositories accessible throughout the agency Business area consolidation Improved coordination between programs and business processes

The figure below shows the transformation envisioned between the existing CA-MMIS and its processes to the new enhanced CA-MMIS Replacement System and its processes.

Figure 9: As-Is and To-Be CA-MMIS Transformation Characteristics


The transition of the CA-MMIS from a MITA Business Architecture perspective is shown in the following diagram.

Figure 10: COO (Business Architecture Transition)

4.4.1 Effectiveness – Increase Business Maturity

Business capabilities link to enabling technical capabilities and are the principal drivers of business services.

As part of the BCM, the business process areas are scored based on different maturity levels. Each general description of a level is supplemented by more specific definitions in a set of qualities. Qualities represent aspects of capabilities that are measurable, such as the following:

Timeliness of business process Data accuracy and accessibility Ease of performance/efficiency Cost effectiveness Quality of process results Value to stakeholders

The BCM contains maturity levels of functionality for each business process in the BPM. Capabilities are assigned at each Business Process level. It defines the boundaries and behavior for each business process in the context of the five (5) levels of the MMM.

The Business Processes identified in the SS-A are scored for the quality attributes. The To-Be BCM must be equal to or surpass the State’s maturity goals. Business processes are assigned a MITA Maturity Level of 1 (lowest level of maturity) through 5 (highest level of maturity) for business capabilities.

DHCS uses the BCM to perform a self-assessment to establish their current maturity level for each business process and select higher levels for future improvements. This assessment provides a foundation for DHCS to develop a strategic plan for continuous improvement, targeting to move to higher levels of maturity. Business process improvement may come in different forms such as new technology adoption, business process re-engineering, change in management direction, process obsolescence etc. in order to reduce costs, improve productivity and deliver services more efficiently. Business changes are documented as part of the CA-MMIS System Replacement Business Change Management Plan (BCMP).


The first table (Table 15) below describes the quality attributes which are used to measure the maturity level of the business processes. The second table (Table 16) shows the template for capturing the maturity levels for the quality attributes for a given business process.

The As-Is and To-Be maturity levels for the CA-MMIS business processes are shown in Appendix B. The MITA Maturity Level is shown in Figure 12.

Table 17: Quality Attributes to Measure Business Process

Quality Attribute Description

Timeliness of Business Process

Time lapse between the State’s initiation of a Business Process and attaining the desired result (e.g., length of time to enroll a provider, assign a member, pay for a service, respond to an inquiry, make a change, or report on outcomes)

Data Accuracy and Accessibility

Ease of access to data that the Business Process requires and the timeliness and accuracy of data used by the Business Process

Ease of Performance Level of effort necessary to perform the Business Process given current resources

Cost Effectiveness Ratio of the amount of effort and cost to the outcome

Quality of Process Results

Demonstrable benefits from using the Business Process

Utility of Value to Stakeholders

Impact of the Business Process on individual members, providers, and State staff


Figure 11: MITA Maturity Level

Table 18: Template for Business Capability Matrix (BCM)

BUSINESS PROCESS : <NAME>

Level 1 Level 2 Level 3 Level 4 Level 5Quality: Timeliness of Business Process

Quality: Data Accuracy and Accessibility

Quality: Efficiency, Ease of Performance

Quality: Cost Effectiveness

Quality: Quality of Process Results

Quality: Utility of Value to Stakeholders


4.4.2 Effectiveness – Improved Performance Standards

DHCS has defined performance standards to be measured for the CA-MMIS System Replacement.

The performance standards include, but are not limited to, the following:

System performance and capacity for current claim volumes and projected growth patterns Supporting current level and future growth in the number of users System availability System response time for online transactions, reports and interfaces

4.5 Compliance

CA-MMIS System Replacement is compliant to federal and state statutes, regulations, and DHCS security policies. It is compliant with the Electronic Data Interchange (EDI) standards as well as the standards determined under provisions of HIPAA.

4.5.1 Security and Confidentiality

Security and Confidentiality for System Replacement facilities and applications are compliant to:

Federal Information Processing Standards (FIPS) Publications State Administrative Manual (SAM) and Health Administration Manual (HAM) Federal and State mandates (including the State Medicaid Manual) Federal and State legislation (including HIPAA and the Information Practices Act (Civil Code section

1798,et. seq.) Office of Management and Budget (OMB) Circular A-130 Federal Information Security Management Act (FISMA) Compliance Applicable International Organization for Standardization (ISO) Standards Sarbanes Oxley California Civil Code Section 1798.29 & 1798.82 Assembly Bill (AB) 1298 (California Civil Code Sections 56.06, 1785.11.2, 1798.29, and 1798.82,

relating to personal information) National Institute of Standards and Technology (NIST) Publications DHCS IT Project Security Requirements 1 (SR 1) Health Information Technology for Economic and Clinical Health Act of 1996 (HITECH)

4.5.2 System Security and Privacy

System Replacement, as well as activities performed in support of System Replacement, is compliant with applicable federal and state security requirements (including HIPAA, NIST, and MITA Security and Privacy Principles and Standards).


4.5.3 Other Standards for Compliance

GUI/Access/Web Services California Enterprise Architecture Program (CEAP) California SOA and Federated Identity Management Technical Vision (January 7, 2008) California Technology Agency (CTA) policies and compliance components, as found in the CA-

MMIS/FI Procurement Federal Americans with Disabilities Act (ADA) Guidelines Web service standards (Oasis and W3C) NIST 800-95 Guide to Secure Web Services MITA Technical Reference Architecture

State Medicaid Manual: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html

State Information Management Manual (SIMM) – IT Policy: http://www.cio.ca.gov/Government/IT_Policy/SIMM.html

4.6 Critical Business Processes

A process will be developed to identify the criteria for determining the criticality of each business process. These criteria include, but are not limited to, external stakeholder involvement, and the need for a business process to achieve a higher maturity. A business process catalog will be created to identify the critical business processes.

The identification of critical business processes helps the Implementation Team perform contingency planning and develop approaches and plans in the event that such business functions are impaired and cannot be carried out as planned.

4.7 Business Architecture – Assumptions, Constraints, and Risks

The following table describes the assumptions, constraints, and risks identified for each CA-MMIS business process. Several business processes do not have assumptions, constraints, and/or risks listed; these may be identified at later dates as the CA-MMIS System Replacement Project advances and more information is known.

Impacts to the actors will be refined with the assistance of the Transition Team during each of the planned releases.


http://www.cio.ca.gov/Government/IT_Policy/SIMM.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html

Table 19: Business Architecture - Assumptions, Constraints, and Risks

CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks

Care Management Authorize Treatment Plan CA will adopt and conform to pending Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) operating rules related to service authorizations.CA will establish and enable policies and processes to support ICD-10 processing.

Xerox transfer systems support ICD 9 and 10 processing.

As-Is CA-MMIS currently does not make use of X12 278 transaction standard.

Health Enterprise supports X12 278 transaction standard.

None identified at this time.

Care Management Establish Case To-Be business process is not anticipating collecting and using clinical data as a part of this business process.

MITA 3.0 business process includes the collection and use of clinical data within its baseline.


Establish CCS/GHPP Case To-Be business process will allow for some automation with changes to CMSNet.

MITA 3.0 business process includes the collection and use of clinical data within its baseline.


Manage Case Information HIE is outside the scope of CA-MMIS System Replacement requirements.

MITA 3.0 baseline capability includes the integration of an HIE.


Manage CCS/GHPP Case HIE is outside the scope of CA-MMIS System Replacement requirements.






CA will establish and enable policies and processes to support ICD-10 processing.

Xerox transfer systems support ICD 9 and 10 processing.

MITA Maturity 3 requires interaction with HIE, outside scope of CA-MMIS.


Medi-Cal Treatment Authorization Requests (TARs)

Rule based logic (SmartPA) will auto-generate pharmacy TARs from submitted claims without human intervention.




HIE is outside the scope of CA-MMIS System Replacement requirements.




Care Management Reserve Service None identified at this time.

As this is a state specific business process, the capabilities of this business process will have to be developed for DHCS.


Contractor Management

Manage CA-MMIS FI Contract The Manage CA-MMIS FI contract business process has no significant enhancements planned in System Replacement requirements.






Health Enterprise will leverage the provider management, communication and contact tracking capabilities for these contractor relationships.

All communications must be approved by DHCS prior to being posted or sent out.


Financial Management

Formulate Medi-Cal Budget CM64 enhancements will automate some of the reporting to CMS.

The Formulate Budget business process is primarily a manual effort performed outside of the system.



CM64 enhancements will automate some of the reporting to CMS.



Manage 1099 None through maturity level 2.



Manage Contractor Payment CA will adopt and conform to CAQH CORE operating rules related to Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA).





None through maturity level 2.



Manage Drug Rebate Rebate Accounting and Information System (RAIS) and all its sub-systems, such as RAIS Datamart , will be decommissioned with the implementation of DRAMS.

RAIS Data Mart holds additional CA-MMIS information beyond drug rebate and invoice information.

Hardcopy documentation will continue to be scanned in and retained indefinitely.

Manage Estate Recovery None through maturity level 2.






CA will adopt and conform to pending CAQH CORE operating rules related for Healthcare Premium Payment.



Manage Incentive Payment None identified at this time.


Incentive payment triggers are not defined or may change.



The baseline MITA process includes payroll activities, which may not be applicable to CA.



None through maturity level 2.




None assuming Maturity Level 2




CA will adopt and conform to CAQH CORE operating rules related to EFT/ERA.

SCO will require system changes also related to EFT/ERA.



CA will adopt and conform to evolving buy-in, Medicare Modernization Act (MMA) and other CMS data exchange formats.




Manage Member Health Care Reimbursement

CA will adopt and conform to pending CAQH CORE operating rules related for Healthcare Premium Payment.







There are no approved national data standards that support MITA Maturity Level 3, nor are most of the automation capabilities described in Maturity Level 3 available to providers.


Manage State Funds None identified at this time.

MITA level 3 requires the use of Nationally Recognized Standards to improve accuracy. These standards are not available.


Manage TPL Recovery Health Enterprise is capable of achieving Maturity Level 2.

Maturity Level 3 requires undefined data standards and sharing COB information via HIE, which is not supported within CA-MMIS.

In California, the MMIS does not perform this function but simply provides data to the State’s TPL department.

CA will establish and enable policies and processes to incorporate ICD-10 in the TPL recovery processes.

Member Eligibility and Enrollment Management

Inquire Medi-Cal Eligibility Voice Response will not give fully CORE content compliant response. EDI and Web Portal will be able to give compliant responses assuming that CA has adopted and implemented CORE Operating rules.


CA will have established infrastructure and processes to support CORE Operating Rules by the time of implementation of SR.



Member Management


Providers inquire on the status of authorization requests on behalf of Medi-Cal Applicant or Member.



Operations Management


Mass Adjustment requests will be initiated through Operating Instruction Letters (OILs), Software Development Notices (SDNs) and other communication mechanisms as they are now and not through automated triggers as described in Maturity Level 2.



Generate Medi-Cal Remittance Advice

CA will adopt and conform to CAQH CORE operating rules related to EFT/ERA.

SCO office may have to support system changes.



CA will adopt and conform to CAQH CORE operating rules related to Inquire Claim Status.



Manage Data CA will establish and enable policies and processes to support ICD-10 processing and the appropriate extracts.

CA will adapt to evolving RAC recovery audit data formats to support ICD-10.

T-MSIS requires data which may be outside of the MMIS. This requires appropriate sourcing, integration and transformation.





Health Enterprise has the ability to receive and process encounters with similar adjudication capability as regular Fee-for-Service claims.

California may only use a subset of the capability within Health Enterprise based on State specific business processes. California does not currently receive encounter data in the 837 format.

MCO’s may not implement ICD-10 processing at the same time as CA-MMIS, potentially causing data issues.


CA will adopt and conform to pending CAQH CORE operating rules related to claims.CA will establish and enable policies and processes to support ICD-10 processing.

Service Level Agreement (SLA) of 6 seconds needs to be met.



CA will adopt and conform to pending CAQH CORE operating rules related to attachments.


Providers have limited ways to submit attachments and enhancements may be needed to conform to new standards.

Plan Management Develop and Manage Performance Measures

CA will accept and implement national quality standards or will define their own performance measures.


CA currently has defined quality and performance standards that are adhered to which may need to be revised.



All transfer systems are enabled for ICD 9 and 10 processing.





Manage Drug Formulary First Data Bank will continue to provide the updates to the formulary file.



Plan Management Manage Medi-Cal Program Information



DHCS sends the changes to policy over in an FI letter and Xerox updates the programs and files as appropriate.

Manage Benefit Information There are no planned changes to the existing business processes. The replacement system will dramatically increase the configurability of benefits.



Maintain Program Policy The replacement system will enable significantly greater policy management through configuration, but not necessarily automation.



Manage Rate Setting The replacement system will enable significantly greater rate setting management through configuration but not necessarily automation.



Program Integrity (Performance) Management

Determine Adverse Action Incident


MITA Maturity Level 3 requires connectivity to State and Federal law enforcement agencies, as well as regional exchange hubs.





Identify Utilization Anomalies CA will establish and enable policies and processes to support ICD-10 processing.

MITA Maturity Level 3 includes connection to HIE, Health Insurance Exchange (HIX), and standardized data exchanges which do not currently exist. State Medicaid Agency (SMA) completes a review in 60 seconds or less with 99% accuracy is not currently possible.

Identifying utilization anomalies across the ICD-10 processing boundary may not be effective. Provider / billing service ICD-10 strategies may mask /exacerbate utilization anomalies.

Establish Compliance Incident None identified at this time.

MITA Maturity Level 3 requires connectivity to State and Federal law enforcement agencies. Provide Notice of Appeal rights within 15 minutes. Requires External sources of information use MITA Framework and industry standards for information exchange.




Manage Compliance Incident Information


All transfer systems support ICD 9 and 10 processing.

MITA Maturity Level 3 requires connectivity to State and Federal law enforcement agencies. Requires External sources of information use MITA Framework and industry standards for information exchange.



Prepare Beneficiary Confirmation Letters

None through maturity level 2





Provider Eligibility and Enrollment Management

Enroll Medi-Cal Provider CA-MMIS System Replacement deals with out-of-state provider enrollment only.

New provider types may need to be enrolled to support the Essential Health Benefits required for Medicaid Expansion.

DHCS will approve providers and enter their information; this will be provided in the daily PMF. DHCS will also be responsible for all provider related policies and rules, and will manage the review and approval of provider enrollment applications for prospective Medi-Cal providers. All prospective providers must be licensed and accredited. DHCS will continue to develop enrollment policies and respond to provider questions related to enrollment issues.

Health Enterprise supports provider enrollment with credentialing supported by Digital Harbor.

DHCS has a number of state specific business processes related to Enroll Provider. This analysis is based on the MITA 3.0 definition. Baseline business process identifies HIX notification which is outside the scope of CA-MMIS process.

The Affordable Care Act (ACA) has recently defined a number of additional requirements for provider enrollment that are not described within these business process steps.

The new Provider Application Verification and Enrollment (PAVE) Project will provide provider enrollment functions. CA-MMIS System Replacement will have to ref-actor code to integrate with PAVE rather than the existing Legacy Provider Master Files.


Automated Voice Response System (AVRS) telephone will not be supported to inquire on provider eligibility.

Only providers enrolled in the Medi-Cal system will have information available.






Determine Medi-Cal Provider eligibility is overseen by DHCS Provider Enrollment Division (PED).

Health Enterprise supports provider enrollment with credentialing supported by Digital Harbor.


The new PAVE Project will provide provider enrollment functions including determine provider eligibility. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files.


Determine Incentive Program Provider Eligibility is overseen by the DHCS Office of Health Information Technology (OHIT) once provider have completed the federal registration process to access the Medi-Cal State Level Registry.



Determine CHDP Provider Eligibility

Determine CHDP l Provider eligibility is overseen by DHCS PED.

Only providers enrolled in the CHDP system will have information available.


Enroll Drug Medi-Cal Provider Determine Drug Medi-Cal Provider eligibility is overseen by DHCS PED.


The new PAVE Project will provide provider enrollment functions. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files.




Enroll Mental Health Provider Determine Mental health Provider eligibility is overseen by DHCS PED.



Enroll Dental Provider Determine Dental Provider eligibility is overseen by DHCS PED.



Enroll CCS Provider Determine CCS Provider eligibility is overseen by DHCS PED.



Enroll CHDP Provider Determine CHDP Provider eligibility is overseen by DHCS PED.



Disenroll Medi-Cal Provider Disenrolling a Medi-Cal Provider is overseen by DHCS PED.


The new PAVE Project will provide provider disenrollment functions. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files.




Disenroll Dental Provider Disenrolling a Dental Provider is overseen by DHCS PED.


The new PAVE Project will provide provider disenrollment functions. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files.

Provider Management


HIX is outside the scope of this project.

The baseline business process includes sharing information with the HIX.


Manage Medi-Cal Provider Grievance & Appeal






Base MITA process includes interaction with HIX and Insurance Affordability Program for provider information.





Communication needs to be properly planned, developed, targeted and delivered to specific provider groups or audiences.


Appendices

A. CA-MMIS Actors Catalog

The following table describes the actors who interact with CA-MMIS directly or indirectly. The actors are sorted by Actor Name within the table. The Entity Type defined in the table identifies whether the actor belongs to Xerox, DHCS, or is an external entity. It helps to categorize the actors and is used in the Actors Catalog Diagram (See Figure 5). The following table also includes the impacts to each of the actors across the lifecycle of the CA-MMIS System Replacement Project.

Table 20: CA-MMIS Actors Catalog

Actor Name Aliases Entity Type Description

Pharmacy Claims and Drug Rebates

Pharmacy Prior Authorizations

Medical Prior Authorizations

Medical Claims

Administration Division

ADM DHCS The Administration Division provides an array of central support services to achieve DHCS program and operations objectives. Staff provides management information and business control functions for the directorate, helping to confirm that the most effective and efficient level of service is achieved. The Administration Division streamlines and simplifies policies and procedures, stressing collaboration and improved communication with program staff; certifies fiscal accountability of programs by overseeing the financial management of DHCS, including budget development and oversight;

DHCS supports program operations and will be impacted in all releases of the CA-MMIS System Replacement Project.

The Administration Division closely monitors the impacts of any changes to policies and procedures for the DHCS Program. Throughout the project, the Administrations Division will manage information, control business functions, and utilize the information to continually look for ways to streamline policy and procedures. The Administration Division is also responsible for overseeing financial management, which includes budgeting and evaluation of business processes for future improvements. With the System Replacement implementation, the changes to policies and procedures can be implemented in a much shorter timeframe. This would allow for better fiscal accountability.






Medical Claims

provides responsive and reliable employee support and human resource management systems; provides guidance and consultation on contract and purchasing services; responsibly manages DHCS physical resources through facilities and telecommunications business services; supports the protection of DHCS employees through the Health and Safety office; and evaluates business processes with attention to improvements in other department-wide support functions.

Appeals Unit Examiner

Appeals Xerox Part of Claims Adjudication. Reviews and processes appeals submitted by providers. (See Actor: Provider for more details)

Processing Pharmacy Appeals, which may be impacted by the implementation of the Pharmacy Claims system.

Processing Pharmacy Appeals, which may include

review of TARs/SARs and the use of the SmartPA and

Medical Prior Authorization systems.

Processing of all Appeals will be impacted when is the entire Appeals Business Process is implemented. Appeals staff will need to be trained in all functionality to support the research of the appeals claims.

Audits & Investigations Division

A&I DHCS The mission of A&I is to protect and enhance the fiscal integrity of the health programs administered by DHCS and confirm a high quality of care is provided to the beneficiaries of these programs. The overall goal of A&I is to improve the efficiency, economy and effectiveness of DHCS

A&I works closely with Xerox to protect the integrity of the health programs. During each release of system changes, they will closely monitor the claims processing system to ensure that Providers are adhering to the billing standards and that the new system has adequate controls in place to prevent Provider and beneficiary fraud.






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and the programs it administers. To carry out its mission, A&I:

Performs various financial and medical audits as well as post-service, post payment utilization reviews to assure Medi-Cal program integrity.

Assures accountability of state and federal health care funding and identifies funds for recovery, where appropriate.

Identifies and investigates Medi-Cal provider and beneficiary fraud, waste and abuse, emphasizing fraud prevention.

Performs internal audits of DHCS programs to assure the adequacy and effectiveness of internal controls.

Performs special audits as needed by DHCS executive management, programs, the California Health and Human Services Agency and the Governor’s Office.

Provides technical assistance and audited data (internally and externally) on various aspects of health care financing and delivery.

Provides technical assistance (financial and medical) for the development, modification and expansion of DHCS health programs and related policy.

Benefits & Waiver Analysis Division

BWARD DHCS The Benefits & Waiver Analysis Division (BWARD) is responsible for managing and ensuring the uniform application of federal and state laws and regulations regarding Medi-Cal benefits and waiver policies that affect

BWARD will need to be kept informed of the progress of each release to determine the impact of policy changes that are in process. During each release of the System Replacement changes, policies will continue to be updated or new ones will be implemented as required by CMS or other State agencies. BWARD will need to be aware of any impacts to ensure compliance with federal and state laws, and to






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more than 150,000 providers of medical services to Medi-Cal beneficiaries. The division is the primary liaison with the federal CMS for waivers and coordinates with other DHCS divisions and state departments to assure compliance with state and federal requirements under those waivers and the State Plan. The division consists of the Medi-Cal Policy branch and the Benefits and Waiver Analysis branch.

determine if any changes to their Departments’ internal process will be necessary.

California Department of Public Health

CDPH External

California Department of Public Health (CDPH) comprises:

Center for Chronic Disease Prevention and Health Promotion

Center for Infectious Diseases

Center for Family Health

Center for Environmental Health

Center for Health Care Quality

Health Information and Strategic Planning

Emergency Preparedness Office

Administration

Office of Public Affairs

The goals of CDPH are to achieve health equities and eliminate health disparities; eliminate preventable disease, disability, injury, and premature death; promote social and physical environments that support

CDPH works with Health Departments and provides information for administration. During the System Replacement releases, CDPH will keep the Health Departments informed of changes that may directly impact their claims processing.






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good health for all; prepare for, respond to, and recover from emerging public health threats and emergencies; improve the quality of the workforce and workplace; and promote and maintain an efficient and effective organization. CDPH works toward these goals through its programmatic and operational support activities and in collaboration with local health departments and other organizations throughout the State.

California Medicaid Management Information System Division

CA-MMIS Division

DHCS The CA-MMIS Division is responsible for activities associated with usage of California’s IT system, which process and pays approximately $19 billion a year in Medi-Cal FFS health care claims, as well as claims for other DHCS health care programs. CA-MMIS processes payments to providers for medical care provided to 7.7 million Medi-Cal beneficiaries in the state. The FI operates and maintains the system. This division is responsible for the administration, management, oversight, and monitoring of the FI contract and services provided under the contract. FI services include the operation of a telephone service center and provider relations functions (publications, outreach and training); system operations, updates and enhancements; processing eligibility inquiry transactions, TARs and service authority requests; and processing more than four million claims per week. Under the CA-MMIS Division’s direction and leadership, the FI is also responsible for planning, developing, designing, testing and implementing a

DHCS Division responsible for oversight of CA-MMIS and contractor activities. The CAMMIS Division will be involved in each release of the System Replacement Project. They will be reviewing and approving all requirements that need to migrate to the new system, as well any new requirements. The CAMMIS-Division will work closely with Xerox during the testing phases , as well as all transition phases from the old to the new systems to ensure that each release is a smooth transition.






Medical Claims

new MMIS that represents current technology and support SOA, consistent with MITA.

Capitation Rates Development Division

CRDD DHCS Capitation Rates Development Division is responsible for the accuracy and integrity of data used to calculate and implement capitation rates in compliance with contractual and regulatory requirements. The Actuary Unit calculates and sets the capitation rates for managed care organizations and performs calculations of budget estimates. The actuaries certify that capitation rates for managed care health plans are determined in compliance with federal requirements. The Financial Management Unit performs research functions and rate calculations on Medi-Cal eligibility data, calculates FFS and managed care data costs for Medi-Cal programs and interprets and analyzes legislative impacts on Medi-Cal managed care programs costs. The Financial Analysis Unit (FAU) assures correct application and payment of capitation rates with regard to contractual agreements and departmental policy. The FAU also acts as the liaison between DHCS’ Fiscal Forecasting Division, the federal CMS, Department of Finance (DOF) and the Legislative Analyst's Office. FAU coordinates the preparation of budget neutrality and quarterly monitoring analyses for managed care programs for federal waivers. The Financial Review Unit assures the timely reporting of financial and accounting data by managed care organizations and provides financial analysis to

DHCS Division works closely with CRDD for financial management, rate calculations on Medi-Cal eligibility data, and fiscal forecasting. During each release of the System Replacement Project, the CRDD will be kept informed of any impact to policy implementations, and changes to reporting capabilities which may be used by the CRDD.






Medical Claims

stakeholders.

Cash Control Analyst

Cash Control

Xerox Part of Research and Correspondence. Manages the processes of check writing, accounts receivable, electronic functions transactions, warrants, 1099's, and overpayments.

Xerox Cash Control unit works with claims payment and needs to be aware of changes which may impact the financial system. During Pharmacy Claims implementation, the Cash Control unit will closely review the impact to pharmacy claims payments and adjustments .

N/A N/A Xerox Cash Control unit works with claims payment and needs to be aware of changes which may impact the financial system. During the implementation of Medical Claims, the Cash Control unit will closely review the impact to all claims payments and adjustments .

Centers for Medicare & Medicaid Services

CMS External

CMS is a branch of the U.S. HHS. CMS is the federal agency which administers Medicare, Medicaid, and the Children's Health Insurance Program. Provides information for health professionals, regional governments, and consumers.

CMS administers programs and provides information which may impact billing of Medi-Cal. During all releases of System Replacement, CMS will be kept informed so that information can be collected and provided to CMS for MMIS certification.

Child Health and Disability Prevention Program Provider

CHDP Provider

External

A subset of the Provider actor group. Provides medical services to members under the CHDP program

N/A N/A N/A CHDP Program submits claims to Medi-Cal and works with Medi-Cal






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Providers. During Release 1, the counties will be kept informed of changes to the CHDP claims processing so that they can provide awareness to their Provider communities. CHDP currently uses non-compliant forms and decisions to go with the standard forms may impact CHDP.

Children’s Medical Services

CMS-DHCS DHCS The Children's Medical Services Branch of DHCS (CMS-DHCS) provides an extensive system of health care for children through preventive screening, diagnostic, treatment, rehabilitation, and follow-up services. CMS-DHCS carries out this mission through a variety of programs meeting specific health care needs of targeted population.

CMS-DHCS Program submits claims to Medi-Cal and works with Medi-Cal Providers. CMS providers submit claims for services

rendered to children under this program. The CMS Branch will need to be kept informed of each release of the System Replacement

changes. This will allow CMS-DHCS to communicate to their provider community any impact to claims submission so that payment for

services is not interrupted.

Claims Adjudication

Claims Adjudication

Xerox Part of Claims Operations. Claims Adjudication verifies and validates claim information to determine if the claim should be paid, denied, or suspended for manual review. Claim

Xerox Claims Adjudication will process claims that are impacted with the changes. The Claims Adjudication area will work closely with the System Replacement Implementation Team to ensure that all staff are trained in each release. All Claims Adjudication staff will need to become familiar with PBM-OS+ and Health Enterprise system screens






Medical Claims

Adjudication is made up of the following two areas: Claims Suspense, and Appeals.

and navigation to appropriately adjudicate claims. The staff will also need to understand the changes when Treatment Authorization / Service Authorizations are implemented and how to use the data as needed in claims adjudication.

Claims Operations

Claims Ops Xerox The primary purpose of the Claims Operations is to receive and adjudicate claims. The Claims Operations Department is organized into three major business areas: Front End, Claims Adjudication, and Medical Professional Service Group.

Xerox Claims Operations will process claims that are impacted with the changes. The Operations areas will be kept informed of the release implementations; however the impact of the system changes will be to the Claims Adjudication areas and the Medical Professionals who adjudicate the claims. These groups will be trained on all aspects of PBM-OS+ and Health Enterprise system screens and navigation to appropriately adjudicate claims. The staff will also need to understand the changes in Treatment Authorizations / Service Authorizations and how to use the data as needed in claims adjudication.

Claims Suspense Examiner

Suspense Xerox Part of Claims Adjudication. Reviews claims that fail an edit or audit. Makes the determination of the appropriate action to take on the claims.

Xerox Claims Operations will process claims that are impacted with the changes. The Claims Adjudication area will work closely with the System Replacement Implementation Team to ensure that all staff are trained in each release. All Claims Adjudication staff will need to become familiar with PBM-OS+ and Health Enterprise system screens and navigation to appropriately adjudicate claims. The staff will also need to understand the changes in Treatment Authorization / Service Authorizations and how to use the data as needed in claims adjudication.






Medical Claims

Clinical Assurance and Administrative Support Division

CAASD DHCS CAASD is comprised of five branches, two pharmacy sections and an appeals and litigation section. CAASD provides strong, cost-effective utilization controls by reviewing and adjudicating TARs for certain medical procedures, services and drugs for FFS Medi-Cal beneficiaries prior to payment for services. In 2011, CAASD processed more than 3.2 million TARs. CAASD also responds to TAR appeals submitted by providers and offers program support to the Office of Legal Services for litigation resulting from denied TAR appeals. In addition, CAASD is responsible for the Designated Public Hospital Project (DPHP), which allows public hospitals in California to use an evidence-based standardized tool to determine medical necessity for hospital days and services for Medi-Cal beneficiaries in lieu of submitting a TAR to the field office.

Prior to January 1, 2014, this Division was known as the Utilization Management Division (UMD).

DHCS – CAASD is responsible for pharmacy sections and appeals and litigations related to TARS and needs to be informed of changes to CA-MMIS. CAASD will be kept informed of all releases of the System Replacement implementation to monitor any impact to the processing of claims that required TARs. During Treatment Authorization / Service Authorizations, CAASD will be closely involved in the system changes that will impact the TAR approval process and the Medical Prior Authorization processing. They will be trained on these releases which may impact the Appeals/litigation of TARs process.

Cost Containment Unit Analyst

Cost Containment

Xerox Part of Provider Integrity Unit. Analyzes and proposes cost containment ideas to DHCS to save Medi-Cal program dollars.

Xerox Cost Containment Unit will analyze claims that may be impacted with the changes. The Xerox Cost Containment Unit will closely monitor all releases for any impact to the Provider Community, claims processing, and reporting process.






Medical Claims

County Office County External

Performs member enrollment, determines member eligibility, and manages member information.

Counties work with DHCS for member enrollment and should be kept informed of changes. The releases should not directly impact the County eligibility offices.

N/A N/A Counties work with DHCS for member enrollment and should be kept informed of changes. The releases should not directly impact the County eligibility offices .

Department of Aging

CDA External

The California Department of Aging (CDA) administers programs that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the State. The Department administers funds allocated under the federal Older Americans Act , the Older Californians Act, and through the Medi-Cal program.

The Department contracts with the network of Area Agencies on Aging, who directly manage a wide array of federal and state-funded services that help older adults find employment; support older and disabled individuals to live as independently as possible in the community; promote healthy aging and community involvement; and assist family members in their vital care giving role. CDA also contracts directly with agencies that operate the Multipurpose Senior Services Program through the Medi-Cal home and community-based waiver for the elderly, and certifies

CDA works with long-term care facilities under the federal Older Americans Act through the Medi-Cal program and processing changes may impact the services provided. Throughout the releases of the System Replacement Project, the CDA will be kept informed of any changes that may impact the ability of their clients to submit claims or TARs for payment .






Medical Claims

Adult Day Health Care centers for the Medi-Cal program.

Department of Health Care Services

DHCS DHCS The single state agency responsible for administration of Medi-Cal. DHCS acts for the State of California as the contract entity.

DHCS is responsible for the administration of Medi-Cal and will be approving the implementation of each release of the System Replacement Project. DHCS will be involved in gathering requirements and making policy decisions for all releases to help increase business maturity of the business processes.

Department of Justice

DOJ External

Works closely with DHCS in monitoring illegal activity.

DOJ works with DHCS and needs to be aware of changes to CA-MMIS for monitoring purposes, as well as changes to reporting that may be used by the DOJ.

Department of Mental Health

DMH External

The Department of Mental Health (DMH) operates five state hospitals throughout California including: Atascadero State Hospital (San Luis Obispo County), Coalinga State Hospital (Fresno County), Metropolitan State Hospital (Los Angeles County), Napa State Hospital (Napa County), and Patton State Hospital (San Bernardino County). Each state hospital provides inpatient treatment services for Californians with serious mental illnesses. Additionally, DHM operates two correctional programs, Salinas Valley Psychiatric Program and Vacaville Psychiatric Program.

As of July 1, 2012, DMH became the new Department of State Hospitals (DSH). As part of the Governor’s goal to give more local control to community mental health functions, many programs formerly under the purview of DMH are transitioned to other state departments and the counties.

DMH should be kept informed of changes to CA-MMIS for billing purposes. They will be kept informed during each release to monitor claims processing, as well as the approval of mental health treatment authorizations.

Department of Social Services

CDSS External

The California Department of Social Services is comprised of more than 54

CDSS will be kept informed of each release and the changes in the Medi-Cal processing systems that may impact the community they






Medical Claims

offices throughout the State and is the state agency responsible for:

Ensuring efficient, accurate, and equitable delivery of payments and benefits

Providing services that foster self-sufficiency and dignity

Providing social services to the elderly, blind, disabled and other children and adults

Licensing and regulating foster homes, group homes, residential care facilities, day care facilities, and preschools

Evaluating eligibility of applicants for federal and State programs

serve.

Department of State Hospitals

DSH External

On December 7, 2011, DMH announced the blueprint to establish the new DSH and reforms to the DMH structure designed to improve the mental hospital system in California.

As of July 1, 2012, DMH became the new DSH. DSH focuses on the care of patients in its seven forensic state hospitals: DSH-Atascadero, DSH-Coalinga, DSH-Metropolitan Los Angeles, DSH-Napa, DSH-Patton, DSH-Salinas Valley, and DSH-Vacaville.

DSH will be kept informed of changes to CA-MMIS for billing purposes. DSH may be impacted by claims processing changes, as well as the changes to the Treatment Authorization system.

Drug Manufacturer / Labeler

Labeler External

Contracted with CMS and DHCS on drug rebate. Receives drug rebate invoices and submits rebates to DHCS.

Drug Manufacturer/Labeler may be impacted with changes to Drug Rebate.

N/A N/A N/A






Medical Claims

Drug Rebate Unit

DRU Xerox Part of Medical Professional Service Group. Responsible for invoicing drug manufacturers for drugs that were dispensed to Medi-Cal members. Manages Drug rebates.

Xerox DRU unit may be impacted by changes to forms processing that providers submit. They may also be impacted by the implementation of DRAMS. They will closely monitor the data that is captured to process Drug Rebates.

N/A N/A Xerox DRU unit may be impacted by changes to forms processing that providers submit.

Drug Use Review

DUR Xerox Xerox Medical Professional Service Group works to improve the quality and cost effectiveness of drug use by ensuring that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical results.

Xerox DUR unit may be impacted by changes to forms, which include TAR processing that providers submit. The DUR review is done based on the data captured at processing and in reporting.

Encounter Data Unit

EDU Xerox Processes and analyzes encounter data records.

Xerox EDU unit may be impacted in data collection by the changes to forms that Providers will use and any release that directly impacts the data storage for these encounter data records.

N/A N/A Xerox EDU unit may be impacted in data collection by the changes to forms that Providers will use and any release that directly impacts the data storage for these encounter data records.






Medical Claims

Fee-For-Service Rates Development Division

FFSRDD DHCS FFSRRD is responsible for developing Medi-Cal reimbursement rates for non-institutional and long-term care services, performing analysis for General Fund cost savings/avoidance proposals and rate methodologies and assisting the Office of Legal Services in defending DHCS in legal actions. FFSRDD serves as a point of contact on matters pertaining to Medi-Cal non-institutional and long-term care rate setting matters in negotiation and/or meetings with health care provider representatives, patient advocates, external state agencies, representatives of county, state and federal governments, industry representatives, special interests groups, the media and other high-level officials regarding Medi-Cal rate policies and issues. FFSRDD also crafts legislation and submits State Plan Amendments regarding changes to provider reimbursements. In addition, FFSRDD administers a quality assurance fee (QAF) program that collects more than $500 million annually.

DHCS FFSRDD area needs to be kept informed of changes to CA-MMIS in order to monitor the impact on claims and Treatment Authorization processing as the changes are implemented and to provide data for future analysis of cost savings/avoidance proposals and rate methodologies. FFSRDD meets with health care Providers’ representatives and patient advocates and will need to understand the many changes to CA-MMIS.






Medical Claims

File Maintenance

Systems Group (SG)

Xerox The File Maintenance Team is responsible for maintaining, updating, and cross verifying all CA-MMIS files and tables, including the MMIS Tables Files, Procedure Code Master File (RF-F-070), Diagnosis Master File (RF-F-001), and Formulary File.

File maintenance will need to understand the PBM OS+ processing of claims for any testing that is required to implement OILs and edit criteria updates related to claims processing.

N/A N/A File maintenance will need to understand the HE system claims processing for any testing that is required to implement OILs and edit criteria updates related to claims processing.

Financial Management Branch

FMB DHCS Performs the accounting function within DHCS.

FMB should be informed of any changes to the CA-MMIS system that may impact financials, which will include claims processing and reporting

N/A N/A FMB should be informed of any changes to the CA-MMIS system that may impact financials, which will include claims processing and reporting

First Data Bank FDB External

Provides updates to formulary file First Data Bank may be impacted by the PBM OS+ and DRAMS changes. Xerox will need to keep them informed of any impact to weekly files they

N/A N/A N/A






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submit.

Fiscal Forecasting Branch

FFB DHCS FFB looks at current revenue trends and expenditures, assesses external factors impacting the program, models different budget scenarios and produces the budget estimates for the Medi-Cal and CCS/GHPP/CHDP Local Assistance program.

N/A N/A N/A N/A

Fiscal Intermediary

FI Xerox The contractor who performs Medi-Cal and other health program claims processing and management reporting functions for DHCS. In California, Xerox is the DHCS FI for CA-MMIS.

Xerox will be involved in all releases of the System Replacement Project and will work closely with DHCS to ensure that all claims processing for Medi-Cal programs continue to run smoothly and that the changes are transparent to the Provider community.

Franchise Tax Board

FTB External

FTB is responsible for administering two of California’s major tax programs: Personal Income Tax and the Corporation Tax. FTB also has responsibility for administering other nontax programs and delinquent debt collection functions.

N/A N/A N/A N/A






Medical Claims

Front End Front End Xerox Part of Claims Operations. Front End is responsible for the receipt and control of hard copy claims. Front End is made up of the following areas: Mailroom, Input Prep, Scanning, and Key Data Entry (KDE).

Xerox Frontend Claims Operations will process Pharmacy claims that are impacted by the changes. There will be no direct impact to this area, but they will be knowledgeable in the changes.

Xerox Frontend Claims Operations may process TARs that are impacted with changes. There should be no direct impact to the front-end process, but the Department will be made aware of the changes to TAR processing.

Xerox Frontend Claims Operations will process claims that are impacted with the System Replacement changes. There will be no direct impact to this area, but they will have knowledge of the changes.






Medical Claims

Information Technology Services Division

ITSD DHCS ITSD provides a secure, reliable IT environment to support the program and administrative objectives of DHCS, Health and Human Services Agency, CDPH, Office of Health Information Integrity and Health Benefit Exchange Board. ITSD establishes IT policy and standards and assures compliance with state and federal laws and regulations regarding the use of IT and the safeguarding of electronic information; supports a complex portfolio of program applications, the largest of which is the MEDS; provides quality application and data services to DHCS programs; facilitates the successful completion of IT projects undertaken by DHCS; and manages the design, installation, upgrade and support of a complex technology infrastructure, including network, servers, desktops, network devices, messaging systems, Web sites, Web applications and databases.

DHCS – ITSD furnishes the MEDS eligibility files daily and will need to be informed of program changes and any possible changes to the daily files that are received.

ITSD must also be informed of any changes to interfaces that originate/terminate at their end to ensure no impact to the eligibility files that are received daily.

ITSD will also help in the development, testing, and deployment of the Member Eligibility Web Service.

Input Prep Input Prep Xerox Part of Front End. Prepares hard copy claims, attachments for scanning, completes visual audits.

Xerox Input Preparation is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the input prep process, but the Department will be made aware of the changes to the claims processing systems.

Internal Revenue Services

IRS External

IRS is the United States government agency responsible for tax collection and tax law enforcement.

N/A N/A N/A N/A

Key Data Entry Operator

KDE Xerox Part of Front End. Manually keys hard copy claim information not recognized by the scanning process Optical Character Recognition (OCR).

Xerox Key Data Entry is a part of Claims Operations and may process claims that are impacted by the changes. Key Data may be impacted in the entry of paper claims, and will work closely with the System Replacement teams from all releases to ensure that they are aware of the changes.






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Legislative & Governmental Affairs Division

LGA DHCS Legislative & Governmental Affairs Division facilitates, coordinates and advocates for the development and enactment of legislation in the interest of public health and health care. As a key player in carrying out DHCS’ mission to protect and advance the health of Californians, LGA assists in the development and refinement of the state's health care laws.

DHCS LGA Division should be informed of changes that may impact claims processing for health care. There should be no direct impact to this area, but this Division needs to be informed of the changes to CA-MMIS.

Local Educational Agency

LEA External

Local Educational Agency delivers services to students receiving special education services and who are on Medi-Cal.

LEA should be informed of changes that may impact claims processing for health care. LEA claims are submitted for processing and they will need to understand if there is any specific impact to their programs.

Long Term Care Division

LTCD DHCS Long Term Care Division is an integral component of California’s Olmstead Plan by ensuring the provision of long-term services and supports to Medi-Cal-eligible frail seniors and persons with disabilities to allow them to live in their own homes or community-based settings instead of in facilities. LTCD directly operates and/or administers five home- and community-based services (HCBS) waivers on behalf of DHCS, as the single state Medicaid agency. LTCD also provides monitoring and oversight for four HCBS waivers and the In-Home Supportive Services state plan benefit operated by the Department of Social Services, Department of Aging and Department of Developmental Services. In addition, LTCD operates two managed care programs, Program of All-inclusive Care for the Elderly and Senior Care Action Network, and the California Partnership for Long-Term Care, a long-term care insurance program. In

DHCS LTCD Division should be informed of changes that may impact claims processing for health care throughout the releases.

DHCS LTCD Division should be informed of changes that may impact TAR processing for health care.

DHCS LTCD Division should be informed of changes that may impact claims processing for health care throughout the releases.






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addition, LTCD administers a federal Money Follows the Person grant to transition Medi-Cal-eligible residents from long-term care facilities back to community living arrangements. LTCD works collaboratively with the Medi-Cal Managed Care Division to integrate long-term services and supports for seniors and persons with disabilities and Medicare/Medi-Cal dual eligible beneficiaries in a managed care delivery system.

Low Income Health Program Division

LIHP Division

DHCS In November 2010, California received approval from the federal CMS to implement a new section 1115 “Bridge to Reform” Medicaid demonstration. The demonstration includes several programs that prepare the state for implementation of the Patient Protection and ACA. LIHP is responsible for administering and managing approximately $3 billion in federal funding to implement the LIHP, which is a significant component of the demonstration. The program extends and expands the Health Care Coverage Initiative program to a statewide local program targeting the Medicaid expansion population and the low-income adult population eligible for participation in the Health Benefit Exchange. The division responsibilities include: developing policies and procedures related to the LIHP, reviewing and approving claiming invoices for federal reimbursement to local LIHPs and providing technical assistance. The division also monitors program compliance with contracts, Special Terms and Conditions, and

DHCS LIHP Division will be informed of changes that may impact claims processing for health care during the System Replacement releases.

DHCS LIHP Division should be informed of changes that may impact TAR processing for health care.

DHCS LIHP Division will be informed of changes that may impact claims processing for health care during the System Replacement releases.






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federal requirements; compiles program data for federal and state reporting requirements; and develops contracts and amendments. In addition, the Division collaborates with program stakeholders and other divisions in planning program transition.

Mailroom Mailroom Xerox Part of Front End. Receives and sorts incoming hard copy claims and form into trays.

Xerox Mailroom is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the Mailroom process, but the Department will be made aware of the changes to the claims processing systems.

Managed Care Organization

MCO External

Manages commercial Medicaid programs. Submits encounters to report services provided to members.

Managed Care Organization’s may be impacted in data collection by the changes to forms that Providers will use. Communication on scheduled releases will be provided.

N/A N/A Managed Care Organization’s may be impacted in data collection by the changes to forms that Providers will use. Medical Claims may impact the Managed Care Organizations who submit encounter data for medical and outpatient claims. Communication on scheduled releases will be provided.






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Maximus MCP Eligibility

External

Performs enrolling and dis-enrolling members to MCPs.

N/A N/A N/A N/A

Medical Case Agent

CMIS-MCM DHCS Creates and works cases - Medical Case Management (Systems of Care Division).

DHCS CMIS-MCM will be informed of changes that may impact Medical Case Management in all releases of the System Replacement Project.

Medi-Cal Consultant

MC DHCS Authorizes Medi-Cal TARs. N/A DHCS Medi-Cal Consultant should be informed of changes that may impact TAR authorization. Changes in Treatment Authorization / Service Authorizations may impact the review process that is currently used by Medi-Cal Consultants

N/A

Medi-Cal Dental Services Division

MDSD DHCS Medi-Cal Dental Services Division is responsible for the provision of dental services to Medi-Cal beneficiaries. Services are provided under FFS and managed care models. The division contracts with a dental FI for FFS and 13 MCPs and prepaid health plans (PHPs) to provide dental care to approximately 7.5 million-plus Medi-Cal beneficiaries. The FFS program is state wide; while the Dental Managed Care Plan (DMC) and PHP are located in Sacramento and Los Angeles counties.

DHCS MDSD; Division should be informed of changes that may impact claims processing and reporting.

N/A N/A DHCS MDSD; Division should be informed of changes that may impact claims processing and reporting.

Medi-Cal Eligibility Division

MCED DHCS Medi-Cal Eligibility Division develops statewide policies, procedures and regulations governing Medi-Cal eligibility and assures eligibility is determined accurately and timely in accordance with state and federal requirements. MCED performs Medi-Cal quality control reviews of county compliance with state and federal

DHCS – MCED assures that eligibility is determined based on program requirements and should be informed of CA-MMIS changes that may impact any necessary Medi-Cal eligibility policy and procedures implementations during the releases.






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eligibility requirements for program integrity and works with the county welfare department consortiums and ITSD to develop the business rules necessary to implement eligibility policy and to maintain the records of beneficiaries in both the county eligibility systems and DHCS’ MEDS. MCED provides county public social service agencies policy direction via County Welfare Directors Letters and Medi-Cal Eligibility Information Letters that implement Medi-Cal eligibility policies and procedures. MCED consists of three branches: Policy Development, Policy Operations and Program Review.

Medi-Cal Managed Care Division

MMCD DHCS Medi-Cal Managed Care Division contracts with managed care organizations to arrange for the provision of health care services for approximately 4.4 million Medi-Cal beneficiaries in 30 counties. MMCD has three primary models: Two-Plan, which operates in 14 counties; County Organized Health Systems (COHS), which operate in 14 counties; and Geographic Managed Care, which operates in two counties. MMCD also contracts with a PHP in one additional county and with two specialty plans. In total, Medi-Cal managed care paid health plans approximately $10.6 billion for rate year 2010-11. MMCD has three branches: Plan Monitoring/Program Integrity, Policy and Financial Management and Plan Management.

DHCS – MMCD may be impacted in data collection by the changes to forms that Providers will use, and releases that may change the data collection process.

N/A N/A DHCS – MMCD may be impacted in data collection by the changes to forms that Providers will use and releases that may change the data collection process.






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Medical Professional Service Group

MPSG Xerox Part of Claims Operations. The Medical Professional Service Group is responsible for reviewing claims for medical judgment. The group is made up of various professionals including doctors, nurses, and pharmacists. Works closely with DHCS on policy considerations and/or issues. The Medical Professional Service Group consists of two areas: DUR, DRU.

Xerox MPSG is part of Claims Medical Professional Service Group and will process claims that are impacted with changes. This team will need to be familiar with how PBM OS+ adjudication works

Xerox MPSG is part of Claims Medical Professional Service Group and may review Treatment Authorization/Service Authorizations that are impacted with changes. The changes for TARS/SARS may impact the way that the approved authorizations can be viewed by Consultants when working a claim. The consultants need to be trained in all aspects of these changes.

Xerox MPSG is part of Claims Medical Professional Service Group and may process claims that are impacted with changes. This team will need to be familiar with how HE adjudication works in order to review the claims.

Medical Review Branch

MRB DHCS Medical Review performs medical and financial audits and federally mandated post service, post payment utilization reviews of non-institutional Medi-Cal providers, including laboratories and pharmacies.

DHCS MRB supports the medical and financial audits for DHCS which may be impacted due to changes in claims processing. The MRB needs to understand how the PBM OS+ system manages claims processing.

N/A N/A DHCS MRB supports the medical and financial audits for DHCS which may be impacted due to changes in processing. The MRB needs to understand how the HE system manages claims processing.

Medicare Medicare External

Submits crossover claims to Medi-Cal. Medicare supports the submission of

N/A N/A Medicare supports the submission of






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crossover claims to Medi-Cal which may be impacted due to changes in processing claims. Medicare will be kept informed of the different releases.

crossover claims to Medi-Cal which may be impacted due to changes in processing of claims. Medicare will be kept informed of the different releases.

Member Member External

Beneficiary of the Medi-Cal and associated programs. Individual or family who has met the eligibility requirements to be enrolled in the Medi-Cal program.

N/A N/A N/A N/A

Office of Civil Rights

OCR DHCS Office of Civil Rights is responsible for overseeing compliance with various federal and state civil rights laws and implementing regulations and executive orders pertaining to employment and services by DHCS and its contractors to assure nondiscrimination in the access and delivery of health care services provided or administered by DHCS. OCR provides departmental guidance, coordination, monitoring, training and investigation of issues relating to DHCS employees through the Internal Equal Employment Opportunity Program (Title VII), External Civil Rights Compliance Program (Title VI) and Reasonable Accommodation Program. Also, OCR coordinates and develops technical, prevention and sensitivity awareness training that

N/A N/A N/A N/A






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deals with Equal Employment Opportunity and disability issues and resolves complaints of discrimination via counseling, informal reviews, investigations and mediations filed by DHCS applicants and employees.

Office of Family Planning

OFP DHCS The Office of Family Planning administers the FPACT program. Effective July 1, 2012, the Office of Family Planning/Family PACT program transitioned from the CDPH to DHCS.

DHCS – OFP may be impacted by the changes to forms that Providers will use and any changes to Family Planning specific reports that may be used by their program.

Office of Health Information Technology

OHIT DHCS OHIT is responsible for implementing the Medi-Cal Electronic Health Record Incentive Program. This incentive program shall improve the quality, safety and efficiency of health care by Medi-Cal hospitals and professionals through incentive payments to encourage the meaningful use of electronic health records. OHIT administers a new program that began making incentive payments in 2011 to qualified Medi-Cal health care providers who adopt and use electronic health records in accordance with the American Recovery and Reinvestment Act of 2009. OHIT sets the policies and procedures for the program, in addition to implementing systems to disburse, track and report the incentive payments. It also develops goals and metrics for the program, including the impact of the program on quality, cost and service.

DHCS – OHIT incentive program by be impacted due to the changes in claims processing under Pharmacy claims. OHIT will be kept informed of the releases to determine any impact to Medi-Cal Health care providers.

N/A N/A DHCS – OHIT incentive program by be impacted due to the changes in claims processing for all other claim types. The OHIT will be kept informed of the releases to determine any impact to Medi-Cal Health care providers.

Office of HIPAA Compliance

OHC DHCS Office of HIPAA Compliance (OHC) is responsible for leadership and

DHCS – OHC is responsible for oversight related to implementation






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oversight related to the implementation and maintenance efforts of a range of federally required initiatives to simplify and standardize the administration of health care while protecting the privacy of patients served by DHCS programs. Federal HIPAA legislation passed in 1996 established national standards for electronic health care transactions and national identifiers for providers, health plans and employers. It also addressed the security and privacy of health data and was adopted to improve the efficiency and effectiveness of the nation’s health care system by encouraging the widespread use of EDI. HIPAA requirements continue to be updated, most recently through administrative simplification provisions included in the ACA. OHC also serves as the DHCS lead for measuring and monitoring progress against the MITA framework, a federal initiative that holds states accountable for federally funded health IT expenditures. An annual operating budget of approximately $50 million is used to fund administrative simplification projects throughout DHCS, primarily for systems maintained by the Medi-Cal program’s FI.

and alignment to MITA and needs to be kept informed.

Office of Legal Services

OLS DHCS Office of Legal Services provides legal services to DHCS and its employees and legal support to departmental programs. OLS's 50 attorneys and nine paralegals are distributed among five large legal teams, each of which focuses on a particular area of departmental legal work:

DHCS – OLS is responsible for Medi-Cal House Counsel Team and supports the Medi-Cal Litigation Team, which needs to be kept informed of

DHCS – OLS is responsible for Medi-Cal House Counsel Team and supports the Medi-Cal Litigation Team, which needs to be kept informed of changes to TARs processing.

DHCS – OLS is responsible for Medi-Cal House Counsel Team and supports the Medi-Cal Litigation Team, which






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The Administrative Litigation Unit represents DHCS in administrative hearings before the Office of Administrative Hearings and Appeals, the State Personnel Board and other state entities, and handles the bulk of DHCS’ legal personnel functions.

The Medi-Cal House Counsel Team serves as DHCS’ primary provider of legal support for programmatic functions, including the drafting and reviewing of much of DHCS’ proposed legislation.

The Medi-Cal Litigation Team provides programmatic legal support, but also serves as DHCS’ liaison to the California Attorney General's Office and other external entities about litigation involving DHCS, and this team provides litigation support for active cases.

The Special Projects Team handles legal assignments that emanate primarily from the directorate, such as implementation projects related to the ACA.

The newly created Medi-Cal Financing and Rates Team specialize in its namesake subject matter.

OLS also contains two sub-specialty programs: the Privacy Office, staffed by attorneys dedicated to privacy legal compliance; and the Office of Regulations, which is responsible for ensuring the consistency and accuracy of regulations that DHCS promulgates.

changes to claims processing and reporting.

needs to be kept informed of changes to claims processing and reporting.

Office of Medi- OMCP DHCS Office of Medi-Cal Procurement is an DHCS – OMCP is DHCS – OMCP is responsible DHCS –






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Cal Procurement

internal consulting and advisory group within DHCS. OMCP’s function is to conduct major procurements and write contracts in support of the various divisions and offices of the Medi-Cal program. These procurements may take the form of Requests for Proposal (RFP) and Requests for Application (RFA), depending upon the services being sought. OMCP is responsible for the entire process from the development of the procurement documents to the evaluation of proposals received in response to those documents through to the development and approval (from the Department of General Services and CMS) of the contract documents. Medi-Cal procurement and contracting procedures are conducted with the highest integrity, with the goal of producing procurement documents and contracts that are effective and cost-efficient for the Medi-Cal program.

responsible for Medi-Cal Procurements and responsible for producing procurement documents and needs to be aware of changes to CA-MMIS claims processing that may impact future procurement efforts.

for Medi-Cal Procurements and responsible for producing procurement documents and needs to be aware of changes to CA-MMIS and the TAR process.

OMCP is responsible for Medi-Cal Procurements and responsible for producing procurement documents and needs to be aware of changes to CA-MMIS claims processing that may impact future procurement efforts.

Office of Multicultural Health

OMH DHCS Office of Multicultural Health serves as the internal focal point for improved planning and coordination of activities and programs that serve California’s racial and ethnic populations. OMH’s mission is to increase the capacity of DHCS and the CDPH, health care providers and ethnic/racial communities to achieve equity, reduce health disparities and improve access to quality care among racial/ethnic, Lesbian, Gay, Bisexual and Transgender (LGBT) and other underserved populations in California. OMH carries out its mission through

N/A N/A N/A N/A






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the following primary functions:

Informing and advocating for policies and practices to increase the effectiveness of programs and services toward reducing health disparities and inequities among diverse racial/ethnic, LGBT and underserved populations.

Informing and advancing national, state and local discussions on multicultural and LGBT health, cultural and linguistic competence, workforce diversity, health equity and the reduction of disparities in health and health care.

Advocating for and using federal, state and community level data to address the issues of health and health care disparities among racial/ethnic, LGBT and underserved populations to monitor and evaluate health outcomes among these population groups.

Creating and strengthening information networks among DHCS and CDPH programs and ethnic/racial, LGBT and underserved communities for the inclusion of community participation in decision-making related to health issues.

Building internal and external






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capacity to achieve equity and reduce health disparities through training, technical assistance, consultation and strategic planning.

Supporting the development and dissemination of information, strategies and resources contributing to the improved health status of racial/ethnic, LGBT and underserved communities.

Office of Public Affairs

OPA DHCS Office of Public Affairs is responsible for overall communications and outreach activities associated with DHCS and serves as the central conduit of information for the department. Staff responds to inquiries, drafts and finalizes approved responses and delivers responses to various stakeholders, the public and media. Staff also assess the impact of actions or situations involving the department and provide guidance on the appropriate message and method of response. OPA crafts statements and press releases, conducts interviews and background briefings and stages press conferences. Staff works to engage the general public and media with compelling, informative features on the home page of the DHCS website and communicates with internal staff primarily through the DHCS Times department newsletter. OPA also assists with DHCS’ public education and outreach programs, such as the California Partnership for Long-Term Care.

DHCS – OPA is responsible for oversight related to communication and outreach activities and needs to be kept informed. OPA will need to understand the specific releases and the changes being made in case they receive inquires or need to publish information related to the system changes.






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Office of Selective Provider Contracting Program

SPCP DHCS Through the Office of Selective Provider Contracting Program, DHCS contracts on a competitive basis with those hospitals that desire to provide inpatient services to Medi-Cal beneficiaries at a negotiated per diem rate for hospital inpatient services.

DHCS – SPCP is responsible for contracts related to hospital and needs to be kept informed of changes to CA-MMIS. These contracted hospitals will need to be kept informed of changes to claims processing which may impact them.

Office of Women’s Health

OWH DHCS Office of Women’s Health was created in 1993 by Governor's Executive Order W-57-93 and in 1994 was permanently established in statute. In 1997, the Gynecological Cancer Information Program was statutorily created within OWH. OWH is a shared policy and program within DHCS and CDPH that guides women’s public health services in a positive way to promote health and well-being and reduce the burden of preventable disease and injury among women and girls in California. OWH serves as a focal point for DHCS and CDPH policies and programs for setting and monitoring women’s health policies that promote more expansive and effective approaches to improve women’s overall health, including quality assessment, monitoring and improvement, coordination of existing programs and resources, enhancing the visibility and prominence of women’s health problems and developing cost-effective innovative approaches to addressing those problems. OWH has five major functions: women’s health policy, women’s health research, program administration of the Gynecological Cancer Information Program, health education and health literacy and outreach. OWH staffs the Women’s

DHCS – OWH is responsible for Women Public Health services and needs to be kept informed of changes to CA-MMIS. OWH will need to be informed of changes related to Pharmacy claims processing.

N/A N/A DHCS – OWH is responsible for Women Public Health services and needs to be kept informed of changes to CA-MMIS. OWH will need to be informed of changes related to System Replacement changes in claims processing.






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Health Council, which advises both directors and programs within DHCS and CDPH on a wide range of issues. OWH chairs the interagency California Women’s Health Survey and its interagency workgroup that researches women’s health and publishes annual reports and research findings.

Operations Training Department

OTD Xerox Responsible for the development and delivery of Operations training

Xerox OTD is responsible for the delivery of Operations training and will train on the CA-MMIS changes. OTD personnel will need to train in PBM OS+ for Pharmacy claims processing.

Xerox OTD is responsible for the delivery of Operations training and will train on the TAR submission changes. OTD personnel will need to train in SmartPA and the Medical Prior Authorization systems to support the future training efforts.

Xerox OTD is responsible for the delivery of Operations training and will train on the CA-MMIS changes. OTD personnel will need to train in HE for processing of all claim types.

Pharmacy Consultant

PC DHCS Authorizes Pharmacy TARs. DHCS – Pharmacy Consultant is responsible for authorizing Pharmacy TARS and needs to be kept informed of changes to CA-MMIS. They will need to train in the Smart PA and Medical Authorization systems.

Pharmacy Provider

Pharmacy Provider

External

A subset of the Provider actor group. Dispenses drugs to members and submits pharmacy claims.

Pharmacy Providers who submit pharmacy claims for services provided need to be kept informed of changes to processing.

Pharmacy Providers who submit pharmacy TARs for services provided need to be kept informed of changes to

N/A N/A






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processing.

Pharmacy Benefits Division

PBD DHCS Pharmacy Benefits Division is responsible for DHCS’ Medi-Cal FFS drug program and for the management of the Medi-Cal managed care pharmacy program. PBD is comprised of four branches: Pharmacy Policy, Enteral and Medical Supplies, Drug Contracting and Drug Rebates. In addition, the Vision Services program and the California Mental Health Care Management Program (CalMEND) fall under the purview of the division. PBD has primary responsibility for ensuring that prescription drug coverage is provided to FFS Medi-Cal beneficiaries. PBD contracts with drug and medical supply manufacturers and providers to assure they meet specific criteria, including safety, effectiveness and essential need, and to eliminate the potential for misuse. In exchange for the ability to contract with Medi-Cal, manufacturers provide rebates to the program, which in 2010-11 was approximately $1.7 billion in total rebates (federal and state). California’s rebate program is considered one of the most aggressive in the country. PBD is also responsible for the Medi-Cal FFS vision program and CalMEND, funded primarily with funding from the Mental Health Services Act (Prop. 63) and charged with improving the health of Medi-Cal beneficiaries with mental illness.

DHCS – PBD are responsible for managed care Pharmacy Policy, Enteral and Medical Supplies, Drug Contracting and Drug Rebates and need to be kept informed of changes to CA-MMIS.

Primary & Rural Health Division

PRHD DHCS The mission of Primary & Rural Health Division is to improve the health status of diverse population groups living in

DHCS-PRHD responsible for Rural Health Care improvements and may need to be kept informed of changes to CA-MMIS and billing for






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medically underserved urban and rural areas. PRHD administers seven programs that seek to improve and make accessible primary care services and other public health services for persons at risk, including the uninsured or indigent, and those who otherwise have limited or no access to services due to geographical, cultural or language barriers. Those programs are: Rural Health Services Development (RHSD), Seasonal and Agricultural Workers (SAMW), Indian Health (IH), California State Office of Rural Health (CalSORH), Medicare Rural Hospital Flexibility/Critical Access Hospital (FLEX/CAH), Small Rural Hospital Improvement (SHIP) and J-1 Visa Waiver. The division functions as the primary liaison for providers and other stakeholders concerned with rural health, IH and primary care clinics. PRHD works with rural health constituents to provide training and technical assistance to strengthen the rural health care infrastructure. PRHD has lead responsibility in ensuring that DHCS complies with federal requirements to seek regular and ongoing advice from tribes and IH program designees on proposed changes to the Medi-Cal program that have a direct impact on Indians and IH providers. PRHD also provides training and technical assistance to IH programs as well as administers the American Indian Infant Health Initiative (AIIHI) and Federal Emergency Preparedness activities. Additionally, PRHD assists in the development of Medi-Cal policies affecting Federally

services.






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Qualified Health Centers, Rural Health Clinics and IH clinics.

Print and Distribution

P&D Xerox Part of Provider Relations Organization. Prints and distributes mass quantities of publications affiliated with the Medi-Cal program.

Xerox – P&D provide the forms distribution and distributions of bulletins which may include processing changes.

N/A N/A Xerox – P&D provide the forms distribution and distributions of bulletins which may include processing changes.

Provider Provider External

Individual or organization enrolled by the Medi-Cal program to provide certain services to Medi-Cal members, including doctors, hospitals, nursing homes, pharmacies, or durable medical supplies retailers.

Pharmacy Providers who submit pharmacy claims for services provided need to be kept informed of changes to processing.

Providers who submit TAR/SAR Request for services provided need to be kept informed of changes to prior authorization request as well as claims processing.

Pharmacy Providers who submit Medical claims for services provided need to be kept informed of changes to processing.

Provider Enrollment Division

PED DHCS Provider Enrollment Division is responsible for the review and appropriate action of FFS provider applications seeking to participate in the Medi-Cal program, including ensuring that applicants meet licensure requirements and participation standards defined by federal and state statutes and regulations. PED also conducts re-enrollment functions of current providers to assure continued compliance with program requirements and standards of participation. PED has responsibility for updating and maintaining the Provider Master File

DHCS – PED Enrolls and updates the provider master file as it relates to Medi-Cal Providers and should be kept informed of changes that may impact the files that are transmitted to CA-MMIS..

N/A N/A DHCS – PED Enroll and update the provider master file as it relates to Medi-Cal Providers and should be kept informed of changes that may impact the files that are transmitted to






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database that is used in the claims payment process. PED is actively involved in Medi-Cal anti-fraud efforts aimed at preventing fraud, waste and abuse in the Medi-Cal program.

Substance Use Disorder clinics and their satellite sites who participate in the Drug Medi-Cal (DMC) Program are certified via the DMC Provider Certification process, as stipulated in the Drug Medi-Cal Standards for Substance Abuse Clinics of 2004.

County Mental Health Plans (MHP) determine initial eligibility for Specialty Mental Health (SMH) program and submit to the MHS Medi-Cal Claims Customer Service office .

CA-MMIS.

Provider Integrity Unit

PIU Xerox Monitors the activities of providers and tracks suspicious activity. There are three departments within the Provider Integrity Unit: Provider Review Unit, Surveillance and Utilization Review Subsystem (SURS) Liaison, and Cost Containment.

Xerox –PIU unit is responsible for providing SURS reports, and Provider Review on claims processed to State Agencies. The PIU will need to understand PBM OS+ and the HE claims processing systems and the impact to running the SURS reports.

Provider Outreach and Education

Provider O&E

Xerox Part of Provider Relations Organization. Disseminates program information and provider education. Coordinates educational provider seminars throughout California.

Xerox - Provider O & E is responsible for the delivery of program information to Providers and training as needed. O&E will have to reach out to the Provider community to train them on Health Enterprise features, as well as on the differences in how the new system will operate compared to how Legacy currently works.

Provider Relations Organization

PRO Xerox The Provider Relations Organization is organized into five major business areas: Telephone Service Center, Research and Correspondence, Provider O&E, Publications, and Print and Distribution.

Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing, reporting, and CA-MMIS to conduct research and answer Provider questions.






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Provider Review Unit

PRU Xerox Part of Provider Integrity Unit. Reviews the activities of providers for suspicious fraudulent or abusive activity.

Xerox –PRU unit is responsible for review of suspect Providers and reporting suspicious activity. The PRU team will need to understand the PBM OS+ and the HE claims processing systems and the impact to claims review for fraudulent or abusive activity.

Publications PUBS Xerox Writes, edits, designs, and routes Medi-Cal content for distribution through both print and the Internet media channels.

Xerox –PUBS unit is responsible for distribution of Medi-Cal bulletins or web notifications regarding changes.

Research and Correspondence

R&C Xerox Part of Provider Relations Organization. Researches and resolves billing issues and communicates in writing to providers regarding complex billing questions and issues.

Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing or CA-MMIS to conduct research, and answer Provider questions.

Safety Net Financing Division

SNFD DHCS Safety Net Financing Division administers supplemental payments in accordance with the “Bridge to Reform” Section 1115 Medicaid Waiver and the Medicaid State Plan. The Medi-Cal Supplemental Payment Section (MSPS) processes and monitors payments for hospitals and other types of providers for various supplemental programs and administers the QAF program. The Hospital/Uninsured Care Demonstration Section (HUCDS) evaluates designated public hospital costs and rates, oversees the development of California’s new waiver, oversees the implementation of the Diagnostic Related Group (DRG) inpatient hospital’s reimbursement methodology and administers the Sub acute Care Program. The Administrative Claiming, Local and School Services Branch provide federal reimbursement to counties and school districts for administrative activities, targeted case management and certain

DHCS – SNFD administers supplemental payments for the DHCS and needs to be kept informed of changes that impact CA-MMIS.






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medically necessary school-based services. The Disproportionate Share Hospital Financing and Non-Contract Hospital Recoupment Branch reimburses eligible hospitals for uncompensated care costs for hospital services and recoups overpayments for inpatient hospital services provided by non-contract hospitals.

Scanning Scanning Xerox Part of Front End. Front End scanning is responsible for scanning in hardcopy claims received using the OCR software. The claims then move to the data entry system where the business rules are applied and data entry operators validate fields that fail a business rule, or that the OCR could not read.

Xerox Scanning is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the scanning area process, but the Department will be made aware of the changes to the claims processing systems.

Xerox Scanning is part of Claims Operations may process TARS that are impacted with changes. There will be no direct impact to the scanning area process, but the Department will be made aware of the changes to the claims processing systems.

Xerox Scanning is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the scanning area process, but the Department will be made aware of the changes to the claims processing systems.

Service Delivery SG Xerox The Service Delivery Team is responsible for managing SDNs and System Change Requests that are received from DHCS. They work closely with their DHCS counterpart to understand the changes that need to be made and to meet the implementation timeframes.

SDNs and OILs that are implemented during development may impact specific releases. The Service Delivery Team will be kept informed of all system changes.






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Small Provider Billing Unit

SPBU Xerox Part of Provider O&E. Provides support and trains small providers (based on number of claims) until they become proficient in creating and submitting Medi-Cal claims.

Xerox - Small Provider Billing Unit needs to be kept informed of any changes to claims processing or CA-MMIS to support the Provider community they support. The SPBU unit will need to be trained on the PBM OS+ system for processing of any Pharmacy claims.

Xerox - Small Provider Billing Unit needs to be kept informed of any changes to TAR processing or CAMMIS to support the Provider community they support.

Xerox - Small Provider Billing Unit needs to be kept informed of any changes to claims processing or CA-MMIS to support the Provider community they support. The SPBU unit will need to be trained on the HE system for processing of any claims.

State Controller's Office

SCO External

Disburses payments to providers. SCO needs to be informed of any change to claims processing and reporting in CA-MMIS that may impact Provider Payments.

N/A N/A SCO needs to be informed of any change to claims processing and reporting in CA-MMIS that may impact Provider Payments.

Submitter Submitter External

Submits claims to CA-MMIS on behalf of providers. Submitters are also known as Clearing House.

Submitters are responsible for submitting claims on behalf of providers and need to be kept informed of

N/A N/A Submitters are responsible for submitting claims on behalf of providers and need to be






Medical Claims

changes to claims processing or submission of the electronic files. .

kept informed of changes to claims processing or submission of the electronic files.

Surveillance Utilization Review Subsystem Liaison

SURS Liaison

Xerox Part of Provider Integrity Unit. Assists with SURS, which monitors fraud and abuse activity.

Xerox –SURS Liaison is responsible for running reports to support fraud and abuse and need to be informed of changes to CA-MMIS.

N/A N/A Xerox –SURS Liaison is responsible for running reports to support fraud and abuse and need to be informed of changes to CA-MMIS.

Systems of Care for Children and Adults Division

SCD DHCS Systems of Care for Children and Adults Division creates effective and efficient systems of care for vulnerable populations with chronic conditions to better improve or maintain their health care status and reduce health care costs. SCD is comprised of two major branches: Statewide Medical Services Branch (SMSB) and Program Operations Branch (POB). SMSB is comprised of medical professionals who have oversight of several programs, including: Medical Therapy, serving 27,000 clients; High-Risk Infant Follow-Up; Child Health and Disability Prevention, serving two million children; Genetically Handicapped Persons, serving 1,500 clients; Newborn Hearing Screening, which screens about 425,000 annually; and Health Care Program for Children in

DHCS – SCD is responsible for the CSC program and needs to be kept informed of changes that impact CA-MMIS.

N/A N/A DHCS – SCD is responsible for the CSC program and needs to be kept informed of changes that impact CA-MMIS.






Medical Claims

Foster Care Programs. The POB has administrative oversight of these same programs. POB is also responsible for the development and implementation of the California Children’s Services (CSC) demonstration pilot program as a component of DHCS’ Section 1115 Medicaid “Bridge to Reform” waiver.

Telephone Service Center Agent

TSC Xerox Part of Provider Relations Organization. Researches, resolves, and responds to Medi-Cal provider and member telephone inquiries.

Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing or CA-MMIS to conduct research, and answer Provider questions.

N/A N/A Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing or CA-MMIS to conduct research, and answer Provider questions.

Third Party Liability and Recovery Division

TPLRD DHCS Third Party Liability and Recovery Division assures that the Medi-Cal program complies with state and federal laws and regulations requiring that Medi-Cal be the payer of last resort. TPLRD accomplishes this by recovering Medi-Cal expenses from liable third parties and avoiding Medi-Cal cost by identifying or purchasing alternative health care coverage. TPLRD’s recovery programs, Estate Recovery, Personal Injury and Overpayments, account for $300 million in annual revenue. TPLRD cost avoidance programs annually process

DHCS – TPLRD is responsible for recovering Medi-Cal expenses from liable third parties program and needs to be kept informed of changes that impact CA-MMIS claims processing and reporting.

N/A N/A DHCS – TPLRD is responsible for recovering Medi-Cal expenses from liable third parties program and needs to be kept informed of changes that impact CA-MMIS claims






Medical Claims

more than 300 million commercial insurance records and pay Medicare premiums for 1.1 million dual eligible beneficiaries, avoiding more than $3 billion in Medi-Cal costs. In addition to the coordination of benefits programs, TPLRD is also responsible for the collection of the Provider QAF, totaling approximately $4 billion annually.

processing and reporting.


B. CA-MMIS Business Process Maturity Level

The table below depicts the As-Is and To-Be maturity levels, where available, based on the SS-A report provided by OHC in October, 2013. Note: Business processes with a To-Be rating of “N/A” indicate they are identified by DHCS as marked for consolidation into another business process. Maturity levels for Inquire Medi-Cal Eligibility are listed as “TBD” because all Eligibility and Member Management business processes are on hold pending the release of the outstanding components of the MITA Framework. The BCM, as explained in Section 1.1.4, will aid in determining if the system meets, exceeds, or does not meet the target To-Be maturity levels.

Table 21: CA-MMIS As-Is and To-Be Maturity Levels

As-Is Maturity Level To-Be Maturity Level

CA-MMIS Business Area



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Dat

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ctiv

enes

s

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cess

Util

ity o

r Val

ue to

St

akeh

olde

rs

Care Management


Authorize CCS/GHPP Services

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A

Medi-Cal Treatment Authorization Requests

2 2 2 2 2 2 2 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2

Case Management

Establish Case 1 1 1 1 1 1 1 2 2 2 2 2 2 2






Ove

rall

Tim

elin

ess

Dat

a A

cces

s &

Acc

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y

Effo

rt to

Per

form

Cos

t Effe

ctiv

enes

s

Acc

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y of

Pro

cess

Util

ity o

r Val

ue to

St

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rs

Ove

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Tim

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ess

Dat

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s &

Acc

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y

Effo

rt to

Per

form

Cos

t Effe

ctiv

enes

s

Acc

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y of

Pro

cess

Util

ity o

r Val

ue to

St

akeh

olde

rs

Establish CCS/GHPP Case

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A

Manage Case Information

1 1 1 1 1 1 1 2 2 2 2 2 2 2

Manage CCS/GHPP Case Information

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A


1 1 1 1 1 1 1 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2

State Specific Reserve Service

2 2 2 2 2 2 2 2 2 2 2 2 2 2

Contractor Management

Contract Management

Manage CA-MMIS FI Contract

2 2 2 2 2 2 2 2 2 2 2 2 2 2

Contractor Support


1 2 1 1 1 2 2 1 2 1 1 1 2 2






Ove

rall

Tim

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ess

Dat

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s &

Acc

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Effo

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Per

form

Cos

t Effe

ctiv

enes

s

Acc

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cess

Util

ity o

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St

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rs

Ove

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Tim

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ess

Dat

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s &

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Effo

rt to

Per

form

Cos

t Effe

ctiv

enes

s

Acc

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y of

Pro

cess

Util

ity o

r Val

ue to

St

akeh

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rs


Accounts Payable Management

Manage 1099 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Manage Contractor Payment

1 1 1 1 1 1 1 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2

Manage Incentive Payment

2 2 2 2 2 2 2 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2


2 2 2 2 2 2 2 2 2 2 2 2 2 2






Ove

rall

Tim

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ess

Dat

a A

cces

s &

Acc

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y

Effo

rt to

Per

form

Cos

t Effe

ctiv

enes

s

Acc

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Pro

cess

Util

ity o

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ue to

St

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rs

Ove

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Tim

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ess

Dat

a A

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s &

Acc

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Effo

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Per

form

Cos

t Effe

ctiv

enes

s

Acc

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y of

Pro

cess

Util

ity o

r Val

ue to

St

akeh

olde

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1 1 1 1 1 1 1 2 2 2 2 2 2 2

Manage Drug Rebate

1 2 1 1 1 2 2 2 2 2 2 2 2 2

Manage Estate Recovery

1 1 1 1 1 1 1 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2

Manage TPL Recovery

1 1 1 1 1 1 1 2 2 2 2 2 2 2

Fiscal Management

Formulate Medi-Cal Budget

1 1 1 1 1 1 1 2 2 2 2 2 2 2






Ove

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Tim

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ess

Dat

a A

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s &

Acc

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y

Effo

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Per

form

Cos

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ctiv

enes

s

Acc

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Pro

cess

Util

ity o

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ue to

St

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rs

Ove

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Tim

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ess

Dat

a A

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s &

Acc

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y

Effo

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Per

form

Cos

t Effe

ctiv

enes

s

Acc

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y of

Pro

cess

Util

ity o

r Val

ue to

St

akeh

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rs


1 2 1 2 2 2 2 2 2 2 2 2 2 2

Manage State Funds

2 2 2 2 2 2 2 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2

Member Eligibility and Enrollment Management

Member Enrollment

Inquire Medi-Cal Eligibility

TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD

Member Management

Member Support Management


(Based on 2008 SS-A)

1 1 1 1 1 1 1 2 2 2 2 2 2 2


Claims Adjudication


2 2 2 2 2 2 2 2 2 2 2 2 2 2






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ess

Dat

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Effo

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Per

form

Cos

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ctiv

enes

s

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Pro

cess

Util

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ue to

St

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Ove

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Tim

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ess

Dat

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Effo

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Per

form

Cos

t Effe

ctiv

enes

s

Acc

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Pro

cess

Util

ity o

r Val

ue to

St

akeh

olde

rs


2 2 2 2 2 2 2 2 2 2 2 2 2 2


2 2 2 2 2 2 2 2 2 2 2 2 2 2


Generate Medi-Cal Remittance Advice

2 2 2 2 2 2 2 2 2 2 2 2 2 2


2 2 2 2 2 2 2 2 2 2 2 2 2 2

Manage Data 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Process Encounter


1 1 1 2 2 2 2 2 2 2 2 2 2 2

Plan Management


Manage Benefit Information

1 1 1 1 1 1 2 1 1 1 1 1 1 1


1 1 1 1 1 1 2 2 2 2 2 2 2 2






Ove

rall

Tim

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ess

Dat

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Effo

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ctiv

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s

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Util

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Cos

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ctiv

enes

s

Acc

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Pro

cess

Util

ity o

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ue to

St

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rs

Manage Drug Formulary

2 2 2 2 2 2 2 N/A N/A N/A N/A N/A N/A N/A

Manage Rate Setting

1 1 1 1 1 1 1 2 2 2 2 2 2 2

Health Plan Administration

Develop and Manage Performance Measures

1 1 1 1 1 1 1 1 1 1 1 1 1 1


1 1 1 1 1 1 1 1 1 1 1 1 1 1

Plan Administration

Maintain Program Policy

1 1 1 1 1 1 2 1 1 1 1 1 1 2


Compliance Management

Determine Adverse Action Incident

1 1 1 1 1 1 1 2 2 2 2 2 2 2

Establish Compliance Incident

1 1 1 1 1 1 1 2 2 2 2 2 2 2

Identify Utilization Anomalies

1 1 1 1 1 1 1 2 2 2 2 2 2 2






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Effo

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Cos

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Pro

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St

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Effo

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Cos

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Acc

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Pro

cess

Util

ity o

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ue to

St

akeh

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1 1 1 1 1 1 1 2 2 2 2 2 2 2


1 1 1 1 1 1 1 2 2 2 2 2 2 2

Provider Eligibility Management

Provider Enrollment


1 1 1 1 1 1 1 3 3 3 3 3 3 3


1 1 1 1 1 1 1 3 3 3 3 3 3 3


1 1 1 1 1 1 1 3 3 3 3 3 3 3


2 2 2 2 2 2 2 N/A N/A N/A N/A N/A N/A N/A






Ove

rall

Tim

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ess

Dat

a A

cces

s &

Acc

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y

Effo

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Per

form

Cos

t Effe

ctiv

enes

s

Acc

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Pro

cess

Util

ity o

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St

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Ove

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Tim

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ess

Dat

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Acc

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Effo

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Per

form

Cos

t Effe

ctiv

enes

s

Acc

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y of

Pro

cess

Util

ity o

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ue to

St

akeh

olde

rs

Determine CHDP Provider Eligibility

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A

Enroll Drug Medi-Cal Provider

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A

Enroll Mental Health Provider

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A

Enroll Dental Provider

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A

Enroll CCS Provider

2 2 2 2 2 2 2 N/A N/A N/A N/A N/A N/A N/A

Enroll CHDP Provider

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A

Disenroll Medi-Cal Provider

1 1 1 1 1 1 1 3 3 3 3 3 3 3

Disenroll Dental Provider

1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A






Ove

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Tim

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Dat

a A

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Acc

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Effo

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Per

form

Cos

t Effe

ctiv

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s

Acc

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Pro

cess

Util

ity o

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ue to

St

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Ove

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Tim

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ess

Dat

a A

cces

s &

Acc

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Effo

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Per

form

Cos

t Effe

ctiv

enes

s

Acc

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y of

Pro

cess

Util

ity o

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ue to

St

akeh

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Provider Management



1 1 1 1 1 1 1 3 3 3 3 3 3 3

Provider Support


1 1 1 1 1 1 1 1 1 1 1 1 1 1


2 2 2 2 2 2 2 2 2 2 2 2 2 2


2 2 2 2 2 2 2 2 2 2 2 2 2 2


C. Actor Primary Interactions with CA-MMIS Business Process

Table 22: CA-MMIS Primary Actor Interactions with Business Processes


CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction

Care Management


Medi-Cal Treatment Authorization Requests

Provider TAR

Medi-Cal Consultant TAR

Authorize CCS/GHPP Services CMS-DHCS SAR


Provider Treatment Plan

Medical Case Agent Treatment Plan

Case Management Establish Case Provider Treatment Plan

Establish CCS/GHPP Case SCD Medical Case

Manage Case Information Medical Case Agent Medical Case

Manage CCS/GHPP Case Information SCD Medical Case

Perform Screening and Assessment LTCD Case Management


LTCD LTCD performs case management for specific waiver programs and special programs.




State Specific Reserve Service Provider Service Reservation Request

Contractor Management Contractor Support

Manage Medi-Cal Contractor Communication Fiscal Intermediary Documentation and Communications in

SharePoint

Manage CA-MMIS FI Contract CA-MMIS Division

CA-MMIS FI contract management is the same as those performed across the Department for the management of all Medi-Cal contracts.

Financial Management Accounts Payable Management Manage 1099 Cash Control

Analyst 1099 reports

Manage Contractor PaymentOverseen by multiple business areas within DHCS

Interaction with many business areas, such as inpatient hospitals and managed care health plans, along with program-specific health services contracts include lab, pharmacy, DME, and disease management.

Manage Health Insurance Premium Payments TPLRD

CA-MMIS Recipient Subsystem: MEDS is accessed and updated to support the HIPP process. CAPMAN system automates the capitation payment calculation process, HIPP premium payments, and generates the HIPAA 820 payment and 834 enrollment transactions.

Manage Incentive Payment Provider Incentive payment

Manage Medi-Cal Accounts Payable Information SCO Warrant numbers; Medi-Cal payments &

disbursements

Manage Medi-Cal Payable Disbursement SCO Payment information & disbursements


TPLRD CA-MMIS Recipient Subsystem: MEDS is updated with Medicare eligibility and buy-in information resulting from data exchanges with CMS.





Manage Cost Reports Settlement TPLRD Cost settlement amounts; Recoupment requests

Manage Drug Rebate DRU Drug Rebate reference information; Drug Rebate invoices

Manage Estate Recovery TPLRDEstate recovery referrals are typically received from vital records data and the descendents representatives

Manage Medi-Cal Accounts Receivable Funds FMB Payments; Provider checks


Cash Control Analyst Accounts Receivable (A/R) transactions

Appeals Examiner Accounts Receivable (A/R) transactions


Cash Control Analyst Provider recoupment transactions

Manage TPL RecoveryTPLRD TPL analysis results; Recoupment

transaction information.

CA-MMIS Division TPL letters

Fiscal Management Manage State Funds DHCS Administration Division (AD)

AD Accounting Section is responsible for reconciling state fund allocations and the drawdown and reporting of FFP




Formulate Medi-Cal Budget Financial Management Branch (FMB) of the Administration Division with input from the FFB

Budget Office of FMB is responsible for State Support and non-Medi-Cal Local Assistance while the FFB looks at current revenue trends and expenditures, assesses external factors impacting the program, models different budget scenarios and produces the budget estimates for the Medi-Cal and CCS/GHPP/CHDP Local Assistance program. DHCS Director has final approval authority for the proposed Medi-Cal budget sent to the Governor.


DHCS Administration Division, FFB

FFB prepares the CMS-37 and CMS-21B reports in support of the budget process and the management of FFP.


Overseen by the CA-MMIS Division

Member reimbursement checks are distributed by the State Controller’s Office.

Member Eligibility and Enrollment Management Member Enrollment Inquire Medi-Cal Eligibility County Office Inquiry transactions

Member Management Member Support Management


TAR Office Consultants

Review the documentation received from Providers on behalf of the Member and make a determination on the TAR request to initiate the NOA letter.

CA-MMIS Receive the NOA response letter and print and mail to Provider on behalf of Member.

Operations Management Claims Adjudication Apply Medi-Cal Mass Adjustment CA-MMIS Division Claims mass adjustment work order

Process Medi-Cal ClaimProvider Claims

Submitter Claims


Provider Claim attachments





Generate Medi-Cal Remittance Advice SCO Medical remittance advice

Inquire Medi-Cal Payment Status Provider Medi-Cal payment status inquiry

Manage Data

Provider Relations Organization Data

Claims Operations Data

DUR Data

Cash Control Analyst Data

Process Encounter Process Managed Care Encounter EDU Managed Care encounter data

Plan Management


Maintain Benefits-Reference Information CA-MMIS Division Policy-triggered transactions

Manage Drug Formulary PBD PBD is responsible for developing the policy instructions needed to add or modify drug codes to the CA-MMIS formulary file

Manage Rate Setting FFSRDD FFSRDD is responsible for rate setting activities for the majority of Medi-Cal services , there are multiple other program areas responsible for rate setting activities such as PBD, MDSD, SNFD,

Hospital contract rates and school-based services, MHSUDS, PED sets rates for certain types of LTC facilities, MHS – Sets rates for mental health services Drug Medi-Cal – Sets rates for the Drug Medi-Cal program

Health Plan AdministrationDevelop and Manage Performance Measures

CA-MMIS Division Program performance measures




Manage Benefit Information DHCS Directorate The various DHCS program areas are responsible for maintaining and updating relevant benefit package information and related changes in Medi-Cal policy.


CA-MMIS Division Policy-triggered transactions

Plan Administration Maintain Program Policy

DHCS Directorate

Various DHCS program areas are responsible for maintaining and updating policies related to Medi-Cal approved services

File Maintenance

File Maintenance Team receives FI letters with OILs to update policy per DHCS instructions. They are responsible for implementing the policy related to the DHCS change requests in the allotted time frames.

Service Delivery Process SDNs and system change requests.


Compliance Management

Determine Adverse Action Incident A&I Division A/R transactions; Suspect hold Providers;

TPL cases; Legal activities

Establish Compliance Incident A&IA&I coordinates with other DHCS Divisions and government agencies for referrals, data and investigative support

Identify Utilization Anomalies CAASDTARs; TAR denial appeals; Claims review for abnormalities in billing & cost containment ideas


A&I A&I coordinates with other DHCS Divisions and government agencies for referrals, data and investigative support.





CA-MMIS Division, MDSD

For medical services, the CA-MMIS FI, Xerox, sends out manual confirmation letters to a select number of beneficiaries. For dental services, the CD-MMIS FI, Delta Dental, produces confirmation letters for beneficiaries that received a service that was preauthorized


Provider Enrollment Determine Medi-Cal Provider Eligibility PED

PED determines eligibility for the majority of providers requesting enrollment into the Medi-Cal program.

Determine Provider Eligibility for Incentive Program OHIT

Applicant providers must first complete the federal registration process prior to being able to access the Medi-Cal State Level Registry for enrollment into the EHR Incentive Program

Determine CHDP Provider Eligibility SCD

Applicant providers must already be enrolled as a Medi-Cal Provider to apply to be a CHDP provider. CHDP providers are location specific and the determination of eligibility process is performed by the local CHDP county offices


Provider Enrollment applications (out-of-state)

PED

Provider eligibility & enrollment applications;Approval/denial letter (out-of-state)

Enroll Drug Medi-Cal Provider PED (SUDS) Substance Use Disorder clinics and their satellite sites who participate in the DMC Program are certified via the DMC Provider Certification process as stipulated in the Drug Medi-Cal Standards for Substance Abuse Clinics of 2004.




Enroll Mental Health Provider DMH

County MHPs determine initial eligibility for SMH program and submit standard forms to the MHS Medi-Cal Claims Customer Service Office (MedCCC) for processing and enrollment.

Enroll Dental Provider MDSD Fiscal Intermediary for the CD-MMIS, Delta Dental, performs the majority of the steps.

Enroll CCS Provider SCD

Applicant providers must already be enrolled as a Medi-Cal Provider to apply to be “paneled” as a CCS provider. Application process is online and auto enrolls the provider into the CCS program if all requirements are met.

Enroll CHDP Provider SCD

Applicant providers must already be enrolled as a Medi-Cal Provider to apply to be a CHDP provider. CHDP providers are location specific and the enrollment process is performed by the local CHDP county offices.

Disenroll Medi-Cal Provider PED

PED performs the steps for a majority of providers requiring disenrollment from the Medi-Cal program. Some provider types are disenrolled from the Medi-Cal program by other state organizations (e.g., Licensing and Certification for institutional providers), for which PED’s primary responsibility is to perform the steps to have the PMF.

Disenroll Dental Provider MDSD The Fiscal Intermediary for the CD-MMIS, Delta Dental, performing the majority of the steps. The Customer Service Department is the Delta Dental organizational component that maintains centralized information on Medi-Cal Dental Program providers, and acts as the primary point of communication between providers and the program.




Inquire Medi-Cal Provider Information PED Inquiry transactions

Provider Management


Manage Medi-Cal Provider Information PED Provider information

Provider Support


Provider Relations Organization Provider appeals & grievances

Manage Medi-Cal Provider Communication Provider O&E Program information;

Medi-Cal Provider education


Provider Communications

Provider O&E Communications to Medi-Cal Providers


D. Medi-Cal Enterprise

For a full view of the diagram on the following page, refer to the Referenced Documents table for the SharePoint link to the Medi-Cal Enterprise Business Process Diagram in SharePoint.

Figure 12: Medi-Cal Enterprise



E. Planned Releases Roadmap

Effective January, 2014, the following figure depicts the roadmap for the planned releases of the CA-MMIS System Replacement Project based on the modified agile approach.

Figure 13: Roadmap for Releases 1 – 5


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