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KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES

DIVISION FOR MEDICAID SERVICES

KENTUCKY MMIS PROCUREMENT 2012MEDICAID INFORMATION TECHNOLOGY

ARCHITECTUREGAP ANALYSIS

Deliverable 8

November 23, 2012

Version 2.0

Prepared by:

7926 Jones Branch Drive, Suite 330McLean, VA 22102

(480) 423-8184www.cognosante.com

http://www.cms.hhs.gov/MedicaidInfoTechArch/Downloads/part1.zip

Kentucky MMIS Procurement 2012MITA SS-A Gap Analysis

REVISION HISTORYVersion Number Date Reviewer CommentsV1.0 7/12/2012 Fred Hinds Initial SubmissionV1.01 11/19/2012 Fred Hinds RevisionsV2.0 11/23/2012 Nancy Ferguson Reviewed and

accepted Fred’s changes.

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TABLE OF CONTENTS1 INTRODUCTION..................................................................................................................51.1 Project Overview................................................................................................................51.2 Cognosante Methodology..................................................................................................61.3 Terminology Clarifications..................................................................................................61.4 MITA Framework 2.01.....................................................................................................10

2 KENTUCKY OVERVIEW....................................................................................................112.1 Kentucky Medicaid Mission..............................................................................................112.2 Kentucky Medicaid Vision................................................................................................112.3 Kentucky Medicaid Values...............................................................................................112.4 Kentucky Medicaid Guiding Principles.............................................................................112.5 Kentucky Goals and Objectives.......................................................................................11

3 RESULTS OF THE MITA BUSINESS PROCESS GAP ANALYSIS.................................133.1 Overview..........................................................................................................................133.2 Future Capabilities of the Kentucky MITA Business Areas..............................................133.2.1 Business Relationship Management.............................................................................163.2.2 Care Management........................................................................................................213.2.3 Contractor Management...............................................................................................253.2.4 Member Management...................................................................................................333.2.5 Operations Management..............................................................................................413.2.6 Program Integrity Management....................................................................................553.2.7 Program Management..................................................................................................593.2.8 Provider Management...................................................................................................68

4 CONCLUSION....................................................................................................................73

APPENDIX A: CMS MITA FRAMEWORK APPENDIX E (STATE SELF-ASSESSMENT DETAILS)....................................................................................................................................75

LIST OF FIGURES AND TABLESFigure 1: To Be Maturity Level Summary....................................................................................14Figure 2: Business Relationship Management............................................................................16Figure 3: Business Relationship Management Maturity Level Summary....................................17Figure 4: Care Management........................................................................................................21Figure 5: Care Management Maturity Level Summary................................................................22Figure 6: Contractor Management...............................................................................................25

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Figure 7: Contractor Management Maturity Level Summary.......................................................26Figure 8: Member Management..................................................................................................33Figure 9: Member Management Maturity Level Summary..........................................................34Figure 10: Operations Management............................................................................................41Figure 11: Operations Management Maturity Level Summary....................................................43Figure 12: Program Integrity Management..................................................................................55Figure 13: Program Integrity Management Maturity Level Summary..........................................55Figure 14: Program Management................................................................................................59Figure 15: Program Management Maturity Level Summary........................................................60Figure 16: Provider Management................................................................................................68Figure 17: Provider Management Maturity Level Summary........................................................69

Table 1: MITA Maturity Model.......................................................................................................9Table 2: Business Relationship Management Business Area.....................................................18Table 3: Care Management Business Area.................................................................................23Table 4: Contractor Management Business Area........................................................................28Table 5: Member Management Business Area...........................................................................36Table 6: Operations Management Business Area.......................................................................45Table 7: Program Integrity Management Business Area.............................................................57Table 8: Program Management Business Area...........................................................................62Table 9: Provider Management Business Area...........................................................................70

LIST OF ACRONYMSThe following acronyms are used throughout this document:

Acronym Definition7C&S Seven Conditions and StandardsACA Affordable Care ActARRA American Recovery and Reinvestment Act of 2009ASC Accredited Standards CommitteeAVRS Automated Voice Response SystemBCCTP Breast and Cervical Cancer Treatment ProgramBCM Business Capability MatrixBP Business ProcessBPM Business Process ModelCAQH Council for Affordable Quality HealthcareCHFS Cabinet for Health and Family ServicesCMS Centers for Medicare and Medicaid Services

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Acronym DefinitionCOB Coordination of Benefits

COTS Commercial off-the-shelf

DCBS Department of Community Based ServicesDMS Division for Medicaid ServicesDW/DSS Data Warehouse/Decision Support SystemEDI Electronic Data InterchangeEHR Electronic Health RecordEOB Explanation of BenefitsEPSDT Early and Periodic Screening, Diagnosis, and TreatmentHBE Health Benefit ExchangeHIE Health Information ExchangeHIPAA Health Insurance Portability and Accountability ActIAPD Implementation Advanced Planning DocumentICD-10 International Statistical Classification of Diseases and Related Health

Problems, Tenth RevisionID IdentificationKAMES Kentucky Automated Management & Eligibility SystemKenPAC Kentucky Patient Access and CareKY KentuckyKYME Kentucky Medicaid EnterpriseMCO Managed Care OrganizationMEMS Medicaid Enterprise Management SystemMITA Medicaid Information Technology ArchitectureMMM MITA Maturity ModelMOU Memoranda of UnderstandingNCPDP National Council for Prescription Drug ProgramsNPI National Provider IdentifierOATS Office of Administrative and Technology ServicesPCCM Primary Care Case ManagerPE Presumptive EligibilityRFP Request for ProposalSNAP Supplemental Nutrition Assistance ProgramSS-A State Self-AssessmentSUR Surveillance and Utilization ReviewTANF Temporary Assistance to Needy FamiliesTPL Third Party Liability

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Acronym DefinitionUPD Universal Provider DatasourceUSPS United States Postal Service

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1 INTRODUCTION1.1 Project Overview

Cognosante is under contract to the Kentucky Cabinet for Health and Family Services (CHFS) to provide consulting services for the Kentucky Medicaid Management Information System (MMIS) Procurement. As part of that work effort, Cognosante is contracted to update the previous Medicaid Information Technology Architecture (MITA) State Self-Assessment (SS-A). Cognosante submits this Gap Analysis deliverable in accordance with Takeover and Replacement Project Amendment 1.

The four key deliverable documents for the Kentucky MITA SS-A update are as follows:

1. Kentucky MITA SS-A As Is update – This deliverable outlines the current capabilities and maturity levels for the various MITA business process (BP) areas.

2. Kentucky MITA SS-A To Be update – The amendment required an examination of the previously produced MITA SS-A document and a determination regarding the impact of the recent Kentucky enhancements to the As Is maturity levels and a review of the impacts that the Affordable Care Act (ACA) and Centers for Medicare and Medicaid Services (CMS) Enhanced Funding Requirements, Seven Conditions and Standards (7C&S) will have on the To Be MITA maturity level goals. This document presents the results of the examination of the To Be assessment of future goals, objectives, opportunities, and challenges.

3. Gap Analysis – This deliverable will identify the gaps between the As Is and the To Be, encompassing the Kentucky Medicaid program’s needs for business process improvements. This deliverable will also include the MITA Framework 2.01 Appendix E, which provides the justification documentation required by CMS for Implementation Advance Planning Document (IAPD)-planned improvement funding requests for the MMIS.

4. Transition Plan – The Transition Plan will highlight a plan to transition from the current MMIS architecture to future business and technology needs and services.

This document represents Deliverable 8: Gap Analysis and will present CHFS with a description and maturity level for the To Be business processes provided by the MITA Framework Version 2.01, Business Process Model (BPM) Version 2.01. This deliverable will describe the capabilities and maturity the Commonwealth wants to achieve (To Be) and provide the supporting detail for maturity level determination.

Section 2 presents Kentucky Medicaid’s goals and objectives as they relate to MITA.

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Section Error: Reference source not found provides details on the current and future levels of maturity of each Division for Medicaid Services (DMS) business process. This section provides a summary overview of the MITA management area within the Kentucky Medicaid Enterprise (KYME). Each subsection includes bulleted capability recommendations for maturity development and a detailed table for each business process. The tables provide the As Is and To Be maturity levels for each process. The tables also provide a description of maturity gaps that need to be met in order to achieve the desired To Be goals.

1.2 Cognosante Methodology

Because the schedule for this engagement was aggressive, Cognosante used the original Kentucky MITA Framework 2.01 material as a foundation with its eight business areas and 79 business processes, as the baseline. The original material was reviewed and placed in standardized templates. A review of recent changes to the MMIS, legislation such as the ACA, and CMS requirements was conducted and any updates and new findings were added to the templates. The detailed templates were used as the basis for the final deliverables. These completed templates will be delivered in a soft copy form because of the size and the need to be able to search the documents electronically. This process assured that all MITA business areas and processes would be addressed.

As a result of the review, the MITA To Be goals of certain business process capabilities were revised in order to meet the new requirements. The gap between the current As Is capabilities and the desired future To Be capabilities is the focus of this document.

1.3 Terminology Clarifications

Several concepts and entities are used in specific sense throughout this document, and the following definitions serve to clarify the in-depth discussions they precede.

1. Enterprise

The term enterprise is used throughout this document. It is preceded by an adjective to describe the processes and systems that make up the Medicaid solution. In this document, the term enterprise means:

A group of organizations (e.g., CHFS operating agencies)

Staff, systems, and interfaces that have a common purpose (e.g., Medicaid)

The following enterprise definitions are used to help the reader understand the context of terms used throughout this document.

CHFS Enterprise – The staff, systems, and interfaces that make up the Kentucky CHFS organization

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o Program Agencies

Department for Aging and Independent Living

Commission for Children with Special Health Care Needs

Department for Community Based Services

Department for Family Resource Centers and Volunteer Services

Office of Health Policy

Department for Income Support

Department for Medicaid Services (DMS)

Department for Behavioral Health, Developmental and Intellectual Disabilities

Department for Public Health

o Program Support Agencies

Governor’s Office for Electronic Health Information

Office of Administrative and Technology Services (OATS)

Office of Health Policy

Office of Communication and Administrative Review

Office of Human Resource Management

Office of the Inspector General

Office of Legal Services

Office of Ombudsman

Office of Policy and Budget

o Divisions

Administrative Hearings

Child Care

Child Support

Disability Determination Services

Family Resource and Youth Services Centers

Family Support

Prevention Violence Resources

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Protection and Permanency

Women’s Physical and Mental Health

o Advisory Commissions, Councils and Boards

Institutional Review Board

Kentucky Commission on Community Volunteerism and Service

Commonwealth Council on Developmental Disabilities

Kentucky e-Health Network Board

Kentucky Health Information Exchange Coordinating Council

Medicaid Enterprise – The staff, systems, and interfaces that are used to process, hold, or distribute Kentucky Medicaid information across the operating agencies

2. Silo

Silo is another term used throughout this document. Along with the term “compartmentalized,” silo is used to describe the lack of system interoperability, communication, and common goals across two or more business areas. For most of the CHFS enterprise management systems, the focus is inward and information communication is vertical. In general, staff members serve as information gatekeepers, making timely coordination and communication among departments difficult to achieve. Information gatekeepers also make seamless interoperability with external parties impractical. In general, silos tend to limit productivity in practically all organizations and provide greater risk for security lapses and privacy breaches.

3. MITA Maturity Model, Maturity Level, and Capability

The MITA Framework is grounded in several significant terms. Among the most significant terms are MITA Maturity Model (MMM), Maturity Level, and Capability.

MMM – A maturity model serves to measure and guide the performance of a specific business area (e.g., a long-term care waiver program) or business function (e.g., enrolling members) across time. The MMM provides each state’s Medicaid Enterprise with a structured timeline for realizing certain performance standards (e.g., within five years, enrolling members occurs online and information is automatically transferred from the application to systems for enrollment).

Maturity Level – Within the MMM there are five maturity levels for the each business process. These maturity levels are the summation of a set of performance standards and represent steps along the MMM. The maturity levels for individual processes are described in the tables beginning with Section 4. Each business process is assessed at one of its five maturity levels. This will be described as a certain business process having been assessed at a “MITA Maturity Level.”

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Table 1: MITA Maturity Model

Definition of State Medicaid Levels of MaturityLevel 1 Level 2 Level 3 Level 4 Level 5

Agency focuses on meeting compliance thresholds for State and Federal regulations, primarily targeting accurate enrollment of program eligibles and timely and accurate payment of claims for appropriate services.

Agency focuses on cost management and improving quality of and access to care within structures designed to manage costs (e.g., managed care, catastrophic care management, and disease management). Focus on managing costs leads to program innovations.

Agency focuses on adopting national standards, collaborating with other agencies in developing reusable business processes, and promoting one-stop-shop solutions for providers and consumers. Agency encourages intrastate data exchange.

Agency benefits from widespread and secure access to clinical data and focuses on improvement of healthcare outcomes, empowering beneficiaries and provider stakeholders, measuring objectives quantitatively, and ensuring overall program improvement.

Agency focuses on fine tuning and optimizing program management, planning and evaluation since it has benefited from national (and international) interoperability and previously noted improvements that maximize automation of routine operations.

Capability – The “performance standards” referred to in the two definitions above, are commonly referred to in the MITA Framework as capabilities. Each of the 79 business processes discussed in these deliverables has a set of capabilities associated with them. For each business process, the sum of capabilities is known as a Business Capability Matrix (BCM). The KY MITA SS-A update was completed using the BCM from MITA Framework 2.01. As noted by CMS, below are the main types of capabilities:1

Timeliness of Business Process – Time lapse between the agency’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

Efficiency; 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 outcome

1 CMS. MITA Framework 2.0. Part 1, Chapter 3, p.5. www.cms.hhs.gov/MedicaidInfoTechArch/Downloads/part1.zip (Accessed 4 June 2009).

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Quality of Process Results – Demonstrable benefits from using the business process

Utility or Value to Stakeholders – Impact of the business process on individual beneficiaries, providers, and Medicaid staff

1.4 MITA Framework 2.01

The goal of this assessment is to bring the previous SS-A materials up to MITA 2.01 in conjunction with the development of a Request for Proposal (RFP) for the MMIS Procurement Project. Cognosante is performing the following activities building upon the existing KY MITA SS-A:

Identifying business processes affected by the CMS published guidance in its 7C&S

Identifying impacts to business, information, and technical state that are different than otherwise specified in the existing Kentucky MITA SS-A

Developing a Gap Analysis of the differences in where the current KYME is and goal of the “To Be” direction

Developing a Transition Plan that outlines the path to satisfy the gaps

The intent of the SS-A update is to identify MITA capabilities that will need to be improved in order to meet CMS requirements and the future needs of the Kentucky Medicaid. These requirements will be reviewed for possible inclusion into the Kentucky Medicaid Enterprise Management System (MEMS) RFP.

The Office of Administrative and Technology Services (OATS) will be leading the effort on the SS-A update to MITA v3.0.

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2 KENTUCKY OVERVIEW2.1 Kentucky Medicaid Mission

Owing to the unbridled spirit of its workforce, the mission of Kentucky Medicaid is to provide innovative opportunities to its members that will promote healthy lifestyles, personal accountability, and responsible program governance for a healthier Kentucky.

2.2 Kentucky Medicaid Vision

Kentucky envisions serving as a national model for achieving excellence in Medicaid by increasing the quality of benefit services, transforming care management, updating relevant technology, providing support for an outstanding workforce, and preventing, detecting, and reducing fraud, waste, and abuse.

2.3 Kentucky Medicaid Values

Respect – for all persons with whom we come in contact

Integrity – in all of our transactions and dealings with one another and the public

Competency – in each task we perform

Collaboration – in making decisions that impact others

Accountability – for our decisions and actions

Excellence – in all that we endeavor to achieve

Commitment – to one another, our members and our providers

2.4 Kentucky Medicaid Guiding Principles

1. Do the right thing, the right way, the first time.

2. All decisions must pass the three way test:

Is it legal?

Is it ethical?

Is it moral?

3. Quality service is the most effective service.

2.5 Kentucky Goals and Objectives

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The Kentucky Medicaid mission seeks to accomplish the following five goals:

1. Integrate care delivery systems and providers for enhanced access and service to Medicaid members.

a. Redesign the behavioral health care delivery system.

b. Increase emphasis on primary care.

2. Develop mechanisms to utilize available resources to most appropriately meet the needs of members.

a. Tailor services to meet the individual needs by developing varying benefit packages designed to address the different populations covered by the Medicaid program and to establish meaningful benefits based on best practices.

b. Ensure that Medicaid is the payer of last resort by establishing an "opt out" option for those Medicaid members who have access to private insurance coverage and to create a financial incentive for them to choose that option.

c. Utilize lessons learned and best practices through proven, traditional insurance and business models and integrate into the Medicaid program.

3. Encourage Medicaid members to be personally responsible for their own healthcare.

a. Design Disease and Care Management programs to improve the health of individuals with specific chronic conditions.

b. Initiate a health literacy program to make the Medicaid eligible more informed about health, healthcare and services.

4. Redesign the Medicaid program infrastructure to utilize and maximize appropriate business practices.

a. Enhancement of cost conscious activities performed by the MMIS.

b. Explore grant opportunities with various foundations for program planning, education and research.

5. Provide thorough, thoughtful educational materials and resources to members and providers to assist and enrich their participation in the Medicaid program.

a. Develop a model of best practices that will support providers and help empower members to live healthier lives.

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3 RESULTS OF THE MITA BUSINESS PROCESS GAP ANALYSIS

3.1 Overview

The MITA Framework Version 2.01 includes 79 business processes. However, the Authorize Referral (OM01) business process is not performed in Kentucky which reduced the total processes performed in Kentucky to 78. The majority (61 of 78) of business processes in Kentucky function at a MITA Maturity Level 1 with a few (17 of 78) functioning at Level 2. However, Kentucky is making significant progress toward increasing maturity levels on several fronts, including increased automation, process improvements, and the implementation and coordination of Health Information Exchange (HIE). Kentucky will also see capabilities increase with the implementation of the Kentucky MEMS. It is Kentucky’s expectation that all processes will be elevated to a maturity level of 2 or higher with the implementation of the new system.

The Gap Analysis results of the MITA business process assessment are presented below by the appropriate MITA business area. Each business area and focused area also includes a bulleted list that summarizes the To Be Gap for each business area. The bulleted lists are included as a starting point for strategic planning within business areas, operating agencies, and the KYME.

3.2 Future Capabilities of the Kentucky MITA Business Areas

Enhancements to the future capabilities of the KYME will focus on improved interoperability, direct access to shared databases, increased web technology, and the use of workflow tools to improve efficiency. The enhancements will also promote self-service for clients, providers, stakeholders, and other members of the Kentucky health community.

Sections 3.2.1 through 3.2.2 provide a detailed As Is level, To Be level, and gap descriptions for each business process. The 78 MITA Business process evaluated in the Commonwealth of Kentucky are separated into the eight MITA Business Areas as follows:

MITA Management Area Business Processes Business Relationship Management:.............................................4Care Management..........................................................................4Contractor Management.................................................................9Member Management:...................................................................8Operations Management:.............................................................25Program Integrity Management:.....................................................2Program Management:.................................................................19Provider Management: ................................................................... 7 Total 78

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Figure 1 provides a summary of the To Be maturity levels for each of the MITA Business Processes. The To Be maturity levels resulting from the improvement projects in Kentucky will result in 62 processes (79 percent) moving to MITA Maturity Level 2, and 1 process moving to Level 3.

Member Management

Provider Management

Contractor Management

Operations Management

Program Management

Business Relationship Management

Program Integrity Management

Care Management

0 5 10 15 20 25 30

8

7

8

25

19

4

2

4

1

Kentucky To Be Maturity Level Summary

Level 1Level 2Level 3

Total Business Processes

MIT

A Bu

sines

s Are

a

Figure 1: To Be Maturity Level Summary

There are several internal and external drivers that will need to be considered and addressed as part of MITA Strategic Roadmap. The key drivers are provided below.

Major External Drivers

CMS Enhanced Funding Requirements: Seven Conditions and Standards

The 7C&S require such significant change to the MMIS Enterprise that Kentucky changed its approach from enhancing the current system to issuing an RFP to replace the system. The 7C&S include a Modularity Standard, MITA Condition, Industry Standards Condition, Leverage Condition, Business Results Condition, Reporting Condition, and an Interoperability Condition.

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Affordable Care Act

The ACA will drive changes in eligibility determination, enrollment, and covered services.

American Recovery and Reinvestment Act of 2009 (ARRA)

The opportunities for improvement through both MITA and ARRA will be met as part of a larger health information technology (HIT) improvement strategy. The projects outlined for the ARRA will dovetail the projects outlined in the MITA Strategic Roadmap and potentially provide an additional funding source for the KYME to realize projects.

Health Insurance Portability and Accountability Act (HIPAA) Standards Legislation

On January 16, 2009, CMS issued two new HIPAA Modification Rules that require the promulgation of several more regulatory mandates in the next few years. The areas most impacted include Privacy and Security and Transactions and Code Sets compliance. CHFS must therefore integrate improvements into its strategic planning that bring existing systems and processes into compliance with these rules.

The first rule requires adoption of significant changes to transaction standards, including X12 (Accredited Standards Committee [ASC] X12) Version 5010 and (National Council for Prescription Drug Programs [NCPDP]) Version D.0, by January 1, 2012. Also included in the rule is a new standard for Medicaid subrogation for pharmacy claims, known as NCPDP Version 3.0.

The second rule requires adoption of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) by October 2014. ICD-10 is an extensive revision to the current methodology for coding patient diagnoses, and as such, will require significant planning and coordination to upgrade system functionality.

Finally, standards for some HIPAA Electronic Data Interchange (EDI) transaction types, notably the claims attachments (278) type, remain in draft form. Once promulgated into law, implementation of these standards will be a requirement to maintain HIPAA compliance. Monitoring the issuance of new transaction standards and integrating into strategic planning efforts must remain a continued focus of the KYME.

MITA

Through the MITA Initiative, CMS has directed states to progress up the MMM. The compartmentalized and complex nature of systems and processes within an entity the size of the KYME will require a thorough review and improvement strategy to transform the MITA maturity capabilities.

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The remaining information provided in Section 3 will focus on the MITA business areas and functional gaps that must be met in order to achieve target To Be maturity levels.

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3.2.1 Business Relationship Management

3.2.1.1 Overview of Business Relationship Management

The Business Relationship Management (BR) business area encompasses those relationships that do not require contracts and may or may not require an exchange of data. Some of these relationships may be formalized by Memoranda of Understanding (MOUs), while others are more informal in nature. Electronic exchange of data is not always required, but there may be an exchange of information. These relationships will be more critical as Electronic Health Records (EHRs) become more prevalent and covered entities develop policies regarding how related clinical data may be exchanged.

Figure 2: Business Relationship Management

This business area owns the standards for interoperability between the agency and its partners. It contains business processes that have a common purpose (i.e., establish the interagency service agreement, identify the types of information to be exchanged, identify security and privacy requirements, define communication protocol, and oversee the transfer of information).

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3.2.1.2 Business Relationship To Be Summary

In reviewing the Business Relationship Management business area, all four business processes are determined to be at a MITA maturity level 1, while a number of these processes are approaching MITA maturity level 2 capabilities. The To Be goals for the Business Relationship Management business area calls for all 4 of the business processes to increase to a maturity level of 2.

BR01 - Establish Business Relationship

BR02 - Manage Business Relationship

BR03 - Terminate Business Relationship

BR04 - Manage Business Relationship Communications

0 1 2 3 4 5

Business Relationship Management Business Area

As IsTo Be

MITA Maturity Level

Figure 3: Business Relationship Management Maturity Level SummaryThe primary factors that will need to be addressed before reaching the To Be level for the Business Relationship Management Business Area include the following:

Automate parts of the process by incorporating steps into an automated workflow tool

Develop internal standards and adopt HIPAA data standards

Implement standards for electronic interchanges

Increase coordination, consistency, and communication through automation and electronic data exchange

Store and track data in a centralized location

3.2.1.3 Business Capabilities Matrix

This section articulates the maturity level of the individual business processes within the Business Relationship Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 2: Business Relationship Management Business Area

STATE BUSINESS PROCESS

AS IS LEVEL OF BUSINESS CAPABILIT

Y

GAPS TO ACHIEVING NEXT LEVEL TO BE LEVEL OF BUSINESS

CAPABILITY

BR01 Establish Business Relationship

1 Automate parts of the process by incorporating steps into an automated workflow tool

Integrate the process within the Medicaid Enterprise and improve the coordination between stakeholders

Increase use of EDI for data exchange


Develop procedures and standards to ensure quality improvement and cost management



2

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Y


CAPABILITY

BR02 Manage Business Relationship







2

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Y


CAPABILITY

BR03 Terminate Business Relationship


Develop standards and methodology within the KYME to terminate agreements

Develop standard agreement to increase accuracy and consistency

Develop process to increase efficiency and completion timeframes

Increase accuracy and consistency with standards based agreements

Automate access to information

Increase automation of data sharing

Develop terms and conditions to improve accuracy

Increase stakeholder satisfaction through local standards

Store and track data in a centralized location

2

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Y


CAPABILITY

BR04 Manage Business Relationship Communication




Increase use of EDI for data exchange


Increase automation and use of HIPAA standards to reduce data inaccuracies



2

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3.2.2 Care Management

3.2.2.1 Overview of Care Management

The Care Management (CM) business area illustrates the growing importance of care management as the Medicaid program evolves. Care Management collects information about the needs of the individual member, plan of treatment, targeted outcomes, and the individual’s health status. It also contains business processes that have a common purpose (i.e., identify clients with special needs, assess needs, develop treatment plan, monitor and manage the plan, and report outcomes). This business area includes processes that support individual care management and population management. Population management targets groups of individuals with similar characteristics and needs and promotes health education and awareness.

Figure 4: Care Management

Care Management includes Disease Management; Catastrophic Case Management; Early and Periodic Screening, Diagnosis, and Treatment (EPSDT); Population Management; Patient Self-Directed Care Management; Immunization and other registries; Waiver Program Case Management; and programs yet to come. With individual patient and case manager access to

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clinical data and treatment history, Care Management continues to evolve and increase in importance in the Medicaid Enterprise.

Members with special needs are the initial focus of Care Management. As the Medicaid Enterprise evolves, all beneficiaries could have access to care management, including self-directed decision-making.

3.2.2.2 Care Management To Be Summary

In reviewing the Care Management business area, all four business processes are determined to be at a MITA maturity level 1. The To Be goal for the Care Management business area calls for all 4 business processes to increase to a maturity level of 2.

CM01 - Establish Case

CM02 - Manage Case

CM03 - Manage Medicaid Population Health

CM04 - Manage Registry

0 1 2 3 4 5

Care Management Business Area

As IsTo Be

MITA Maturity Level

Figure 5: Care Management Maturity Level SummaryThe primary factors that will need to be addressed before reaching the To Be level for the Care Management Business Area include the following:


Automate the process of case tracking

Increase accuracy and consistency of data through use of HIPAA standards

Increase cost effectiveness and efficiency through automation

Integrate the Care Management processes into the Medicaid Enterprise using standard interfaces


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This section articulates the maturity level of the individual business processes within the Care Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 3: Care Management Business Area



Y


CAPABILITY

CM01 Establish Case

1 Integrate the process within the Medicaid Enterprise as an exposed service

Establish internal data standards and the use of HIPAA standards for transactions

Reduce manual processes by utilizing a business rules engine and workflow tools

2

CM02 Manage Case

1 Develop automated processes and reporting

Develop Commonwealth standards and begin adhering to Federal and HIPAA regulations

Automate process used to track cases

Allow users to access various sources to retrieve information

Increase efficiency of reporting through automation

Increase accuracy and consistency of data through use of HIPAA standards

Allow immediate and online access to data

Develop Commonwealth standards for processing data


Improve stakeholder satisfaction

2

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Y


CAPABILITY

CM03 Manage Medicaid Population

1 Replace some of the manual intervention tasks with automation

Integrate the process within the KYME

Implement internal data standards

Utilize HIPAA data standards

Automate business rules to improve accuracy

2

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Y


CAPABILITY

CM04 Manage Registry

1 Automate all activities of the process

Enable data exchange between the KYME and stakeholders

Develop internal data standards for data format and use existing HIPAA standards

Increase the use of EDI


Interface with internal and external data sources

Develop standards to improve coordination and consistency for communication and processing

Standardize data to reduce inaccuracies

Implement standards to simplify data access




2

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3.2.3 Contractor Management

3.2.3.1 Overview of Contractor Management

The Contractor Management (CO) business area accommodates states that have managed care contracts or a variety of outsourced contracts. Some states may, for example, group Provider and Contractor in one business area. The Contractor Management business area has a common focus (i.e., manage outsourced contracts), owns and uses a specific set of data (i.e., information about the contractor or the contract), and uses business processes that have a common purpose (i.e., solicitation, procurement, award, monitoring, management, and closeout of a variety of contract types).

Figure 6: Contractor Management

Creating a separate business area for Contractor Management allows the MITA BPM to highlight this part of the Medicaid Enterprise, which is becoming increasingly important to state Medicaid agencies. Indeed, it is the primary focus in some states that have comprehensive managed care or multiple-contractor operations. In the Contractor Management business area, the many types of healthcare service delivery contracts (i.e., managed care, at-risk mental health or dental care, primary care physician) and the many types of administrative services

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(i.e., fiscal agent, enrollment broker, Surveillance and Utilization Review (SUR) staff, and third-party recovery) are treated as single business processes because the business process activities are the same, even though the input and output data and the business rules may differ.

3.2.3.2 Contractor Management To Be Summary

In reviewing the Contractor Management business area, 8 business processes are determined to be at a MITA maturity level 1. The business process, CO01: Produce Administrative or Health Services Contract is at a level 2. A number of these processes are approaching MITA maturity level 2 capabilities. The To Be goals for the Contractor Management business area call for 8 of the 9 business processes to increase to a maturity level of 2 with 1 increasing to level 3.

CO01 - Produce Administrative or Health Services RFP

CO02 - Award Administrative or Health Services Contract

CO03 - Manage Administrative or Health Services Contract

CO04 - Close-Out Administrative or Health Services Contract

CO05 - Manage Contractor Information

CO06 - Manage Contractor Communication

CO07 - Perform Contractor Outreach

CO08 - Support Contractor Grievance and Appeal

CO09 - Inquire Contractor Information

0 1 2 3 4 5

Contractor Management Business Area

As IsTo Be

MITA Maturity Level

Figure 7: Contractor Management Maturity Level SummaryThe primary factors that will need to be addressed before reaching the To Be level for the Contractor Management Business Area include the following:

Implement centralized electronic storage of contract data

Increase standardization to simplify data access

Coordinate with other agencies to eliminate duplication

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Standardize data and formats using MITA standards

Standardize contract content and format

Improve stakeholder satisfaction by improving communication, automation, and consistency of the process


This section articulates the maturity level of the individual business processes within the Contractor Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 4: Contractor Management Business Area



Y

GAPS TO ACHIEVING NEXT LEVEL

TO BE LEVEL OF BUSINESS

CAPABILITY

CO01 Produce Administrative or Health Services RFP

2 Automate centralized contract data

Coordinate with other Commonwealth agencies to eliminate duplication

Fully integrate MITA standards to ensure compliance and outcome oriented program management

Track and maintain requirements and contract data electronically

Standardize data and format using MITA standard interfaces

Develop guidelines to ensure efficiency and timeliness

Provide easily retrievable information for RFP development and content

Standardize process to allow for effective communication with potential respondents

Increase stakeholder satisfaction by reducing confusing and providing accurate data

3

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Y



CAPABILITY

CO02 AwardAdministrative or Health Services Contract

1 Allow for electronic submittal and storage of proposals and materials

Implement electronic communication

Develop Commonwealth requirements and instructions for electronic submissions

Automate some verification of Contractor information

Implement internal data standards to increase accuracy

Increase standardization to simplify data access

Define Commonwealth data and content standards to promote cost management and quality improvement

Increase automation to reduce duplicative and repetitive process steps

Increase staff satisfaction of process

Increase respondent satisfaction when submitting

Increase consistency through use of electronic submittals

2

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Y



CAPABILITY

CO03 ManageAdministrative or Health Services Contract

1 Utilize electronic methods for exchange of contract information

Standardize contract format and content

Store contract information in centralized location

Increase accuracy and consistency of content

Increase accessibility through improved standards

Coordinate among agency programs to reduce contract management costs

Implement quality improvement process

Enhance contract performance measurements

Develop and apply business rules consistently


2

CO04 Close-Out Administrative or Health Services Contract

1 Utilized electronic methods for exchange of contract information

Develop data formats and standards

Automate parts of process to reduce time of end-to-end process

Develop interface standards

Store data in centralized location


2

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Y



CAPABILITY

CO05 Manage Contractor Information

1 Develop Commonwealth specific rules pertaining to verification of contractor information

Integrate Commonwealth and Federal standards into process

Automate process to increase cost-benefit ratio

2

CO06 Manage Contractor Communication

1 Develop query standards

Develop formal Communications Management Plan

Establish portals for contractors

Standardize responses for the portal

Automate responses to contractors

Automate the process to increase benefits

Increase efficiency of communications with contractors

Develop formal, automated process to ensure requirements are met

Increase stakeholder satisfaction

2

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Y



CAPABILITY

CO07 Perform Contractor Outreach

1 Verify communications for accuracy

Increase availability of electronic information and outreach

Develop standards for launching of outreach material

Develop methods to match outreach with target audience

Identify levels of stakeholder satisfaction


2

CO08 Support Contractor Grievance and Appeal

1 Conduct some activities electronically

Scan documents for electronic data capture

Standardize the administration of the process

Increase coordination and improve consistency of process

Develop formal Management Plan

Automate management of case files

Provide access to program rules for contractors

Increase benefit by lowering cost of operations

2

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Y



CAPABILITY

CO09 Inquire Contractor Information

1 Provide portal for inquiries and responses

Develop requirements for access to public information

Provide detailed information for inquiries

Provide immediate responses via the portal

Improve portal data accuracy

Provide access outside of business hours to the portal

Improve cost-effectiveness of portal

Improve efficiency and adherence to performance guidelines

Develop business rules to reduce errors

Improve accuracy of results

Improve stakeholder satisfaction and expectations

2

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3.2.4 Member Management

3.2.4.1 Overview of Member Management

The Member Management (ME) business area is a collection of business processes involved in communications between the Medicaid agency and the prospective or enrolled members and actions that the agency takes on behalf of the member. These processes share a common set of member-related data. The goal for this business area is to improve healthcare outcomes and raise the level of consumer satisfaction.

This business area is transformed in the future from agency staff performing eligibility and enrollment functions to more patient self-directed decision making. Member Management business processes consolidate many eligibility and enrollment functions into a single, generic business process.

Figure 8: Member Management

Medicaid eligibility in Kentucky is determined by the Department of Community Based Services (DCBS) using the Kentucky Automated Management & Eligibility System (KAMES). Case workers at local offices in each of Kentucky’s 120 counties use a computer-based interactive interview using the KAMES system. KAMES is used to capture data and process eligibility determinations for various programs, including the Supplemental Nutrition Assistance Program

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(SNAP, formerly referred to as the Food Stamp Program), Temporary Assistance to Needy Families (TANF), Breast and Cervical Cancer Treatment Program (BCCTP), Presumptive Eligibility (PE), as well as Medicaid.

3.2.4.2 Member Management To Be Summary

In reviewing the Member Management business area, 6 of the 8 business processes are determined to be at a MITA maturity level 1 with 2 of the processes at level 2. The To Be goals for the Member Management Business Area call for the 6 business processes at level 1 to increase to a maturity level of 2.

ME01 - Determine Eligibility

ME02 - Enroll Member

ME03 - Disenroll Member

ME04 - Inquire Member Eligibility

ME05 - Manage Applicant and Member Communication

ME06 - Manage Member Grievance and Appeal

ME07 - Manage Member Information

ME08 - Perform Population and Member Outreach

0 1 2 3 4 5

Member Management Business Area

As IsTo Be

MITA Maturity Level

Figure 9: Member Management Maturity Level Summary

The primary factors that will need to be addressed before reaching the To Be level for the Member Management Business Area include the following:

Allow for entry of application at any location using the Internet

Establish automated business rules for less manual intervention

Support HIPAA transactions

Develop Member Registry with integrated records of eligibility data

Automate member requests through the web portal

Electronically store grievance case files

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Standardize and automate data updates

Improve timeliness of notifications

Improve access to stored data


This section articulates the maturity level of the individual business processes within the Member Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 5: Member Management Business Area



Y

GAPS TO ACHIEVING NEXT LEVEL TO BE LEVEL OF BUSINESS CAPABILITY

ME01 Determine Eligibility

2 DMS is currently operating at the desired To Be maturity level 2

ME02 Enroll Member 1 Allow for submittal of applications via telephone or web

Streamline process to increase efficiency and accuracy and reduce program costs

Standardize application data

Support HIPAA transaction needs

2

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Y


ME03 Disenroll Member

1 Automatically apply business rules

Increase automation of process

Apply HIPAA standards to business process

Develop disenrollment rules to be used among agencies

Increase efficiency of disenrollment process

Improve access to disenrollment information

Provide easily accessible data

Improve cost containment and efficiency through automation

Standardize disenrollment data

Develop policy to be applied during decision making to increase uniformity

Make improvements to process to increase stakeholder satisfaction

2

ME04 Inquire Member Eligibility


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Y


ME05 Manage Applicant and Member Communication

1 Allow for electronic communication

Provide program and provider information via websites

Provide responses to inquiries via phone or online

Develop standards for member communications

Automate member requests via Automated Voice Response System (AVRS) or web portal

Standardize communications to increase accuracy, efficiency, and cost effectiveness

Develop policy to increase timeliness of responses

Automate responses to inquiries to improve accuracy


2

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Y


ME06 Manage Member Grievance and Appeal

1 Electronically store case files

Automate process to allow sharing among case workers

Establish document standardization

Develop standards to automate review process

Increase staff productivity and consistency through automated processes

Automate requests for member information via AVRS, web portal, and EDI

Define grievance within State Medicaid

Improve access to information by authorized viewers

Improve staff productivity and efficiency through automation

Develop method of measuring member satisfaction with the grievance process


2

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Y


ME07 Manage Member Information

1 Use external measures to validate business process

Automate updates of member information

Improve internal quality controls specifically for duplicate entries

Immediately notify stakeholders of updated member information

Integrate with eligibility system

Standardize and automate data updates

Develop rules to validate data and improve consistency

Improve update schedule

Improve timeliness of notifications

Improve access to stored data

Increase productivity, cost effectiveness, and efficiency through automation


2

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Y


ME08 Perform Population and Member Outreach

1 Improve data manipulation for decision support

Share program data and analysis

Measure quality of outreach activities

Ensure materials are provided to targeted populations

Provide access to help lines for stakeholders

Improve outreach material for increased functionality

Improve variety of media used to deliver outreach

Improve access to demographic data

Increase timeliness when delivering outreach materials

Adopt United States Postal Service (USPS) mailing standards

Standardize communications to increase accuracy, efficiency, and cost effectiveness

Provide electronic access to outreach materials

Automate process to increase proficiency

Define and measure effectiveness of outreach materials

Monitor use of web portal

Track stakeholder feedback to increase satisfaction

2

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3.2.5 Operations Management

3.2.5.1 Overview of Operations Management

The Operations Management (OM) business area is the focal point of most State Medicaid Enterprises today. It includes operations that support the payment of providers, managed care organizations (MCOs), other agencies, insurers, and Medicare premiums and support the receipt of payments from other insurers, providers, and member premiums.

This business area focuses on payments and receivables and “owns” all information associated with service payment and receivables. Most states have automated operations that support these payments and this area is probably the part of Medicaid that is most representatively aligned for all state Medicaid programs.

Common business processes include validating requests for payment and determining payable amount; responding to premium payment schedules and determining payable amount; and identifying and pursuing recoveries. The MITA Operations Management business area is illustrated by the diagram below:

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Figure 10: Operations Management

Outside the Medicaid Enterprise, numerous other programs within CHFS have a role in a number of processes associated with this business area. This is especially true for any program that covers targeted services for eligible members, receives requests for payment for services rendered, processes payment requests, and makes payments.

The Authorize Referral Business Process is no longer performed by DMS and has been removed from the assessment. The previous Primary Care Case Manager (PCCM) process, called Kentucky Patient Access and Care (KenPAC), was replaced with an expansion of the managed care program. The MCOs are now responsible for managing any provider to provider referrals.

3.2.5.2 Operations Management To Be Summary

In reviewing the Operations Management business area, 15 business processes are determined to be at a MITA maturity level 1 and 10 are at a MITA maturity level of 2. The To Be goal for the

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Operations Management business area is to bring all of the Operations Management business processes to a minimum maturity level of 2. To accomplish this, the 15 business processes currently at level 1 will need to be improved to a maturity level of 2.

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OM01 - Authorize Referral

OM02 - Authorize Service

OM03 - Authorize Treatment Plan

OM04 - Apply Attachment

OM05 - Apply Mass Adjustment

OM06 - Edit Claims-Encounter

OM07 - Audit Claim-Encounter

OM08 - Price Claim-Value Encounter

OM09 - Prepare Remittance Advice-Encounter Report

OM10 - Prepare Provider EFT-check

OM11 - Prepare COB

OM12 - Prepare EOB

OM13 - Prepare Home and Comm. Based Services Payment

OM14 - Prepare Premium EFT

OM15 - Prepare Capitation Premium Payment

OM16 - Prepare Health Insurance Premium Payment

OM17 - Prepare Medicare Premium Payment

OM18 - Inquire Payment Status

OM19 - Manage Payment Information

OM20 - Calculate Spend-Down Amount

OM21 - Prepare Member Premium Invoice

OM22 - Manage Drug Rebate

OM23 - Manage Estate Recovery

OM24 - Manage Recoupment

OM25 - Manage Cost Settlement

OM26 - Manage TPL Recovery

0 1 2 3 4 5

Operations Management Business Area

As IsTo Be

MITA Maturity Level

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Figure 11: Operations Management Maturity Level SummaryThe primary factors that will need to be addressed before reaching the To Be level for the Operations Management Business Area include the following:

Implement the use of HIPAA standard transaction sets where applicable

Use of workflow tools to automate processes to reduce manual effort

Automate edit rules to minimize manual intervention and coding

Exchange claim data in HIPAA formats with payers

Use of a Rules Engine to eliminate manual labor, improve efficiency, and consistency of results

Integrate separate systems into the Medicaid Enterprise with standard interfaces and data structures

Increase the use of data interchange (internally and externally) to gain faster access to data


This section articulates the maturity level of the individual business processes within the Operations Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 6: Operations Management Business Area



Y


CAPABILITY

OM01 Authorize Referral

N/A Note: This process is not currently done in Kentucky. N/A

OM02 Authorize Service

1 Decrease amount of time to complete process

Provide better access to data to make decisions

Implement the use of HIPAA standard transactions

Increase accuracy of data

2

OM03 Authorize Treatment Plan

1 Implement the use of X12 277 and 278 transactions

Reduce the manual development of treatment plans with some automation

Use automated tools to reduce processing time

Improve access to data to improve efficiency and accuracy

2

OM04 Apply Attachment

1 Begin the use of HIPAA compliant electronic attachments to reduce the volume of paper attachments

Automatically match electronic attachments to claims

Use electronic attachments to improve accuracy, consistency, and efficiency

2

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Y


CAPABILITY

OM05 Apply Mass Adjustment

1 Automate identification of affected claims

Automate adjustment process

Provide an audit trail

Decrease timeliness of processing

Develop data format standards

Provide online access to data

Develop standards for processing of batches

Reduce staff effort and increase efficiency through automation

Develop agency policy for the Apply Mass Adjustment process to result in higher consistency


2

OM06 Edit Claim/ Encounter

1 Support multiple formats and mapping of nonstandard claim data

Accept data from sister agency programs

Automate edit rules to minimize manual intervention

Decrease the effort of changes to edits

Increase accuracy of results through automation


2

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Y


CAPABILITY

OM07 Audit Claim/Encounter

1 Develop additional history validations

Implement audit rules or use Commercial off-the-shelf (COTS) applications

Automate use of business rules

Reduce time of changes to process

Increase accuracy of error rates


2

OM08 Price Claim/Value Encounter


OM09 Prepare Remittance Advice


OM10 Prepare Provider EFT/Check


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Y


CAPABILITY

OM11 Prepare COB

1 Automate the Coordination of Benefits (COB) business process

Exchange HIPAA claim data with payers

Use HIPAA standard transaction data

Allow COB to be performed outside of regular payment cycles

Improve accuracy though use of HIPAA standard claim transaction

Improve cost effectiveness and efficiency through automation

Coordinate with other processes to increase efficiency

Develop standards to reduce duplicative work

Increase accuracy of results

Improve stakeholders level of satisfaction

2

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Y


CAPABILITY

OM12 Prepare EOMB

1 Automate generation of Explanation of Benefits (EOB)

Enhance sampling through the Medicaid Enterprise

Adopt HIPAA standards for procedure codes

Enhance the formats of EOBs

Improve cost to benefit ration

Increase accuracy of results

Identify gaps to improve stakeholder satisfaction

2

OM13 Prepare Home and Community Based Services Payment


OM14 Prepare Premium EFT


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Y


CAPABILITY

OM15 Prepare Capitation Premium Payment

1 Increase automation of payment calculation

Automate synchronization of Provider and Member data

Improve accuracy, productivity and efficiency

Automate data set generation

Develop internal assignment process

2

OM16 Prepare Health Insurance Premium Payment

1 Automate Premium payments

Utilize HIPAA standard transactions

Implement national MITA standards for interfaces and

Increase efficiency of process

Automate access to some of data needed

Increase accuracy and consistency of data

Improve cost effectiveness

Coordinate with other processes

Develop standards to reduce duplicative work

Identify gaps to increase stakeholder satisfaction

2

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Y


CAPABILITY

OM17 Prepare Medicare Premium Payment


OM18 Inquire Payment Status


OM19 Manage Payment Information


OM20 Calculate Spend Down Amount


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Y


CAPABILITY

OM21 Prepare Member Premium Invoice

1 Automate invoicing and other accounting functions

Automate some of data processing function

Develop state specific data standards

Update Member cost sharing accounts by claims or member payment activity

Improve the generation of invoices to a staggered monthly schedule

Improve accessibility and accuracy of data

Implement other options for distribution of statements and other notices

Increased the efficiency and accuracy of the process


2

OM22 Manage Drug Rebate


OM23 Manage Estate Recovery

1 Utilize electronic data interchange and automated steps for gathering information from local and state agencies

Use of automation to reduce manual steps

Agencies begin to standardize data and improve coordination between entities

Stakeholder satisfaction improves to level 2

2

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Y


CAPABILITY

OM24 Manage Recoupment

1 Increase amount of electronic communication with providers

Increase payer to payer interchanges

Increase coordination and communication of efforts between other portions of agency

Develop and implement internal data standards.

Ensure data and format is HIPAA compliant

Improve timeliness through use of electronic interchange

Standardize data to reduce inaccuracies

Increase access to data

Reduce redundancies through standardization

Automate some of the process to reduce costs

Increase efficiency

Improve rule application and consistency through interagency communication


2

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Y


CAPABILITY

OM25 Manage Cost Settlement

1 Increase integration of process

Improve consistency of rule application

Allow application-to-application updates in some cases

Automate some steps

Develop State-specific data standards

Improve timeliness through use of electronic interchange

Reduce inaccuracy through use of HIPAA data exchange standards

Improve data accuracy

Simplify access to data

Ensure cost settlement is completed in a timely manner

Reduce duplicative work through automation and coordination with other processes.

Improve consistency and accuracy of results


2

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Y


CAPABILITY

OM26 Manage TPL Recovery

1 Increase coordination and integration with other programs

Process payer-to-payer COB

Automate communication with providers and other payers via HIPAA compliant electronic interchange

Improve timeliness of process

Increase coordination and consistency through data standardization

Monitor cost to benefit results

Increase Third Party Liability (TPL) recovery goals

2

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3.2.6 Program Integrity Management

3.2.6.1 Overview of Program Integrity Management

The Program Integrity (PI) business area incorporates those business activities that focus on program compliance (i.e., auditing and tracking medical necessity and appropriateness of care and quality of care, fraud, waste, and abuse, erroneous payments, and administrative abuses).

Program Integrity collects information about an individual provider or member (i.e., demographics; information about the case itself such as case manager identification, dates, actions, and status; and information about parties associated with the case). The business processes in this business area have a common purpose (i.e., to identify case, gather information, verify information, develop case, report on findings, make referrals, and resolve case). As with the previous business areas, a single business process may cover several types of cases. The input, output, shared data, and the business rules may differ by type of case, but the business process activities remain the same.

Figure 12: Program Integrity Management

3.2.6.2 Program Integrity Management To Be Summary

The two Program Integrity business processes have been determined to be at MITA maturity level 1. The DMS To Be goal for both of the Program Integrity business processes is MITA maturity level 2.

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PI01 - Identify Candidate Case

PI02 - Manage Case

0 1 2 3 4 5

Program Integrity Management Business Area

As Is5-Year To Be

MITA Maturity Level

Figure 13: Program Integrity Management Maturity Level SummaryThe primary factors that will need to be addressed before reaching the To Be level for the Program Integrity Management Business Area include the following:

Integrate the process within the KYME and improve the coordination between stakeholders

Increase automation by using enhanced parameters for evaluation of data and case identification

Implement HIPAA standards for data transactions and establish internal data standards

Enhance the use of electronic interfaces for data exchange


This section articulates the maturity level of the individual business processes within the Program Integrity Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 7: Program Integrity Management Business AreaSTATE

BUSINESS PROCESS

AS IS MATURITY

LEVEL GAPS TO ACHIEVING NEXT LEVEL

TO BE MATURITY

LEVEL

PI01 Identify Candidate

1 Integrate the process within the Medicaid Enterprise and improve the coordination between stakeholders

Increase automation by using enhanced parameters for case identification


Improve cost effectiveness by increasing business process automation

Improve communications and turnaround time

Define criteria used to identify cases

Increase stakeholder satisfaction through electronic interchange, consistency, and timeliness

2

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AS IS MATURITY

LEVEL GAPS TO ACHIEVING NEXT LEVEL

TO BE MATURITY

LEVEL

PI02 Manage Case

1 Integrate the process within the Medicaid Enterprise and improve the coordination between stakeholders

Increase automation where possible

Develop state specific requirements for obtaining information and reporting

Develop methods to automate the evaluation of data

Improve coordination and consistency through the use of EDI and automation


Enhance the use of electronic interfaces for data exchange

Standardize the format for case tracking

Integrate the processes with state specific processes to eliminative duplicity

2

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3.2.7 Program Management

3.2.7.1 Overview of Program Management

The Program Management (PG) business area houses the strategic planning, policy making, monitoring, and oversight activities of the agency. These activities depend heavily on access to timely and accurate data and the use of analytical tools. This business area uses a specific set of data (i.e., information about the benefit plans covered, services rendered, expenditures, performance outcomes, and goals and objectives) and contains business processes that have a common purpose (i.e., managing the Medicaid program to achieve the agency’s goals and objectives such as by meeting budget objectives, improving customer satisfaction, and improving quality and health outcomes).

This business area includes a wide range of planning, analysis, and decision-making activities, including benefit plan design, rate setting, healthcare outcome targets, and cost-management decisions. It also contains budget analysis, accounting, quality assessment, performance analysis, outcome analysis, continuity of operations plan, and information management.

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Figure 14: Program Management

3.2.7.2 Program Management To Be Summary

Within the Medicaid Enterprise, there are a number of opportunities for improvement in Program Management business processes. There are 19 total business processes and 15 have been determined to currently be at MITA maturity level 1. Four of the processes are at a MITA maturity level of 2. The To Be goal is to improve all Program Management business processes to a minimum maturity level of 2.

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PG01 - Designate Approved Service/ Drug Formulary

PG02 - Develop and Maintain Benefit Package

PG03 - Manage Rate Setting

PG04 - Develop Agency Goals and Objectives

PG05 - Develop and Maintain Program Policy

PG06 - Maintain State Plan

PG07 - Formulate Budget

PG08 - Manage FFP for MMIS

PG09 - Manage F-Map

PG10 - Manage State Funds

PG11 - Manage 1099s

PG12 - Generate Financial and Program Analysis Report

PG13 - Maintain Benefits-Reference Information

PG14 - Manage Program Information

PG15 - Perform Accounting Functions

PG16 - Develop and Manage Perf. Measures and Reporting

PG17 - Monitor Performance and Business Activity

PG18 - Draw and Report FFP

PG19 - Manage FFP for Services

0 1 2 3 4 5

Program Management Business Area

As IsTo Be

MITA Maturity Level

Figure 15: Program Management Maturity Level SummaryThe primary factors that will need to be addressed before reaching the To Be level for the Program Management Business Area include the following:

Coordinate the processes with other agencies across the Medicaid Enterprise

Improve accuracy and consistency of data used

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Provide online access to rate setting data

Improve internal and external interfaces to increase automation

Improve accuracy with use of electronic interchange

Adopt HIPAA transactions and internal data standards

Use of Rules Engine and workflow tool to automate some processes

Automation of tasks to allow the staff to focus more on cost management, quality management, and health outcomes

Utilize a central data warehouse to improve accuracy of reporting and forecasting


This section articulates the maturity level of the individual business processes within the Program Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 8: Program Management Business Area



Y


CAPABILITY

PG01 Designate Approved Services and Drug Formulary

1 Process begins to be coordinated across siloed programs and more centralized Use EDI to increase accuracy Some use of clinical data allows an analysis of health outcomes Centralization increases the consistency of communication

2

PG02 Develop and Maintain Benefit Package


PG03 Manage Rate Setting

1 Improve accuracy and consistency of data used Provide online access to data Improve rate setting process Encourage provider participation Improve stakeholder satisfaction

2

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Y


CAPABILITY

PG04 Develop Agency Goals and Objectives

1 Standardize data and format by developing internal standards Accept data electronically Develop regulations to facilitate cost management and quality improvement Improve internal and external interfaces to increase automation Increase coordination and consistency through automation Reduce inaccuracies Simplify access to data Coordinate with other processes to improve efficiency Improve accuracy with use of electronic interchange

2

PG05 Develop and Maintain Program Policy

1 Implement internal data standards including HIPAA standard transactions Increase automation and coordination with other processes Implement state defined data and content standards Shift focus to cost management and quality improvement

2

PG06 Maintain State Plan

1 Centralize data for more accurate information Centralize data necessary to maintain the state plan

2

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Y


CAPABILITY

PG07 Formulate Budget

1 Implement expenditure forecasting tools as part of a decision support system Collaborate with stakeholders and other agencies to develop an enterprise-wide

budget Increase automation of data capture from other systems to improve accuracy of

forecasting

2

PG08 Manage FFP for MMIS

1 Implement a standard methodology to organize and manage FFP reporting requirements

Centralize and standardize information needed for FFP Reporting

2

PG09 Manage FMAP

1 Coordinate with other agencies which share in the delivery of services to the Medicaid population.

Implement enhanced data definitions to improve accuracy of data to assign F-MAP rates

Implement automation to improve access to data

2

PG10 Manage State Funds

1 Implement some automation using COTS financial tools to analyze and make decisions regarding allocation and reporting

Use automation to improve accuracy and reduce errors Automation allows staff to focus on analysis of data, projections, and

recommendations for improvement

2

PG11 Manage 1099s


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Y


CAPABILITY

PG12 Generate Financial and Program Analysis


PG13 Maintain Benefits/Reference Information

1 Increase the use of EDI and automated processes Centralize common processes Centralized communication to improve consistency

2

PG14 Manage Program Information

1 Automate some pieces of process Provide capability to access information directly Adopt HIPAA data requirements Collaborate with other Commonwealth agencies Reduce process turnaround time Provide ability to users to perform their own inquiries Improve accuracy and consistency of data through use of COTS packages Provide online access to data Improve cost effectiveness and efficiency Improve stakeholder satisfaction

2

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Y


CAPABILITY

PG15 Perform Accounting Function


PG16 Develop and Manage Performance Measures and Reporting

1 Automate some pieces of the process Integrate with the Medicaid Enterprise Improve coordination between the KYME and other stakeholders Implement data standards Implement HIPAA standards for transactions Accept data electronically Interface with different stakeholders and data sources Improve coordination and consistency to increase timeliness of process and

communication Reduce inaccuracies Simplify data access Improve efficiency through automation and coordination with other processes Develop Commonwealth data and content standards to reduce process costs

and allow for ongoing quality improvement Improve stakeholder satisfaction

2

PG17 Monitor Performance and Business Activity

1 Use standard reports to improve the accuracy and consistency of the data Improvements to performance monitoring include a review of cost effectiveness Expand the monitoring process to include the majority of core operations

2

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Y


CAPABILITY

PG18 Draw and Report FFP

1 Implement automation between the Medicaid Enterprise and the state’s accounting system for most accounts receivables and accounts payables

Adopt national standards Automate processes between the MMIS and the Medicaid financial system Data is updated after each payment cycle with minimal staff involvement

2

PG19 Manage FFP for Services

1 Implement table driven FFP calculation process Process automation helps Medicaid Enterprise meet goals for obtaining FFP

2

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3.2.8 Provider Management

3.2.8.1 Overview of Provider Management

The Provider Management (PM) business area is a collection of business processes that focus on recruiting potential providers, supporting the needs of the population, maintaining information on the provider, and communicating with the provider community. The goal of this business area is to maintain a robust provider network that meets the needs of both beneficiaries and provider communities and allows the State Medicaid agency to monitor and reward provider performance and improve healthcare outcomes.

Figure 16: Provider Management

3.2.8.2 Provider Management To Be Summary

In reviewing the Provider Management business area, all seven business processes are determined to be at a MITA maturity level 1, while a number of these processes are approaching MITA maturity level 2 capabilities. The To Be goal for the Provider Management Business Area is to increase the capabilities for all processes to a maturity level of 2.

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PM01 - Enroll Provider

PM02 - Disenroll Provider

PM03 - Inquire Provider Information

PM04 - Manage Provider Communication

PM05 - Manage Provider Grievance and Appeal

PM06 - Manage Provider Information

PM07 - Perform Provider Outreach

0 1 2 3 4 5

Provider Management Business Area

As IsTo Be

MITA Maturity Level

Figure 17: Provider Management Maturity Level SummaryThe primary factors that will need to be addressed before reaching the To Be level for the Provider Management Business Area include the following:

Automation of enrollment business rules

Utilize a workflow tool to automate tasks to improve timeliness of processing

Establishing standard services for inquiries and updates

Establishing standard interfaces with appropriate data sources for provider validations

Establishing the National Provider Identifier (NPI) as the identification (ID) of record

Automate and standardize changes and validation of data in the Provider Registry

Establish an average competition of enrollment process in 15-30 days

Improve provider outreach by coordinating communication across agencies and using centralized data warehouse to improve targeting of communication


This section articulates the maturity level of the individual business processes within the Provider Management Business Area for the Medicaid Enterprise. While all MITA Framework 2.01 capabilities will be addressed for each target maturity level, the table below focuses on the key rationale to support the maturity level determinations.

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Table 9: Provider Management Business Area



Y

MITA FRAMEWORK CAPABILITY GAPS TO ACHIEVING NEXT LEVELTO BE LEVEL OF

BUSINESS CAPABILITY

PM01 Enroll Provider

1 Automate business rules (e.g. verify information supplied., assign ID, associate rates, and map provider attributes to program needs, e.g., linguistic, specialty care)

Automate the provider re-enrollment process

Automate the validation of credentials

Establish average competition of process in 15-30 days

Standardize application data and format for use within the agency

Increase the use of NPI as the ID of record

Increase inter-agency data sharing

Enhance the enrollment verification process

Improve accuracy of enrollment validation and verification results

Increase the use of data sharing amongst other agencies to prevent enrollment of sanctioned providers


2

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Y


BUSINESS CAPABILITY

PM02 Disenroll Provider

1 Implement automated business processes and activities

Establish standards and regulations to standardize disenrollment requests

Coordinate efforts to share data with other agencies

Complete processing of disenrollment requests in 5 days or less

Increase accuracy of disenrollment accuracy

Increase availability of disenrollment information to be accessed immediately

Automate and standardize process to improve cost-effectiveness, quality assurance, and accuracy

Identify stakeholder expectations to increase satisfaction

2

PM03 Inquire Provider Information

1 Standardize and automate routine requests for information

Automate process to improve access, timeliness, and accuracy of responses

2

PM04 Manage Provider Communication

1 Routine requests from providers are standardized and automated

Routine responses are more consistent and timely and requires fewer staff

Routine communications are created to meet the needs of managed care, waiver, atypical, and special program providers

2

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Y


BUSINESS CAPABILITY

PM05 Manage Provider Grievance and Appeal

1 Provide access to the process via the web portal

Automate portions of the research process to increase efficiency

Document and record the results in an easily accessible format

2

PM06 Manage Provider Information

1 Automate and standardize changes and validation of data in the Provider Registry

Increase the use of NPI as ID of record

Provide immediate updates of provider information to users and business processes

Establish data shares with outside agencies (e.g., NPI, CAQH, UPD)

Ensure data management meets agency standards

Increase stakeholder satisfaction through automation and accuracy of data

2

PM07 Perform Provider Outreach

1 Implement agency standards for provider data to improve targeting of communication to providers

Improve demographic data to better target provider communication

Utilize inter-agency coordination on provider outreach

Use the web portal to make outreach materials available on demand

Use improved data analytics to improve the efficiency of the process

2

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4 CONCLUSIONThe Kentucky MITA SS-A focuses on assessing the current status of Medicaid business processes, future goals for improvements, and identifying the gaps that need to be overcome. The continued prevalence of manual processes, compartmentalized operations, and restrictive policies that hinder increasing business process automation have kept Kentucky Medicaid in the compliance mode for most business processes.

For all business processes, Kentucky is currently at a MITA Maturity Level of 1 or 2. The Commonwealth’s goals are to increase the MITA capabilities to a maturity level of 2 and address the capabilities required to meet the CMS 7C&S Requirements. Kentucky is currently in the process of procuring a replacement for its current MMIS. The upcoming Kentucky MEMS procurement is an opportunity to address the gaps identified in this analysis by including new requirements for the replacement system that address the needed capabilities.

Business Relationship Management –The Business Relationship Management processes are working well for transaction based data exchanges. The non-standard requests would benefit from workflow tools and the standardization of requests and data. DMS should develop internal standards and adopt HIPAA data standards.

Care Management –The shift to managed care will shift the care management process from a task-oriented process to one of management and evaluation. DMS should develop standards and monitor MCO performance against those standards. The care management goals should also be incorporated into the MCO contracts. DMS will need to have access to Data Warehouse/Decision Support System (DW/DSS) tools to monitor effectiveness of care to capitated members.

Contractor Management – As a result of the shift to managed care, the health services contracts will need to be standardized and efficient. The ACA expands eligibility which will result in increased enrollment in the program and subsequently the MCOs. The ACA will also expand the covered services so the contracts need to allow for the policy changes. The data transfers to and from the MCOs need to utilize the standard HIPAA transactions and MITA formats.

DMS should work with other agencies to automate contract data, access, format, and eliminate duplication. While the contracts are currently stored in electronic format in a central location, the process needs better access to the centralized data.

Member Management – The Member Management business area suffers from many obstacles seen in other business areas and will see improvement from many of the same solutions. The implementation of the Health Benefit Exchange (HBE) system will improve automation in the eligibility determination and enrollment processes. The development of open interfaces and

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increased system interoperability will result in better access to the global view of the member’s activity.

The increased use of managed care has resulted in the additional step of assigning the members into a managed care plan. The use of managed care has also shifted the focus from claims processing and administration to monitoring the quality and effectiveness of care.

Operations Management – Within the Operations Management business area, manual processes and paper documents are the primary drivers for the business processes. In order for the KYME to move to the next levels of MITA Maturity, manual processes need to be replaced by automation and inputs and outputs need to be in electronic format. The automation of tasks using workflow tools and a separate business rules engine will serve a dual benefit by improving MITA capabilities and also meeting 7C&S requirements.

The shift to dual model with MCOs handling the majority of the members will reduce the utilization of the Operations Management processes but not entirely eliminate the activity.

Program Integrity Management – The process needs to be integrated among the stakeholders in the enterprise. This would improve coordination. The program should also utilize more automated tools to improve the efficiency of the process. Other improvements needed to meet the To Be goals include the full use of HIPAA standards for transactions and the use of standard electronic interfaces for data exchange.

Program Management – The Program Management area has several opportunities for maturity improvement. The leading capability improvements are in the areas of improved data access, improved data accuracy, improved reporting, and the automation of manual tasks. DMS has already begun using HIPAA standard transactions and that process should be adopted as the standard.

The current political environment has generated numerous program policy changes that the Division will be required to implement. The political environment will continue to change and the Division needs a flexible and rules driven system that can rapidly adjust to change.

With the change to the dual model, the Division will need improved access to the encounter data to monitor the quality of care delivered to the MCO enrolled members.

Provider Management – Kentucky is making strides in offering automated, self-service channels for providers such as the KYMMIS and KYHealthNet websites. Significant barriers still exist to achieving higher MITA Maturity Levels. Continuing reliance on hardcopy forms prevents complete automation of some processes in this business area (e.g., provider enrollment).

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The key areas required for maturity level improvement include the use of a rules engine in the enrollment process, establishing the NPI as the ID of record, establishing standard interfaces for provider validations, and improving the timeliness for enrollment.

In the next SS-A Deliverable, Cognosante presents the Transition Plan. The Transition Plan is a high-level work plan and narrative that identifies key projects that are needed to enable the KYME to address the gaps that have been indentified between the As Is and the To Be states, and transition the Medicaid Enterprise to an increased level of MITA Maturity.

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APPENDIX A: CMS MITA FRAMEWORK APPENDIX E (STATE SELF-ASSESSMENT DETAILS)

MITA BUSINESS

AREA

STATE BUSINESS

AREA

MITA BUSINESS PROCESS



Y

TO BE LEVEL OF BUSINESS CAPABILITY




BR Establish Business

Relationship

BR01 Establish Business

Relationship1 2



BR Manage Business

Relationship

BR02 Manage Business

Relationship 1 2



BR Terminate Business

Relationship

BR03 Terminate Business

Relationship

1 2



BR Manage Business

Relationship Communication

BR04 Manage Business

Relationship Communication

1 2

Care Management

Care Management

Care Management

CM Establish Case

CM01 Establish Case

1 2

Care Management

Care Management

CM Manage Case

CM02 Manage Case

1 2

Care Management

Care Management

CM Manage Medicaid

Population Health

CM03 Manage Medicaid

Population Health

1 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y


Care Management

Care Management

CM Manage Registry

CM04 Manage Registry

1 2




CO Produce Administrative

or Health Services RFP

CO01 Produce Administrative

or Health Services RFP

2 3



CO Award Administrative

or Health Services Contract

CO02 Award Administrative


1 2



CO Manage Administrative


CO03 Manage Administrative


1 2



CO Close-out Administrative


CO04 Close-out

Administrative or Health Services Contract

1 2



CO Manage Contractor Information

CO05 Manage Contractor Information

1 2



CO Manage Contractor

Communication

CO06 Manage Contractor

Communication1 2



CO Perform Contractor Outreach

CO07 Perform Contractor Outreach

1 2



CO Support Contractor

CO08 Support Contractor

1 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y


Grievance and Appeal

Appeal



CO Inquire Contractor Information

CO09 Inquire Contractor Information

1 2

Member Management

Member Management

Beneficiary Management

ME Determine Eligibility

ME01 Determine Eligibility

2 2

Member Management


ME Enroll Member

ME02 Enroll Beneficiary

1 2

Member Management


ME Disenroll Member

ME03 Disenroll Beneficiary

1 2

Member Management


ME Inquire Member Eligibility

ME04 Inquire Beneficiary Eligibility

2 2

Member Management


ME Manage Applicant and

Member Communication

ME05 Manage Applicant and Beneficiary

Communication

1 2

Member Management


ME Manage Member


ME06 Manage Beneficiary


1 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y


Member Management


ME Manage Member

Information

ME07 Manage Beneficiary Information

1 2

Member Management


ME Perform Population and

Member Outreach

ME08 Perform Population and

Beneficiary Outreach

1 2




OM Authorize Referral

OM01 Authorize Referral

1 2



OM Authorize Service

OM02 Authorize Service

1 2



OM Authorize Treatment Plan

OM03 Authorize

Treatment Plan1 2



OM Apply Attachment

OM04 Apply Attachment

1 2



OM Apply Mass

Adjustment

OM05 Apply Mass

Adjustment1 2



OM Edit Claims-

Encounter

OM06 Edit Claims-

Encounter1 2



OM Audit Claim-

Encounter

OM07 Audit Claim-

Encounter1 2



OM Price Claim-Value Encounter

OM08 Price Claim-Value Encounter

2 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y




OM Prepare Remittance

Advice-Encounter

Report

OM09 Prepare Remittance

Advice-Encounter

Report

2 2



OM Prepare Provider EFT-

Check

OM10 Prepare Provider EFT-

Check2 2



OM Prepare COB

OM11 Prepare COB

1 2



OM Prepare EOB

OM12 Prepare EOB

1 2



OM Prepare Home and Community

Based Services Payment

OM13 Prepare Home and Community

Based Services Payment

2 2



OM Prepare Premium EFT

OM14 Prepare Premium EFT

2 2



OM Prepare Capitation Premium Payment

OM15 Prepare Capitation Premium Payment

1 2



OM Prepare Health

Insurance Premium Payment

OM16 Prepare Health

Insurance Premium Payment

1 2



OM Prepare Medicare Premium Payments

OM17 Prepare Medicare Premium Payments

2 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y




OM Inquire Payment Status

OM18 Inquire Payment

Status2 2



OM Manage Payment

Information

OM19 Manage Payment

Information2 2



OM Calculate Spend-Down

Amount

OM20 Calculate

Spend-Down Amount

2 2



OM Prepare Member Premium Invoice

OM21 Prepare Beneficiary Premium Invoice

1 2



OM Manage Drug Rebate

OM22 Manage Drug Rebate

2 2



OM Manage Estate

Recovery

OM23 Manage Estate

Recovery1 2



OM Manage Recoupment

OM24 Manage Recoupment

1 2



OM Manage Cost

Settlement

OM25 Manage Cost

Settlement1 2



OM Manage TPL Recovery

OM26 Manage TPL Recovery

1 2

Program Integrity Management

Program Integrity

Management

Program Integrity

Management

PI Identify Candidate

Case

PI01 Identify Candidate

Case1 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y


Program Integrity

Management

Program Integrity

Management

PI Manage Case

PI02 Manage Case

1 2

Program Management

Program Management

Program Management

PG Designate Approved

Services/ Drug Formulary

PG01 Designate Approved

Services/ Drug Formulary

1 2

Program Management

Program Management

PG Develop and Maintain

Benefit Package

PG02 Develop and Maintain

Benefit Package

2 2

Program Management

Program Management

PG Manage Rate Setting

PG03 Manage Rate Setting

1 2

Program Management

Program Management

PG Develop Agency Goals and Objectives

PG04 Develop Agency Goals and Objectives

1 2

Program Management

Program Management

PG Develop and Maintain

Program Policy

PG05 Develop and Maintain

Program Policy1 2

Program Management

Program Management

PG Maintain State Plan

PG06 Maintain State Plan

1 2

Program Management

Program Management

PG Formulate Budget

PG07 Formulate

Budget1 2

Program Management

Program Management

PG Manage FFP for MMIS

PG08 Manage FFP for MMIS

1 2

Program Management

Program Management

PG Manage F-MAP

PG09 Manage F-MAP

1 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y


Program Management

Program Management

PG Manage State Funds

PG10 Manage State Funds

1 2

Program Management

Program Management

PG Manage 1099s

PG11 Manage 1099s

2 2

Program Management

Program Management

PG Generate Financial and

Program Analysis

PG12 Generate Financial and

Program Analysis

2 2

Program Management

Program Management

PG Maintain Benefits/

Reference Information

PG13 Maintain Benefits/

Reference Information

1 2

Program Management

Program Management

PG Manage Program

Information

PG14 Manage Program

Information1 2

Program Management

Program Management

PG Perform Accounting Functions

PG15 Perform Accounting Functions

2 2

Program Management

Program Management

PG Develop and Manage Performance

Measures and Reporting

PG16 Develop and Manage Performance

Measures and Reporting

1 2

Program Management

Program Management

PG Monitor Performance and Business

Activity

PG17 Monitor Performance and Business

Activity

1 2

Program Management

Program Management

PG Draw and Report FFP

PG18 Draw and Report

FFP1 2

Program Management

Program Management

PG Manage FFP for Services

PG19 Manage FFP for Services

1 2

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MITA BUSINESS

AREA

STATE BUSINESS

AREA




Y


Provider Management

Provider Management

Provider Management

PM Enroll Provider

PM01 Enroll Provider

1 2

Provider Management

Provider Management

PM Disenroll Provider

PM02 Disenroll Provider

1 2

Provider Management

Provider Management

PM Inquire Provider

Information

PM03 Inquire Provider

Information1 2

Provider Management

Provider Management

PM Manage Provider

Communication

PM04 Manage Provider

Communication1 2

Provider Management

Provider Management

PM Manage Provider


PM05 Manage Provider Appeal

1 2

Provider Management

Provider Management

PM Manage Provider

Information

PM06 Manage Provider

Information1 2

Provider Management

Provider Management

PM Perform Provider Outreach

PM07 Perform Provider Outreach

1 2

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