The MITA Business Architecture May 8, 2006

Medicaid IT Architecture – MITA

Business Architecture

Technical Architecture

Information Architecture

2

Individual State Process ModelsState Visioning Surveys

Concept ofOperations

MITA MaturityModel

Business Process Model

Business Capability

Matrix

State Self-Assess-

ment

Industry MaturityModel

IndustryConcept ofOperations

3

Business Capability

Business Capabilities 1 2 3 4 5

Trigger Business Process

Business Logic

Result

1 2 3 4 5

COO

Concept of Operations(COO)

Business Process Model (BPM)

Trigger Business Process

Business Logic

Result MITA MaturityModel (MMM)

1 2 3 4 5

Model (BCM) State Self-Assessment

4

Concept of Operations

COO

5

Provi

C O O

AS IS Concept of Operations der Business Provider Provider Provider

Sends Contract

Associates

Sends Paymentand RA

Receives Enrollment Information

and ID

2629-06—087

CMS Other

Bank

Managed Care

Medicaid Beneficiary

Managed Care

EligibilitySource

PaymentManagement

External Data-Sharing

Exchange

Information Management

Member Management

Provider and Contract Mgmt.

Medicaid Agency Utilization

and QualityManagement

Beneficiary Services

Provider

Communication

Member

Communication

Decisi

onSu

pport

StrategicPlanning

ExternalReporting

Data

Sharing

Multi-Entry

Collaboration M

S

Data

Sharin

Medicaid/Public

Health

Collaboration

Audits

QualityAssurance

UtilizationReview

&FraudDetection

Case Management

Service Auth. and Prepayment Review

Fina cial

AdminPa

ment Proces

sing

A

entgla

im

ncou

sContracts

edCare

ElD

ility Inqu

Auth.

Auths.

Payer

Provider

Care

Responds

Dual - E

ligibles

Initiatives

Medicaid/C

g

nistration

y

djustm

Proc

essinC

oordinationof

Benefits

Cs&E

nter

Processing

Rates

andFe

e

Network

Adm

inistra

tionA

dministrative

Manag

Contracts

Proent

vider

EnrollmBeft

tioen

it

Adminis

ran

igibility

etermination

Eligib

iryEnrollment

Provider

Provider Provider

Medicaid Beneficiary

Request

Receives

Other

Receives Provider Managed

Provider

Provider

ceives Sends RequestsInformation s

Mak s Sends Report

Re

eInquiries

Information Record

Makes Inquiries

Receives Information

Sends Treatment

Receives Approval

PrRe

ovides cords

Inquiries

Repayment Sends 1099

Sends

Notifies Readjustment

Enrollment ID

Sends gnApplication

Sends Eligibility Contract

Information

RequestsPayments

end

Sends Encounters

S s Claims

Managed Care

Receives Rates

Assi ment

Receives

Sends Proposal

tsal

Submi s Propo

Agencies

6

CMS

Eligibility Source Other Agencies

Provider

Provider

Finance Member Management

Data Sharing and

Communications

StrategicPlanning

Decision

Management

Provider and Contract Management

Support

Medicaid Agency

Other RHIOs

Bank Medicaid

Beneficiary

Provider Other Payer

Managed Care

2629-06—088

TO BE Concept of Operations C O O

7

Strategic

Tactical Operational

Strategic Tactical

Operational

C O O

Medicaid Operations Transformation

AS IS TO BE

8

MITA Maturity Model

1 2 3 4 5

9

1 2 3 4 5 MITA Maturity Model

Definition of State Medicaid Levels of Maturity

Level 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.

5 YEARS 10+ YEARS NOW

10

MITA Business Process Model Major Business Areas

Business RelationshipManagement

OperationsManagementMember

Management

ProgramIntegrity

Management

Care Management

ProgramManagement

Contractor Management

Provider Management

11

Provider Enrollment Provider

Information Management

Provider Support

Provider Management

Enroll Provider

Disenroll Provider

ManageProvider

Information

Manage ProviderCommunication

Inquire ProviderInformation

Manage ProviderGrievance and

Appeal

Perform Provider Outreach

12

The Business Process Is the Focus of the BPM

Business RelationshipManagement

OperationsManagement

Member Management

ProgramIntegrity

Management

Care Management

ProgramManagement

Contractor Management

Provider Management

Business Logic

Business Process

Trigger Result

•Definition •Description of Business Logic •Performance Measures

13

MITA Business Process

•Definition •Description of Business Logic •Performance Measures

Result (Data)Business LogicTrigger Event (Data)

Business Process

•Shared Data •Predecessor and Successor •Constraints •Failures

14

Enroll Provider Business Process

Shared Data: License, Prior History, NPI

Trigger: Provider

Application Data

Result: Provider

Enrollment Status Data

Provider Enrollment

Steps

15

MITA Business Process and Business Capabilities

Business Process

Trigger Event Business Logic Result

Business Capabilities

Level 1 Level 2 Level 3 Level 4 Level 5 Capability Capability Capability Capability Capability

16

5 YEARSNOW

Business Capability Matrix

Beneficiaries enroll at multiple locations for

different benefit plans. Treatment is not

coordinated across programs.

Beneficiaries enroll at any location for all benefit

plans. Treatment iscoordinated. Programs

share business services and data.

Beneficiaries are pre-enrolled based on

clinical and administrative data shared across programs and State

boundaries.

LEVE

L 1

LEVE

L 3

LEVE

L 5

5 YEARS 10+ YEARS NOW

17

[Business Process Title]

Business Capability Descriptions [for each Level of Maturity] 5 YEARS 10+ YEARS NOW

Level 1 Level 2 Level 3 Level 4 Level 5

�Timeliness of the results

�Data accuracy and accessibility

�Ease of performance; efficiency

�Cost effectiveness

�Quality of process results

�Value to the stakeholders

�Conformance Criteria

18

Provider Enrollment Business Capabilities

5 YEARS 10+ YEARS NOW

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

Enroll Provider Business Capabilities

Level 1 Level 2 Level 3 Level 4 Level 5 Agency reviews (nonstandard) application data and validates much of it manually. Agency conducts verification by contacting internal and external sources via phone or fax. Agency decisions may be inconsistent. Agency requires a large staff. Agency decisions may take several days.

Agency receives standardized and automated applications that providers can submit via a portal. Agency conducts verification by a mix of manual and automated steps. Agency decisions improve in consistency. Agency requires fewer staff. Agency decisions take less time.

Agency reviews application data that is standardized nationally (“one-stop shop” within a State or region). Almost all verifications can be automated, though agency may continue to take some manual steps. Agency decisions are consistent. Agency decisions can be immediate.

Agency receives internal and external validation sources, notices of change in provider status, and recertification notices automatically. Agency can access clinical data directly and use it to process enrollment requests. Agency takes manual steps only to handle exceptions. Agency decisions can be immediate.

Agency can send or receive enrollment process inquiries on provider status to or from any other State or Federal agency or other entity. Data exchange partners can send notifications regarding providers enrolled with the Medicaid program in any State.

19

The Business Capability Is the Cornerstone

ConceptualBusiness Data ModelProcess

LogicalData Model

Business Capability

20

Sample State Self-Assessment Profile

Business Process Level 1 Level 2 Level 3 Level 4 Level 5

Enroll Provider As-Is Audit Claim and Encounter As-Is To-Be

Authorize Service As-Is To-Be Manage Provider Grievance and Appeal

As-Is To-Be

Inquire Member Eligibility As-Is

Inquire Payment Status As-Is To-Be

Develop and Maintain Benefit Package

As-Is

21

Business Capabilities

1 2 3 4 5

Business Logic Result

Business Capabilities

1 2 3 4 51 2 3 4 5

Business Logic Result

Detailed Requirements

Contract

APD Trigger

Business Process

Business Capabilities

1 2 3 4 5

Trigger

Business Process

Trigger

Business Process Business

Logic Result

State Self-Assessment

RequirementsDesign

Development

AcceptanceTest

OperationalReadiness Test

RFP

Certification

22

Business Architecture Take-aways

z The business process/ business capability/logicaldata combination is the cornerstone of the BA and the driver for the TA

z Business processes map to the Conceptual DataModel; business capabilities map to the LogicalData Model

z The BA is not complete without the IA z The business process model is neutral re any

organization, location, staff, outsourcing, anddegree of automation

23

Business Architecture Take-aways

z States map their business processes to the MITABusiness Process Model and match their level of maturity against the definitions in the BusinessCapability Matrix

z Each business process has one or more levels ofcapability

z Vendors and technical enablers can assist States to achieve higher levels of maturity

z Capabilities will become more objective asattributes and conformance criteria are defined

24

QUESTIONS

25