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
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[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
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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
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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
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