Abstract:
A high-performance capability assessment model helps a Medicaid program meet the challenges of the health market. As a result, the Medicaid program can achieve the clarity, consistency, and well-defined execution of core processes that reduce inefficiencies and waste that result from unnecessary process complexity and exceptions. In addition, the high-performance capability assessment model helps the Medicaid program to identify specific areas in which improvements may be made, to understand how to make said improvements, and to establish levels of capability along the way to reaching an ultimate capability goal.

Description:
BACKGROUND OF THE INVENTION 
     1. Technical Field 
     This disclosure concerns a system and method for identifying the performance of an organization on a scale of mastery across representative capabilities of the organization&#39;s industry. In particular, this disclosure relates to an efficient and cost effective way to assess the performance level of key capability areas within the processes of a Medicaid program. 
     2. Background Information 
     Modern Medicaid programs operate in an increasingly challenging environment. To survive, Medicaid programs must adapt to this environment and execute in a clear, consistent, and efficient manner. Furthermore, the competitive nature, regulatory requirements, low profit margins, and competitive challenges of Medicaid programs greatly increase the complexity and difficulty of surviving on a day-to-day basis. 
     Despite the need for Medicaid programs to meet the challenges of the health-related market, it is still often the case that the programs lack clarity, consistency, and well-defined execution of its core processes. These shortcomings severely constrain the programs, and lead directly to inefficiencies and waste due to unnecessary complexity, process exceptions, and customer dissatisfaction. At the same time, it can be very difficult to identify specific processes to which improvements may be made, either because the program management itself does not have the expertise to identify the processes or because the complexities of the programs frustrate attempts to clearly delineate the processes to be improved. 
     Even if the Medicaid programs, on their own, could identify one of the many processes that it needs to improve, the business or management would not necessarily know how to improve the process or be able to identify a concrete and measurable improvement goal. Another difficulty exists in determining whether there are any intermediate goals that should be reached along the way. As Medicaid programs struggle to meet the demands of the modern economic and health landscape, they fail to identify opportunities for maximizing efficiency, category expansion, multi-channel execution, customer satisfaction, and to reach other important goals. 
     Therefore, a need exists for an efficient and effective system and method to assess the performance level of key assessment areas within the processes of a Medicaid program. 
     SUMMARY 
     A high-performance capability assessment (HPCA) model helps a Medicaid program meet the challenges of the market segment by defining a scale of performance mastery along which the current practices of the program may be located. The HPCA model accelerates the discovery of process and performance gaps within program operations. In addition, the HPCA model also helps the program to identify specific areas in which improvements may be made, how to make the improvements, and how to establish performance measures during the course of attempting to achieve an ultimate goal. As a result, the programs can achieve the clarity, consistency, and well-defined execution of core processes that maximize the operating budget for optimum outcomes. 
     The HPCA model includes a key factor dimension and a performance mastery scale dimension. The performance mastery scale dimension defines multiple mastery levels. The performance mastery levels form a scale of increasing organizational performance. The scale includes a ‘Basic’ mastery level, a ‘Competitive’ mastery level, and a ‘Market Leading’ mastery level along a horizontal axis. Each performance mastery level includes criteria specific to a corresponding key assessment area. Each key assessment area identifies some aspect of a capability of a Medicaid program. 
     A capability can be defined as a bundle of closely integrated skills, knowledge, technologies, and cumulative learning that is exercised through a set of processes and that collectively represents an program&#39;s ability to create value by producing outcomes and results. Capability areas do not represent a delineation of organizational responsibilities because the outcomes of a capability may be the result of a number of cross-functional teams. Capabilities of a business may be grouped into areas and/or platforms, including platforms and sub-platforms, depending on the organizational structure of the business. 
     For example, the HPCA model groups the capabilities of the Medicaid program into nine main areas or platforms, which may also be thought of as “program areas,” namely a program management platform, a care management platform, a contractor management platform, a program integrity management platform, a business relationship management platform, a provider management platform, a member management platform, an operations management platform, and an enterprise platform. Each platform may include multiple sub-platforms. For example, the program integrity management platform may include three sub-platforms, namely an identify candidate case sub-platform, a manage case sub-platform, and a payment integrity sub-platform. 
     Some of the platforms and sub-platforms may include additional or further levels, while others may not, and may also include capabilities at their lowest level. Examples of capabilities within the program quality management sub-platform include, for example, a manage business performance capability and a manage quality, risk, and performance capability. 
     The key factor dimension establishes a set of key assessment areas in which to analyze the capabilities of a business. Key assessment areas include performance capability criteria. Performance capability criteria populate the performance capability assessment model. The performance capability criteria may be specific to any one of many different business capabilities. Any number of performance capability assessment models and performance capability criteria may be defined and stored in a capability detail pool for subsequent retrieval and application to a business under examination. Accordingly, the HPCA model provides a flexible and adaptive scale of performance capability against which business practices may be compared to ascertain where the capabilities of a program under examination fall along the scale. 
     Other systems, methods, features, and advantages will be, or will become, apparent to one with skill in the art upon examination of the following figures and detailed description. All such additional systems, methods, features, and advantages are included within this description, are within the scope of the invention, and are protected by the following claims. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The Medicaid high-performance capability assessment model and system may be better understood with reference to the following drawings and description. The elements in the figures are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the capability assessment techniques. In the figures, like-referenced numerals designate corresponding parts throughout the different views. 
         FIG. 1  shows a high-performance capability assessment model with a performance scale of mastery and performance criteria shown for different capabilities showing multiple platforms, including a program management platform, a care management platform, a contractor management platform, a program integrity management platform, a business relationship management platform, a provider management platform, a member management platform, an operations management platform, and an enterprise platform. 
         FIG. 2  shows a high-performance capability assessment model with capabilities for sub-platforms, including a program quality management sub-platform, a cost containment sub-platform, a program administration sub-platform, a budget sub-platform, a risk and issue management sub-platform, a policy management sub-platform, a program information sub-platform, an accounting sub-platform, and a benefits administration sub-platform, all corresponding to the program management platform. 
         FIG. 3  shows a high-performance capability assessment model with capabilities for sub-platforms, including a manage Medicaid population health sub-platform, an establish case sub-platform, a manage case sub-platform, a manage registry sub-platform, and a quality and outcomes reporting sub-platform, all corresponding to the care management platform. 
         FIG. 4  shows a high-performance capability assessment model with capabilities for sub-platforms, including a health services contracting sub-platform, a contract information management sub-platform, an administration contracting sub-platform, and a contractor support sub-platform, all corresponding to the contractor management platform. 
         FIG. 5  shows a high-performance capability assessment model with capabilities for sub-platforms, including an identify candidate case sub-platform, a manage case sub-platform, and a payment integrity sub-platform, all corresponding to the program integrity management platform. 
         FIG. 6  shows a high-performance capability assessment model with capabilities for sub-platforms, including an establish business relationship sub-platform, a manage business relationship sub-platform, a manage business relationship communication sub-platform, a terminate business relationship sub-platform, and a determine strategic alliances sub-platform, all corresponding to the business relationship management platform. 
         FIG. 7  shows a high-performance capability assessment model with capabilities for sub-platforms, including a provider enrollment sub-platform, a provider information management sub-platform, a provider support sub-platform, and a provider network management strategy sub-platform, all corresponding to the provider management platform. 
         FIG. 8  shows a high-performance capability assessment model with capabilities for sub-platforms, including an eligibility determination sub-platform, an enrollment sub-platform, a member information management sub-platform, a prospective and current member support sub-platform, and a market products and services sub-platform, all corresponding to the member management platform. 
         FIG. 9  shows a high-performance capability assessment model with capabilities for sub-platforms, including a service authorization sub-platform, a member payment information sub-platform, a claims-encounters adjudications sub-platform, a cost avoidance sub-platform, a cost recoveries sub-platform, a payment and reporting sub-platform, a payment information management sub-platform, and a capitation and premium preparation sub-platform, all corresponding to the operations management platform. 
         FIG. 10  shows a high-performance capability assessment model with capabilities for sub-platforms, including a health informatics sub-platform, a procurement management sub-platform, a privacy and compliance management sub-platform, a legal management sub-platform, a human resources sub-platform, an information technology operations sub-platform, and a facilities management sub-platform, all corresponding to the enterprise platform. 
         FIG. 11  shows a capability detail pool providing a multidimensional Medicaid program performance reference set where multiple key assessment performance reference tables are collected and stored. 
         FIG. 12  shows a capability assessment system. 
         FIG. 13  shows a flow diagram for establishing high-performance capability assessment models. 
         FIG. 14  shows a flow diagram for retrieving and applying high-performance capability assessment models. 
         FIG. 15  shows a flow diagram for analyzing representative practice data to determine a Medicaid program and Medicaid key assessment area to which the representative practice data applies. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
       FIG. 1  shows a high-performance capability assessment (HPCA) model  100 . The HPCA model  100  specifies nine platforms, including a program management platform  102 , a care management platform  104 , a contractor management platform  106 , a program integrity management platform  108 , a business relationship management platform  110 , a provider management platform  112 , a member management platform  114 , an operations management platform  116 , and an enterprise platform  118 . Each platform  102 ,  104 ,  106 ,  108 ,  110 ,  112 ,  114 ,  116 , and  118  may include sub-platforms. The HPCA model  100  is not limited to the form shown in  FIG. 1 . Instead, the HPCA model  100  may be adapted and modified to full a wide variety of analysis roles. Additional, different, or fewer platforms may be used in other implementations, with each platform defining additional, different, or fewer capabilities. Each platform and/or sub-platform includes one or more multiple &lt;platform/sub-platform name&gt;capabilities  130 . 
     The HPCA model  100  establishes a multidimensional Medicaid program performance reference set that includes multiple key assessment performance levels  138 , further described below in reference Tables 1-3. The performance levels  138  establish a scale of increasing effectiveness in delivery of each capability. The key assessment performance reference tables include a ‘Basic’  140  delivery level, a ‘Competitive’  142  delivery level, and a ‘Market Leading’  144  delivery level. The performance levels establish a scale of mastery  146  along which current program practices may be located and identified with respect to any platform and capability within a platform according to an analysis of performance capability criteria (PCC). The capability under evaluation may be assigned the performance level  138  based on a delivery effectiveness position  158  along the scale of mastery  146 . 
     The ‘Basic’ delivery level  140  specifies ‘Basic’ performance assessment criteria, the ‘Competitive’ delivery level  142  specifies ‘Competitive’ performance assessment criteria, and the ‘Market Leading’ delivery level  144  specifies ‘Market Leading’ performance assessment criteria. The HPCA model  100  receives input data that specifies a Medicaid program platform (e.g., a Medicaid program area) and a Medicaid program key assessment area for analysis. The HPCA model  100  searches the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program platform and corresponding program capability within the platform and the Medicaid program key assessment area, and retrieves the matching key assessment performance reference table. The HPCA model  100  initiates analysis of the matching key assessment performance reference table to obtain a resultant performance assessment level for the Medicaid program key assessment area. 
     Tables 1-3 below provide an explanation of each of the capability levels  140 ,  142 , and  144 . 
     
       
         
               
             
               
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 ‘Basic’ Delivery Level 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 Description: 
                 Capability mastery at the basic level is  
               
               
                   
                   
                 competitive on a domestic or local 
               
               
                   
                   
                 level and selectively on a global basis. 
               
               
                   
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
           
               
                 TABLE 2 
               
               
                   
               
               
                 ‘Competitive’ Delivery Level 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Description: 
                 Capability mastery at a competitive level  
               
               
                   
                 is in the top 50% of performers when compared  
               
               
                   
                 to domestic and international peer groups. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
               
             
           
               
                 TABLE 3 
               
               
                   
               
               
                 ‘Market Leading’ Delivery Level 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 Description: 
                 Capability mastery at a market leading  
               
               
                   
                   
                 level implies that few companies 
               
               
                   
                   
                 globally are performing at this level,  
               
               
                   
                   
                 and can include emerging capabilities 
               
               
                   
                   
                 where companies have committed  
               
               
                   
                   
                 significant levels of investment and 
               
               
                   
                   
                 resources. 
               
               
                   
                   
               
             
          
         
       
     
     For  FIGS. 2-10  the capability under evaluation may be assigned a level of mastery  138  based on the program&#39;s position along the scale of mastery  146  (e.g., the ‘Basic,’ ‘Competitive,’ or ‘Market Leading’ delivery level). Performance criteria corresponding to the basic  140 , competitive  142 , and market leading  144  performance levels populate the HPCA model  100 . The performance criteria capture characteristics, and/or other features of the delivery of a capability at a particular performance level. Examples below illustrate performance criteria that provide analysis and benchmarking for Medicaid programs. The HPCA model  100  performance criteria provide a tool for determining where a platform and capability under examination fall along the scale of mastery  146 . 
     For example, business consultants and business process engineers may interview a business or receive data about the business to determine, measure, or otherwise ascertain the characteristics, criteria, and other features of a particular capability implemented within the program. The consultants and engineers may compare the characteristics of the business to the performance criteria in the HPCA model  100  and arrive at an assessment level  138  for the capability under examination. In doing so, for example, the consultants and engineers may identify where the capability under examination falls in terms of the performance level for each key assessment area of a capability and determine an overall position on the scale of mastery  146  for the capability under examination. Performance criteria may populate the HPCA model  100  in whole or in part. Multiple high-performance capability assessments may be collected and stored with the performance criteria for future retrieval and possible modification in a capability detail pool, discussed below. 
       FIG. 2  shows the program management platform  102  divided into respective capability areas  202 . The program management platform  102  includes a program quality management sub-platform  220 , a cost containment sub-platform  222 , a program administration sub-platform  224 , a budget sub-platform  226 , a risk and issue management sub-platform  228 , a policy management sub-platform  230 , a program information sub-platform  232 , an accounting sub-platform  234 , and a benefits administration sub-platform  236 . 
       FIG. 3  shows the care management platform  104  divided into respective capability areas  302 . The care management platform  104  includes a manage Medicaid population health sub-platform  320 , an establish case sub-platform  322 , a manage case sub-platform  324 , a manage registry sub-platform  326 , and a quality and outcomes reporting sub-platform  328 . 
       FIG. 4  shows the contractor management platform  106  divided into respective capability areas  402 . The contractor management platform  106  includes a health services contracting sub-platform  420 , a contract information management sub-platform  422 , an administration contracting sub-platform  424 , and a contractor support sub-platform  426 . 
       FIG. 5  shows the program integrity management platform  108  divided into respective capability areas  502 . The program integrity management platform  108  includes an identify candidate case sub-platform  520 , a manage case sub-platform  522 , and a payment integrity sub-platform  524 . 
       FIG. 6  shows the business relationship management platform  110  divided into respective capability areas  602 . The business relationship management platform  110  includes an establish business relationship sub-platform  620 , a manage business relationship sub-platform  622 , a manage business relationship communication sub-platform  624 , a terminate business relationship sub-platform  626 , and a determine strategic alliances sub-platform  628 . 
       FIG. 7  shows the provider management platform  112  divided into respective capability areas  702 . The provider management platform  112  includes a provider enrollment sub-platform  720 , a provider information management sub-platform  722 , a provider support sub-platform  724 , and a provider network management strategy sub-platform  726 . 
       FIG. 8  shows the member management platform  114  divided into respective capability areas  802 . The member management platform  114  includes an eligibility determination sub-platform  820 , an enrollment sub-platform  822 , a member information management sub-platform  824 , a prospective and current member support sub-platform  826 , and a market products and services sub-platform  828 . 
       FIG. 9  shows the operations management platform  116  divided into respective capability areas  902 . The operations management platform  116  includes a service authorization sub-platform  920 , a member payment information sub-platform  922 , a claims-encounters adjudications sub-platform  924 , a cost avoidance sub-platform  926 , a cost recoveries sub-platform  928 , a payment and reporting sub-platform  930 , a payment information management sub-platform  932 , and a capitation and premium preparation sub-platform  934 . 
       FIG. 10  shows the enterprise platform  118  divided into respective capability areas  1002 . The enterprise platform  118  includes a health informatics sub-platform  1020 , a procurement management sub-platform  1022 , a privacy and compliance management sub-platform  1024 , a legal management sub-platform  1026 , a human resources sub-platform  1028 , an information technology operations sub-platform  1030 , and a facilities management sub-platform  1032 . 
     The tables provided in the appendix immediately following the abstract, which form part of this disclosure, provide an explanation of the capabilities and corresponding key assessment areas and performance criteria for some of the capabilities within the respective sub-platforms. Each capability may include one or more key assessment areas. Each key assessment area may include one or more additional key assessment areas. In other words, a business capability may include sub-capabilities, and therefore, key assessment areas corresponding to the multiple sub-capabilities. The tables in the appendix show specific criteria used to analyze each capability. 
       FIG. 11  shows a multidimensional Medicaid program performance reference set  1100  (“reference set  1100 ”) that provides a capability detail pool from which the system described below may obtain benchmarking tables for a Medicaid program. The reference set  1100  includes multiple key assessment performance reference tables (“reference tables”), two of which are labeled  1102  and  1104 . Each reference table may provide the benchmarking criteria for a specific capability, such as those noted above with respect to  FIGS. 2-10 . 
     One dimension of each table may establish the ‘Basic’ performance level  140  specifying ‘Basic’ performance assessment criteria, the ‘Competitive’ performance level  142  specifying ‘Competitive’ performance assessment criteria, and the ‘Market Leading’ performance level  144  specifying ‘Market Leading’ performance assessment criteria. Another dimension of each table may specify one or more key assessment areas (KAAs), several of which are labeled  1106 ,  1108 , and  1110 . As noted above, performance criteria, e.g., the PCC  1112 , populate each key assessment performance reference table to provide benchmark criteria for ‘Basic,’ ‘Competitive,’ and ‘Market Leading’ characteristics. 
     The reference set  1100  represents the HPCA model  100 . Consistent with the HPCA model  100 , the reference set  1100  may organize multiple reference tables into a hierarchical structure defining discrete changes in granularity. In one implementation, the hierarchical structure includes reference tables, high-level platforms, platforms, sub-platforms, and models.  FIG. 11  labels three sub-platforms  1114 ,  1116 , and  1118 . The reference set  1100  may further organize the platforms, two of which are labeled  1120  and  1122 . Platforms aggregate into the HPCA model  100  and corresponding reference set  1100 . Additional, different, or fewer levels of granularity may be defined in the HPCA model  100 . 
     The reference set  1100  may dynamically populate the reference tables with the most up-to-date performance criteria, for example upon retrieval and presentation by a business analysis consultant. The performance criteria may be retrieved from a performance capability criteria database or other information source. 
       FIG. 11  also shows an example of a database implementation  1124  of a portion of a reference table. In particular, the database implementation  1124  includes records (e.g., the records  1126 ,  1128 ,  1130 ) that establish each PCC  1112 . In the example shown, each record includes a PCC field  1132 , a category specifier field  1134 , and a KAA specifier field  1136 . Other fields may be provided, such as a reference table assignment field or reference set assignment field. The records categorize each PCC into a specific category (e.g., ‘Basic’), into a specific KAA, and, optionally, into a specific reference table in a specific reference set for any particular HPCA model. 
       FIG. 12  shows a high-performance capability assessment system (“system”)  1200 . The system  1200  includes a processor  1202  and a memory  1204 . Several databases support the operation of the system  1200 , including a performance capability database  1206 , a performance measured database  1208 , a capability detail pool database  1210 , and an assessment results database  1226 . The system  1200  may include a local display  1212  and input/output interfaces  1217  (e.g., including a keyboard, mouse, microphone, speakers, or other device), and, through the communication interface  1214  and networks  1216 , may communicate with remote devices  1218  and remote displays  1220 . The networks  1216  may be any combination of external networks (e.g., the Internet) and internal networks (e.g., corporate LANs). The displays  1212  and  1220  may, for example, present performance capability assessment models  1222  that the system  1200  retrieves from the capability detail pool database  1210  for review, modification, and application by process engineers or other individuals. With regard to local access or access by the remote devices  1218 , the system  1200  may include a login processing program  1224  to authenticate and/or authorize access to the system  1200 . To that end, the login processing program  1224  may include username/password verification, private/public key encryption, or other validation and data protection capabilities. 
     In one implementation, the capability performance database  1206  stores performance criteria. As will be described in more detail below, the system  1200  may populate performance capability assessment models with performance capability criteria suited to any particular platform or sub-platform (e.g., a program quality management sub-platform  220 ) and business capability at one or more capability levels across one or more key assessment areas. The performance measured database  1208  may store the determined, measured, or otherwise ascertained characteristics, criteria, and other measured data of a particular key assessment area as representative practice data  1248 . The representative practice data  1248  may be obtained through interviews with business consultants and industrial engineers, through online questionnaires, through manual or automated analysis of business data (e.g., year-end operating reports), or by other means. The capability detail pool database  1210  stores the capability detail pool  1100 , which includes pre-defined performance capability assessment models  1222 . The assessment results database  1226  stores determined capability levels for specific capabilities that have been analyzed. 
     The system  1200  facilitates the review, modification, creation, and application of performance capability assessment models. In that role, performance capability assessment model manipulation logic (“manipulation logic”)  1246  within the system  1200  creates, retrieves, and stores capability assessment data  1228  in the memory  1204 . The manipulation logic  1246  may establish capability assessment data  1228  in the memory  1204 , including a capability assessment data structure  1230  with multiple capability levels (“CL”)  1232  organized along a scale of mastery dimension, multiple key assessment areas (“KAA”)  1234  organized along a key factor dimension, and performance criteria (“PCC”)  1236  that populate the performance capability assessment model  1230 . The manipulation logic  1246  may vary widely in implementation, and, as one example, may include data storage logic  1252  that saves data in memory and user interface logic that accepts capability level specifications, key assessment area specifications, and performance capability criteria inputs to create new performance capability assessment models, to modify existing performance capability assessment models, to delete performance capability assessment models, or to retrieve performance capability assessment models for review. 
     In one implementation, the manipulation logic  1246  establishes the capability assessment data structure  1230  to include a multidimensional Medicaid program performance reference set that includes multiple key assessment performance reference tables in which the key assessment performance reference tables include a ‘Basic’ capability performance level, a ‘Competitive’ capability performance level, and a ‘Market Leading’ capability performance level. 
     The capability assessment data  1228  may also include a capability position specifier  1238 . The capability position specifier  1238  may record the capability level along the scale of mastery  146 , as determined for any particular capability. Thus, the system  1200  may store the performance level in the assessment results database  1226  or elsewhere for future retrieval and review. 
     In one implementation, the data population logic  1240  may be a data population program executed by the processor  1202  that populates template performance capability assessment models. For example, the data population logic  1240  may include input logic  1250  that accepts input specifying a capability of interest that indicates a particular performance capability assessment model. The data population logic  1240  may include query logic  1245  that executes database queries and prompts a user for input to obtain the corresponding performance capability criteria for the capability of interest. 
     In another implementation, for example, the query logic  1245  may receive an input specifying a Medicaid program area and a Medicaid program key assessment area with the Medicaid program area for analysis. The query logic  1245  searches the multidimensional Medicaid program performance reference set for a matching key assessment performance reference table that matches the Medicaid program area and the Medicaid program key assessment area, and retrieves the matching key assessment performance reference table. 
     The data population logic  1240  may further include storage logic that adds the retrieved performance capability criteria to the template performance capability assessment model. The data population logic  1240  produces populated performance capability assessment structures  1242  that may be stored in the capability detail pool database  1210 . 
     In addition to the analysis process described above, the system  1200  may provide an automated analysis of representative practice data  1248  that identifies relevant performance capability criteria and determines the position on the scale of mastery  146  of each key assessment area corresponding to the performance capability criteria for the representative practice data  1248 . As one example, the system  1200  may implement capability assessment logic  1244  that includes comparison and/or matching logic that analyzes the representative practice data  1248  with respect to performance capability criteria to locate key assessment areas for which the system  1200  can determine capability levels to obtain a resultant performance level for each key assessment area. 
     Furthermore, the capability assessment logic  1244  may determine an overall position on the scale of mastery  146  as the capability position specifier  1238  for a capability under examination given the knowledge of where the key assessment areas corresponding to the capability under examination fall in each capability level. Thus, for example, the capability assessment logic  1244  may determine an overall capability level for a capability corresponding to the capability level for the majority of the key assessment areas, or it may apply a weighted analysis technique to give more emphasis to some key assessment areas than others in determining the overall position on the scale of mastery  146  for a capability. As another example, the capability assessment logic  1244  may implement an expert system (e.g., based on a neural network trained on prior determinations) that analyzes the determined characteristics with respect to the performance capability criteria and ascertains where the capability under examination falls along the scale of mastery  146  for each of the key assessment areas, or overall on the scale of mastery. 
       FIG. 13  shows a flow diagram  1300  for creating performance capability assessment models. The performance capability assessment model creator (e.g., the manipulation logic  1246 ) establishes a key factor dimension for the performance capability assessment model ( 1302 ). The performance capability assessment model creator also establishes a capability scale dimension for the performance capability assessment model ( 1304 ). The capability scale dimension may define a scale of increasing organizational capability. For example, the structure creator may create the ‘Basic’ level  140 , the ‘Competitive’ level  142 , and the ‘Market Leading’ level  144 . The performance capability assessment model creator also populates the performance capability assessment model with capability performance criteria ( 1306 ). A capability detail pool  1100  may be formed to hold multiple tailored key assessment performance reference tables ( 1308 ). The performance capability assessment model creator may store the populated assessment structure in the capability detail pool for subsequent retrieval and analysis ( 1310 ). 
       FIG. 14  shows a flow diagram  1400  for retrieving and applying performance capability assessment models. A selection of a capability to be analyzed is obtained ( 1402 ). In one implementation, the system  1200  receives input data that specifies a Medicaid program area and a Medicaid program key assessment area for analysis. For example, the system  1200  may accept input from a business consultant that specifies a capability for analysis. The system  1200  may query the capability detail pool  1100  for a corresponding performance capability assessment model ( 1404 ). The corresponding performance capability assessment model may be pre-defined in the capability detail pool  1100 , or the data population logic  1240  (or other actor) may populate a performance capability assessment model template that the system  1200  newly creates, or that the system  1200  retrieves from a data store, such as the capability detail pool database  1210 . 
     In another example, the system  1200  searches the multidimensional Medicaid program performance reference set in the capability detail pool  1100  for a matching key assessment performance reference table based on the input data that specifies a Medicaid program platform and a Medicaid program key assessment area. The system  1200  retrieves the matching key assessment performance reference table and initiates analysis of the matching key assessment performance reference table to obtain a resultant performance level for the Medicaid program key assessment area. 
     The system  1200  obtains representative practice data  1248  for the capability under examination in the specific business under review ( 1406 ). For example, a business consultant may interview the business to determine how the business currently executes the capability under review. As another example, a representative from the business may complete a questionnaire, submit business data for analysis and parameter extraction, or otherwise provide the characteristics of their current capability execution. As a further example, the system  1200  may retrieve the representative practice data  1248  from a database of previously obtained representative practice data. 
     The system  1200  compares the representative practice data  1248  to the performance criteria in the performance capability assessment model ( 1408 ). For example, a business consultant may use his or her expertise to determine the level for the business and the capability under examination ( 1410 ). Alternatively or additionally, the capability assessment logic  1244  may perform an automated analysis of the assessment results data in the assessment results database  1226  and ascertain the performance level on the scale of mastery  146 . The system  1200  may store the assessment results, including the determined performance level, for future reference in the assessment results database  1226  or other location ( 1412 ). 
       FIG. 15  shows a flow diagram  1500  for analyzing representative practice data  1248  to determine a Medicaid program and a Medicaid program assessment area to which the representative practice data applies. The system  1200  receives representative practice data  1248  as input data ( 1502 ). The system  1200  may receive the representative practice data  1248  from a database query performed by the query logic  1245  that the query logic executes periodically, when instructed by an operator, and/or automatically against any number of available database sources that store representative practice data  1248 . The capability assessment logic  1244  analyzes the representative practice data  1248  to identify performance capability criteria in the capability detail pool  1100  that the capability assessment logic  1244  determines relevant to the representative practice data  1248  ( 1504 ). For example, the capability assessment logic  1244  may compare and/or match the content of the representative practice data  1248  with the performance capability criteria by using natural language processing (NLP), text string, and/or substring matching, by comparing tags linked to the representative practice data  1248  and that specify that any portion of the representative practice data  1248  is applicable to a specific PCC, by querying for a manual classification of the representative practice data  1248  to a PCC, or by using other matching techniques. The capability assessment logic  1244  may score and/or weight a performance capability criteria and compare the score and/or weight to a user specified relevance threshold to rank the relevance of the performance capability criteria to the representative practice data  1248  ( 1506 ). The user may specify particular terms and/or phrases to search and match between the performance capability criteria and the representative practice data  1248 , in order to score the performance capability criteria. 
     The capability assessment logic  1244  may determine, based on the number of performance capability criteria that meet or exceed the relevance threshold, that the capability assessment logic  1244  has identified a sufficient number of performance capability criteria for a specific key assessment area in order to determine a performance level for the capability as a whole or any key assessment area within the capability ( 1508 ). As one example, where at least 51% of the performance capability criteria for a particular key assessment area meet or exceed the relevance threshold, the capability assessment logic  1244  applies the performance capability criteria to the representative practice data  1248 . In another example, the performance capability criteria for a particular key assessment area may be ranked in importance and/or designated as mandatory in order to assess the key assessment area. In the event the capability assessment logic  1244  identifies the mandatory performance capability criteria for a key assessment area, the capability assessment logic  1244  applies the performance capability criteria to the representative practice data  1248 . 
     The capability assessment logic  1244  may apply the performance capability criteria meeting or exceeding the relevance threshold to the representative practice data  1248  to determine whether any particular PCC is met. Accordingly, as the capability assessment logic  1244  analyzes the PCC, the system  1200  tracks the best fit of the representative practice data  1248  to the PCCs in the key assessment performance reference tables. In other words, the system  1200  determines how the representative practice data  1248  meets (or does not meet) each PCC, thereby gaining insight into whether the representative practice data  1248  is indicative of ‘Basic,’ ‘Competitive,’ or ‘Market Leading’ practices. 
     The system  1200  may also gauge the position on the scale of mastery  146  of each key assessment area corresponding to the performance capability criteria ( 1510 ). The capability assessment logic  1244  may further determine an overall position on the scale of mastery  146  for a capability ( 1512 ). The capability assessment logic  1244  may establish that a desired number and/or designated mandatory performance capability criteria for the key assessment areas have been identified as relevant to a capability and sufficient to determine the position on the scale of mastery  146  for the capability. For example, the capability assessment logic  1244  may determine an overall performance level for the capability based on the performance level determined for the majority of the key assessment areas. The capability assessment logic  1244  may apply a weighted analysis technique to give more emphasis to some key assessment areas than others in determining the overall position on the scale of mastery  146  for the capability. Although selected aspects, features, or components of the implementations are depicted as being stored in computer-readable memories (e.g., as computer-executable instructions or performance capability assessment models), all or part of the systems and structures may be stored on, distributed across, or read from other computer-readable media. The computer-readable media may include, for example, secondary storage devices such as hard disks, floppy disks, and CD-ROMs; a signal, such as a signal received from a network or received at an antenna; or other forms of memory, including ROM or RAM, either currently known or later developed. 
     Various implementations of the system  1200  may include additional or different components. A processor may be implemented as a microprocessor, a microcontroller, a DSP, an application specific integrated circuit (ASIC), discrete logic, or a combination of other types of circuits or logic. Similarly, memories may be DRAM, SRAM, Flash, or any other type of memory. The processing capability of the system may be distributed among multiple system components, such as among multiple processors and memories, optionally including multiple distributed processing systems. Parameters, databases, and other data structures may be separately stored and managed, may be incorporated into a single memory or database, may be logically and physically organized in many different ways, and may be implemented in many ways, including data structures such as linked lists, hash tables, or implicit storage mechanisms. Programs may be combined or split among multiple programs, or distributed across several memories and processors. 
     The logic, circuitry, and processing described above may be encoded or stored in a machine-readable or computer-readable medium such as a compact disc read only memory (CDROM), magnetic or optical disk, flash memory, random access memory (RAM) or read only memory (ROM), erasable programmable read only memory (EPROM) or other machine-readable medium such as, for example, instructions for execution by a processor, controller, or other processing device. 
     The medium may be implemented as any device that contains, stores, communicates, propagates, or transports executable instructions for use by or in connection with an instruction executable system, apparatus, or device. Alternatively or additionally, the logic may be implemented as analog or digital logic using hardware, such as one or more integrated circuits, or one or more processors executing instructions; or in software in an application programming interface (API) or in a Dynamic Link Library (DLL), functions available in a shared memory or defined as local or remote procedure cells; or as a combination of hardware and software. 
     In other implementations, the logic may be represented in a signal or a propagated-signal medium. For example, the instructions that implement the logic of any given program may take the form of an electronic, magnetic, optical, electromagnetic, infrared, or other type of signal. The systems described above may receive such a signal at a communication interface, such as an optical fiber interface, antenna, or other analog or digital signal interface, recover the instructions from the signal, store them in a machine-readable memory, and/or execute them with a processor. 
     The systems may include additional or different logic and may be implemented in many different ways. A processor may be implemented as a controller, microprocessor, microcontroller, application specific integrated circuit (ASIC), discrete logic, or a combination of other types of circuits or logic. Similarly, memories may be DRAM, SRAM, Flash, or other types of memory. Parameters (e.g., conditions and thresholds) and other data structures may be separately stored and managed, may be incorporated into a single memory or database, or may be logically and physically organized in many different ways. Programs and instructions may be parts of a single program, separate programs, or distributed across several memories and processors. 
     The HPCA  100  model provides unexpectedly good results for a performance capability assessment model, particularly in the Medicaid program area. In particular, the combinations of key assessment areas and particular assessment criteria of the HPCA model, including the criteria noted in the Appendix of Tables, provide significant advantages over other assessment models. The unexpectedly good results include clearly identifying and delineating from among multiple related complex processes the specific processes to improve, how to improve the process, and identifying concrete and measurable improvement goals. 
     While various embodiments of the invention have been described, it will be apparent to those of ordinary skill in the art that many more embodiments and implementations are possible within the scope of the invention. Accordingly, the invention is not to be restricted except in light of the attached claims and their equivalents. 
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Quality Management 
                 Capability: Manage  
               
               
                   
                 Business Performance 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 1.5.3.1 Manage Productivity,  
                   
                   
               
               
                 Capacity &amp; Cost 
                   
                   
               
               
                 1.5.3.2 Manage Knowledge,  
                   
                   
               
               
                 Processes &amp; Best Practices 
                   
                   
               
               
                 1.5.3.3 Manage Service Quality 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 2 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Quality Management 
                 Capability: Manage  
               
               
                   
                 Quality, Risk, and  
               
               
                   
                 Performance 
               
               
                   
               
             
          
           
               
                   
                   
                 Market  
               
               
                 Basic 
                 Competitive 
                 Leading 
               
               
                   
               
               
                 1.5.4.1 Define Approach and Program 
                   
                   
               
               
                 1.5.4.2 Establish Metrics and Indicators 
                   
                   
               
               
                 1.5.4.3 Collect and Analyze Information 
                   
                   
               
               
                 1.5.4.4 Provide Feedback and Change  
                   
                   
               
               
                 Practices as Appropriate 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 3 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Cost Containment 
                 Capability: Perform  
               
               
                   
                 Cost Containment  
               
               
                   
                 Functions 
               
               
                   
               
             
          
           
               
                   
                   
                 Market  
               
               
                 Basic 
                 Competetive 
                 Leading 
               
               
                   
               
               
                 1.9.1.1 Perform ongoing research  
                   
                   
               
               
                 and analysis to identify possible 
                   
                   
               
               
                 areas for cost containment. 
                   
                   
               
               
                 1.9.1.2 Identify methods to reduce  
                   
                   
               
               
                 program administrative  
                   
                   
               
               
                 at health care costs 
                   
                   
               
               
                 1.9.1.3 Review options, estimate of  
                   
                   
               
               
                 benefits, impact assessments,  
                   
                   
               
               
                 and alternatives 
                   
                   
               
               
                 1.9.1.4 Prioritize initiatives 
                   
                   
               
               
                 1.9.1.5 Implement approved cost  
                   
                   
               
               
                 reduction initiatives 
                   
                   
               
               
                 1.9.1.6 Determine measurement  
                   
                   
               
               
                 methodology and benchmarks. 
                   
                   
               
               
                 1.9.1.7 Continually measure and  
                   
                   
               
               
                 analyze cost reduction measures. 
                   
                   
               
               
                 1.9.1.8 Provide reports on effectiveness  
                   
                   
               
               
                 of cost reduction measures 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 4 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Administration 
                 Capability: Develop Agency Goals and Initiatives 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Agency receives notices that a review of current 
                 More in depth review of Agency Goals and 
                 Basic review of Agency Goals and 
               
               
                 goals and objectives is warranted. 
                 Objectives takes place. 
                 Objectives takes place 
               
               
                 Basic review of Agency Goals and 
                 Consensus on changes is established with 
                 Consensus on changes is established with 
               
               
                 Objectives takes place. 
                 stakeholders 
                 stakeholders 
               
               
                 Consensus on changes is established with 
                 Publish new statement of goals and objectives is 
                 Publish new statement of goals and objectives is 
               
               
                 stakeholders. 
                 published, including electronic forms  
                 published 
               
               
                 Publish new statement of goals and objectives is 
                 of publication. 
                   
               
               
                 published. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 5 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Administration 
                 Capability: Develop and Maintain Program Policy 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competetive 
                 Market Leading 
               
               
                   
               
               
                 Requests to add, delete, or change policy  
                 Requests to add, delete, or change policy  
                 Basic review of Agency Goals and Objectives  
               
               
                 are handled through a manual process. 
                 are handed through a combination of man- 
                 takes place 
               
               
                 Research staff are required to analyze policy  
                 ual/automated processes.  
                 Consensus on changes is established with 
               
               
                 and assess the impact of policy on budget,  
                 Few research staff are required to analyze  
                 stakeholders 
               
               
                 stakeholders, and other benefits. 
                 policy and assess the impact of policy on  
                 Publish new statement of goals and objectives  
               
               
                 Public hearings are held to explain existing  
                 budget, stakeholders, and other benefits. 
                 is published 
               
               
                 policy and policy changes. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 6 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Administration 
                 Capability: Maintain State Plan 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Notifications to review and update the state plan  
                 Notifications to review and update the state plan  
                 Even fewer staff is required to review the current 
               
               
                 are sent manually. 
                 are sent through an automated process. 
                 state plan, analyze changes to the state plan, and  
               
               
                 Additional staff is required to review the current  
                 Fewer staff is required to review the current  
                 research and assess impact of state plan changes.  
               
               
                 state plan, analyze changes to the state plan, and  
                 stateplan, analyze changes to the state plan, and  
                   
               
               
                 research and assess impact of state plan changes. 
                 research and assess impact of state plan changes. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 7 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Administration 
                 Capability: Perform  
               
               
                   
                 Organizational  
               
               
                   
                 Planning 
               
               
                   
               
             
          
           
               
                   
                   
                 Market  
               
               
                 Basic 
                 Competitive 
                 Leading 
               
               
                   
               
               
                 1.2.6.1 Conduct Environmental Analysis 
                   
                   
               
               
                 1.2.6.2 Develop Strategic Plan 
                   
                   
               
               
                 1.2.6.3 Develop Business and Tactical Plans 
                   
                   
               
               
                 1.2.6.4 Develop Implementation Plans 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 8 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Administration 
                 Capability: Market  
               
               
                   
                 the Organization 
               
               
                   
               
             
          
           
               
                   
                   
                 Market  
               
               
                 Basic 
                 Competitive 
                 Leading 
               
               
                   
               
               
                 1.2.1.1 Develop Marketing Plan 
                   
                   
               
               
                 1.2.1.2 Develop Collateral Materials 
                   
                   
               
               
                 1.2.1.3 Conduct Advertising 
                   
                   
               
               
                 1.2.1.4 Conduct Public Relations 
                   
                   
               
               
                 1.2.1.5 Manage Quality and  
                   
                   
               
               
                 Performance of the Marketing Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 9 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Program Administration 
                 Capability:  
               
               
                   
                 Provide Governance 
               
               
                   
               
             
          
           
               
                   
                   
                 Market  
               
               
                 Basic 
                 Competitive 
                 Leading 
               
               
                   
               
               
                 1.2.5.1 Establish Mission, Value,  
                   
                   
               
               
                 and Direction 
                   
                   
               
               
                 1.2.5.2 Develop and Operate the 
                   
                   
               
               
                 Governance Infrastructure 
                   
                   
               
               
                 1.2.5.3 Formulate and  
                   
                   
               
               
                 Approve Organization Policies 
                   
                   
               
               
                 1.2.5.4 Provide Oversight 
                   
                   
               
               
                 1.2.5.5 Select and Evaluate  
                   
                   
               
               
                 Executive Management 
                   
                   
               
               
                 1.2.5.6 Represent the Organization 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 10 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - 
               
               
                 Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: 
               
               
                 Budget  
                 Formulate Budget 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Review of current budget takes place 
                   
                   
               
               
                 1.3.1.2 Research and request information  
                   
                   
               
               
                 regarding revenue, costs, and benefits 
                   
                   
               
               
                 1.3.1.3 Develop and discuss budget  
                   
                   
               
               
                 scenarios with stakeholders 
                   
                   
               
               
                 1.3.1.4 Create, review, and approve  
                   
                   
               
               
                 new budget 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 11 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - 
               
               
                 Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: 
               
               
                 Budget  
                 Manage F-MAP 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitve 
                 Market Leading 
               
               
                   
               
               
                 1.3.3.1 Receive and review notification 
                   
                   
               
               
                 1.3.3.2 Request, review, and analyze  
                   
                   
               
               
                 F-MAP, FFP, and applicable laws 
                   
                   
               
               
                 1.3.3.3 Propose and submit change in  
                   
                   
               
               
                 approach to calculating F-MAP, FFP 
                   
                   
               
               
                 1.3.3.4 Develop guidelines for change  
                   
                   
               
               
                 and implementation plan 
                   
                   
               
               
                 1 .3.3.5 Develop algorithms 
                   
                   
               
               
                 1.3.3.6 Publish newFFP rules 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 12 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Budget  
                 Capability: Manage FFP for MMIS 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitve 
                 Market Leading 
               
               
                   
               
               
                 The Manage Federal Financial  
                 The Manage Federal Financial Participation business 
                 Improves on previous level capability plus: 
               
               
                 Participation business process is likely  
                 process increases its use of electronic interchange 
                 Virtual access to administrative and clinical 
               
               
                 primarily paper/phone/fax based 
                 and automated processes. 
                 records 
               
               
                 processing and some proprietary EDI. 
                 Agencies centralize common processes and are run 
                 Increased use of clinical data 
               
               
                 Timeliness of responses to inquiries  
                 as enterprises with “cost centers” responsible for 
                 Improves on previous level capability plus: 
               
               
                 and data reporting is indeterminate. 
                 meeting performance benchmarks. 
                 Focused data - data of record 
               
               
                   
                 The agency has central point for developing 
                 Self adjusting business rules 
               
               
                   
                 customer communications. 
                 Improves on previous level capability plus: 
               
               
                   
                 Communications to customers are consistent, timely 
                 Use of clinical data to increase the accuracy of 
               
               
                   
                 and appropriate. 
                 processes 
               
               
                   
                 Improves on previous level capability plus by: 
                 Clinical staff focuses on exception cases 
               
               
                   
                 Point-to-point or, wrapped connectivity to client- 
                 Improves on previous level capability plus: 
               
               
                   
                 Point-to-point interfaces segregated by interface type 
                 Point-to-point collaboration 
               
               
                   
                 Improves on previous level capability plus by.  
                 Content sensitive business logic 
               
               
                   
                 Enhanced consistent timing for response to primary 
                 Improves on previous level capability plus: 
               
               
                   
                 client 
                 Business Process Management 
               
               
                   
                 Different interfaces with different data format and 
                 Metadata - Shared nationally 
               
               
                   
                 semantics 
                 Improves on previous level capability plus: 
               
               
                   
                 Improves on previous level capability plus by: 
                 Full interoperability other local, state, and 
               
               
                   
                 Transactions are received and responded to via EDI, 
                 federal programs to provide complete virtual patient 
               
               
                   
                 Web Portal 
                 clinical record and administrative data 
               
               
                   
                 Business areas are structured functionally and not 
                 A business process collaborates with other 
               
               
                   
                 by program/product line. 
                 processes in a peer2peer environment, eliminating 
               
               
                   
                 Data is standardized for automated electronic 
                 redundant collection and interchange of data, and 
               
               
                   
                 interchanges (interfaces) 
                 improving realtime, multi-axial processing. 
               
               
                   
                 The Agency supports data and technology 
                 Members empowered to make own treatment 
               
               
                   
                 integration end interoperability. 
                 decisions. 
               
               
                   
                 Customers are able to access the information 
                 Most services instantly authorized or denied from 
               
               
                   
                 required regardless of their entry point into the 
                 point of service; payment automaticallly established 
               
               
                   
                 enterprise. 
                 without need of invoice. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 13 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Budget  
                 Capability: Manage State Funds 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 A business process is likely primarily 
                 The Manage Federal Financial Participation 
                 Improves on previous level capability plus: 
               
               
                 paper/phone/fax based processing and some 
                 business process increases its use of 
                 Virtual access to administrative and clinical 
               
               
                 proprietary EDI. Programs are siloed so 
                 electronic interchange and automated 
                 records 
               
               
                 uncoordinated 
                 processes 
                 Improves on previous level capability plus: 
               
               
                 Non-standerdized data makes any type of 
                 Agencies centralize common processes and 
                 Increased use of clinical data 
               
               
                 cross program performance monitoring, 
                 are run as enterprises with “cost centers” 
                 Improves on previous level capability plus: 
               
               
                 management reporting, fraud detection, or 
                 responsible for meeting performance 
                 Focused data - data of record 
               
               
                 reporting and analysis difficult and costly. 
                 benchmarks 
                 Improves on previous level capability plus: 
               
               
                 Customers have difficulty accessing 
                 The agency has central point for developing 
                 Self-adjusting business rules 
               
               
                 consistent, quality, or complete information 
                 customer communications. Communications 
                 Improves on previous level capability plus: 
               
               
                 about programs, eligibility, services or 
                 to customers are consistent, timely and  
                 Use of clinical data to increase the accuracy, 
               
               
                 providers 
                 appropriate. 
                 of processes 
               
               
                 Communications are often not linguistically, 
                 Improves on previous level capability plus by: 
                 Improves on previous level capability plus: 
               
               
                 culturally or competency appropriate and 
                 Point-to-point or wrapped connectivity to 
                 Clinical staff focuses on exception cases 
               
               
                 socio-economic barriers to accessing 
                 client 
                 Improves on previous level capability plus: 
               
               
                 information and health care. 
                 Improves on previous level capability pus by: 
                 Point-to-point collaboration 
               
               
                 Programs create inconsistent rules across the 
                 Point-to-point interfaces segregated by 
                 Improves on previous level capability plus: 
               
               
                 Agency and apply their own rules 
                 interface type 
                 Content sensitive business logic 
               
               
                 inconsistently. 
                 Improves on previous level capability plus by: 
                 Improves on previous level capability plus: 
               
               
                 Indeterminate connectivity to client 
                 Enhanced consistent timing for responses to  
                 Business Process Management 
               
               
                 Programs create inconsistent rules across the 
                 primary client 
                 Improves on previous level capability plus: 
               
               
                 Agency and apply their own rules 
                 Improves on previous level capability plus by: 
                 Metadata - Shared nationally 
               
               
                 inconsistently. 
                 Different interfaces with different data format 
                 Improves on previous level capability plus: 
               
               
                 Programs create inconsistent rules across the 
                 and semantics 
                 Full interoperability with other local, state, 
               
               
                 Agency and apply their own rules 
                 Improves on previous level capability plus by: 
                 and federal programs to provide complete 
               
               
                 inconsistently. 
                 Transactions are received and responded to 
                 virtual patient clinical record and administrative 
               
               
                 Inconsistent timing for response to primary 
                 via EDI, Web Portal 
                 data 
               
               
                 client 
                 Business areas are structured functionally and 
                 Improves on previous level capability plus: 
               
               
                 Programs create inconsistent rules across the 
                 not by program/product line. 
                 Access to national clinical guidelines 
               
               
                 Agency and apply their own rules 
                 Data is standardized for automated electronic 
                 A business process collaborates with other 
               
               
                 inconsistently. 
                 interchanges (interfaces) 
                 processes in a peer2peer enviroment,  
               
               
                 Multiple data formats and semantics 
                 The Agency supports data and technology 
                 eliminating redundant collection and 
               
               
                 Programs create inconsistent rules across the 
                 integration and interoperability 
                 interchange of data, and improving realtime 
               
               
                 Agency and apply their own rules 
                 Customers are able to access the information  
                 multi-axial processing. 
               
               
                 inconsistently. 
                 required regardless of their entry point into the 
                 . . .  
               
               
                 External inputs &amp; outputs are received/sent 
                 enterprise. 
                 Members empowered to make own treatment 
               
               
                 manually via paper, telephone, &amp; fax 
                   
                 decisions 
               
               
                 Transactions are individually reviewed using 
                   
                 Most services instantly authorized or denied 
               
               
                 inconsistent interpretation of guidelines 
                   
                 from point of service; payment automatically 
               
               
                 responded to via paper, USPS or fax. 
                   
                 established without need of invoice. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 14 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - 
               
               
                 Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Risk 
                 Capability: Manage 
               
               
                 and Issue Management 
                 Business Change 
               
               
                   
               
             
          
           
               
                   
                 Basic 
                   
               
               
                   
               
               
                   
                 1.7.1.1 Identify Business Case for Change 
                   
               
               
                   
                 1.7.1.2 Assess Alignment with Strategic Direction 
                   
               
               
                   
                 1.7.1.3 Define Change Program 
                   
               
               
                   
                 1.7.1.4 Manage H/R Components of Transformation 
                   
               
               
                   
                 Staff and Manage Transformation Team 
                   
               
               
                   
                 Plan H/R Needs for Transformed Organization 
                   
               
               
                   
                 Manage Transformation Communications 
                   
               
               
                   
                 Manage Transformation Training 
                   
               
               
                   
                 Align Culture 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 15 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Capability: 
               
               
                 Policy Management 
                 React to Changes in Law 
               
               
                   
               
             
          
           
               
                   
                 Basic 
                   
               
               
                   
               
               
                   
                 1.8.1.1 Review the Medicaid Plan amendment  
                   
               
               
                   
                 from the State as a result of a change in law 
                   
               
               
                   
                 1.8.1.2. Assess impact of changes to the 
                   
               
               
                   
                 Medicaid program 
                   
               
               
                   
                 Cost cut the changes 
                   
               
               
                   
                 Identify the areas impacted 
                   
               
               
                   
                 1.8.1.3 Submit impact of changes to CMS for 
                   
               
               
                   
                 approval 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 16 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model -  
               
               
                 Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Receive State 
               
               
                 Policy Management 
                 and Federal Legislative Inquiries 
               
               
                   
               
             
          
           
               
                   
                 Basic 
                   
               
               
                   
               
               
                   
                 1.8.4.1 Capture types of inqiiries 
                   
               
               
                   
                 1.8.4.2 Assess the inquiries/complaints for 
                   
               
               
                   
                 management to focus on 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 17 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model -  
               
               
                 Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Respond to 
               
               
                 Policy Management 
                 CMS and GAO Audits 
               
               
                   
               
             
          
           
               
                   
                 Basic 
                   
               
               
                   
               
               
                   
                 1.8.3.1 Indicate agreement/disagreement  
                   
               
               
                   
                 with the findings 
                   
               
               
                   
                 1.8.3.2 Indicate agreement/disagreement with 
                   
               
               
                   
                 CMS/GAO recommendations and monetary 
                   
               
               
                   
                 amounts, including costs questioned and other 
                   
               
               
                   
                 estimates 
                   
               
               
                   
                 1.8.3.3 Identify target dates for completion of final 
                   
               
               
                   
                 action on recommendations with which management 
                   
               
               
                   
                 agrees. 
                   
               
               
                   
                 1.8.3.4 Indicate agreement/disagreement with 
                   
               
               
                   
                 findings of reportable material weakness. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 18 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - 
               
               
                 Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Work with the 
               
               
                 Policy Management 
                 Office of Government Affairs 
               
               
                   
               
             
          
           
               
                   
                 Basic 
                   
               
               
                   
               
               
                   
                 1.8.2.1 Identify program impact and record it 
                   
               
               
                   
                 1.8.2.2 Identify policy impact and record it 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 19 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Generate Financial 
               
               
                 Program Information  
                 and Program Analysis Report 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The Generate Financial &amp; Program Analysis 
                 The business process increases its use of 
                 The business process interfaces with other 
               
               
                 Reports business process is likely done with a 
                 electronic interchange and automated 
                 processes via federated architectures or 
               
               
                 mix of tape, CD and some proprietary EDI. 
                 processes. Agencies are run as enterprises 
                 collaborates with other processes in a 
               
               
                 Programs are siloed so uniformity of data is 
                 with “cost centers” responsible for meeting 
                 peer2peer environment, eliminating redundant 
               
               
                 uncoordinated and non-standardized data 
                 performance benchmarks. 
                 collection and interchange of data, and 
               
               
                 makes any type of cross program performance 
                 Programs are agile and able to adjust their 
                 improving realtime, multi-axial processing 
               
               
                 monitoring, management reporting, fraud 
                 rules quickly when business activity monitoring 
                   
               
               
                 detection, or reporting and analysis difficult and 
                 indicates that the rules are no longer yielding 
                   
               
               
                 costly. 
                 desired benchmarks 
                   
               
               
                   
                 Agencies centralize and standardize data to 
                   
               
               
                   
                 increase its usefulness for performance 
                   
               
               
                   
                 monitoring, management reporting, fraud 
                   
               
               
                   
                 detection, and reporting and analysis. 
                   
               
               
                   
                 Business areas are structured functionaly and 
                   
               
               
                   
                 not by program/product line with infrastructure 
                   
               
               
                   
                 architected to support this design. 
                   
               
               
                   
                 Data is standardized for automated electronic 
                   
               
               
                   
                 interchanges (interfaces) Agency supports 
                   
               
               
                   
                 data and technology integration and 
                   
               
               
                   
                 interoperability. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 20 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability: Maintain Benefit/ 
               
               
                 Program Information 
                 Reference Information 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
             
          
           
               
                 A business process is likely primarily 
                 A business process increases its use of 
               
             
          
           
               
                 paper/phone/fax based processing and some 
                 electronic interchange and automated 
                 A business process interfaces with other 
               
               
                 proprietary EDI. Programs are siloed so 
                 processes. Agencies centralize common 
                 processes via federated architectures or 
               
               
                 uncoordinated. 
                 processes and are run as enterprises with 
                 collaborates with other processes in a 
               
               
                 Non-standardized data makes any type of 
                 “cost centers” responsible for meeting 
                 peer2peer environment, eliminating redundant 
               
               
                 cross program performance monitoring, 
                 performance benchmarks. 
                 collection and interchange of data, and 
               
               
                 management reporting, fraud detection, or 
                 Centralization increases consistency of 
                 improving realtime, multi-axial processing 
               
               
                 reporting and analysis difficult and costly.  
                 communications. Agency business 
                   
               
               
                 Clinical data is rarely the basis for decisions, 
                 relationships are increasingly hub and spoke 
                   
               
               
                 and requires accessing paper medical records. 
                 vs. point to point with each internal and 
                   
               
               
                 Most data is administrative use of encounter 
                 external party. 
                   
               
               
                 data. Timeliness of responses to inquiries and 
                 These changes improve customers ability to 
                   
               
               
                 data reporting is indeterminate. 
                 reliably access the information and services 
                   
               
               
                 Customers have difficulty accessing 
                 they require. 
                   
               
               
                 consistent, quality, or complete information 
                 Business areas are structured functionally and  
                   
               
               
                 about programs, eligibility, services or 
                 not by program/product line with infrastructure 
                   
               
               
                 providers. 
                 architected to support this design. 
                   
               
               
                 Communications are often not linguistically, 
                 Data is standardized for automated electronic 
                   
               
               
                 culturally or competency appropriate and 
                 interchanges (interfaces) that are oblivious to 
                   
               
               
                 socio-economic barriers to accessing 
                 whether the sender or receiver is internal or 
                   
               
               
                 information and health care. Programs create  
                 external, applying appropriate levels of security 
                   
               
               
                 inconsistent rules across the Agency and 
                 to each request/receiver. 
                   
               
               
                 apply their own rules inconsistently. 
                 . . . 
                   
               
               
                   
                 The Agency supports data and technology 
                   
               
               
                   
                 integration and interoperability. 
                   
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 21 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability: Manage 
               
               
                 Program Information  
                 Program Information 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Data from enterprise information registries  
                 Records are processed using both manual and 
                 Records are sent through a fully automated 
               
               
                 or repositories is available to load 
                 automated processes, making the data easier to 
                 process. 
               
               
                 Records are processed manually, but the  
                 access. 
                 Even more sophisticated reporting, analysis,  
               
               
                 data is not made easily available. 
                 More sophisticated reporting, analysis, and  
                 and decision support capabilities are available. 
               
               
                 Basic reporting, analysis, and decision  
                 decision support capabilities are available. 
                 Data is archived in accordance with state and  
               
               
                 support capabilities are available. 
                 Data is archived in accordance with state record  
                 federal record retention requirements. 
               
               
                 Agency possesses record retention  
                 retention requirements. 
                   
               
               
                 requirements. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 22 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Accounting  
                 Capability: Manage 1099s 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The Manage 1099s business process is likely 
                 The business process is increasing its use of 
                   
               
               
                 primarily paper/phone/fax based processing and 
                 electronic interchange and automated processes. 
                 The business process interfaces with other 
               
               
                 some proprietary EDI. Programs are siloed and 
                 Agencies are completely centralized. Data is 
                 processes via federated architectures  
               
               
                 multiple 1099s may be created by different  
                 standardized for automated electronic interchanges  
                 or collaborates with other processes in a  
               
               
                 payment systems. 
                 (interfaces). 
                 peer2peer environment, eliminating redundant  
               
               
                 Timeliness of responses to inquiries and data 
                 Agencies are centralizing common processes to 
                 collection and interchange of data, and 
               
               
                 reporting is indeterminate. 
                 achieve economies of scale and increase 
                 improving realtime, multi-axial processing 
               
               
                   
                 coordination. The Agency supports data and 
                   
               
               
                   
                 technology integration and interoperability. 
                   
               
               
                   
                 Centralization increases consistency of 
                   
               
               
                   
                 communications. Agency business relationships are 
                   
               
               
                   
                 increasingly hub and spoke vs. point to point with 
                   
               
               
                   
                 each internal and external party. 
                   
               
               
                   
                 The Agency actively supports and enables its 
                   
               
               
                   
                 customers to access information electronically. 
                   
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 23 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - 
               
               
                 Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Perform 
               
               
                 Accounting 
                 Accounting Functions 
               
               
                   
               
             
          
           
               
                   
                 Basic 
                   
               
               
                   
               
               
                   
                 1.4.2.1 Continuity Planning 
                   
               
               
                   
                 1.4.2.2 General Ledger (includes Accounts  
                   
               
               
                   
                 Payable and Receivable) 
                   
               
               
                   
                 1.4.2.3 Reporting 
                   
               
               
                   
                 1.4.2.4 Account Maintenance 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 24 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Program Management - Develop and Maintain Medical and Network Policies 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Designate Approved 
               
               
                 Benefits Administration  
                 Service/Drug Formulary 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The Designate Approved Services/Drug  
                 The Designate Approved Services/Drug 
                 A business process interfaces with  
               
               
                 Formulary process is primarily a manuel process  
                 Formulary process is coordinated across  
                 other processes via federated architectures  
               
               
                 and may occur in silos without coordination. 
                 siloed systems, is centralized by the 
                 or collaborates with other  
               
               
                 Decisions are primarily based on fiscal impact and 
                 enterprise &amp; is highly automated. 
                 processes in a peer2peer environment,  
               
               
                 regulatory requirements rather than clinical data. 
                 Review processes are centralized and 
                 eliminating redundant collection 
               
               
                 Notification to trading partners is not timely and  
                 standardized processes are emerging across  
                 and interchange of data, and improving 
               
               
                 is labor intensive accomplished primarily on  
                 systems, types of services and benefit packages. 
                 realtime, multi-axial processing. 
               
               
                 paper through use of provider mass mailings. 
                 Decisions are based on fiscal impacts and  
                   
               
               
                 Communications to impacted members  
                 regulatory requirements, but increased use of  
                   
               
               
                 are not linguistically, culturally or  
                 EDI increases accuracy of and access to  
                   
               
               
                 competency appropriate and socio-economic 
                 clinical data to allow for analysis of health  
                   
               
               
                 barriers to accessing information  
                 care outcomes as a determining factor. 
                   
               
               
                 and health care are not addressed well. 
                 Agencies centralize provider notification  
                   
               
               
                   
                 and client communication functions  
                   
               
               
                   
                 requiring fewer staff and capitalizing on  
                   
               
               
                   
                 efficiencies. Communications to customers 
                   
               
               
                   
                 are consistent, timely and appropriate. 
                   
               
               
                   
                 The Agency actively supports and enables its 
                   
               
               
                   
                 customers to access information electronically. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 25 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Benefits  
                   
               
               
                 Administration 
                 Capability: Develop and Maintain Benefit Package  
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Benefit packages selections  
                 All programs introduce flexibility  
                 Services and providers are  
               
               
                 have pre-set services and 
                 within benefit packages, enabling 
                 selected within funding limits of  
               
               
                 provider types. Each eligible 
                 “consumer driven” health care 
                 benefit packages available to the 
               
               
                 may be offered only packages 
                 with more choices among  
                 member based on clinical and  
               
               
                 available via eligibility  
                 services and provider types  
                 socio-economic factors 
               
               
                 determination pathway taken. 
                 available within the funding 
                   
               
               
                   
                 limits of all benefit packages for  
                   
               
               
                   
                 which the member is eligible. 
                   
               
               
                 Within each silo, eligible may  
                 Design of benefit packages is  
                 Services and providers are  
               
               
                 only be assigned to the best  
                 manual and is based on limited 
                 selected within member  
               
               
                 available package available  
                 paper-based access to external  
                 preferences such as health status, 
               
               
                 despite eligibility for more 
                 clinical data. 
                 desire to remain in the home,  
               
               
                 expansive services because 
                   
                 what is culturally appropriate,  
               
               
                 systems may be limited to  
                   
                 and functional competencies. 
               
               
                 supporting one eligibility span  
                   
                   
               
               
                 at a time. 
                   
                   
               
               
                   
                   
                 Design of benefit packages  
               
               
                   
                   
                 is automated with electronic access 
               
               
                   
                   
                 to electronic clinical data. 
               
               
                   
                   
                 Consumer-driven benefit  
               
               
                   
                   
                 packages are designed and  
               
               
                   
                   
                 updated real time based on  
               
               
                   
                   
                 collaborative interfaces with  
               
               
                   
                   
                 members&#39; federated electronic 
               
               
                   
                   
                 health records. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 26 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Benefits  
                 Capability: Develop  
               
               
                 Administration 
                 Products and Services 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 1.1.4.1 Conduct Product Market  
                   
                   
               
               
                 Analysis and Define Segments 
                   
                   
               
               
                 1.1.4.2 Position Product 
                   
                   
               
               
                 Concept Relative to 
                   
                   
               
               
                 Competition &amp; Perform  
                   
                   
               
               
                 Concept Test 
                   
                   
               
               
                 1.1.4.3 Design Products and  
                   
                   
               
               
                 Services 
                   
                   
               
               
                 1.1.4.3.1 Develop Detailed  
                   
                   
               
               
                 Product Design 
                   
                   
               
               
                 1.1.4.3.2 Build product  
                   
                   
               
               
                 infrastructure 
                   
                   
               
               
                 1.1.4.4 Develop Product Pricing  
                   
                   
               
               
                 Strategy and Structure 
                   
                   
               
               
                 1.1.4.5 Obtain Regulatory  
                   
                   
               
               
                 Approval 
                   
                   
               
               
                 1.1.4.6 Perform Testing and  
                   
                   
               
               
                 Roll-Out 
                   
                   
               
               
                 1.1.4.6.1 Pilot Project 
                   
                   
               
               
                 1.1.4.6.2 Product Iteration 
                   
                   
               
               
                 1.1.4.7 Launch Product 
                   
                   
               
               
                 1.1.4.8 Manage Product and  
                   
                   
               
               
                 Segment Product Portfolio 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 27 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Program Management 
               
             
          
           
               
                   
                 Capability: Manage  
               
               
                   
                 Actuarial Services 
               
               
                 Sub-Platform: Benefits  
                 and Medical  
               
               
                 Administration 
                 Economics 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 1.1.6.1 Manage  
                   
                   
               
               
                 Actuarial/Pricing Function 
                   
                   
               
               
                 1.1.6.2 Manage Medical  
                   
                   
               
               
                 Economics 
                   
                   
               
               
                 1.1.6.3 Manage External  
                   
                   
               
               
                 Reporting of Medical Cost &amp;  
                   
                   
               
               
                 Quality Metrics 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 28 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Program Management 
               
             
          
           
               
                 Sub-Platform: Benefits  
                   
               
               
                 Administration 
                 Capability: Manage Rate Setting 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Notifications of rate  
                 Automated notifications of rate  
                 Rate changes 
               
               
                 changes are largely a  
                 changes. 
                 can be applied  
               
               
                 manual process. 
                   
                 nationally. 
               
               
                 Research staff  
                 Fewer research staff required to  
                   
               
               
                 required to  
                 conduct rate analysis for rate 
                   
               
               
                 conduct rate analysis  
                 changes. 
                   
               
               
                 for rate changes 
                   
                   
               
               
                 Rate updates are  
                 Automated rate updates 
                   
               
               
                 manually  
                   
                   
               
               
                 applied 
                   
                   
               
               
                   
                 Automated validation process for  
                   
               
               
                   
                 validating rates. 
                   
               
               
                   
                 Institutional services use the  
                   
               
               
                   
                 annual DRG Rate Setting Process  
                   
               
               
                   
                 to determine the Base Standard  
                   
               
               
                   
                 Dollar Amount (SDA) and DRG  
                   
               
               
                   
                 weight information for each State  
                   
               
               
                   
                 Fiscal Year. 
                   
               
               
                   
                 HHSC approves fee schedules 
                   
               
               
                   
                 for professional services  
                   
               
               
                   
                 according to set criteria for each  
                   
               
               
                   
                 provider type. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 29 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Program Management 
               
             
          
           
               
                   
                 Capability:  
               
               
                 Sub-Platform: Benefits 
                 Sell Products 
               
               
                 Administration 
                 and Services 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 1.1.5.1 Determine and  
                   
                   
               
               
                 Implement Distribution  
                   
                   
               
               
                 Channels 
                   
                   
               
               
                 1.1.5.2 Perform Sales to  
                   
                   
               
               
                 Consumers and Employers  
                   
                   
               
               
                 Generate Leads 
                   
                   
               
               
                 Create Proposals (for new &amp;  
                   
                   
               
               
                 existing employers)  
                   
                   
               
               
                 Sell to New Employers  
                   
                   
               
               
                 Sell (Retail) to Consumers  
                   
                   
               
               
                 (new &amp; existing) 
                   
                   
               
               
                 1.1.5.3 Perform Underwriting  
                   
                   
               
               
                 and Develop Account-Specific  
                   
                   
               
               
                 Pricing and Financial  
                   
                   
               
               
                 Arrangements 
                   
                   
               
               
                 1.1.5.4 Manage Quality and  
                   
                   
               
               
                 Performance of the Sales  
                   
                   
               
               
                 Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 30 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Care Management 
               
             
          
           
               
                   
                 Capability: Provide  
               
               
                   
                 Access to Tailored  
               
               
                 Sub-Platform: Manage Medicaid  
                 Health 
               
               
                 Population Health 
                 and Wealth Messages 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Ensure that all client materials  
                   
                   
               
               
                 are accurate, appropriate, and  
                   
                   
               
               
                 written at a 4th to 6th grade  
                   
                   
               
               
                 reading comprehension level,  
                   
                   
               
               
                 with demonstrated  
                   
                   
               
               
                 comprehension by the Medicaid  
                   
                   
               
               
                 targeted populations. 
                   
                   
               
               
                 Ensure that all client materials  
                   
                   
               
               
                 are available in the languages of  
                   
                   
               
               
                 the population groups served. 
                   
                   
               
               
                 Ensure acceptable materials are  
                   
                   
               
               
                 available for the blind and  
                   
                   
               
               
                 visually impaired. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 31 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Care Management  
               
             
          
           
               
                   
                 Capability: Manage  
               
               
                 Sub-Platform: Manage Case 
                 Medical Resource Use 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Perform Utilization Management  
                   
                   
               
               
                 Perform Prior Authorization  
                   
                   
               
               
                 Perform Concurrent Stay  
                   
                   
               
               
                 Review 
                   
                   
               
               
                 Perform Case Management  
                   
                   
               
               
                 and Disease Management  
                   
                   
               
               
                 Identification of member  
                   
                   
               
               
                 candidates 
                   
                   
               
               
                 Perform Case Management  
                   
                   
               
               
                 and Disease Management  
                   
                   
               
               
                 Perform Case Management  
                   
                   
               
               
                 a. Develop and implement  
                   
                   
               
               
                 case management services  
                   
                   
               
               
                 based on nationally recognized  
                   
                   
               
               
                 standards for all clients with  
                   
                   
               
               
                 chronic, complex, and acute  
                   
                   
               
               
                 medical conditions. 
                   
                   
               
               
                 Perform Case Management  
                   
                   
               
               
                 and Disease Management  
                   
                   
               
               
                 Perform Disease Management  
                   
                   
               
               
                 Perform Longitudinal  
                   
                   
               
               
                 case/care management  
                   
                   
               
               
                 (delivered by professional  
                   
                   
               
               
                 nurses involves following  
                   
                   
               
               
                 patients from the inpatient to  
                   
                   
               
               
                 the outpatient arena) 
                   
                   
               
               
                 Perform Case Management  
                   
                   
               
               
                 and Disease Management  
                   
                   
               
               
                 Perform Retrospective Review  
                   
                   
               
               
                 Manage outsourcing vendors 
                   
                   
               
               
                 Perform Case Management  
                   
                   
               
               
                 and Disease Management  
                   
                   
               
               
                 Coordinate with state  
                   
                   
               
               
                 agencies providing case  
                   
                   
               
               
                 management and other  
                   
                   
               
               
                 services.  
                   
                   
               
               
                 Evaluate the need for  
                   
                   
               
               
                 extension of services or  
                   
                   
               
               
                 alternative services when  
                   
                   
               
               
                 benefits cease or are  
                   
                   
               
               
                 exhausted. 
                   
                   
               
               
                 Perform Advanced Care  
                   
                   
               
               
                 Management  
                   
                   
               
               
                 Identification of member  
                   
                   
               
               
                 candidates  
                   
                   
               
               
                 Manage internal program  
                   
                   
               
               
                 Manage outsourcing vendors  
                   
                   
               
               
                 Internal or outsourced 
                   
                   
               
               
                 Perform Demand Management 
                   
                   
               
               
                 Manage Quality and  
                   
                   
               
               
                 Performance of the Medical  
                   
                   
               
               
                 Resource Use Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 32 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Health Services  
                   
               
               
                 Contracting 
                 Capability: Award Health Services Contract 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Indeterminate format for  
                 Application data are standardized  
                 External and internal validation  
               
               
                 proposal data 
                 nationally. All verifications can  
                 sources automatically send notice  
               
               
                   
                 be automated. Rules are  
                 of change in contractor status. 
               
               
                   
                 consistently applied. 
                   
               
               
                 Much of the information is  
                 Contractors can submit  
                 National interoperability permits  
               
               
                 manually validated. 
                 applications via a portal. 
                 the enrollment process to send  
               
               
                   
                   
                 inquiries to any other agency,  
               
               
                   
                   
                 stale, federal, or other entities  
               
               
                   
                   
                 regarding the status of a  
               
               
                   
                   
                 contractor. 
               
               
                 Staff contact external and  
                 Decisions are uniform. Some 
                 Any data exchange partner can  
               
               
                 internal document verification 
                 manual steps may continue. 
                 send a notification regarding a  
               
               
                 sources via phone, fax. 
                   
                 contractor enrolled with the state  
               
               
                   
                   
                 Medicaid program. 
               
               
                 Decisions may be inconsistent. 
                 Turnaround time can be 
                 Recertification notices are  
               
               
                   
                 immediate. 
                 automatically generated. 
               
               
                 Requires large numbers of staff. 
                 Services created for the  
                 Clinical data is accessible by  
               
               
                   
                 following steps and can be  
                 direct access. Manual steps only 
               
               
                   
                 shared.  
                 required for exception handling. 
               
               
                   
                 1. Verify Credentials  
                   
               
               
                   
                 2. Verify ID 
                   
               
               
                   
                 3. Assign ID  
                   
               
               
                   
                 4. Assign Rates 
                   
               
               
                   
                 5. Negotiate Contract 
                   
               
               
                 Decisions may take several  
                   
                   
               
               
                 days. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 33 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Health Services  
                   
               
               
                 Contracting 
                 Capability: Close Out Health Services Contract 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the Close out 
                 At this level, the business process 
                 The business process 
               
               
                 Health Services Contract 
                 improves on the previous level 
                 incorporates the previous level 
               
               
                 business process has: 
                 capability by: 
                 capability plus: 
               
               
                 Indeterminate connectivity to 
                 Point-to-point or wrapped 
                 Virtual records 
               
               
                 client 
                 connectivity to client 
                   
               
               
                 At this level, the Close out 
                 At this level, the business 
                 The business process 
               
               
                 Health Services Contract 
                 process improves on the previous 
                 incorporates the previous level 
               
               
                 business process has: 
                 level capability by: 
                 capability plus: 
               
               
                 Inconsistent timing for 
                 Point-to-point interfaces 
                 Use of clinical data 
               
               
                 response to primary client 
                 (trading partner agreements) 
                   
               
               
                   
                 segregated by interface type 
                   
               
               
                 At this level, the Close out 
                 At this level, the business 
                 The business process 
               
               
                 Health Services Contract 
                 process improves on the previous 
                 incorporates the previous level 
               
               
                 business process has: 
                 level capability by: 
                 capability plus: 
               
               
                 Multiple data formats and 
                 Enhanced consistent timing for 
                 Focused data - data of record 
               
               
                 semantics 
                 response to primary client 
                   
               
               
                 At this level, the Close out 
                 At this level, the business 
                 The business process 
               
               
                 Health Services Contract 
                 process improves on the previous 
                 incorporates the previous level 
               
               
                 business process has: 
                 level capability by: 
                 capability plus: 
               
               
                 External inputs &amp; outputs are 
                 Different interfaces with 
                 Use of metadata 
               
               
                 received/sent manually via 
                 different data format and 
                   
               
               
                 paper, telephone, &amp; fax 
                 semantics 
                   
               
               
                 At this level, the Close out 
                 At this level, the business 
                 The business process 
               
               
                 Health Services Contract 
                 process improves on the previous 
                 incorporates the previous level 
               
               
                 business process has: 
                 level capability by: 
                 capability plus: 
               
               
                 Transactions are individually 
                 Transactions are received and 
                 Self adjusting business rules 
               
               
                 reviewed using inconsistent 
                 responded to via EDI, Web Portal 
                   
               
               
                 interpretation of guidelines 
                   
                   
               
               
                 responded to via paper/USPD 
                   
                   
               
               
                 or fax 
                   
                   
               
               
                   
                 At this level, the business 
                 The business process 
               
               
                   
                 process improves on the previous 
                 incorporates the previous level 
               
               
                   
                 level capability by: 
                 capability plus: 
               
               
                   
                 Virtual access to administrative 
                 Use of clinical data to increase 
               
               
                   
                 and clinical records 
                 the accuracy of processes 
               
               
                   
                 At this level, the business 
                 The business process 
               
               
                   
                 process improves on the previous 
                 incorporates the previous level 
               
               
                   
                 level capability by: 
                 capability plus: 
               
               
                   
                 Increased use of clinical data 
                 Clinical staff focuses on 
               
               
                   
                   
                 exception cases. 
               
               
                   
                 At this level, the business 
                 The business process 
               
               
                   
                 process improves on the previous 
                 incorporates the previous level 
               
               
                   
                 level capability by: 
                 capability plus: 
               
               
                   
                 Focused data - data of record 
                 Point-to-point collaboration 
               
               
                   
                 At this level, the business 
                 The business process 
               
               
                   
                 process improves on the previous 
                 incorporates the previous level 
               
               
                   
                 level capability by: 
                 capability plus: 
               
               
                   
                 Use of metadata 
                 Content sensitive business logic 
               
               
                   
                 At this level, the business 
                 The business process 
               
               
                   
                 process improves on the previous 
                 incorporates the previous level 
               
               
                   
                 level capability by: 
                 capability plus: 
               
               
                   
                 Self adjusting business rules 
                 Business Process Management 
               
               
                   
                 At this level, the business 
                 The business process 
               
               
                   
                 process improves on the previous 
                 incorporates the previous level 
               
               
                   
                 level capability by: 
                 capability plus: 
               
               
                   
                 Use of clinical data to increase 
                 Metadata - Shared nationally 
               
               
                   
                 the accuracy of processes 
                   
               
               
                   
                 At this level, the business 
                 The business process 
               
               
                   
                 process improves on the previous 
                 incorporates the previous level 
               
               
                   
                 level capability by: 
                 capability plus: 
               
               
                   
                 Clinical staff focuses on 
                 Full interoperability with other 
               
               
                   
                 exception cases 
                 local, state, and federal programs 
               
               
                   
                   
                 to provide complete virtual 
               
               
                   
                   
                 patient clinical record and 
               
               
                   
                   
                 administrative data 
               
               
                   
                 At this level, the business 
                 Access to national clinical 
               
               
                   
                 process improves on the previous 
                 guidelines 
               
               
                   
                 level capability by: 
                   
               
               
                   
                 Members empowered to make 
                   
               
               
                   
                 own treatment decisions 
                   
               
               
                   
                 Use of electronic Claim 
                 The business process 
               
               
                   
                 Attachment for Adjudication. 
                 incorporates the previous level 
               
               
                   
                   
                 capability plus: 
               
               
                   
                   
                 Most services instantly 
               
               
                   
                   
                 authorized or denied from point 
               
               
                   
                   
                 of service; payment 
               
               
                   
                   
                 automatically established without 
               
               
                   
                   
                 need of invoice 
               
               
                   
                   
                 Members empowered to make 
               
               
                   
                   
                 own treatment decisions. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 34 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Health  
                   
               
               
                 Services Contracting 
                 Capability: Manage Health Services Contract 
               
             
          
           
               
                 Basic  
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 At this level, the business 
                 The business process has almost 
                 The business process interfaces 
               
               
                 process is likely primarily 
                 eliminated its use of 
                 with other processes via 
               
               
                 paper/phone/fax based 
                 nonelectronic interchange and 
                 federated architectures and 
               
               
                 processing and some 
                 has automated most processes to 
                 collaborates with other processes 
               
               
                 proprieiary EDI. 
                 the extent feasible. 
                 in a peer2peer environment, 
               
               
                   
                   
                 eliminating redundant collection 
               
               
                   
                   
                 and interchange of data 
               
               
                 Timeliness of responses to 
                 Agencies centralize common 
                 At this level, the business process 
               
               
                 inquiries and data reporting 
                 processes to achieve economies 
                 interfaces with other processes 
               
               
                 indeterminate 
                 of scale. 
                 via federated architectures and 
               
               
                   
                   
                 collaborates with other processes 
               
               
                   
                   
                 in a peer2peer environment and 
               
               
                   
                   
                 improving real-time, multiaxial 
               
               
                   
                   
                 processing. 
               
               
                   
                 Data is standardized for 
                   
               
               
                   
                 automated electronic 
                   
               
               
                   
                 interchanges 
                   
               
               
                   
                 Communications are consistent, 
                   
               
               
                   
                 timely and appropriate. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 35 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contract Management 
               
             
          
           
               
                   
                 Capability: Inquire  
               
               
                 Sub-Platform: Contract  
                 Contractor  
               
               
                 Information Management 
                 Information 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 7.3.2.1 Receipt of contract  
                   
                   
               
               
                 verification information data set 
                   
                   
               
               
                 7.3.2.2 Determine request status  
                   
                   
               
               
                 as initial or duplicate 
                   
                   
               
               
                 7.3.2.3 Verify requestor  
                   
                   
               
               
                 authorization to receive  
                   
                   
               
               
                 requested information 
                   
                   
               
               
                 7.3.2.4 Query contractor  
                   
                   
               
               
                 registry for requested  
                   
                   
               
               
                 information 
                   
                   
               
               
                 7.3.2.5 Process and log  
                   
                   
               
               
                 response 
                   
                   
               
               
                 7.3.2.6 Prepare response data  
                   
                   
               
               
                 set 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 36 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contract Management 
               
             
          
           
               
                 Sub-Platform: Contract  
                 Capability: Manage 
               
               
                 Information Management  
                 Contractor Information 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Requests are received  
                 Requests are standardized  
                   
               
               
                 from disparate sources in 
                 and automated. 
                   
               
               
                 indeterminate formats. 
                   
                   
               
               
                 Validation is inconsistent  
                 Validation is consistent. 
                   
               
               
                 and not rules-based. 
                   
                   
               
               
                 There are delays in  
                 Updates are timelier 
                   
               
               
                 completing updates. 
                   
                   
               
               
                 Duplicate entries may go 
                 More automation of rules  
                   
               
               
                 undetected. 
                 to maintain integrity  
                   
               
               
                   
                 of data repository. 
                   
               
               
                 Irregular notification  
                 Change is immediately  
                   
               
               
                 of change to users and  
                 available to users and  
                   
               
               
                 processes that need 
                 processes that need 
                   
               
               
                 to know. 
                 to know. 
                   
               
               
                   
                 Determinate interfaces  
                   
               
               
                   
                 (trigger event and results;  
                   
               
               
                   
                 messages to external  
                   
               
               
                   
                 entities), standardized data,  
                   
               
               
                   
                 consistent business rules 
                   
               
               
                   
                 and decisions, easy to  
                   
               
               
                   
                 change business logic. 
                   
               
               
                   
                 Manage Contractor 
                   
               
               
                   
                 Information is handled  
                   
               
               
                   
                 by a business service. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 37 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Administration  
                   
               
               
                 Contracting 
                 Capability: Award Administrative Contract 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The business process uses 
                 The process uses application data 
                 At this level, the business process 
               
               
                 indeterminate formal for 
                 that is standardized nationally. 
                 interfaces with other processes 
               
               
                 application data 
                   
                 via federated architectures and 
               
               
                   
                   
                 collaborates with other processes 
               
               
                   
                   
                 in a peer2peer environment, 
               
               
                   
                   
                 eliminating redundant collection 
               
               
                   
                   
                 and interchange of data 
               
               
                 Much of the information is 
                 All verifications can be 
                 At this level, the business process 
               
               
                 manually validated. 
                 automated. 
                 interfaces with other processes 
               
               
                   
                   
                 via federated architectures and 
               
               
                   
                   
                 collaborates with other processes 
               
               
                   
                   
                 in a peer2peer environment and 
               
               
                   
                   
                 improving real-time, multiaxial 
               
               
                   
                   
                 processing. 
               
               
                 Staff contact external and 
                 Rules are consistently applied. 
                   
               
               
                 internal document verification 
                   
                   
               
               
                 sources via phone, fax. 
                   
                   
               
               
                 Decisions may be inconsistent. 
                 Contractors can submit 
                   
               
               
                   
                 applications via a portal. 
                   
               
               
                 Requires large numbers of staff. 
                 Decisions are uniform. Some 
                   
               
               
                   
                 manual steps may continue 
                   
               
               
                 Decisions may take several 
                 Turnaround time can be 
                   
               
               
                 days. 
                 immediate 
                   
               
               
                   
                 Services created for the following 
                   
               
               
                   
                 steps and can be shared 
                   
               
               
                   
                 1. Verify Credentials 
                   
               
               
                   
                 2. Verify ID 
                   
               
               
                   
                 3. Assign ID 
                   
               
               
                   
                 4. Assign Rates 
                   
               
               
                   
                 5. Negotiate Contract 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 38 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Administration  
                   
               
               
                 Contracting 
                 Capability: Close Out Administrative Contract 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the business 
                 The business process has almost 
                 At this level, the business process 
               
               
                 process uses indeterminate 
                 eliminated its use of 
                 interfaces with other processes 
               
               
                 connectivity to client. 
                 nonelectronic interchange and 
                 via federated architectures and 
               
               
                   
                 uses application data that is 
                 collaborates with other processes 
               
               
                   
                 standardized nationally. 
                 in a peer2peer environment, 
               
               
                   
                   
                 eliminating redundant collection 
               
               
                   
                   
                 and interchange of data 
               
               
                 Internal and external inputs and 
                 All verifications can be 
                 At this level, the business process 
               
               
                 outputs are received or sent 
                 automated. Rules are 
                 interfaces with other processes 
               
               
                 manually via paper, telephone 
                 consistently applied. 
                 via federated architectures and 
               
               
                 and fax. 
                   
                 collaborates with other processes 
               
               
                   
                   
                 in a peer2peer environment and 
               
               
                   
                   
                 improving real-time, multiaxial 
               
               
                   
                   
                 processing. 
               
               
                 Decisions may be inconsistent. 
                 Decisions are uniform. Some 
                   
               
               
                   
                 manual steps may continue. 
                   
               
               
                 Requires large numbers of staff. 
                 Turnaround time can be 
                   
               
               
                   
                 immediate. 
                   
               
               
                 Inconsistent timing for response 
                   
                   
               
               
                 to primary client. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 39 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Administration  
                   
               
               
                 Contracting 
                 Capability: Manage Administrative Contract 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The business process uses 
                 The process uses application data 
                 At this level, the business process 
               
               
                 indeterminate format for 
                 that is standardized nationally. 
                 interfaces with other processes 
               
               
                 application data 
                   
                 via federated architectures and 
               
               
                   
                   
                 collaborates with other processes 
               
               
                   
                   
                 in a peer2peer environment, 
               
               
                   
                   
                 eliminating redundant collection 
               
               
                   
                   
                 and interchange of data 
               
               
                 Much of the information is 
                 All verifications can be 
                 At this level, the business process 
               
               
                 manually validated. 
                 automated. 
                 interfaces with other processes 
               
               
                   
                   
                 via federated architectures and 
               
               
                   
                   
                 collaborates with other processes 
               
               
                   
                   
                 in a peer2peer environment and 
               
               
                   
                   
                 improving real-time, multiaxial 
               
               
                   
                   
                 processing 
               
               
                 Staff contact external and 
                 Rules are consistently applied. 
                   
               
               
                 internal document verification 
                   
                   
               
               
                 sources via phone, fax. 
                   
                   
               
               
                 Decisions may be inconsistent. 
                 Contractors can submit 
                   
               
               
                   
                 applications via a portal. 
                   
               
               
                 Requires large numbers of staff. 
                 Decisions are uniform. Some 
                   
               
               
                   
                 manual steps may continue. 
                   
               
               
                 Decisions may take several 
                 Turnaround time can be 
                   
               
               
                 days. 
                 immediate. 
                   
               
               
                   
                 Services created for the following 
                   
               
               
                   
                 steps and can be shared. 
                   
               
               
                   
                 1. Verify Credentials 
                   
               
               
                   
                 2. Verify ID 
                   
               
               
                   
                 3. Assign ID 
                   
               
               
                   
                 4. Assign Rates 
                   
               
               
                   
                 5. Negotiate Contract 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 40 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Contractor Support 
                 Capability: Manage Contractor Communication 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The process is primarily  
                 At this level, the contractor  
                 There is support collaborative  
               
               
                 conducted via paper and phone. 
                 communications are primarily 
                 discernment of communication 
               
               
                   
                 electronic, with paper used only 
                 needs of prospective and current 
               
               
                   
                 secondarily. 
                 contractors via PHRs. 
               
               
                 Contractor communications are  
                 Communications are centralized  
                 Interoperability and data sharing  
               
               
                 likely uncoordinated among 
                 ensuring agencywide 
                 agreements among states will  
               
               
                 multiple, siloed programs and 
                 coordination and greater ability 
                 facilitate contractor 
               
               
                 not systematically triggered by 
                 to measure the efficacy of 
                 communications across state 
               
               
                 agency-wide processes; lacks 
                 provider communications 
                 lines. 
               
               
                 data to appropriately target 
                   
                   
               
               
                 contractors; may encounter 
                   
                   
               
               
                 obstacles to delivery. 
                   
                   
               
               
                 Responses may be untimely, 
                 Contractor registries use  
                   
               
               
                 inconsistent and is labor 
                 standardized contact data, 
                   
               
               
                 intensive. 
                 including NPS address standards, 
                   
               
               
                   
                 to alleviate postal delivery 
                   
               
               
                   
                 failures. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 41 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Contractor Support 
                 Capability: Perform Potential Contractor Outreach 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The process is primarily 
                 At this level, the process is  
                 The process may include  
               
               
                 conducted via paper and phone. 
                 primarily electronic, with paper 
                 automated targeting of providers 
               
               
                   
                 used only secondarily. 
                 via RHIO, PHRs and EHRs based 
               
               
                   
                   
                 on analysis of performance and 
               
               
                   
                   
                 business activity monitoring. 
               
               
                   
                 Outreach is centralized which  
                 Process may include  
               
               
                   
                 ensures that current and 
                 collaborative discernment of 
               
               
                   
                 prospective providers will be able 
                 individual contractor entities or 
               
               
                   
                 to access information. 
                 organizations to whom outreach 
               
               
                   
                   
                 communications should be sent 
               
               
                   
                 Access to standardized electronic  
                 based on indicator algorithms that 
               
               
                   
                 clinical data via registries, 
                 trigger during business activity 
               
               
                   
                 electronic prescribing, claims and 
                 monitoring at the agency. 
               
               
                   
                 service review attachments and 
                   
               
               
                   
                 electronic health records, as well 
                   
               
               
                   
                 as use of GIS and socioeconomic 
                   
               
               
                   
                 indicators. 
                   
               
               
                   
                 Contractor registries use 
                   
               
               
                   
                 standardized contact data, 
                   
               
               
                   
                 including NPS address standards, 
                   
               
               
                   
                 to alleviate postal delivery 
                   
               
               
                   
                 failures. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 42 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Contractor Management 
               
             
          
           
               
                 Sub-Platform: Contractor Support 
                 Capability: Support Contractor Grievance and Appeal 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The process is entirely paper  
                 The process conducts much of its  
                 The process enables contractors  
               
               
                 based, which results in poor 
                 business electronically, except  
                 to file grievances and appeals in a  
               
               
                 document management and 
                 where paper documents are 
                 collaborative environment via  
               
               
                 process inefficiencies that 
                 required by law, which are 
                 PHRs and EHRs. 
               
               
                 impact timeliness. 
                 OCRM for electronic data  
                   
               
               
                   
                 capture. 
                   
               
               
                 Grievances and appeals are  
                 Access to administrative data is  
                 Program Quality Management is  
               
               
                 filed, managed, and resolved by 
                 readily available and 
                 better able to apply performance 
               
               
                 siloed programs 
                 standardized. 
                 measures and focus business  
               
               
                   
                   
                 activity monitoring on  
               
               
                   
                   
                 operational data to detect  
               
               
                   
                   
                 opportunities for process,  
               
               
                   
                   
                 provider to alleviate issues that  
               
               
                   
                   
                 give rise to grievances and  
               
               
                   
                   
                 appeals 
               
               
                 Providers may have difficulty:  
                 Improved process timeliness,  
                 Program Quality Management is  
               
               
                 Finding the “Right Door” for 
                 document management, and 
                 better able to apply performance  
               
               
                 filing grievances and appeals 
                 supports business activity  
                 measures and focus business  
               
               
                   
                 monitoring of performance  
                 activity monitoring on  
               
               
                   
                 measures. 
                 operational data to detect 
               
               
                   
                   
                 opportunities for contractor  
               
               
                   
                   
                 improvements to alleviate issues  
               
               
                   
                   
                 that give rise to grievances and  
               
               
                   
                   
                 appeals. 
               
               
                 Providers may have difficulty:  
                 Clinical data is still paper-based  
                 Providers can access program  
               
               
                 Accessing program rules to 
                 and difficult to access in a timely 
                 rules to discern whether their 
               
               
                 discern the merit of their 
                 manner 
                 grievances or appeals have merit 
               
               
                 grievance or appeal 
                   
                   
               
               
                 Providers may have difficulty:  
                 The process is administered as  
                   
               
               
                 Getting assistance on their 
                 part of the Medicaid enterprise. 
                   
               
               
                 case or providing additional 
                   
                   
               
               
                 information 
                   
                   
               
               
                 Providers may have difficulty: 
                 Contractors can electronically 
                   
               
               
                 Receiving consistent 
                 access program rules to discern 
                   
               
               
                 responses or communications 
                 whether their grievances or 
                   
               
               
                 that are linguistically, culturally 
                 appeals have merit. 
                   
               
               
                 and competency appropriate 
                   
                   
               
               
                   
                 Communications are consistent 
                   
               
               
                   
                 and timely. 
                   
               
               
                   
                 The process supports the Program 
                   
               
               
                   
                 Quality Management Business 
                   
               
               
                   
                 Area 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 43 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability  
               
               
                 Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider  
                 Capability: Develop  
               
               
                 Enrollment 
                 and Manage Network 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 6.1.3.1 Develop &amp; Maintain 
                   
                   
               
               
                 Network Composition/  
                   
                   
               
               
                 Expansion Policy and Service  
                   
                   
               
               
                 Strategy 
                   
                   
               
               
                 6.1.3.2 Recruit Providers 
                   
                   
               
               
                 6.1.3.3 Credential and Re- 
                   
                   
               
               
                 Credential Providers 
                   
                   
               
               
                 6.1.3.4 Contract with Providers 
                   
                   
               
               
                 6.1.3.5 Develop &amp; Maintain  
                   
                   
               
               
                 Contracting and Incentive  
                   
                   
               
               
                 Policies 
                   
                   
               
               
                 6.1.3.6 Manage provider  
                   
                   
               
               
                 reimbursement program 
                   
                   
               
               
                 6.1.3.7 Profile Providers 
                   
                   
               
               
                 6.1.3.8 Manage and Monitor  
                   
                   
               
               
                 Provider 
                   
                   
               
               
                 6.1.3.9 Manage Quality and  
                   
                   
               
               
                 Performance of the Network  
                   
                   
               
               
                 Management Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 44 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider Enrollment 
                 Capability: Disenroll Provider 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 6.1.2.1 Receive disenrollment  
                   
                   
               
               
                 request/information 
                   
                   
               
               
                 6.1.2.2 Assign identifier for  
                   
                   
               
               
                 tracking and validate 
                   
                   
               
               
                 application syntax/semantic 
                   
                   
               
               
                 6.1.2.3 Determine  
                   
                   
               
               
                 disenrollment request/  
                   
                   
               
               
                 information status, verify 
                   
                   
               
               
                 disenrollment information, and 
                   
                   
               
               
                 validate against state rules 
                   
                   
               
               
                 6.1.2.4 Produce disenrollment  
                   
                   
               
               
                 record in provider registry 
                   
                   
               
               
                 6.1.2.5 Request preparation of  
                   
                   
               
               
                 disenrollment notification and  
                   
                   
               
               
                 appeal rights 
                   
                   
               
               
                 6.1.2.6 Request provider  
                   
                   
               
               
                 outreach and send relevant state 
                   
                   
               
               
                 policy information 
                   
                   
               
               
                 6.1.2.7 Alert operations and  
                   
                   
               
               
                 program management 
                   
                   
               
               
                 disenrollment information has  
                   
                   
               
               
                 been loaded into the provider 
                   
                   
               
               
                 registry 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 45 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider Enrollment 
                 Capability: Enroll Provider 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Provider enrollment staff meet 
                 Provider enrollment staff receive 
                 The enrollment process has access 
               
               
                 state and federal requirements 
                 and process paper and Web-based 
                 to all provider registries 
               
               
                 for processing applications 
                 applications adhering to state 
                 nationally via data sharing and 
               
               
                 timely and accurately. 
                 Medicaid agency specific 
                 interoperability agreements. 
               
               
                   
                 standards. 
                   
               
               
                 Staff receive and process paper 
                 Providers are enrolled timely and 
                 Messages are automatically sent 
               
               
                 enrollment applications and 
                 accurately with additional data 
                 to the special programs to 
               
               
                 manually apply the agency&#39;s 
                 that match provider to patient 
                 consider enrollment of providers 
               
               
                 business rules resulting in 
                 needs, identify provider business 
                 mapping to criteria. 
               
               
                 creating and maintaining a 
                 relationships, and support 
                   
               
               
                 provider network that provides 
                 monitoring of delivery and quality 
                   
               
               
                 access to benefits for eligible 
                 of care. 
                   
               
               
                 members. 
                   
                   
               
               
                 Decisions on application may 
                 The majority of applications are 
                 All enrollment application 
               
               
                 take several days but \vithin 
                 automated and use MITA standard 
                 processes are automated; staff 
               
               
                 State regulations. 
                 interfaces for receipt of the 
                 only handle exceptions. 
               
               
                   
                 application and the automated 
                   
               
               
                   
                 result messages 
                   
               
               
                 Application data and format are 
                 Most verification and validation 
                 The National Health Information 
               
               
                 non standard. 
                 of application information are 
                 Network supports federated 
               
               
                   
                 automated. Manual intervention 
                 registries that identify providers 
               
               
                   
                 is required on an exception basis. 
                 across the country who are 
               
               
                   
                   
                 qualified to serve special 
               
               
                   
                   
                 populations or who are 
               
               
                   
                   
                 disqualified based on criminal 
               
               
                   
                   
                 activity. 
               
               
                 Some enrollment records are 
                 MITA standard interfaces are used 
                 Turnaround time is immediate, on 
               
               
                 stored electronically but storage 
                 to validate credentials and verify 
                 a national scale. 
               
               
                 is not centralized. 
                 or obtain ID numbers. 
                   
               
               
                 Provider data, including ID and 
                 Other agencies within the state 
                 Medicaid Provider Registries are 
               
               
                 taxonomy, is not comparable 
                 collaborate with Medicaid to offer 
                 federated with regional data 
               
               
                 across provider types and 
                 a one-stop shop to the applicant by 
                 exchange networks across the 
               
               
                 programs, reducing ability to 
                 adopting the MITA standard 
                 country and if desired, 
               
               
                 monitor performance or detect 
                 interfaces. 
                 internationally. 
               
               
                 fraud and abuse. 
                   
                   
               
               
                 Staff contact external and 
                 There is a timely, robust, and 
                 Authorized, authenticated parties 
               
               
                 internal credentialing and 
                 coordinated provider network. 
                 have virtual, instant access to 
               
               
                 verification sources via phone, 
                   
                 provider data, nationally. 
               
               
                 fax. A large staff is required to 
                   
                   
               
               
                 meet targets for manual 
                   
                   
               
               
                 enrollment of providers. 
                   
                   
               
               
                 Requires large numbers of staff. 
                 The NPI is the ID of record. 
                 Access to clinical data improves 
               
               
                   
                   
                 capability to select providers that 
               
               
                   
                   
                 meet quality standards. 
               
               
                 Much of the application 
                 Credentials are automatically re- 
                 Any daia exchange partner can 
               
               
                 information is manually 
                 validated and staff receive alerts 
                 send a notification regarding a 
               
               
                 validated. 
                 when adverse results occur. 
                 provider enrolled with any 
               
               
                   
                   
                 program in the U.S. 
               
               
                 Decisions may be inconsistent 
                 Through use of federated 
                 Nationally interoperable 
               
               
                   
                 registries. Medicaid staff expands 
                 validation sources automatically 
               
               
                   
                 its ability to identify providers 
                 send notice of change in provider 
               
               
                   
                 with special qualifications 
                 status, eliminating the need to 
               
               
                   
                 suitable for enrollment in 
                 reverify, supports detection of 
               
               
                   
                 programs that serve special 
                 sanctioned providers in real time 
               
               
                   
                 populations. 
                 anywhere in the U.S. 
               
               
                 Due to limited monitoring and 
                 Members interact directly with 
                 Full automation of the process 
               
               
                 re-verification of enrolled 
                 providers. 
                 plus access to national clinical 
               
               
                 providers&#39; status, sanctioned 
                   
                 data reduces staff requirements to 
               
               
                 providers may continue to be 
                   
                 a core team of professionals who 
               
               
                 enrolled. 
                   
                 monitor provider network 
               
               
                   
                   
                 performance. 
               
               
                 Focus on building a provider 
                 Cultural and linguistic indicators 
                 Prospective monitoring of 
               
               
                 network that meets needs of the 
                 improve selection of appropriate 
                 program integrity during 
               
               
                 members. 
                 providers. 
                 adjudication improves detection 
               
               
                   
                   
                 of fraud and abuse, resulting in 
               
               
                   
                   
                 timelier sanctioning 
               
               
                 Staff do not have time to focus 
                 Turnaround time on application 
                 Clinical data can be accessed, 
               
               
                 on cultural and linguistic 
                 decision can be immediate 
                 nationally, and monitored for 
               
               
                 compatibility, member 
                   
                 measuring performance. 
               
               
                 satisfaction, or provider 
                   
                   
               
               
                 performance. 
                   
                   
               
               
                   
                 Application data interfaces are 
                 Performance measures can be 
               
               
                   
                 standardized nationally using 
                 shared via federated Provider 
               
               
                   
                 MITA standards. 
                 Registries, nationally. 
               
               
                   
                 Enrollment records are stored in 
                 Providers and care managers 
               
               
                   
                 either a single Provider Registry 
                 access standardized National 
               
               
                   
                 or federated Provider Registries 
                 Provider Registries and view 
               
               
                   
                 that can be accessed by all 
                 clinical performance indicators to 
               
               
                   
                 participants. 
                 make informed decisions re 
               
               
                   
                 The NPI is the identifier of 
                 provider selection, provider 
               
               
                   
                 record. 
                 referrals. 
               
               
                   
                 Providers, members, and state 
                   
               
               
                   
                 enrollment staff have secure 
                   
               
               
                   
                 access to appropriate data on 
                   
               
               
                   
                 demand. 
                   
               
               
                   
                 Performance data is only 
                   
               
               
                   
                 periodically measured and 
                   
               
               
                   
                 requires sampling and statistical 
                   
               
               
                   
                 calculation. 
                   
               
               
                   
                 Enrollment processes continue to 
                   
               
               
                   
                 be handled by siloed programs 
                   
               
               
                   
                 according to program-specific 
                   
               
               
                   
                 rules. 
                   
               
               
                   
                 Providers can submit on paper 
                   
               
               
                   
                 and electronically via a portal 
                   
               
               
                   
                 which improves turnaround time, 
                   
               
               
                   
                 but most applications are 
                   
               
               
                   
                 submitted electronically. 
                   
               
               
                   
                 Verifications are a mix of manual 
                   
               
               
                   
                 and automated steps. 
                   
               
               
                   
                 Electronic applications adhere to 
                   
               
               
                   
                 MITA standard interface 
                   
               
               
                   
                 requirements. 
                   
               
               
                   
                 Medicaid and sister agencies 
                   
               
               
                   
                 collaborate on provider 
                   
               
               
                   
                 enrollment processes. 
                   
               
               
                   
                 Manual steps may continue only 
                   
               
               
                   
                 for exceptions. 
                   
               
               
                   
                 Process requires fewer staff and 
                   
               
               
                   
                 improves on results. 
                   
               
               
                   
                 Shared processes and inter-agency 
                   
               
               
                   
                 collaboration contribute to 
                   
               
               
                   
                 streamline the process. 
                   
               
               
                   
                 Automation of some business 
                   
               
               
                   
                 rules improves accuracy of 
                   
               
               
                   
                 validation and verification. 
                   
               
               
                   
                 The emphasis on managed care 
                   
               
               
                   
                 and waiver programs encourages 
                   
               
               
                   
                 more scrutiny of and reporting to 
                   
               
               
                   
                 national databases. 
                   
               
               
                   
                 All verifications can be automated 
                   
               
               
                   
                 and conducted via standardized 
                   
               
               
                   
                 interfaces. 
                   
               
               
                   
                 Consistent enrollment rules, 
                   
               
               
                   
                 standardized data available from a 
                   
               
               
                   
                 single source support continuous 
                   
               
               
                   
                 performance measures that can be 
                   
               
               
                   
                 used to adjust rates in real time. 
                   
               
               
                   
                 The agency sends verification 
                   
               
               
                   
                 inquiries to any other agency 
                   
               
               
                   
                 regarding the status of a provider. 
                   
               
               
                   
                 The quality of the provider 
                   
               
               
                   
                 network is improved. 
                   
               
               
                   
                 Guidelines ensure adequacy of 
                   
               
               
                   
                 network. 
                   
               
               
                   
                 Members are assigned to PCPs to 
                   
               
               
                   
                 coordinate their care. 
                   
               
               
                   
                 Members interact directly with 
                   
               
               
                   
                 provider and can view provider 
                   
               
               
                   
                 profiles and locations, make 
                   
               
               
                   
                 informed choices 
                   
               
               
                   
                 Cultural and linguistic indications 
                   
               
               
                   
                 improve selection of appropriate 
                   
               
               
                   
                 providers. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 46 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider  
                 Capability: Manage Quality and  
               
               
                 Information Management 
                 Performance of HCD Processes 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Develop &amp; Maintain Quality  
                   
                   
               
               
                 Policies 
                   
                   
               
               
                 Evaluate, Monitor &amp; Collect  
                   
                   
               
               
                 Data for Required Metric  
                   
                   
               
               
                 Measurement Information 
                   
                   
               
               
                 Maintain &amp; Prepare for  
                   
                   
               
               
                 Accreditation 
                   
                   
               
               
                 Develop &amp; Monitor  
                   
                   
               
               
                 COMPLAINT, Concern,  
                   
                   
               
               
                 Appeals (CCA) Process 
                   
                   
               
               
                 Develop &amp; Implement Quality  
                   
                   
               
               
                 Improvement Initiatives 
                   
                   
               
               
                 Monitor and Measure  
                   
                   
               
               
                 Performance and Quality  
                   
                   
               
               
                 Management Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 47 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider Information Management  
                 Capability: Inquire Provider Information 
               
             
          
           
               
                 Basic 
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 Inquiries are received from 
                 Routine inquiries for provider 
                 Provider registry is federated with 
               
               
                 different sources to obtain 
                 information are standardized and 
                 RHIOs nationally so that any 
               
               
                 information about a provider in 
                 automated within the agency via 
                 stakeholder can request provider 
               
               
                 nonstandard formats. 
                 AVRS, Web portal, EDI 
                 information to the extent 
               
               
                   
                   
                 authorized anywhere in the 
               
               
                   
                   
                 country. 
               
               
                 Most requests are sent via 
                 Responses are immediate or 
                 Pointers to selected clinical 
               
               
                 telephone, fax, or USPS. 
                 within batch response parameters. 
                 information are added to the 
               
               
                   
                   
                 provider registry data 
               
               
                 Research is performed manually. 
                 Responses are consistent and 
                 Turnaround time is immediate, on 
               
               
                   
                 timely 
                 a national scale. 
               
               
                 Responses are inconsistent and 
                 A reduced work force is required 
                 Information, including clinical, 
               
               
                 manual. 
                 to handle problems and direct 
                 can be shared among authorized 
               
               
                   
                 telephone inquiries. 
                 entities within the state. 
               
               
                 There may be delays in 
                 MITA standard interfaces are used 
                 Medicaid Provider Registries are 
               
               
                 responses. 
                 for inquiries regarding provider 
                 federated with regional data 
               
               
                   
                 registry information. 
                 exchange networks across the 
               
               
                   
                   
                 country and if desired, 
               
               
                   
                   
                 internationally. 
               
               
                 Complies with agency goals and 
                 Other agencies statewide can 
                 All authorized data exchange 
               
               
                 expectations. 
                 adopt MITA standard interfaces 
                 partners can access provider 
               
               
                   
                 and participate in the inquiry 
                 information. 
               
               
                   
                 process. 
                   
               
               
                 Most requests for verification of 
                 NPI is the ID of record used in the 
                 Inquiries include summary 
               
               
                 provider information are 
                 inquiry regarding provider 
                 clinical information relating to 
               
               
                 received and responded to 
                 information 
                 provider performance and quality 
               
               
                 manually via phone, fax, USPS. 
                   
                 of care. 
               
               
                 Information is researched 
                 Requests for provider information 
                 Automated access to information 
               
               
                 manually. There may be 
                 are automated via AVRS, Web 
                 nationally further improves 
               
               
                 inconsistencies in responses. 
                 portal, EDI within an agency 
                 efficiency. 
               
               
                   
                 using agency standards for 
                   
               
               
                   
                 messages 
                   
               
               
                 Staff research and respond to 
                 Responses are immediate. 
                 Regional and national, federated 
               
               
                 requests manually. 
                   
                 provider registries eliminate 
               
               
                   
                   
                 redundant overhead, i.e., one-stop 
               
               
                   
                   
                 shop inquiries. 
               
               
                 Requires research staff. 
                 Information can be shared among 
                 Incorporation of clinical data, 
               
               
                   
                 authorized entities within the 
                 nationally, improves accuracy of 
               
               
                   
                 state. 
                 some responses. 
               
               
                 Responses are manually 
                 Automation improves access and 
                 Requesters benefit from access to 
               
               
                 validated. 
                 accuracy. 
                 national clinical data as an added 
               
               
                   
                   
                 value. 
               
               
                 Process complies with agency 
                 Access is via Web portal and EDI 
                   
               
               
                 requirements. 
                 channels. 
                   
               
               
                 Requesters receive the 
                 Data inquiry message use MITA 
                   
               
               
                 information they need. 
                 standard interfaces, improving 
                   
               
               
                   
                 accuracy. 
                   
               
               
                   
                 Collaborating agencies using the 
                   
               
               
                   
                 MITA standard interfaces can 
                   
               
               
                   
                 exchange data on registered 
                   
               
               
                   
                 providers. 
                   
               
               
                   
                 Responses to requests to inquire 
                   
               
               
                   
                 about provider information are 
                   
               
               
                   
                 automated. 
                   
               
               
                   
                 Fewer staff required to support 
                   
               
               
                   
                 Provider information is 
                   
               
               
                   
                 continuously refreshed. 
                   
               
               
                   
                 One stop shop for agencies who 
                   
               
               
                   
                 share providers. 
                   
               
               
                   
                 Automation leads to fewer staff. 
                   
               
               
                   
                 Number of responses per day 
                   
               
               
                   
                 increases significantly. 
                   
               
               
                   
                 Use of MITA standard interfaces 
                   
               
               
                   
                 streamlines the inquiry process. 
                   
               
               
                   
                 Automation improves accuracy of 
                   
               
               
                   
                 responses. 
                   
               
               
                   
                 MITA standard interfaces produce 
                   
               
               
                   
                 consistent responses to inquiries. 
                   
               
               
                   
                 Requesters receive immediate 
                   
               
               
                   
                 responses. 
                   
               
               
                   
                 Requesters have a one-stop shop 
                   
               
               
                   
                 to access collaborating agencies 
                   
               
               
                   
                 to obtain information on a 
                   
               
               
                   
                 provider. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 48 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider Information Management 
                 Capability: Manage Provider Information 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Changes to provider registry are 
                 Changes to provider registry are 
                 The agency&#39;s provider registry is 
               
               
                 managed manually. 
                 standardized within the agency 
                 federated with statewide RHIOs 
               
               
                   
                 and automated. 
                 and is connected to all other 
               
               
                   
                   
                 RHIOs and registries nationally 
               
               
                   
                   
                 through the NHIN. 
               
               
                 Accuracy of data is manually 
                 Validation of changed data is 
                 Information and changes re a 
               
               
                 verified. There is no single 
                 consistent 
                 provider are shared by all entities 
               
               
                 standard for data stored for 
                   
                 that contract with that provider 
               
               
                 different types of providers. 
                   
                   
               
               
                 Duplicate entries may go 
                 Updates are timely (within 24 
                 Provider registry&#39; information 
               
               
                 undetected. 
                 hours). 
                 includes performance measures 
               
               
                   
                   
                 automatically communicated 
               
               
                   
                   
                 from the provider&#39;s clinical 
               
               
                   
                   
                 record. 
               
               
                 Notification to users re changes 
                 Changes are immediately 
                 Turnaround time is immediate, on 
               
               
                 to registry is nonstandard. 
                 available to users and business 
                 a national scale 
               
               
                   
                 processes that need to use this 
                   
               
               
                   
                 information. 
                   
               
               
                 Needs of various users of 
                 MITA standard interfaces are 
                 Updates are available to all data 
               
               
                 provider data are uncoordinated 
                 used for changes to provider 
                 exchange partners. 
               
               
                 and may be unmet. 
                 registry. 
                   
               
               
                 Manual and semi-automated 
                 Other agencies statewide can 
                 Medicaid Provider Registries are 
               
               
                 steps require some days to 
                 collaborate with Medicaid and 
                 federated with regional data 
               
               
                 complete update and 
                 accept the MITA standard 
                 exchange networks across the 
               
               
                 maintenance process. 
                 interface 
                 country and if desired, 
               
               
                   
                   
                 internationally 
               
               
                 Updates are made to data 
                 NPI is the ID of record and this 
                 Information is accessible to all 
               
               
                 manually. Inconsistencies and 
                 standard is used by all 
                 data exchange partners. Clinical 
               
               
                 inaccuracies can go undetected. 
                 downstream business processes. 
                 data is included in the data set. 
               
               
                 Staff perform the updates 
                 Provider updates are automated 
                 Updates are immediately posted 
               
               
                 manually. 
                 with date stamp and audit trail 
                 and accessible to all data 
               
               
                   
                   
                 exchange partners. 
               
               
                 Requires large data entry staff. 
                 Update can be immediate. 
                 Clinical data is used to trigger 
               
               
                   
                   
                 provider registry updates. 
               
               
                 Updates are manually validated. 
                 Data exchange partners receive 
                 Any data exchange partner can 
               
               
                   
                 update information instantly. 
                 send a notification regarding a 
               
               
                   
                   
                 provider record update to any 
               
               
                   
                   
                 other program in the USA 
               
               
                 Process complies with agency 
                 Automated updates are consistent 
                 Nationally interoperable 
               
               
                 requirements. 
                 according to agency standards 
                 validation sources automatically 
               
               
                   
                   
                 send notice of change in provider 
               
               
                   
                   
                 status, eliminating the need to 
               
               
                   
                   
                 reverify. 
               
               
                 Provider update information is 
                 Dala conforms to M1TA standard 
                 Supports detection of sanctioned 
               
               
                 maintained and available to 
                 interfaces. 
                 providers in real time anywhere 
               
               
                 other business processes. 
                   
                 in the USA. 
               
               
                   
                 Provider records are stored in 
                 Can be expanded to any other 
               
               
                   
                 either a single Provider Registry 
                 country to obtain information on 
               
               
                   
                 or federated Provider Registries 
                 an immigrant or guest provider 
               
               
                   
                 that can be accessed by all users 
                   
               
               
                   
                 of provider data 
                   
               
               
                   
                 Updates are automatically 
                 Full automation of the process 
               
               
                   
                 processed. Edits are consistent. 
                 plus access to clinical data on a 
               
               
                   
                   
                 national scale reduces staff 
               
               
                   
                   
                 requirements to a core team of 
               
               
                   
                   
                 professionals who monitor 
               
               
                   
                   
                 provider network performance 
               
               
                   
                   
                 Regional, federated provider 
               
               
                   
                   
                 registries eliminate redundant 
               
               
                   
                   
                 overhead 
               
               
                   
                 Updates are distributed to data 
                 Providers, members, and care 
               
               
                   
                 sharing partners. One stop shop 
                 managers access standardized 
               
               
                   
                 for entities who share providers. 
                 National Provider Registries and 
               
               
                   
                   
                 view clinical performance 
               
               
                   
                   
                 indicators to make informed 
               
               
                   
                   
                 decisions re provider selection, 
               
               
                   
                   
                 provider referrals. 
               
               
                   
                 Fewer staff required to support. 
                   
               
               
                   
                 Distributed updates of changes to 
                   
               
               
                   
                 provider registry reduce start 
                   
               
               
                   
                 requirements. 
                   
               
               
                   
                 Automation improves accuracy or 
                   
               
               
                   
                 validation and verification of 
                   
               
               
                   
                 database updates. 
                   
               
               
                   
                 NPI is the ID of record and 
                   
               
               
                   
                 standardizes ID and taxonomy 
                   
               
               
                   
                 updates. 
                   
               
               
                   
                 In managed care and waiver 
                   
               
               
                   
                 settings, guidelines ensure 
                   
               
               
                   
                 adequacy of network 
                   
               
               
                   
                 Members are assigned to PCPs to 
                   
               
               
                   
                 coordinate their care. 
                   
               
               
                   
                 Automated maintenance of 
                   
               
               
                   
                 provider information ensures that 
                   
               
               
                   
                 timely, accurate data are available 
                   
               
               
                   
                 to support member assignment 
                   
               
               
                   
                 Members can view provider 
                   
               
               
                   
                 profiles and locations, make 
                   
               
               
                   
                 informed choices. 
                   
               
               
                   
                 Cultural and linguistic indicators 
                   
               
               
                   
                 improve selection of appropriate 
                   
               
               
                   
                 providers. 
                   
               
               
                   
                 Provider and member satisfaction 
                   
               
               
                   
                 improves because of speed and 
                   
               
               
                   
                 accuracy of enrollment process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 49 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                   
                 Capability: Develop and  
               
               
                   
                 Maintain Medical and  
               
               
                 Sub-Platform: Provider Support  
                 Network Policies 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 6.3.4.1 Develop and Maintain  
                   
                   
               
               
                 Contracting and  
                   
                   
               
               
                 Reimbursement Policies  
                   
                   
               
               
                 Define Standard Contracting  
                   
                   
               
               
                 Methodologies  
                   
                   
               
               
                 Define approved non-standard  
                   
                   
               
               
                 variations and rules for use 
                   
                   
               
               
                 6.3.4.2 Develop and Maintain  
                   
                   
               
               
                 Medical Policies  
                   
                   
               
               
                 Define approved sources of  
                   
                   
               
               
                 external clinical information/  
                   
                   
               
               
                 current practices  
                   
                   
               
               
                 Create external review &amp;  
                   
                   
               
               
                 advice boards 
                   
                   
               
               
                 6.3.4.2 Develop and Maintain  
                   
                   
               
               
                 Medical Policies  
                   
                   
               
               
                 Determine and monitor state/  
                   
                   
               
               
                 federal requirements and  
                   
                   
               
               
                 impacts on medical policy and  
                   
                   
               
               
                 its application 
                   
                   
               
               
                 6.3.4.3 Develop and Maintain  
                   
                   
               
               
                 Network Strategy and Plan 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 50 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                   
                 Capability:  
               
               
                 Sub-Platform: Provider Support 
                 Manage Pharmacy 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 6.3.5.1 Develop &amp; Maintain  
                   
                   
               
               
                 Pharmacy Contracting  
                   
                   
               
               
                 Business terms  
                   
                   
               
               
                 NCPDP and code issues 
                   
                   
               
               
                 6.3.5.2 Perform Pharmacy Prior  
                   
                   
               
               
                 Authorization 
                   
                   
               
               
                 6.3.5.3 Perform Pharmacy  
                   
                   
               
               
                 Retrospective Review 
                   
                   
               
               
                 6.3.5.4 Perform Pharmacy  
                   
                   
               
               
                 Credentialing 
                   
                   
               
               
                 6.3.5.5 Manage Specially Pharmacy  
                   
                   
               
               
                 Contracting terms  
                   
                   
               
               
                 Prior Authorization 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 51 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider Support 
                 Capability: Manage Provider Communication 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Requests are received from 
                 Routine requests from providers 
                 Medicaid provider registry is 
               
               
                 providers in non-standard 
                 are standardized and automated 
                 federated with RHIOs on a 
               
               
                 formats. Most requests are sent 
                 within the agency via AVRS, Web 
                 national scale which enables the 
               
               
                 via telephone, fax, or USPS. 
                 portal, EDI. 
                 Medicaid agency to reach all 
               
               
                   
                   
                 targeted providers statewide to 
               
               
                   
                   
                 receive general communiqués or 
               
               
                   
                   
                 public health alerts. 
               
               
                 Research is performed manually. 
                 Research and response for these 
                 All health care agencies are able 
               
               
                   
                 standardized communications are 
                 to collaborate in sending and 
               
               
                   
                 immediate or within batch 
                 receiv ing communications 
               
               
                   
                 response parameters. 
                 between agencies and among all 
               
               
                 Responses are inconsistent and 
                 Routine responses are consistent 
                 providers statewide. 
               
               
                 manual. There may be delays in 
                 and timely and require fewer staff. 
                 Many typical provider 
               
               
                 responses. 
                   
                 communications are handled 
               
               
                   
                   
                 directly by connectivity between 
               
               
                   
                   
                 the provider&#39;s clinical record 
               
               
                   
                   
                 system and the Medicaid agency 
               
               
                 Complies with agency goals and 
                 The majority of communications 
                 Requests can be received and 
               
               
                 expectations. 
                 is automated. 
                 responded to nationally and 
               
               
                   
                   
                 internationally. 
               
               
                 Requires significant labor force. 
                 MITA standard interfaces are used 
                 Messages can be sent from one 
               
               
                   
                 for automated messages between 
                 state Medicaid to providers in 
               
               
                   
                 provider and agency 
                 other states depending on inter- 
               
               
                   
                   
                 agency agreements. 
               
               
                 Provider communication is not 
                 Provides a one-stop shop for 
                 Indicator algorithms can trigger 
               
               
                 coordinated among multiple, 
                 frequently asked questions for 
                 communication messages directly 
               
               
                 siloed programs and not 
                 Medicaid and other collaborating 
                 to the provider. 
               
               
                 systematically . . .  
                 agencies that accept the MITA 
                   
               
               
                   
                 standard interfaces. 
                   
               
               
                 No emphasis on linguistic, 
                 Communications are standardized 
                 Inquiry and response, and 
               
               
                 cultural or competency-based 
                 within the Medicaid agency. 
                 communications sent by the 
               
               
                 considerations. 
                   
                 agency are immediate. 
               
               
                   
                   
                 Turnaround time is immediate, on 
               
               
                   
                   
                 a national scale 
               
               
                 May encounter obstacles to 
                 Use of electronic communications 
                 Interaction between provider 
               
               
                 delivery. 
                 makes provision of appropriate 
                 clinical data and the agency is 
               
               
                   
                 messages more feasible and cost- 
                 automatic. 
               
               
                   
                 effective. 
                   
               
               
                 Manual and semi-automated 
                 Provider registries use 
                 Medicaid Provider Registries are 
               
               
                 steps may require some days to 
                 standardized contact data, 
                 federated with regional data 
               
               
                 complete response. 
                 including NPI address standards, 
                 exchange networks across the 
               
               
                   
                 to alleviate postal delivery 
                 country and if desired, 
               
               
                   
                 failures. 
                 internationally. 
               
               
                 Responses are made manually 
                 Provider requests and responses 
                 Responses are standardized and 
               
               
                 and there may be inconsistency 
                 are automated via Web, AVRS, 
                 are immediately available. 
               
               
                 and inaccuracy (within agency 
                 EDI with dale stamp and audit 
                   
               
               
                 tolerance level). 
                 trail. 
                   
               
               
                 Staff research and respond to 
                 Inquiries and responses using 
                 The provider clinical record 
               
               
                 requests manually. 
                 MITA standard interfaces are 
                 information can trigger messages 
               
               
                   
                 immediate. 
                 to and from the provider and the 
               
               
                   
                   
                 Medicaid agency. 
               
               
                 Requires large research staff. 
                 Automated response increase 
                 Access to clinical information can 
               
               
                   
                 accuracy 
                 improve efficiency especially in 
               
               
                   
                   
                 alert messaging 
               
               
                 Responses are manually 
                 Access is via Web portal and EDI 
                 Automated access to information 
               
               
                 validated, e.g., call center audits; 
                 channels. 
                 nationally further improves 
               
               
                 provider satisfaction survey. 
                   
                 efficiency. 
               
               
                 Process complies with agency 
                   
                   
               
               
                 requirements. 
                   
                   
               
               
                 Providers receive the 
                 Requests and responses are 
                 Full automation of the process 
               
               
                 information they need. 
                 standardized as MITA interfaces, 
                 plus access to national clinical 
               
               
                   
                 improving accuracy. 
                 data reduces staff requirements to 
               
               
                   
                   
                 a core team of professionals who 
               
               
                   
                   
                 monitor provider satisfaction with 
               
               
                   
                   
                 responses to inquiries. 
               
               
                   
                 Provider information is accessed 
                 Access to national clinical data 
               
               
                   
                 via either a single Provider 
                 improves accuracy of targeted 
               
               
                   
                 Registry&#39; or federated Provider 
                 alerts. 
               
               
                   
                 Registries. 
                   
               
               
                   
                 Provider information belonging to 
                 Some inquiries/responses are 
               
               
                   
                 different entities can be virtually 
                 replaced by automated messaging, 
               
               
                   
                 consolidated to form a single 
                 on a national scale. 
               
               
                   
                 view. 
                   
               
               
                   
                 Responses to routine provider 
                   
               
               
                   
                 requests are automated. 
                   
               
               
                   
                 Fewer staff required to support. 
                   
               
               
                   
                 Information requested by provider 
                   
               
               
                   
                 is continuously refreshed 
                   
               
               
                   
                 Collaboration among agencies 
                   
               
               
                   
                 achieve a one-stop shop to 
                   
               
               
                   
                 provider inquiries. 
                   
               
               
                   
                 Automation leads to fewer staff. 
                   
               
               
                   
                 Number of responses per day 
                   
               
               
                   
                 increases significantly. 
                   
               
               
                   
                 Use of MITA standards and 
                   
               
               
                   
                 collaboration among agencies 
                   
               
               
                   
                 increases effectiveness. 
                   
               
               
                   
                 Automation improves accuracy of 
                   
               
               
                   
                 responses. 
                   
               
               
                   
                 MITA standard interfaces specify 
                   
               
               
                   
                 requests and response messages 
                   
               
               
                   
                 and are used by collaborating 
                   
               
               
                   
                 agencies in the state. 
                   
               
               
                   
                 Providers have no delay in 
                   
               
               
                   
                 obtaining responses. 
                   
               
               
                   
                 Providers have a one stop shop to 
                   
               
               
                   
                 access collaborating agencies to 
                   
               
               
                   
                 obtain information. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 52 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider Support 
                 Capability: Manage Provider Grievance and Appeal 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 This is an all-manual process. 
                 Grievance and appeal cases are 
                 Clinical data is automatically 
               
               
                 Grievances and appeals are filed 
                 filed via USPS and fax. 
                 accessed to substantiate case 
               
               
                 via fax and USPS. 
                   
                 findings. 
               
               
                 Requests for documents are 
                 Documents are scanned and the 
                 Automated business rules that 
               
               
                 managed manually. 
                 case file is automated and can be 
                 include clinical data lead to earlier 
               
               
                   
                 shared among case workers. 
                 resolution of cases. 
               
               
                 Confidential documents are 
                 Some review steps are automated 
                 The original case against a 
               
               
                 transferred by certified mail. 
                 using agency specific standards. 
                 provider may be triggered directly 
               
               
                   
                   
                 from the clinical record. 
               
               
                 Verification of information is 
                 Time required to develop the case 
                 Interoperability and data sharing 
               
               
                 handled manually 
                 is reduced. 
                 agreements across states facilitate 
               
               
                   
                   
                 case resolution. 
               
               
                 The process is lengthy 
                 There is more consistency in the 
                 Responses to research questions 
               
               
                   
                 steps taken in the review and 
                 are immediate. 
               
               
                   
                 resolution process. 
                   
               
               
                 There may be inconsistencies 
                 MITA standard interfaces are used 
                 Turnaround time of information 
               
               
                 between cases of same type 
                 for Grievance and Appeal triggers 
                 gathering is immediate, on a 
               
               
                   
                 and results 
                 national scale. 
               
               
                 This is an all-manual process. 
                 MITA standard interfaces are used 
                 Medicaid Provider Registries are 
               
               
                 Cases typically require months 
                 to initiate and develop the case. 
                 federated with regional data 
               
               
                 to complete. 
                   
                 exchange networks across the 
               
               
                   
                   
                 country and if desired, 
               
               
                   
                   
                 internationally. 
               
               
                 Information is researched 
                 Case file is Web-enabled; 
                 All authorized data exchange 
               
               
                 manually 
                 information is shared among staff 
                 partners can access provider 
               
               
                   
                 in managing the case. 
                 information, including clinical 
               
               
                   
                   
                 data. 
               
               
                 There may be inconsistencies in 
                 Medicaid collaborates with other 
                 Automated access to information 
               
               
                 responses. 
                 health and human service 
                 nationally further improves 
               
               
                   
                 agencies that manage appea/s (o 
                 efficiency. 
               
               
                   
                 create a one-stop shop model for 
                   
               
               
                   
                 both provider and consumer 
                   
               
               
                   
                 appeals. 
                   
               
               
                 There are no standards for case 
                 Requests for provider information 
                 Automated business rules that 
               
               
                 data. 
                 are automated via AVRS, Web 
                 include clinical data lead to earlier 
               
               
                   
                 portal. EDI within an agency 
                 resolution of cases 
               
               
                 Staff research and maintain 
                 Responses to research questions 
                 The original case against a 
               
               
                 manually. 
                 within the agency are immediate 
                 provider may be triggered directly 
               
               
                   
                 across all data sharing partners 
                 from the clinical record. 
               
               
                   
                 within the state. 
                   
               
               
                 Process is labor-intensive. 
                 Over all timeline to resolve a case 
                 Full automation of the process 
               
               
                   
                 is shortened. 
                 plus access to national clinical 
               
               
                   
                   
                 data reduce staff requirements to a 
               
               
                   
                   
                 core team of professionals who 
               
               
                   
                   
                 monitor stakeholder satisfaction 
               
               
                   
                   
                 with responsiveness to inquiries. 
               
               
                 Results take several months. 
                 Automation improves access and 
                 Regional and national, federated 
               
               
                   
                 accuracy. 
                 provider registries eliminate 
               
               
                   
                   
                 redundant overhead. 
               
               
                 Terms of the settlement or 
                 Access is via Web portal and EDI 
                 Incorporation of national clinical 
               
               
                 results of the hearing are 
                 channels. 
                 data improves accuracy of final 
               
               
                 manually documented according 
                   
                 disposition of the case. 
               
               
                 to the administrative rules of the 
                   
                   
               
               
                 state. 
                   
                   
               
               
                 There may be inconsistencies 
                 Agency standards for inquiries are 
                 Use of national clinical evidence 
               
               
                 between similar cases. 
                 introduced. 
                 reduces false positives and 
               
               
                   
                   
                 improves consistency of results. 
               
               
                 Process complies with agency 
                 Standard MITA interfaces 
                   
               
               
                 requirements 
                 improve accuracy of content. 
                   
               
               
                 Business process complies with 
                 Responses to requests to verify 
                   
               
               
                 agency and state requirement for 
                 provider case information are 
                   
               
               
                 a fair hearing and disposition. 
                 automated. 
                   
               
               
                   
                 Fewer staff required to support. 
                   
               
               
                   
                 MITA standard interfaces 
                   
               
               
                   
                 standards are used for creation of 
                   
               
               
                   
                 a case and publication of results. 
                   
               
               
                   
                 MITA standard interfaces are also 
                   
               
               
                   
                 used for inquiry and response to 
                   
               
               
                   
                 acquisition of information needed 
                   
               
               
                   
                 to build the case. 
                   
               
               
                   
                 Automation of some research 
                   
               
               
                   
                 steps reduces level of staffing 
                   
               
               
                   
                 required to manage a case. 
                   
               
               
                   
                 Collaboration with sister agencies 
                   
               
               
                   
                 that conduct appeals cases 
                   
               
               
                   
                 increases cost-effectiveness. 
                   
               
               
                   
                 Standardization of input and case 
                   
               
               
                   
                 results allows staff to focus on 
                   
               
               
                   
                 analytical activities. 
                   
               
               
                   
                 Automation is introduced into the 
                   
               
               
                   
                 case management process. 
                   
               
               
                   
                 Results are documented and 
                   
               
               
                   
                 recorded and can be accessed and 
                   
               
               
                   
                 retrieved as needed. 
                   
               
               
                   
                 MITA standard interface 
                   
               
               
                   
                 improves accuracy of case results. 
                   
               
               
                   
                 The provider and the agency 
                   
               
               
                   
                 benefit from introduction of 
                   
               
               
                   
                 automation to speed up the case 
                   
               
               
                   
                 resolution. 
                   
               
               
                   
                 Agencies benefit from 
                   
               
               
                   
                 introduction of MITA standard 
                   
               
               
                   
                 interfaces. 
                   
               
               
                   
                 Providers benefit from 
                   
               
               
                   
                 consistency and predictability of 
                   
               
               
                   
                 the process. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 53 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Provider Management 
               
             
          
           
               
                 Sub-Platform: Provider Support 
                 Capability: Perform Provider Outreach 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The business process is 
                 Increased use of agency standards 
                 Provider clinical information can 
               
               
                 primarily manual. 
                 for provider data improves 
                 trigger outreach and educational 
               
               
                   
                 identification of targeted, enrolled 
                 material that are automatically 
               
               
                   
                 providers; and aids in 
                 generated and sent to the 
               
               
                   
                 identification of provider gaps. 
                 provider. 
               
               
                 Agencies use TV, radio, posters 
                 Electronic outreach and 
                 States can share provider 
               
               
                 for public transportation and 
                 educational materials are 
                 outreach and education materials 
               
               
                 community centers and clinics, 
                 available to providers via a Web 
                 with other states. 
               
               
                 and newspaper advertisements 
                 portal. 
                   
               
               
                 to distribute outreach and 
                   
                   
               
               
                 educational information to 
                   
                   
               
               
                 targeted providers. 
                   
                   
               
               
                 Identification of targeted 
                 Standard educational and policy 
                 Triggers create messages from 
               
               
                 enrolled providers is based on 
                 information for enrolled providers 
                 provider clinical records that map 
               
               
                 provider registry data and 
                 is maintained electronically by 
                 to automated response messages 
               
               
                 claims history. 
                 the agency and is distributed to 
                 contained in an Outreach and 
               
               
                   
                 the providers via electronic 
                 Education database. 
               
               
                   
                 media 
                   
               
               
                 Outreach is uncoordinated 
                 Automated translation and 
                 Turnaround time to identify target 
               
               
                 among multiple, siloed 
                 repositories of cultural and 
                 provide and transmit information 
               
               
                 programs. 
                 competency appropriate 
                 is immediate. 
               
               
                   
                 statements makes provision of 
                   
               
               
                   
                 appropriate outreach material 
                   
               
               
                   
                 more feasible and cost-effective. 
                   
               
               
                 Linguistic and cultural 
                 Use of GIS and socioeconomic 
                 Turnaround time for triggering, 
               
               
                 sensitivity refinements are 
                 indicators support targeting 
                 sending appropriate information 
               
               
                 absent. 
                 providers for outreach. 
                 is immediate, on a national scale. 
               
               
                 Quality and consistency of 
                 Provider registries, use 
                 CMS can send NPI and PDP 
               
               
                 outreach and education efforts 
                 standardized contact data, 
                 messages to all providers via 
               
               
                 are difficult to maintain. 
                 including NPI, to alleviate postal 
                 federated registries. 
               
               
                   
                 delivery failures. 
                   
               
               
                 The agency may encounter 
                 Outreach and education materials 
                 Medical Provider Registries are 
               
               
                 obstacles to delivery. 
                 are available via state Medicaid 
                 federated with regional data 
               
               
                   
                 portal and are shared with other 
                 exchange networks across the 
               
               
                   
                 collaborating agencies. 
                 country 
               
               
                 Outreach and education 
                 Electronic storage and 
                 Access to clinical data facilitates 
               
               
                 materials are manually prepared 
                 dissemination of provider manual 
                 identification of targeted 
               
               
                 and updated. 
                 materials shortens the time to 
                 providers and focuses the 
               
               
                   
                 reach the provider. Non-routine 
                 outreach or education message. 
               
               
                   
                 outreach is still timeconsuming. 
                   
               
               
                 Provider manuals are constantly 
                 Outreach and education 
                 Access to clinical information 
               
               
                 revised and new pages are 
                 information are immediately 
                 improves efficiency by 
               
               
                 mailed to providers. 
                 available to providers across 
                 automatically mapping provider 
               
               
                   
                 collaborating agencies. 
                 who needs assistance with 
               
               
                   
                   
                 generation of appropriate 
               
               
                   
                   
                 materials. 
               
               
                 Preparation of materials is 
                 Automation improves access and 
                 Automated business rules that 
               
               
                 clunky. 
                 accuracy 
                 include clinical data lead to faster 
               
               
                   
                   
                 identification of target list 
               
               
                 Information is subject to 
                 Access is via Web portal for 
                 Outreach and education can be 
               
               
                 inaccuracies and 
                 outreach material and via 
                 interoperable among states 
               
               
                 inconsistencies. 
                 electronic media for routine 
                 sharing business services. 
               
               
                   
                 information distributed to 
                   
               
               
                   
                 enrolled providers. 
                   
               
               
                 Staff develop and maintain 
                 Provider information is accessed 
                 Full automation of the process of 
               
               
                 materials manually. 
                 via federated Provider Registries 
                 identification of need plus access 
               
               
                   
                 that can be accessed by all 
                 to clinical data reduces staff 
               
               
                   
                 authorized entities within the 
                 requirements. 
               
               
                   
                 state 
                   
               
               
                 Effort is required to research 
                 Identification of targeted 
                 Regional, federated provider 
               
               
                 target provides population and 
                 providers and dissemination of 
                 registries eliminate redundant 
               
               
                 track mailings. 
                 information improve in accuracy. 
                 overhead in locating addresses 
               
               
                 Process is labor-intensive and 
                 Materials can be posted on a Web 
                 Outreach and education can be 
               
               
                 incurs postal expense. 
                 site for downloading by 
                 interoperable among states sharing 
               
               
                   
                 providers. 
                 MITA standard interfaces 
               
               
                 Difficult to determine impact of 
                 Easier to identify target 
                 Incorporation of clinical data 
               
               
                 outreach and education. 
                 population and disseminate 
                 improves accuracy of 
               
               
                   
                 appropriate information. 
                 identification or targeted 
               
               
                   
                   
                 providers and dissemination of 
               
               
                   
                   
                 appropriate messages. 
               
               
                 Studies are conducted to see if 
                 Automation reduces level of 
                 Access to provider information 
               
               
                 there are improvements in 
                 staffing required to perform 
                 on a regional or national basis. 
               
               
                 provider performance 
                 outreach and education. 
                   
               
               
                 associated with outreach and 
                   
                   
               
               
                 education 
                   
                   
               
               
                 Business process complies with 
                 Easier to identify target 
                 Provider registries improve 
               
               
                 agency and state requirements 
                 population and disseminate 
                 accuracy of contact information. 
               
               
                 for educating the provider 
                 appropriate information. 
                   
               
               
                 network regarding rules and 
                   
                   
               
               
                 regulations and how to 
                   
                   
               
               
                 communicate with the agency. 
                   
                   
               
               
                   
                 Use of portal by provider is 
                 Outreach and education 
               
               
                   
                 monitored to ensure that all are 
                 communications can be triggered 
               
               
                   
                 actively engaged in downloading 
                 by automated messaging 
               
               
                   
                 information. 
                   
               
               
                   
                 Easier to target provider 
                   
               
               
                   
                 populations and disseminate 
                   
               
               
                   
                 information appropriate to the 
                   
               
               
                   
                 needs. 
                   
               
               
                   
                 Agency can target providers who 
                   
               
               
                   
                 are not accessing information. 
                   
               
               
                   
                 Provider and agency benefit from 
                   
               
               
                   
                 introduction of automation to 
                   
               
               
                   
                 speed up the outreach and 
                   
               
               
                   
                 education process. 
                   
               
               
                   
                 Agencies benefit from sharing of 
                   
               
               
                   
                 information with other agencies. 
                   
               
               
                   
                 Providers benefit from 
                   
               
               
                   
                 consistency and timeliness of the 
                   
               
               
                   
                 information transmitted. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 54 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform: Eligibility Determination 
                 Capability; Determine Eligibility 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the business 
                 The business process benefits 
                 The business process has ease of 
               
               
                 process is designed to serve 
                 from member centric. No Wrong 
                 access to external sources of data, 
               
               
                 social services programs and 
                 Door initiatives and the 
                 including clinical data 
               
               
                 FFS Medicaid programs. 
                 technology support provided by 
                   
               
               
                   
                 SOA and rules-engines to meet 
                   
               
               
                   
                 the needs of programs besides 
                   
               
               
                   
                 FFS. 
                   
               
               
                 The process is constrained by 
                 All programs introduce flexibility 
                 National interoperability permits 
               
               
                 FAMIS or state eligibility 
                 within benefit packages. 
                 the eligibility process to send 
               
               
                 system functionality. 
                   
                 inquiries to any other agency, 
               
               
                   
                   
                 state, federal, or other entities in 
               
               
                   
                   
                 any part of the country. 
               
               
                 Indeterminate format for 
                 Application data are standardized. 
                 External and internal validation 
               
               
                 application data. 
                 All verifications can be 
                 sources automatical!)&#39; send notice 
               
               
                   
                 automated. Rules are consistently 
                 of change in member status. 
               
               
                   
                 applied. 
                   
               
               
                 Information is manually 
                 Decisions are uniform. Some 
                 Direct access to clinical data 
               
               
                 validated. 
                 manual steps may continue. 
                 improves the determination 
               
               
                   
                   
                 process. Manual validation steps 
               
               
                   
                   
                 only required for exception 
               
               
                   
                   
                 handling. 
               
               
                 Staff contact external and 
                 Requires fewer staff. 
                 Agency receives automated 
               
               
                 internal document verification 
                   
                 notifications from the SSA and 
               
               
                 sources via phone, fax. 
                   
                 other in-state and state and 
               
               
                   
                   
                 federal agencies with which it has 
               
               
                   
                   
                 data sharing agreements. 
               
               
                 Decisions may be inconsistent. 
                 Turnaround time can be 
                 Consumer-driven benefit 
               
               
                   
                 immediate. 
                 packages are designed and 
               
               
                   
                   
                 updated real time based on 
               
               
                   
                   
                 collaborative interfaces with 
               
               
                   
                   
                 members&#39; federated electronic 
               
               
                   
                   
                 health records. 
               
               
                 Requires large staff. 
                 Different types of eligibility 
                   
               
               
                   
                 pathways are merged into a single 
                   
               
               
                   
                 process. 
                   
               
               
                 Decisions take several days. 
                 Spend-down is calculated 
                   
               
               
                   
                 automatically by the Calculate 
                   
               
               
                   
                 Spend-down process in the 
                   
               
               
                   
                 Operations Management, 
                   
               
               
                   
                 Member Payment business area. 
                   
               
               
                 There are many pathways for 
                 Spend-down is treated as a 
                   
               
               
                 determining eligibility. 
                 deductible that these eligibles 
                   
               
               
                   
                 must pay out-of-pocket before 
                   
               
               
                   
                 Medicaid will pay. 
                   
               
               
                 When eligibility information is 
                   
                   
               
               
                 transferred from FAMIS to 
                   
                   
               
               
                 MMIS, it must be converted and 
                   
                   
               
               
                 data is lost. 
                   
                   
               
               
                 Benefit packages selections 
                   
                   
               
               
                 have pre-set services and 
                   
                   
               
               
                 provider types. 
                   
                   
               
               
                 Spend-down amounts are 
                   
                   
               
               
                 calculated manually. 
                   
                   
               
               
                 Member&#39;s record reflects 
                   
                   
               
               
                 whether spend-down amount is 
                   
                   
               
               
                 reached. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 55 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                   
                 Capability:  
               
               
                 Sub-Platform: Enrollment 
                 Disenroll Member 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 9.2.1.1 Receive member 
                   
                   
               
               
                 eligibility termination request 
                   
                   
               
               
                 9.2.1.2 Assign identifier and 
                   
                   
               
               
                 track processing status of 
                   
                   
               
               
                 eligibility termination and 
                   
                   
               
               
                 disenrollment request 
                   
                   
               
               
                 9.3.1.3 Validate compliance of 
                   
                   
               
               
                 state application submission 
                   
                   
               
               
                 rules. 
                   
                   
               
               
                 9.2.1.4 Verify demographic 
                   
                   
               
               
                 data and residence does 
                   
                   
               
               
                 not meet enrollment 
                   
                   
               
               
                 requirements 
                   
                   
               
               
                 9.2.1.5 Create disenrollment 
                   
                   
               
               
                 data set to load 
                   
                   
               
               
                 disenrollment record into 
                   
                   
               
               
                 member registry 
                   
                   
               
               
                 9.2.1.6 Alert applicant, 
                   
                   
               
               
                 provider, and contractor 
                   
                   
               
               
                 systems disenrollment 
                   
                   
               
               
                 information is loaded into 
                   
                   
               
               
                 member registry to prepare 
                   
                   
               
               
                 notifications 
                   
                   
               
               
                 9.2.1.7 Prepare education 
                   
                   
               
               
                 materials for disenrollment 
                   
                   
               
               
                 reason in member outreach 
                   
                   
               
               
                 process 
                   
                   
               
               
                 9.2.1.8 Alert operations, 
                   
                   
               
               
                 payment and billing systems of 
                   
                   
               
               
                 member disenrollment 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 56 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform: Enrollment 
                 Capability: Enroll Member 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Enrollment processes are paper- 
                 Automated business rules 
                 Enrollment/eligibility 
               
               
                 based and siloed within 
                 facilitate design or seamless and 
                 determination processes are 
               
               
                 programs with no cross program 
                 coordinated package of quality. 
                 automated services triggered by 
               
               
                 coordination. 
                   
                 point of service applications 
               
               
                   
                   
                 including PHRs and EHRs and 
               
               
                   
                   
                 run collaboratively. 
               
               
                 Stall makes decisions 
                 All verification of financial, 
                 If the provider&#39;s system is service 
               
               
                 autonomously and without 
                 socio-economic and health status 
                 enabled, it can prepopulate 
               
               
                 consultation with other 
                 information is automated and 
                 appropriate enrollment 
               
               
                 programs. 
                 some is real time. 
                 application(s) and to request 
               
               
                   
                   
                 additional information needed 
               
               
                   
                   
                 from the provider/applicant. 
               
               
                 Eligibility determination must 
                 Contractors and providers can 
                 The applicant is able to use online 
               
               
                 precede enrollment and is done 
                 query the registry to determine 
                 PHR or Web portal to fill out a 
               
               
                 separately. 
                 eligibility and program 
                 pre-populated application. 
               
               
                   
                 enrollment 
                   
               
               
                 Enrollment policies, procedures, 
                 Contractors may batch download 
                 Automated verification and 
               
               
                 benefits and application forms 
                 enrolled members rather than 
                 application response are real time. 
               
               
                 are program specific. 
                 receive theHIPAA834. 
                   
               
               
                 Applicants must submit paper 
                 Process takes less time. Although 
                 Benefits are memberspecific, 
               
               
                 application forms to each 
                 data is electronic, some of the 
                 seamless and coordinated package 
               
               
                 program separately and 
                 reviewed verification of 
                 of quality. 
               
               
                 responses may take several 
                 information for waiver programs 
                   
               
               
                 days. 
                 must be done manually. 
                   
               
               
                 Process focus is on manually 
                 Turnaround time on application 
                 The Agency can automatically 
               
               
                 applying the agency&#39;s business 
                 decision can be immediate. 
                 query regional patient registries 
               
               
                 rules to ensure that enrollment 
                   
                 for member enrollment 
               
               
                 meets state and federal 
                   
                 information for verification and 
               
               
                 requirements. 
                   
                 adjudication purposes such as 
               
               
                   
                   
                 COB 
               
               
                 Staff manually verifies financial, 
                 Medicaid and contractor member 
                 Agency receives automated 
               
               
                 socio-economic and health 
                 registries are updated in near real 
                 enrollment notifications from the 
               
               
                 status information. 
                 time as changes occur. 
                 SSA, EHRs, PHRs, intraand 
               
               
                   
                   
                 interstate sources and federal 
               
               
                   
                   
                 agencies. 
               
               
                 Enrollment in managed care and 
                 Managed care enrollment is rule 
                 Turnaround time is immediate, on 
               
               
                 waiver program requires 
                 driven and automated 
                 a national scale 
               
               
                 cumbersome extension of 
                   
                   
               
               
                 traditional fee-for-service 
                   
                   
               
               
                 processes. 
                   
                   
               
               
                 Benefits cannot be 
                 Enrollment application and 
                 Member registries are federated 
               
               
                 “blended” across programs. 
                 exchange data are standardized 
                 with regional data exchange 
               
               
                   
                 nationally among Medicaids 
                 networks across the country and if 
               
               
                   
                 improving access and accuracy. 
                 desired, internationally. 
               
               
                 Staff does not have the time or 
                 All programs use the HIPAA834 
                 Agency automatically receives 
               
               
                 means to focus on meeting 
                 Enrollment transaction and 
                 standardized, timely and complete 
               
               
                 members&#39; health, functions, 
                 implement a standard response 
                 enrollment data notifications 
               
               
                 cultural or linguistic needs. 
                 transaction from the contractors 
                 about members for verification 
               
               
                   
                 for corrections. 
                 and adjudication purposes. 
               
               
                 Staff must send paper 
                 Enrollment records are stored in 
                 Authorized, authenticated parties 
               
               
                 enrollment notification to 
                 either a single member registry or 
                 have virtual, instant access to 
               
               
                 contractors. 
                 federated Agency member 
                 enrollment data, nationally. 
               
               
                   
                 registries that can be accessed by 
                   
               
               
                   
                 all applications. 
                   
               
               
                 Decisions on application may 
                 Member IDs are linked 
                 Any data exchange partner 
               
               
                 take several days, longer if 
                 algorithmically based on other 
                 nationally, and even 
               
               
                 verification of information is 
                 standardized data so that 
                 internationally, can query and 
               
               
                 difficult. 
                 enrollment records are 
                 receive appropriate data relating 
               
               
                   
                 automatically linked across 
                 to an enrolled member 
               
               
                   
                 programs. 
                   
               
               
                 Contractors do not receive 
                 Providers, members and state 
                 Enrollment alerts to providers 
               
               
                 timely enrollment information. 
                 enrollment staff have secure 
                 reduces staff needed for 
               
               
                   
                 access to appropriate and accurate 
                 enrollment outreach and 
               
               
                   
                 data on demand 
                 verification of health status. 
               
               
                 Enrollment data and format are 
                 Performance data is only 
                 More effective enrollment data 
               
               
                 indeterminate. 
                 periodically measured and 
                 exchange because information 
               
               
                   
                 requires sampling and statistical 
                 about all enrollment events of 
               
               
                   
                 calculation. 
                 interest are pushed vs. querying 
               
               
                   
                   
                 potential sources of enrollment 
               
               
                   
                   
                 data. 
               
               
                 Enrollment applications are not 
                 Applications are only submitted 
                 Ability to auto/ad hoc query 
               
               
                 standardized and may still be 
                 electronically 
                 federated registries to access 
               
               
                 hard copy. 
                   
                 enrollment and verification data 
               
               
                   
                   
                 increases data reliability and 
               
               
                   
                   
                 completeness, ensuring better 
               
               
                   
                   
                 process results. 
               
               
                 Some enrollment records are 
                 Medicaid centralizes all member 
                 “ . . . events of . . . ty and . . . 
               
               
                 stored electronically but storage 
                 enrollment processes, has a single 
                 [proce? ]ss results.” 
               
               
                 is not centralized. 
                 set of enrollment rules. 
                 ABOVE TEXT IS OBSCURED 
               
               
                   
                   
                 BY THE FOLLOWING TEXT 
               
               
                   
                   
                 IN A BOX OVERLAPPING IT: 
               
               
                   
                   
                 Medicaid centralizes all 
               
               
                   
                   
                 member enrollment processes; 
               
               
                   
                   
                 has a single set of enrollment 
               
               
                   
                   
                 rules. 
               
               
                 Member data is not comparable 
                 “Enrollments and verif . . . 
                 Applicants are “presumptively 
               
               
                 across programs reducing ability 
                 automated/* 
                 eligibili/ed/enrolled” 
               
               
                 to monitor program outcomes or 
                 ABOVE TEXT IS OBSCURED 
                 automatically at the point of care 
               
               
                 detect fraud and abuse. 
                 BY THE FOLLOWING TEXT 
                 based on national verification of 
               
               
                 Notifications to contractors are 
                 IN A BOX OVERLAPPING IT: 
                 health and socio-economic data, 
               
               
                 state-specific and differ by 
                 Medicaid centralizes all 
                 ensuring immediate access to 
               
               
                 contractor type. 
                 member enrollment processes; 
                 needed healthcare 
               
               
                   
                 has a single set of enrollment 
                   
               
               
                   
                 rules. 
                   
               
               
                 Notifications to contractors are 
                 Services created for the 
                   
               
               
                 state-specific and differ by 
                 enrollment process can be shared 
                   
               
               
                 contractor type. 
                 among states. 
                   
               
               
                 Enrollment may occur in silos 
                 Process requires fewer staff and 
                   
               
               
                 without coordination, i.e., 
                 improves on results. 
                   
               
               
                 different processes and multiple 
                   
                   
               
               
                 pathways for each type of 
                   
                   
               
               
                 enrollment. 
                   
                   
               
               
                 Applicants and members can 
                 Shared services and inter-agency 
                   
               
               
                 submit applications, make 
                 collaboration contribute to 
                   
               
               
                 inquiries and choose providers 
                 streamline the process. 
                   
               
               
                 and MCOs on paper. 
                   
                   
               
               
                 Staff contact external and 
                 Fewer applicants and members 
                   
               
               
                 internal financial, 
                 are enrolled erroneously, reducing 
                   
               
               
                 socioeconomic, demographic 
                 program costs. 
                   
               
               
                 and health status verification 
                   
                   
               
               
                 sources via phone, fax. 
                   
                   
               
               
                 Requires a large staff to meet 
                 Automation of business rules 
                   
               
               
                 targets for manual enrollment of 
                 improves accuracy of validation 
                   
               
               
                 members. 
                 and verification. 
                   
               
               
                 Siloed enrollment processes 
                 Automation of enrollment and 
                   
               
               
                 result in redundant 
                 verification data interchange 
                   
               
               
                 infrastructure, effort and costs. 
                 improves timeliness and quality of 
                   
               
               
                   
                 data. 
                   
               
               
                 Much of the application 
                 Automated application of 
                   
               
               
                 information is manually 
                 enrollment business rules 
                   
               
               
                 validated and verification may 
                 improves consistency 
                   
               
               
                 be difficult. 
                   
                   
               
               
                 Decisions may be inconsistent. 
                 Permits blending of program 
                   
               
               
                   
                 benefits to provide more 
                   
               
               
                   
                 appropriate services to members. 
                   
               
               
                 Ineligible members may 
                 Synchronization of eligibility and 
                   
               
               
                 continue to be enrolled due to 
                 enrollment processes ensures data 
                   
               
               
                 limited monitoring and re- 
                 and decision consistency, thereby 
                   
               
               
                 verification of enrolled member 
                 improving results. 
                   
               
               
                 status. 
                   
                   
               
               
                 MMIS and Contractor member 
                 Automated enrollment 
                   
               
               
                 registries frequently are not 
                 coordination of program benefits 
                   
               
               
                 synchronized. 
                 improves the members&#39; access to 
                   
               
               
                   
                 appropriate services and 
                   
               
               
                   
                 compliance with state/federal law. 
                   
               
               
                 Focus is on accurately 
                 Members experience a seamless 
                   
               
               
                 processing enrollment and 
                 and efficient eligibility/enrollment 
                   
               
               
                 manually verifying information 
                 process no matter how or where 
                   
               
               
                 as efficiently as possible. 
                 they contact the Agency. 
                   
               
               
                 Staff does not have time to focus 
                 Members receive benefit 
                   
               
               
                 on health, functional, cultural 
                 packages, specifically designed to 
                   
               
               
                 and linguistic compatibility of 
                 meet individual&#39;s health, 
                   
               
               
                 provider or program for the 
                 functional, cultural and linguistic 
                   
               
               
                 member, or member satisfaction. 
                 needs. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 57 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                   
                 Capability:  
               
               
                 Sub-Platform: Enrollment 
                 Perform Underwriting 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 9.2.3.1 Develop New Business 
                   
                   
               
               
                 Quote 
                   
                   
               
               
                 9.2.3.2 Complete Underwriting 
                   
                   
               
               
                 Case Installation Tasks 
                   
                   
               
               
                 9.2.3.3 Conduct Financial 
                   
                   
               
               
                 Account Management 
                   
                   
               
               
                 9.2.3.4 Produce Customer 
                   
                   
               
               
                 Financial Reports 
                   
                   
               
               
                 9.2.3.5 Develop Renewal Quote 
                   
                   
               
               
                 &amp; Implement Sold Rates 
                   
                   
               
               
                 9.2.3.6 Prepare Year-End 
                   
                   
               
               
                 Customer Settlement 
                   
                   
               
               
                 9.2.3.7 Manage Underwriting 
                   
                   
               
               
                 Operations 
                   
                   
               
               
                 9.2.3.8 Manage Underwriting 
                   
                   
               
               
                 Support 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 58 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform:  
                   
               
               
                 Member Information Management 
                 Capability: Inquire Member Eligibility 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Most requests for verification of 
                 Member eligibility/enrollment 
                 Turnaround time is immediate, on 
               
               
                 member information are 
                 verification is automated via 
                 a national scale. 
               
               
                 received and responded to 
                 AVRS, point of services devices, 
                   
               
               
                 manually via phone, fax, USPS. 
                 Web portal, EDI, but remains 
                   
               
               
                   
                 siloed. 
                   
               
               
                 Information is researched 
                 Responses can be immediate 
                 Information, including clinical, 
               
               
                 manually. There may be 
                   
                 can be shared among authorized 
               
               
                 inconsistencies in responses. 
                   
                 entities within theRHIO. 
               
               
                 Staff research and respond to 
                 Information can be shared among 
                 Medicaid Member Registries are 
               
               
                 requests manually. High rate of 
                 entities authorized by the Agency. 
                 federated with RHIOs. 
               
               
                 erroneous eligibility 
                   
                   
               
               
                 information. 
                   
                   
               
               
                 Verification takes effort and too 
                 Automation improves access and 
                 Medicaid Member Registries are 
               
               
                 much time for providers. 
                 accuracy. 
                 federated with regional data 
               
               
                   
                   
                 exchange networks across the 
               
               
                   
                   
                 country and if desired, 
               
               
                   
                   
                 internationally. 
               
               
                   
                 Access is via AVRS, point of 
                 All authorized data exchange 
               
               
                   
                 sen ice devices, Web portal, and 
                 partners can access member 
               
               
                   
                 EDI channels. 
                 information 
               
               
                 Requires research staff. 
                 Increased use of HIPAA 
                   
               
               
                 Mailing ID cards to members 
                 eligibility/enrollment data but not 
                   
               
               
                 monthly is costly. 
                 the program and benefit data 
                 Access to clinical information can 
               
               
                 Verification is too expensive for 
                 Member eligibility/enrollment, 
                 improve efficiency for treatment, 
               
               
                 providers to use for each 
                 program, and benefit data and 
                 payment and operations. 
               
               
                 encounter but providers risk 
                 messaging formats adhere to 
                 Automated access to information 
               
               
                 cost of denied claims for 
                 MITA standard interfaces 
                 nationally further improves 
               
               
                 ineligible members and 
                 Member information is accessible 
                 I efficiency. 
               
               
                 noncovered services. 
                 from federated Member 
                 Full automation of the process 
               
               
                 Responses are manually 
                 Registries within the state 
                 plus access to clinical data 
               
               
                 validated. 
                 Enterprise. 
                 reduces staff requirements to a 
               
               
                   
                   
                 core team of professionals. 
               
               
                 Process complies with agency 
                 Responses to requests to verify 
                 Regional, federated provider 
               
               
                 requirements. 
                 member information are 
                 registries eliminate redundant 
               
               
                   
                 automated. 
                 overhead. 
               
               
                 Requestors receive the 
                 Fewer staff required to support. 
                 Access to member information on 
               
               
                 information they need. 
                 Electronic verification is easier 
                 a national basis. 
               
               
                   
                 and faster, so providers use it 
                   
               
               
                   
                 more often. 
                   
               
               
                   
                 Member information is 
                 Incorporation of clinical data, on 
               
               
                   
                 continuously refreshed. 
                 a national scale, improves 
               
               
                   
                   
                 accuracy&#39; of some responses. 
               
               
                   
                 One stop shop for programs that 
                 Some inquiries/responses are 
               
               
                   
                 share members. 
                 replaced by automated 
               
               
                   
                   
                 messaging, on a national scale, 
               
               
                   
                   
                 where authorized. 
               
               
                   
                 Automation leads to few staff. 
                   
               
               
                   
                 Number of responses per day 
                   
               
               
                   
                 increases significantly. 
                   
               
               
                   
                 Electronic verification lowers 
                   
               
               
                   
                 cost to providers and reduces 
                   
               
               
                   
                 denied claims for ineligible 
                   
               
               
                   
                 members and non-covered 
                   
               
               
                   
                 services. 
                   
               
               
                   
                 Use of MITA standard interfaces 
                   
               
               
                   
                 increase cost-effectiveness. 
                   
               
               
                   
                 Because covered services are 
                   
               
               
                   
                 included in eligibility verification 
                   
               
               
                   
                 responses, providers experience 
                   
               
               
                   
                 fewer claim denials based on 
                   
               
               
                   
                 noncovered services. 
                   
               
               
                   
                 Automation improves accuracy of 
                   
               
               
                   
                 responses. 
                   
               
               
                   
                 Business services standardize 
                   
               
               
                   
                 requests and responses nationally 
                   
               
               
                   
                 More robust use of the HIPAA 
                   
               
               
                   
                 transactions increases accuracy-. 
                   
               
               
                   
                 Providers have no delay in 
                   
               
               
                   
                 obtaining responses. 
                   
               
               
                   
                 Providers have a one stop shop to 
                   
               
               
                   
                 access collaborating agencies to 
                   
               
               
                   
                 obtain information. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 59 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform:  
                   
               
               
                 Member Information Management 
                 Capability: Manage Member Information 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The business process is 
                 Updates are automated with date 
                 At this level, the business process 
               
               
                 designed to serve FFS Medicaid 
                 stamp and audit trail; notification 
                 improves data availability and 
               
               
                 programs and meet MMIS 
                 to interested users and processes 
                 access for external users 
               
               
                 certification requirements such 
                 is immediate. 
                 nationally. 
               
               
                 as MARS and MSIS reporting. 
                   
                   
               
               
                 Data requests are received from 
                 Integration with FAMIS supports 
                 Member Registry accessed 
               
               
                 disparate sources in 
                 day based eligibility/enrollment. 
                 collaboratively by authorized data 
               
               
                 indeterminate formats. 
                   
                 sharing partner applications 
               
               
                   
                   
                 nationally during shared business 
               
               
                   
                   
                 processes such as verifying COB. 
               
               
                 Data is shared in batch on a 
                 Member information is integrated 
                 Member information can be 
               
               
                 scheduled or ad hoc basis. 
                 via Member registry. 
                 shared across states 
               
               
                 Validation is inconsistent and 
                 Standard interfaces. 
                 Ability to access clinical data 
               
               
                 not rules-based. 
                   
                 electronically to calculate 
               
               
                   
                   
                 performance and outcome 
               
               
                   
                   
                 measures. 
               
               
                 There are delays in completing 
                 Standardized data 
                 Turnaround time is immediate, on 
               
               
                 updates and loading member 
                   
                 a national scale. 
               
               
                 data generated from multiple 
                   
                   
               
               
                 sources. 
                   
                   
               
               
                 Duplicate entries may go 
                 Consistent business rules and 
                 Updates are available to all 
               
               
                 undetected. 
                 decisions. 
                 authorized data exchange 
               
               
                   
                   
                 partners. 
               
               
                 Irregular update notification to 
                 Easy to change business logic. 
                 Medicaid Member Registries are 
               
               
                 interested users and processes. 
                   
                 federated with regional data 
               
               
                   
                   
                 exchange networks across the 
               
               
                   
                   
                 country and if desired, 
               
               
                   
                   
                 internationally. 
               
               
                 Agencies may be limited to 
                 Manage Member Information is 
                 Updates notifications are 
               
               
                 monthly eligibility periods vs. 
                 handled by a business service. 
                 automatically sent to all 
               
               
                 day based 
                   
                 authorized interested data 
               
               
                 eligibility/enrollment. 
                   
                 exchange partners. 
               
               
                 Manual and semi-automated 
                 Member updates and data 
                 Any data exchange partner can 
               
               
                 steps delay updates, 
                 extractions can be immediate. 
                 send a notification regarding a 
               
               
                 maintenance processes and 
                   
                 member record update to any 
               
               
                 require system down-time. 
                   
                 other program in the USA. 
               
               
                 Inadequate audit trails. 
                 Data exchange partners receive 
                 Nationally interoperable 
               
               
                   
                 update notifications instantly. 
                 validation sources automatically 
               
               
                   
                   
                 send notice of change in member 
               
               
                   
                   
                 enrollment and socioeconomic 
               
               
                   
                   
                 status in real time anywhere in 
               
               
                   
                   
                 the USA. 
               
               
                 Updates are made to individual 
                 Automated updates are made to 
                 Ability to access clinical data 
               
               
                 files manually. 
                 individual files and databases. 
                 electronically to calculate 
               
               
                   
                 Databases may be relational. 
                 performance and outcome 
               
               
                   
                   
                 measures. 
               
               
                 Data issues duplicate 
                 Updates, notifications, and data 
                 Clinical data could be used to 
               
               
                 identifiers, discrepancies 
                 extractions are standardized. 
                 trigger member registry updates 
               
               
                 between data stores, and 
                   
                 and to push member data to other 
               
               
                 information quality and 
                   
                 applications. 
               
               
                 completeness. 
                   
                   
               
               
                 Staff must key new 
                 Member records are stored in 
                 Full automation of the process 
               
               
                 information, make updates 
                 either a single Member Registry 
                 plus access to clinical data on a 
               
               
                 manually, reconcile and 
                 or federated Member Registries 
                 national basis reduces staiT 
               
               
                 validate manually. 
                 that can be accessed by all 
                 requirements to a core team of 
               
               
                   
                 authorized applications. 
                 professionals. 
               
               
                 Legacy systems limit Agency&#39;s 
                 Updates are distributed to data 
                 Regional, federated member 
               
               
                 ability to start and end 
                 sharing partners. One stop shop 
                 registries eliminate redundant 
               
               
                 eligibility in the MCOs within a 
                 for entities who share members. 
                 overhead. 
               
               
                 month. 
                   
                   
               
               
                 Requires numerous data entry 
                 Updates are automatically 
                 Using clinical data electronically 
               
               
                 staff to key new and updated 
                 processed. Edits are consistent. 
                 vs. paper charts lowers costs to 
               
               
                 information, and reconcile 
                   
                 calculate performance and 
               
               
                 duplicates and data 
                   
                 outcome measures. 
               
               
                 inconsistencies. 
                   
                   
               
               
                 IT staff needed to load member 
                 Fewer staff required to support. 
                 Automation and association of 
               
               
                 information generated from 
                   
                 clinical data to member records 
               
               
                 other systems. 
                   
                 improves accuracy of enrollment, 
               
               
                   
                   
                 performance measurement and 
               
               
                   
                   
                 care management processes. 
               
               
                 Updates and reconciliations 
                 MCO premiums are paid on a 
                 National access to member 
               
               
                 must be manually validated. 
                 daily rate, lowering capitation 
                 enrollment/clinical data improves 
               
               
                   
                 premium costs for ineligible 
                 research, reporting, performance 
               
               
                   
                 members. 
                 measures, outcome studies, 
               
               
                   
                   
                 care/disease management, and 
               
               
                   
                   
                 fraud detection. 
               
               
                 Process focus is on compliance 
                 Distributed update notifications 
                 Providers, members, and care 
               
               
                 with agency requirements and 
                 to federated member registries 
                 managers access standardized 
               
               
                 less on ensuing timely 
                 and automation reduces staff 
                 Member Registries on a national 
               
               
                 availability of quality/complete 
                 requirements 
                 scale to view clinical data needed 
               
               
                 data for users. 
                   
                 for EHRs, PHRs, and care/disease 
               
               
                   
                   
                 management. 
               
               
                 Member information is 
                 Member data is associated 
                 Ability to access de-identified 
               
               
                 maintained and available to 
                 algorithmically to support 
                 member clinical data 
               
               
                 other business processes and 
                 federated access, automated 
                 electronically to calculate 
               
               
                 users. 
                 updates, reconciliation and 
                 performance and outcome 
               
               
                   
                 extraction of complete and 
                 measures improves member and 
               
               
                   
                 quality data 
                 regional patient care. 
               
               
                 Inquiries about members&#39; 
                 Automation improves accuracy of 
                 Medicaid Member Registries are 
               
               
                 eligibility/enrollment are 
                 validation, verification, and 
                 federated with RHIOs nationally. 
               
               
                 received in non-standard 
                 reconciliation of data base 
                   
               
               
                 formats. 
                 updates. 
                   
               
               
                 Providers cannot be sure of the 
                 Automated maintenance of 
                 Providers can inquire about 
               
               
                 source from which to request 
                 member information ensures that 
                 member health records in other 
               
               
                 eligibility verification. 
                 timely, accurate data are available 
                 states. 
               
               
                   
                 to support all processes needing 
                   
               
               
                   
                 member information 
                   
               
               
                 Most requests are sent via 
                 Data Accessibility increases the 
                 Requests are expanded to include 
               
               
                 telephone, fax or point of 
                 efficiency, speed, and accuracy of 
                 inquiries re clinical information. 
               
               
                 service device. Media, data 
                 eligibility/enrollment and other 
                   
               
               
                 format and content differ by 
                 processes. 
                   
               
               
                 program. 
                   
                   
               
               
                 Providers often depend on 
                 The sources of eligibility 
                 Eligibility verification, program, 
               
               
                 paper member ID cards that can 
                 information are siloed within 
                 benefit, and Member Registry 
               
               
                 be inaccurate. 
                 different programs. 
                 health record locator services are 
               
               
                   
                   
                 integrated into applications. 
               
               
                 Newly eligible members must 
                 Routine inquiries for member 
                   
               
               
                 wait to receive mailed ID cards 
                 information are automated. 
                   
               
               
                 or the provider must verify 
                 Responses are immediate or 
                   
               
               
                 eligibility by telephone 
                 within batch. 
                   
               
               
                 Verification is performed 
                 MITA standard interfaces 
                   
               
               
                 manually 
                 incorporate full HIPAAdata 
                   
               
               
                   
                 schemas. 
                   
               
               
                 Responses are inconsistent, 
                 Member information is integrated 
                   
               
               
                 sometimes incorrect, and 
                 via a Member Registry. 
                   
               
               
                 untimely. 
                   
                   
               
               
                   
                 Sister agencies adopt MITA 
                   
               
               
                   
                 standard interfaces to present a 
                   
               
               
                   
                 one-slop shop for inquiries 
                   
               
               
                   
                 regarding enrolled members. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 60 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform: Prospective and  
                 Capability:  
               
               
                 Current Member Support 
                 Manage Applicant and Member Communication 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Member communications are 
                 Member communications are 
                 Certain messages to member are 
               
               
                 primarily conducted via paper 
                 primarily electronic, with paper 
                 triggered by an individual&#39;s 
               
               
                 and phone. 
                 used only as needed to reach 
                 entries into personal health 
               
               
                   
                 populations. 
                 records for prospective and 
               
               
                   
                   
                 current members. 
               
               
                 Member communications are 
                 Member communication is 
                 Member communications posted 
               
               
                 uncoordinated among multiple, 
                 organized around the “no wrong 
                 by an agency can be accessed by 
               
               
                 siloed programs and not 
                 door” concept. 
                 a member anywhere in the 
               
               
                 systematically triggered by 
                   
                 country. 
               
               
                 agency-wide processes. 
                   
                   
               
               
                 Requests are received from 
                 Agencies support deployment of 
                 Information entered into provider 
               
               
                 members in non-standard 
                 internet access points to alleviate 
                 electronic health records can also 
               
               
                 formats. 
                 communications barriers. 
                 trigger specific messages to 
               
               
                   
                   
                 members regarding special 
               
               
                   
                   
                 programs and disease 
               
               
                   
                   
                 management information. 
               
               
                 Most requests are sent via 
                 Use of electronic 
                 Personal health records are 
               
               
                 telephone, fax, or USPS. 
                 communications makes provision 
                 available for free via the internet 
               
               
                   
                 of appropriate member 
                 and accessible via kiosk and low 
               
               
                   
                 communications more feasible 
                 cost telecommunication devices. 
               
               
                   
                 and cost-effective. 
                   
               
               
                 Research is performed 
                 Member Registries use 
                 Member Registry is federated 
               
               
                 manually. 
                 standardized contact data to 
                 with RHIOs. 
               
               
                   
                 alleviate postal delivery failures. 
                   
               
               
                 Responses are inconsistent and 
                 MITA standard interfaces are 
                 Public health alerts can be 
               
               
                 manual. 
                 used by Medicaid agency and 
                 triggered by clinical information 
               
               
                   
                 collaborating sister agencies. 
                 in the patient&#39;s electronic health 
               
               
                   
                   
                 record. 
               
               
                   
                 Routine requests from members 
                 Turnaround time is immediate, on 
               
               
                 There may be delays in 
                 are standardized and automated 
                 a national scale. 
               
               
                 responses. 
                 within the agencv via AVRS, Web 
                   
               
               
                   
                 portal, EDI 
                   
               
               
                 Complies with agency goals and 
                 Research and response for these 
                 Member Registries are federated 
               
               
                 expectations. 
                 standardized communications are 
                 with regional data exchange 
               
               
                   
                 immediate or within batch 
                 networks across the countrv and 
               
               
                   
                 response parameters. 
                 if desired, internationally. 
               
               
                 Requires signification labor 
                 Responses are consistent and 
                 Responses are standardized and 
               
               
                 force. 
                 timely. 
                 can include clinical data 
               
               
                 Manual and semi-automated 
                 Requires fewer staff. 
                 Responses are standardized and 
               
               
                 steps may require some days to 
                   
                 can include clinical data 
               
               
                 complete response. 
                   
                   
               
               
                 Responses are made manually 
                 Member requests and responses 
                 Responses are immediately 
               
               
                 and there may be inconsistency 
                 are automated via Web, AVRS, 
                 available. 
               
               
                 and inaccuracy (within agency 
                 EDI with data stamp and audit 
                   
               
               
                 tolerance level). 
                 trail. 
                   
               
               
                 Staff research and respond to 
                 Inquiries can be made to multiple 
                 Automated access to information 
               
               
                 requests manually. 
                 agencies via collaboration. 
                 nationally improves efficiency. 
               
               
                 Requires research staff. 
                 Response can be immediate . 
                 Full automation or the process 
               
               
                   
                   
                 plus access to clinical data, on a 
               
               
                   
                   
                 national scale, reduces staff 
               
               
                   
                   
                 requirements to a core team of 
               
               
                   
                   
                 professionals who monitor 
               
               
                   
                   
                 member satisfaction with 
               
               
                   
                   
                 responsiveness to inquiries. 
               
               
                 Responses are manually 
                 Automated responses increase 
                 Incorporation of clinical data, on 
               
               
                 validated 
                 accuracy. 
                 a national scale, improves 
               
               
                   
                   
                 accuracy of some responses 
               
               
                 Process complies with agency 
                 Access is via Web portal and EDI 
                 Some inquiries/responses are 
               
               
                 requirements 
                 channels. 
                 replaced by automated messaging 
               
               
                   
                   
                 on a national scale. 
               
               
                 Members receive the 
                 Requests and responses are 
                   
               
               
                 information they needed 
                 standardized nationally, 
                   
               
               
                   
                 improving accuracy. 
                   
               
               
                   
                 Member information is accessed 
                   
               
               
                   
                 via either a single Member 
                   
               
               
                   
                 Registry or federated Member 
                   
               
               
                   
                 Registries. 
                   
               
               
                   
                 Member information belonging to 
                   
               
               
                   
                 different entities can be virtually 
                   
               
               
                   
                 consolidated to form a single 
                   
               
               
                   
                 view. 
                   
               
               
                   
                 Responses lo member requests 
                   
               
               
                   
                 are automated. 
                   
               
               
                   
                 Fewer staff required to support. 
                   
               
               
                   
                 Information requested by member 
                   
               
               
                   
                 is continuously refreshed. 
                   
               
               
                   
                 Collaboration among agencies 
                   
               
               
                   
                 achieves a one-stop shop for 
                   
               
               
                   
                 member inquiries. 
                   
               
               
                   
                 Automation leads to fewer staff. 
                   
               
               
                   
                 Number of responses per day- 
                   
               
               
                   
                 increases significantly. 
                   
               
               
                   
                 Collaboration and shared services 
                   
               
               
                   
                 increase cost effectiveness. 
                   
               
               
                   
                 Automation improves accuracy of 
                   
               
               
                   
                 responses. 
                   
               
               
                   
                 MITA standard interfaces 
                   
               
               
                   
                 improves requests and responses 
                   
               
               
                   
                 nationally. 
                   
               
               
                   
                 Members have no delay obtaining 
                   
               
               
                   
                 responses. 
                   
               
               
                   
                 Members have a one stop shop to 
                   
               
               
                   
                 access collaborating agencies to 
                   
               
               
                   
                 obtain information. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 61 
               
             
             
               
                   
               
               
                 Global Heallh and Life Sciences High Performance  
               
               
                 Capability- Assessment Model - Public Heallh Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform: Prospective and  
                 Capability: Manage  
               
               
                 Current Member Support 
                 Customer Relationships 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 9.4.4.1 Manage Quality and  
                   
                   
               
               
                 Performance of the Customer  
                   
                   
               
               
                 Relationship Management  
                   
                   
               
               
                 Process  
                   
                   
               
               
                 Handle Member Profile Calls  
                   
                   
               
               
                 Escalate &amp; Follow-up on 
                   
                   
               
               
                 Inquiries  
                   
                   
               
               
                 Handle Misdirected Calls 
                   
                   
               
               
                 9.4.4.2 Manage member  
                   
                   
               
               
                 relations 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 62 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform: Prospective and  
                 Capability: Manage Member  
               
               
                 Current Member Support 
                 Grievance and Appeal 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 9.4.2.1 Receive grievance or 
                   
                   
               
               
                 appeal 
                   
                   
               
               
                 9.4.2.2 Request additional 
                   
                   
               
               
                 documentation as appropriate 
                   
                   
               
               
                 9.4.2.3 Determine grievance or 
                   
                   
               
               
                 appeal status (initial, second, or 
                   
                   
               
               
                 expedited) 
                   
                   
               
               
                 9.4.2.4 Triage to appropriate 
                   
                   
               
               
                 personnel for review 
                   
                   
               
               
                 9.4.2.5 Schedule and conduct 
                   
                   
               
               
                 hearing within required time 
                   
                   
               
               
                 9.4.2.6 Determine disposition 
                   
                   
               
               
                 9.4.2.7 Request preparation of a 
                   
                   
               
               
                 formal disposition to be sent to 
                   
                   
               
               
                 applicant member 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 63 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Member Management 
               
             
          
           
               
                 Sub-Platform: Prospective and  
                 Capability:  
               
               
                 Current Member Support 
                 Perform Population and Member Outreach 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Business process is 
                 The business process is organized 
                 At this level, the business process 
               
               
                 uncoordinated among multiple, 
                 around the “no wrong door” 
                 is national in scope, based on 
               
               
                 siloed programs and not 
                 concept. 
                 analysis of clinical, demographic, 
               
               
                 systematically triggered by 
                   
                 and socioeconomic indicators and 
               
               
                 agency-wide processes. 
                   
                 shared among Medicaids and 
               
               
                   
                   
                 other public programs 
               
               
                 Outreach is primarily manual 
                 States use Websites, Agencies use 
                 Outreach triggers are event 
               
               
                 and conducted by paper or 
                 TV, radio and advertisements to 
                 driven. 
               
               
                 phone. 
                 distribute outreach information to 
                   
               
               
                   
                 targeted members 
                   
               
               
                 Outreach materials are 
                 Agencies support deployment of 
                 Peer2peer business process 
               
               
                 manually prepared and 
                 internet access points. 
                 collaboration between the Agency 
               
               
                 updated. 
                   
                 and EHRs or other program 
               
               
                   
                   
                 applications. 
               
               
                 Identification of targeted 
                 The business process is primarily 
                 Access to standardized electronic 
               
               
                 members is based primarily on 
                 electronic, with paper used only 
                 clinical data facilitates 
               
               
                 member records and limited to 
                 secondarily. 
                 identification of and may trigger 
               
               
                 current program information. 
                   
                 electronic messages to members 
               
               
                   
                   
                 in need of outreach and/or 
               
               
                   
                   
                 education. 
               
               
                 Outreach to prospective 
                 Use of electronic communications 
                 Coordinated outreach and 
               
               
                 members is sporadic and lacks 
                 makes production of appropriate 
                 education can be regional and 
               
               
                 analysis needed for targeting 
                 outreach material more feasible 
                 Pan-Medicaid in scope. 
               
               
                 specific populations. 
                 and cost-effective. 
                   
               
               
                 Current and prospective 
                 Access to standardized electronic 
                 Outreach material are 
               
               
                 members have difficulty 
                 clinical data as well as use of GIS 
                 automatically generated and sent 
               
               
                 locating needed information 
                 and socio-economic indicators 
                 to members in response to 
               
               
                 because of siloed programs. 
                 support targeting populations for 
                 requests made via email or PHRs, 
               
               
                   
                 outreach. 
                 or by scheduled release. 
               
               
                 Education materials are lacking 
                 Shortened time for materials to 
                 Staff focuses on maintaining a 
               
               
                 because difficult and costly to 
                 reach the members. 
                 data base of functionally, 
               
               
                 produce. 
                   
                 linguistically, culturally, and 
               
               
                   
                   
                 competency appropriate outreach 
               
               
                   
                   
                 and education materials. 
               
               
                 Quality and consistency of 
                 Member registries use 
                 Triggers create messages from 
               
               
                 outreach and education efforts 
                 standardized contact data 
                 members&#39; EHRs/PHRs that map 
               
               
                 are difficult to maintain. 
                   
                 to automated response messages. 
               
               
                 Primarily an all manual 
                 Members are able to access 
                 Turnaround time for sending 
               
               
                 process. 
                 information regardless of their 
                 appropriate information is 
               
               
                   
                 channel of inquiry. 
                 immediate on a national or 
               
               
                   
                   
                 regional scale. 
               
               
                 Members must wait in phone 
                 Outreach materials are developed 
                 Turnaround time to identify target 
               
               
                 queue to make inquiries and 
                 and stored in electronic format 
                 member and transmit information 
               
               
                 may have to contact multiple 
                 and made available to members 
                 is immediate. 
               
               
                 programs to access the needed 
                 via a Web portal, public media, or 
                   
               
               
                 information. 
                 kiosks. 
                   
               
               
                 Mailings take a number of days 
                 Outreach and education materials 
                 Nearly eliminates time current 
               
               
                 to produce and send. 
                 are available via state Medicaid 
                 and prospective members must 
               
               
                   
                 portal and are shared with other 
                 spend discovering and submitting 
               
               
                   
                 collaborating agencies. 
                 needed information to all social 
               
               
                   
                   
                 services. 
               
               
                 Due to lack of electronic 
                 Access to electronic sources or 
                 Access to standardized clinical 
               
               
                 sources or outreach and 
                 outreach and education materials 
                 data facilitates identification of 
               
               
                 education materials, current 
                 greatly reduces time that current 
                 targeted current and prospective 
               
               
                 and prospective members must 
                 and prospective members must 
                 members. 
               
               
                 spend a great deal of time 
                 spend discovering needed 
                   
               
               
                 discovering needed 
                 information. 
                   
               
               
                 information. 
                   
                   
               
               
                 Preparation of materials is 
                 Automation improves access and 
                 Standardized services support 
               
               
                 clunky. Information is subject 
                 accuracy. 
                 application interfaces for 
               
               
                 to inaccuracies and 
                   
                 electronic interchange of outreach 
               
               
                 inconsistencies. 
                   
                 and education material to 
               
               
                   
                   
                 targeted . . .  
               
               
                 Lack of functionally, 
                 Current and prospective members 
                 Outreach and education materials 
               
               
                 linguistically, culturally, and 
                 can access needed information via 
                 can be effectively pushed on an as 
               
               
                 competency appropriate 
                 Web portal. 
                 needed basis because of 
               
               
                 outreach and education 
                   
                 standardized data used by 
               
               
                 materials likely limit members&#39; 
                   
                 Member Registries nationally. 
               
               
                 access to information 
                   
                   
               
               
                 Mailings are not delivered 
                 Increased standardization of 
                 Standardized business process 
               
               
                 because contract data in 
                 administrative data, and improved 
                 collaboration protocols support 
               
               
                 members&#39; records do not meet 
                 data manipulation for decision 
                 application interfaces for 
               
               
                 NPS standards. 
                 support improves accuracy of 
                 peer2peer outreach and education 
               
               
                   
                 populating targeting 
                 processes. 
               
               
                 Staff develops and maintains 
                 Increasing use of functionally, 
                 Access to clinical information 
               
               
                 materials manually 
                 linguistically, culturally, and 
                 improves efficiency by 
               
               
                   
                 competency appropriate outreach 
                 automatically mapping member 
               
               
                   
                 and education materials improve 
                 who needs assistance with 
               
               
                   
                 members&#39; access to information 
                 generation of appropriate 
               
               
                   
                   
                 materials. 
               
               
                 Developing functionally, 
                 Member information is accessed 
                 Automated business rules that 
               
               
                 linguistically, culturally, and 
                 via federated Member Registries 
                 include clinical data lead to faster 
               
               
                 competency appropriate 
                 that can be accessed by all 
                 identification of target 
               
               
                 outreach and education 
                 authorized entities within the 
                 populations. 
               
               
                 materials is difficult. 
                 state. 
                   
               
               
                 Effort is required to research 
                 Algorithmic identification of and 
                 Outreach and education materials 
               
               
                 target current and prospective 
                 analysis based on standardized 
                 can be effectively pushed on an as 
               
               
                 target populations and track 
                 data to targeted members improve 
                 needed basis regionally or 
               
               
                 mailings. 
                 in accuracy. 
                 nationally via federated Member 
               
               
                   
                   
                 Registries. 
               
               
                 Mailings are not delivered 
                 Use of NPS standards for member 
                 The target population analysis is 
               
               
                 because of inaccurate, 
                 data improves accuracy for 
                 based on real time access to 
               
               
                 nonstandard contact 
                 mailing purposes. 
                 health and socioeconomic 
               
               
                 information, resulting in need 
                   
                 indicators drawn from 
               
               
                 to follow up with members by 
                   
                 standardized person/patient data 
               
               
                 other means or missing 
                   
                   
               
               
                 outreach and education 
                   
                   
               
               
                 opportunities. 
                   
                   
               
               
                 Process is labor-intensive. 
                 Populations are targeted more 
                 Full automation of the process of 
               
               
                   
                 effectively because programs are 
                 identification of need, mapping to 
               
               
                   
                 able to share member analysis. 
                 the right message, plus access to 
               
               
                   
                   
                 clinical data reduces staff 
               
               
                   
                   
                 requirements to a core team of 
               
               
                   
                   
                 professionals who monitor the 
               
               
                   
                   
                 education and outreach process. 
               
               
                 Paper materials are expensive 
                 Materials can be posted on a Web 
                 Outreach and education can be 
               
               
                 to produce. 
                 site for downloading by members. 
                 interoperable among states 
               
               
                   
                   
                 sharing business services, 
               
               
                   
                   
                 reducing redundant effort and 
               
               
                   
                   
                 optimizing delivery of appropriate 
               
               
                   
                   
                 needed material real time to the 
               
               
                   
                   
                 point of care. 
               
               
                 Incurs postal expenses and cost 
                 Fewer staff required to support. 
                 Incorporation of clinical data 
               
               
                 of undelivered mail. 
                   
                 improves accuracy of 
               
               
                   
                   
                 identification of targeted members 
               
               
                   
                   
                 and dissemination of appropriate 
               
               
                   
                   
                 messages. 
               
               
                 Staff still needed where the 
                 Delivery of appropriate outreach 
                 Member registries improve 
               
               
                 materials are not appropriate 
                 and education materials is eased 
                 accuracy of contact information. 
               
               
                 for member. 
                 with electronic and public media 
                   
               
               
                   
                 channels. 
                   
               
               
                 Difficult to determine impact 
                 National standards are developed 
                 Access to member information on 
               
               
                 of outreach and education. 
                 for creation education and 
                 a regional or national basis. 
               
               
                   
                 outreach materials. 
                   
               
               
                 Current and prospective 
                 Business services are developed 
                 Outreach and education 
               
               
                 members continue to need 
                 and shared nationally to support 
                 communications can be triggered 
               
               
                 assistance by phone. 
                 target population identification. 
                 by automated messaging. 
               
               
                 Business process complies 
                 Mailings are more successful 
                 Use of clinical evidence creates 
               
               
                 with agency and state 
                 because member records have 
                 better target groups and improves 
               
               
                 requirements for educating the 
                 NPS standard data and member 
                 consistencv of results 
               
               
                 members regarding rules and 
                 registries1 use algorithmic 
                   
               
               
                 regulations and how to 
                 identification to improve data 
                   
               
               
                 communicate with the Agency. 
                 accuracy. 
                   
               
               
                   
                 Automation reduces level of 
                 Access to member information on 
               
               
                   
                 staffing required to target 
                 a regional or national basis. 
               
               
                   
                 populations needing outreach and 
                   
               
               
                   
                 education. 
                   
               
               
                   
                 Availability of online materials 
                   
               
               
                   
                 reduces paper and mailing costs. 
                   
               
               
                   
                 Collaboration, data sharing, and 
                   
               
               
                   
                 shared services increase cost- 
                   
               
               
                   
                 effectiveness. 
                   
               
               
                   
                 NPS standard member contact 
                   
               
               
                   
                 information decreases 
                   
               
               
                   
                 undelivered mailings. 
                   
               
               
                   
                 Use of portal by members is 
                   
               
               
                   
                 monitored to ensure that a 
                   
               
               
                   
                 sufficient number of the targeted 
                   
               
               
                   
                 populations are actively engaged 
                   
               
               
                   
                 in downloading information. 
                   
               
               
                   
                 Agency can target members who 
                   
               
               
                   
                 are not accessing informatioa 
                   
               
               
                   
                 Business services standardize 
                   
               
               
                   
                 messages sent to members. 
                   
               
               
                   
                 The members and the agency 
                   
               
               
                   
                 benefit from introduction of 
                   
               
               
                   
                 automation to speed up the 
                   
               
               
                   
                 outreach and education process. 
                   
               
               
                   
                 Agencies benefit from sharing of 
                   
               
               
                   
                 the business service and 
                   
               
               
                   
                 information with other agencies. 
                   
               
               
                   
                 Members benefit from 
                   
               
               
                   
                 consistency and timeliness of the 
                   
               
               
                   
                 information transmitted 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 64 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Service Authorization 
                 Capability: Authorize Referral 
               
             
          
           
               
                 Basic 
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 At this level, the Authorize 
                 At this level, the Authorize 
                 The process queries national and 
               
               
                 Referral Request process is 
                 Referral process transaction, 
                 regional registries for pointers to 
               
               
                 performed primarily using a 
                 receives only EDI transactions 
                 repositories of member&#39;s clinical 
               
               
                 paper/phone/fax process. 
                 via electronic means that support 
                 data and provider credentialing 
               
               
                   
                 even small, rural, and waiver 
                 and sanction data for prospective 
               
               
                   
                 providers. 
                 program integrity audits. 
               
               
                 Review of authorization 
                 Web portal support error free 
                 Meta-data is used to locate the 
               
               
                 requests are performed 
                 submissions with data field 
                 records and to ensure semantic 
               
               
                 manually which is resource 
                 masks, client-side edits, and 
                 inoperability of the data even 
               
               
                 intensive, untimely and may 
                 pre-populated fields. 
                 where the data mav be based on 
               
               
                 result in inconsistent: 
                   
                 different coding schemes or data 
               
               
                 Application of business rules 
                   
                 models. 
               
               
                 Review of authorization 
                 The service requests may be 
                 Inter-enterprise business process 
               
               
                 requests are performed 
                 accepted by internet Web portals, 
                 management between Medicaid 
               
               
                 manually which is resource 
                 email, dial-up, and via 
                 systems and Clinical data during 
               
               
                 intensive, untimely and may 
                 transferable electronic media such 
                 an episode of care eliminates the 
               
               
                 result in inconsistent: 
                 as disks and tape. 
                 need for providers to submit 
               
               
                 Communication of errors to 
                   
                 referral data 
               
               
                 providers 
                   
                   
               
               
                 Review of authorization 
                 If a referral data set fails review, 
                 Real-time access to source data 
               
               
                 requests are performed 
                 rather than the reviewer having to 
                 ensures accuracy and improved 
               
               
                 manually which is resource 
                 manually contact the submitter, 
                 process performance. 
               
               
                 intensive, untimely and may 
                 the process can now generate an 
                   
               
               
                 result in inconsistent: 
                 electronic request for additional 
                   
               
               
                 Decisions on the need for or 
                 information via an XI2 277. 
                   
               
               
                 sufficiency of additional 
                   
                   
               
               
                 information 
                   
                   
               
               
                 If the referral request requires 
                 Standardized data enable tracking 
                 Member and provider data 
               
               
                 additional information, the 
                 overutilization of similar services 
                 accessible in regional registries 
               
               
                 reviewer must manually contact 
                 that are coded differently for 
                 are recognized by all participating 
               
               
                 the submitter/provider, which 
                 prospective program integrity and 
                 applications as the “source of 
               
               
                 delays processing and is 
                 tracking contraindication of 
                 truth”. 
               
               
                 resource intensive. 
                 services provided for medical 
                   
               
               
                   
                 appropriateness. 
                   
               
               
                 Format and content is not 
                   
                 Service referrals no longer need 
               
               
                 HIPAA compliant, and is likely 
                   
                 to be checked because business 
               
               
                 state-specific. 
                   
                 rules alert the provider about 
               
               
                   
                   
                 clinical prerequisites for service 
               
               
                   
                   
                 coverage. MCO use of service 
               
               
                   
                   
                 authorization can be monitored 
               
               
                   
                   
                 for underutilizations by review of 
               
               
                   
                   
                 the encounter data. 
               
               
                 The service requests are 
                   
                 There are established RHIOs and 
               
               
                 primarily manually validated 
                   
                 semantic interoperability. 
               
               
                 against state-specific business 
                   
                   
               
               
                 rules. However, when there is 
                   
                   
               
               
                 automated validation, rules lack 
                   
                   
               
               
                 flexibility. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 65 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Service Authorization 
                 Capability: Authorize Service 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Authorize Service request is 
                 The Agency receives EDI 
                 Service authorization is embedded 
               
               
                 primarily paper, phone or 
                 transactions via electronic means 
                 in the provider to payer system 
               
               
                 faxbased. Format and content 
                 that support even small, rural, and 
                 communication. As the provider 
               
               
                 are not H1PAA compliant. 
                 waiver providers 
                 enters service data into the 
               
               
                   
                   
                 CLINICAL DATA, authorization 
               
               
                   
                   
                 is immediately established by the 
               
               
                   
                   
                 payer application. 
               
               
                 Each state has developed many 
                 Web portals support error free 
                 Capabilities are expanded to a 
               
               
                 paper forms to support this 
                 submissions with data field 
                 national base of data via NHIN. 
               
               
                 process. Information is 
                 masks, client-side edits, and pre- 
                   
               
               
                 manually validated and 
                 populated fields. 
                   
               
               
                 manually transferred from 
                   
                   
               
               
                 submitted paper to the MM IS. 
                   
                   
               
               
                 If a Authorize Service request 
                 Processes generate an electronic 
                 The Medicaid agency and 
               
               
                 requires additional information, 
                 request for additional information 
                 providers establish pointers to 
               
               
                 the reviewer must manually 
                 via an X12277 if additional 
                 national repositories of member&#39;s 
               
               
                 contact the submitter/provider, 
                 information is required. 
                 clinical data Direct access to 
               
               
                 which delays processing and is 
                   
                 Clinical data eliminates the need 
               
               
                 resource intensive. 
                   
                 for additional information within 
               
               
                   
                   
                 the Authorize Service process. 
               
               
                 Authorize Service requests are 
                 The process is completely 
                 Meta-data is used to locate the 
               
               
                 primarily manually validated 
                 automated and only rare 
                 records and to ensure semantic 
               
               
                 against statespecific business 
                 exceptions must be manually 
                 interoperability of the data even 
               
               
                 rules. 
                 reviewed. 
                 where the data may be based on 
               
               
                   
                   
                 different coding schemes or data 
               
               
                   
                   
                 models. 
               
               
                 Inflexibility in Authorize 
                 Processing is highly flexible so 
                 This data takes the form of virtual 
               
               
                 Service processing is a key 
                 that rule changes can be made 
                 records used to inform the 
               
               
                 factor in the proliferation or 
                 quickly and inexpensively in 
                 Authorize Service process. 
               
               
                 siloed systems outside of the 
                 response to need for new or 
                   
               
               
                 MMIS. 
                 different rules 
                   
               
               
                 Especially for waiver programs 
                 The process uses complex 
                 The process is an inter-enterprise 
               
               
                 that determine medical 
                 algorithms and the application of 
                 business process between 
               
               
                 appropriateness and service 
                 structured clinical data allowing 
                 Medicaid systems and Clinical 
               
               
                 authorization differently than 
                 for high automation. 
                 data during an episode of care. 
               
               
                 traditional Medicaid programs 
                   
                   
               
               
                   
                 All programs use semantically 
                 Through peer-lo-peer 
               
               
                   
                 interoperable data in the process. 
                 collaboration, the CLINICAL 
               
               
                   
                   
                 DATA assists the provider with 
               
               
                   
                   
                 Medicaid clinical protocols 
               
               
                   
                   
                 required for coverage. 
               
               
                   
                 Standardized data and Authorize 
                 There are established RHIOs and 
               
               
                   
                 Service rules enable tracking of 
                 semantic interoperability 
               
               
                   
                 overutilization of similar services 
                   
               
               
                   
                 that are coded differently 
                   
               
               
                   
                 Related processes are decoupled, 
                   
               
               
                   
                 allowing changes to be made in 
                   
               
               
                   
                 the Authorize Service process 
                   
               
               
                   
                 with reduced potential for 
                   
               
               
                   
                 unintended downstream 
                   
               
               
                   
                 processing consequences. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 66 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Service Authorization 
                 Capability: Authorize Treatment Plan 
               
             
          
           
               
                 Basic  
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The Authorize Treatment Plan 
                 The process is a mix of paper/ 
                 The process is simplified querying 
               
               
                 process is performed primarily 
                 phone/fax and EDI. The 
                 national and regional registries for 
               
               
                 using a paper/phone/fax process. 
                 authorize treatment plan requests 
                 pointer to repositories of 
               
               
                   
                 may be accepted by internet Web 
                 member&#39;s EHRs for clinical data 
               
               
                   
                 portals, email, dial-up, and via 
                 and provider credentialing and 
               
               
                   
                 transferable electronic media such 
                 sanction data for prospective 
               
               
                   
                 as disks and tape. 
                 program integrity audits. 
               
               
                 Review of authorization of 
                 The Web portals support error free 
                 Meta-data is used to locate the 
               
               
                 treatment plan requests are 
                 submission with data field masks, 
                 records and to ensure semantic 
               
               
                 performed manually. 
                 client-side edits, and 
                 interoperability of the data even 
               
               
                   
                 pre-populated fields. 
                 where the data may be based on 
               
               
                   
                   
                 different coding schemes or data 
               
               
                   
                   
                 models. 
               
               
                 If the treatment plan request 
                 If a treatment plan data set fails 
                 Interenterprise business process 
               
               
                 requires additional information, 
                 review, rather than the reviewer 
                 management between Medicaid 
               
               
                 the reviewer must manually 
                 having to manually contact the 
                 systems and Clinical data during 
               
               
                 contact the submitter/provider. 
                 submitter, the process can now 
                 an episode of care eliminates the 
               
               
                   
                 generate an electronic request for 
                 need for providers to submit 
               
               
                   
                 additional information via an 
                 treatment plan data 
               
               
                   
                 X12 277. 
                   
               
               
                 Format and content is not 
                 Standardized data enable tracking 
                 Real-time access to source data 
               
               
                 standardized and is likely state- 
                 of over-utilization of similar 
                 ensures accuracy and improves 
               
               
                 specific. 
                 services that are coded differently 
                 process performance. 
               
               
                   
                 for prospective program integrity 
                   
               
               
                   
                 and tracking contraindication of 
                   
               
               
                   
                 services provided for medical 
                   
               
               
                   
                 appropriateness. 
                   
               
               
                 The requests are primarily 
                   
                 Member and provider data 
               
               
                 manually validated against state- 
                   
                 accessible in regional registries 
               
               
                 specific business rules. 
                   
                 are recognized by all participating 
               
               
                   
                   
                 applications as the “source of 
               
               
                   
                   
                 truth”. 
               
               
                 When there is automated 
                   
                 Treatment plans for claims no 
               
               
                 validation, rules lack flexibility 
                   
                 longer needs to be checked 
               
               
                 and are costly to change. 
                   
                 because Medicaid business rules 
               
               
                   
                   
                 alert the provider about clinical 
               
               
                   
                   
                 prerequisites for service coverage 
               
               
                 Related processes are tightly 
                   
                 There are established RHIOs and 
               
               
                 integrated, making it difficult to 
                   
                 semantic interoperability. 
               
               
                 ensure that changes to service 
                   
                   
               
               
                 authorization process do not 
                   
                   
               
               
                 result in unintended 
                   
                   
               
               
                 crossprocess consequences. 
                   
                   
               
               
                 Maintenance is expensive and 
                   
                   
               
               
                 time-consuming. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 67 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Member Payment Information 
                 Capability: Calculate Spend-Down Amount 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The Calculate Spend-Down 
                 The business process is conducted 
                 Providers enter new service 
               
               
                 Amount business process is 
                 electronically and does not require 
                 information into clinical records 
               
               
                 primarily paper based. An 
                 that members report their costs. 
                 at various locations if a client is 
               
               
                 applicant&#39;s costs for health 
                   
                 flagged as a candidate. 
               
               
                 services are tracked by adding 
                   
                   
               
               
                 paper bills and receipts until the 
                   
                   
               
               
                 spend-down amount for each 
                   
                   
               
               
                 period is met 
                   
                   
               
               
                 Applicants may be required to 
                 Members are made eligible for 
                   
               
               
                 submit a paper spend-down 
                 Medicaid coverage with a 
                   
               
               
                 report 
                 deductible amount equal to their 
                   
               
               
                   
                 spenddown requirements for the 
                   
               
               
                   
                 specified period. 
                   
               
               
                 Stall applies spend down rules 
                 Applicants submit electronic 
                   
               
               
                 to decide whether the submitted 
                 spend-down reports, and either 
                   
               
               
                 costs are allowable and in which 
                 scan, fax, or mail health care bills 
                   
               
               
                 period to apply the costs, 
                 and receipts. 
                   
               
               
                 sometimes resulting in 
                   
                   
               
               
                 inconsistent determinations or 
                   
                   
               
               
                 controversy with the applicant. 
                   
                   
               
               
                 If spend-down is met, staff keys 
                 Agencies support transmission of 
                   
               
               
                 change in eligibility status into 
                 spend down information on the 
                   
               
               
                 the applicant&#39;s record so that 
                 X12 270-271. 
                   
               
               
                 subsequent claims will pay for a 
                   
                   
               
               
                 specified period. 
                   
                   
               
               
                   
                 Providers are able to determine 
                   
               
               
                   
                 the spend-down amount when 
                   
               
               
                   
                 they verify eligibility. 
                   
               
               
                   
                 The member&#39;s account 
                   
               
               
                   
                 accumulator automatically 
                   
               
               
                   
                 accounts for excess resources 
                   
               
               
                   
                 during claims processing by 
                   
               
               
                   
                 debiting the amount paid by the 
                   
               
               
                   
                 member 
                   
               
               
                   
                 Once spend-down has been met. 
                   
               
               
                   
                 Medicaid payments to begin 
                   
               
               
                   
                 and/or resume. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 68 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability:  
               
               
                 Member Payment Information 
                 Prepare Member Premium Invoice 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The agency uses manual 
                 Information from all program 
                   
               
               
                 procedures to maintain member 
                 eligibility systems is used to 
                   
               
               
                 accounting for premium 
                 establish the amount of the 
                   
               
               
                 invoicing and payment. 
                 member liability in a centralized 
                   
               
               
                   
                 member accounting system 
                   
               
               
                   
                 associated with the Member 
                   
               
               
                   
                 Registry. 
                   
               
               
                 The agency uses manual 
                 Member liability amounts are 
                   
               
               
                 procedures to maintain 
                 updated by MMIS with online 
                   
               
               
                 transaction history of all monies 
                 adjustment capability. 
                   
               
               
                 received or paid out of the 
                   
                   
               
               
                 member account 
                   
                   
               
               
                 The agency uses manual 
                 The process creates a debit when 
                   
               
               
                 procedures to reimburse 
                 payments are made, 
                   
               
               
                 members for HIP payments; and 
                 overpayments are credited to the 
                   
               
               
                 support member contribution 
                 account and refunds made to the 
                   
               
               
                 accumulators to determine out 
                 member by check, EBT. 
                   
               
               
                 of pocket maximums or spend 
                   
                   
               
               
                 down requirements. 
                   
                   
               
               
                 Member liability records are 
                 Notices automatically are sent to 
                   
               
               
                 siloed by program and based on 
                 the member from a central 
                   
               
               
                 program specific eligibility 
                 enterprise-wide member 
                   
               
               
                 records. 
                 communications management 
                   
               
               
                   
                 business area. 
                   
               
               
                 Invoicing and payment receipt 
                 Member cost sharing accounts are 
                   
               
               
                 are manual processes requiring 
                 maintained and updated by claims 
                   
               
               
                 data entry for payment 
                 or member direct premium or pay 
                   
               
               
                 processing and for the changes 
                 in payments activity. 
                   
               
               
                 in member liability due to 
                   
                   
               
               
                 eligibility status. 
                   
                   
               
               
                 Member accounting may be 
                 Total payments are automatically 
                   
               
               
                 program specific, resulting in 
                 compared to the member&#39;s benefit 
                   
               
               
                 members receiving invoices and 
                 package requirement for out of 
                   
               
               
                 reimbursement from, and 
                 pocket expenses. 
                   
               
               
                 making premium payments to 
                   
                   
               
               
                 different parts of the Agency. 
                   
                   
               
               
                 Total payments are manually 
                 Payments can be accepted at all 
                   
               
               
                 compared to the member&#39;s 
                 Agency sites. Payment can be in 
                   
               
               
                 benefit package requirement for 
                 the form of cash, check, or credit 
                   
               
               
                 out of pocket expenses. 
                 or debt card. 
                   
               
               
                 Notices are manually generated 
                 Details of the transaction are 
                   
               
               
                 and sent on paper to members 
                 posted to the member accounting 
                   
               
               
                 advising them of their hearing 
                 modules on the MMIS and then 
                   
               
               
                 rights and the amount of their 
                 sent to the Agency financial 
                   
               
               
                 contribution. 
                 systems. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 69 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Claims/Encounters  
                   
               
               
                 Adjudications 
                 Capability: Apply Claim Attachment 
               
             
          
           
               
                 Basic 
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 Paper claims attachments are 
                 The agency receives a mix of 
                 Attachments are no longer 
               
               
                 sent separately from the claim; 
                 paper and electronic attachments. 
                 required because the payer has 
               
               
                 the two documents are matched 
                 Electronic attachments are 
                 direct access to the clinical data 
               
               
                 up, requiring some manual 
                 automatically matched to 
                 stored in the clinical data record. 
               
               
                 intervention 
                 corresponding claim. 
                   
               
               
                 There are limited, 
                 Electronic attachments meet 
                 Through the NHIN, the Medicaid 
               
               
                 agencyspecific requirements for 
                 HIPAA standards and MITA 
                 agency can view clinical data 
               
               
                 the attachments. Medical 
                 standard interface requirements 
                 stored in Clinical data in any 
               
               
                 records are delivered in paper 
                 with agency-specific 
                 location in the country. 
               
               
                 format with no standards. 
                 Implementation Guide 
                   
               
               
                   
                 instructions. Some manual 
                   
               
               
                   
                 processing is still required. 
                   
               
               
                 Claims requiring attachments 
                 Electronic attachments are 
                 Clinical information needed for 
               
               
                 are subject to delays. 
                 required for electronically 
                 adjudicating payment for a 
               
               
                   
                 submitted claims. 
                 service is instantly accessed 
               
               
                   
                   
                 (including nationally). 
               
               
                 Manual matches and reviews 
                 Agency continues to accept paper 
                 Access is immediate, with data 
               
               
                 result in inconsistency and 
                 attachments from a small number 
                 available nationally. 
               
               
                 errors. 
                 of disadvantaged providers who 
                   
               
               
                   
                 still submit paper claims 
                   
               
               
                 Labor-intensive, requires 
                 Electronic attachments shorten 
                 Accuracy increases based on 
               
               
                 professional review staff. 
                 time required to match with claim 
                 direct access to source clinical 
               
               
                   
                 and edit. 
                 data, no translation. 
               
               
                 Costly, but meets agency goals 
                 Use of MITA national standards 
                 No human intervention is 
               
               
                 for ensuring appropriateness of 
                 for claims attachments increases 
                 required on a national scale, 
               
               
                 payment. 
                 speed of processing. 
                 therefore, maximum efficiency. 
               
               
                 There are inconsistencies in 
                 Electronic attachments increase 
                 Maximum accuracy 
               
               
                 results in the manual matching 
                 accuracy State complies with 
                   
               
               
                 and processing of attachments. 
                 HIPAA standards but also has its 
                   
               
               
                   
                 own IG requirements. 
                   
               
               
                   
                 Electronic attachments are 
                   
               
               
                   
                 required for electronic claims and 
                   
               
               
                   
                 a MITA national standard is used. 
                   
               
               
                   
                 This increases access and 
                   
               
               
                   
                 accuracy of data 
                   
               
               
                   
                 Electronic attachments reduce 
                   
               
               
                   
                 staff requirements. 
                   
               
               
                   
                 More managed care enrollment 
                   
               
               
                   
                 means fewer claims/attachments. 
                   
               
               
                   
                 Use of MITA national standards 
                   
               
               
                   
                 for the Claim Attachment 
                   
               
               
                   
                 facilitates performance. 
                   
               
               
                   
                 Accuracy is improved 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 70 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability:  
               
               
                 Claims/Encounters Adjudications  
                 Apply Mass Adjustment 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The agency identifies the claims 
                 Improvements throughout the 
                   
               
               
                 to be adjusted, sets 
                 Medicaid program operations 
                   
               
               
                 the parameters, and applies the 
                 reduce the number of mass 
                   
               
               
                 retroactive rates through 
                 adjustments required. 
                   
               
               
                 primarily manual processes. 
                   
                   
               
               
                   
                 Identification of claims to be 
                   
               
               
                   
                 adjusted and application of the 
                   
               
               
                   
                 adjustment are automated with 
                   
               
               
                   
                 audit trail. 
                   
               
               
                   
                 Adjustment data is specific to 
                   
               
               
                   
                 the agency. 
                   
               
               
                   
                 MITA standard interfaces for 
                   
               
               
                   
                 mass adjustments are used by  
                   
               
               
                   
                 the state Medicaid agency. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 71 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability:  
               
               
                 Claims/Encounters Adjudications  
                 Audit Claim-Encounter 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The agency recieves paper  
                 The agency continues to accept 
                 Direct connection between 
               
               
                 claims, EDI transactions, and 
                 paper claims from a small number 
                 Medicaid systems and providers&#39; 
               
               
                 POS conforming to state 
                 of disadvantaged providers, but 
                 Clinical data during an episode of 
               
               
                 standards. 
                 the majority of transactions are 
                 care eliminates the need for 
               
               
                   
                 submitted electronically. 
                 providers to submit claim data or 
               
               
                   
                   
                 attachments requiring editing. 
               
               
                 Paper transactions are batched 
                 Electronic transactions meet 
                 Through peer-to-peer 
               
               
                 and scanned (or data entered). 
                 HIPAA data standards. 
                 collaboration, member and  
               
               
                   
                   
                 provider data accessible in 
               
               
                   
                   
                 regional registries are recognized 
               
               
                   
                   
                 by all participating applications as  
               
               
                   
                   
                 the “source of truth”. 
               
               
                 State-specified data elements 
                 Electronic transactions meet 
                 The process queries national and  
               
               
                 trigger the Edit and Audit 
                 MITA data standards. 
                 regional registries for member 
               
               
                 Claim/Encounter business 
                   
                 and provider information. 
               
               
                 process. 
                   
                   
               
               
                 Encounter data is recieved via 
                 Payer-specific implementation 
                 The process is able to locate and 
               
               
                 tape in state-specified format 
                 Guides are replaced by MITA 
                 query the members&#39; Clinical data 
               
               
                 and data content. 
                 standards. 
                 to validate health status data. 
               
               
                 Sister agencies and waiver 
                 Translators convert national data 
                 The Edit process can rely on the 
               
               
                 programs manage their own Edit 
                 standards to statespecific data to 
                 real-time updates to the Reference 
               
               
                 and Audit Claim process. 
                 support business processes. 
                 Repository from authoritative 
               
               
                   
                   
                 sources for definitive coding 
               
               
                   
                   
                 schemes. 
               
               
                 Payer implementation Guides 
                 The business process uses MITA 
                 The process can locate members&#39; 
               
               
                 impose additional payer-specific 
                 standard data and therefore no 
                 primary payers&#39; benefit repository 
               
               
                 rules. 
                 translation is required. 
                 to access services covered under 
               
               
                   
                   
                 each third-party resource. 
               
               
                 Suspend claims require 
                 Encounters are submitted as  
                 There are established RHIOs and 
               
               
                 lengthy manual resolution. 
                 HIPAA compliant COB claims 
                 semantic interoperability. 
               
               
                   
                 from managed care organizations 
                   
               
               
                   
                 and any other external processor. 
                   
               
               
                 Data are not comparable across 
                 Encounter data meets MITA 
                 Real-time access to source data 
               
               
                 silos. 
                 standard interface requirements. 
                 ensures accuracy and improves 
               
               
                   
                   
                 process performance. 
               
               
                 For EDI claims/encounters 
                 Medicaid agency coordinates with 
                 Real-time access to source data 
               
               
                 edits are automated for many 
                 other sister agencies and waivers 
                 enables enhanced business 
               
               
                 steps, but are manual for 
                 programs to accept, process, and 
                 activity monitoring is baesd on 
               
               
                 attachments and suspended 
                 access MITA standard data 
                 optimal data streams to fine-tune 
               
               
                 claims/encounters: 
                 elements. 
                 business process rules to meet 
               
               
                 Claims/encounters EDI format 
                   
                 operational parameters, thereby 
               
               
                 and content is not HIPAA 
                   
                 ensuring that Agency objectives 
               
               
                 compliant. 
                   
                 are met. 
               
               
                 Attachment data is unstructured 
                 Electronic claim processing and 
                 Access to additional data form 
               
               
                 It is difficult for reviewers to 
                 POS adjudication greatly increase 
                 national sources adds to accuracy 
               
               
                 consistently interpret and apply 
                 timeliness. 
                 of editing. 
               
               
                 adjudication rules. 
                   
                   
               
               
                 For EDI claims/encounters, 
                 Waiver claims continue to be 
                 Claim processing is replaced by 
               
               
                 edits are automated for many steps, 
                 submitted to siloed payment 
                 direct communication between 
               
               
                 but are manual for 
                 systems using state specific 
                 provider system and payer 
               
               
                 attachments and suspended 
                 format and data, such as provider 
                 system. 
               
               
                 claims/encounters. 
                 type and service codes. 
                   
               
               
                 COB is conducted by denying 
                 All programs, even those not 
                 All claims for members with 
               
               
                 claims using the resource 
                 covered under HIPAA, use 
                 known third-party&#39;s resources are  
               
               
                 intensive payer-toprovider 
                 semantically interoperable data in 
                 flagged for payer-to-payer COB, 
               
               
                 model. 
                 the edit prcess. 
                 reducing provider burden and 
               
               
                   
                   
                 improving thre timelines of 
               
               
                   
                   
                 reimbursement. 
               
               
                 Edited fields are validated 
                 If a claim/encounter data set fails 
                 Related processes are decoupled, 
               
               
                 against standard and  
                 edit validation, the process can 
                 allowing changes to be made in 
               
               
                 state specific code sets. 
                 now generate an electronic 
                 the Edit/Encounter process 
               
               
                   
                 request for corrections via an X12 
                 with reduced potential for 
               
               
                   
                 276. If additional information  
                 unintended downstream 
               
               
                   
                 is required, an electronic request is 
                 processing consequences. 
               
               
                   
                 made, e.g., via an X12 277. 
                   
               
               
                 Maintenance is expensive and 
                 Standardized data and edit rules 
                 The process is completely 
               
               
                 time-consuming. 
                 enable tracking of overutilization 
                 automated and only rare edit 
               
               
                   
                 of similar services that are coded 
                 exceptions must be manually 
               
               
                   
                 differently for disallowance. 
                 reviewed. Optimizing automation 
               
               
                   
                   
                 improves error rates and  
               
               
                   
                   
                 timeliness, thereby enabling 
               
               
                   
                   
                 support of real-time 
               
               
                   
                   
                 claims/encounter processing. 
               
               
                 Rules lack flexibility and are 
                 All siloed payment systems are 
                   
               
               
                 costly to change. Therefore, 
                 integrated or retired, saving 
                   
               
               
                 when new programs, code sets, 
                 resources and optimizing FFP, and 
                   
               
               
                 or edits are added, claims/ 
                 data quality is improved. 
                   
               
               
                 encounters with these changes 
                   
                   
               
               
                 may need to be edited manually, 
                   
                   
               
               
                 which may not be cost effective 
                   
                   
               
               
                 in the long term. 
                   
                   
               
               
                 Results meet agency 
                 Edit processing is highly flexible 
                   
               
               
                 requirements for timeliness and 
                 so that edit rules and code set of 
                   
               
               
                 accuracy. 
                 changes can be made quickly and  
                   
               
               
                   
                 inexpensively. 
                   
               
               
                   
                 Edit rules engines support 
                   
               
               
                   
                 complex algorithems so that 
                   
               
               
                   
                 benefit packages can be 
                   
               
               
                   
                 customized for members eligible 
                   
               
               
                   
                 for multiple programs 
                   
               
               
                   
                 Edits can be structured for both 
                   
               
               
                   
                 traditional and waiver programs 
                   
               
               
                   
                 Maintenance continues to be 
                   
               
               
                   
                 expensive and timeconsuming 
                   
               
               
                   
                 Despite progress, related 
                   
               
               
                   
                 processing continue to be tightly 
                   
               
               
                   
                 integrated, so that changes to edit 
                   
               
               
                   
                 can result in unintended 
                   
               
               
                   
                 downstream processing 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 72 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability:  
               
               
                 Claims/Encounters Adjudications 
                 Price Claim-Value Encounter 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Standard Medicaid services are 
                 More services are automatically 
                 Pricing is embedded in the  
               
               
                 automatically priced using rate 
                 priced and there are fewer “by- 
                 provider to payer system 
               
               
                 and fee reference data. Values 
                 report” manual pricing 
                 communication. As the provider 
               
               
                 are assigned to services reported  
                 exceptions. 
                 enters service data into the 
               
               
                 on encounters, using the same 
                   
                 clinical record, authorization and 
               
               
                 reference data. 
                   
                 pricing are immediately 
               
               
                   
                   
                 established by the payer 
               
               
                   
                   
                 application. 
               
               
                 “By-report” pricing is 
                 Medicaid agency coordinates with 
                 The agency uses the NHIN to 
               
               
                 performed manually. 
                 sister agencies and waiver 
                 compare and select prices based 
               
               
                   
                 programs to present a one-stop 
                 on regional averages or other new 
               
               
                   
                 shop claim adjudication and 
                 pricing methodologies (TBD). 
               
               
                   
                 pricing process. 
                   
               
               
                 Staff manually prepare 
                 Most single claim adjustments are  
                 Supports regional pricing profiles 
               
               
                 adjustment transactions 
                 automated. 
                 that can be factored into the 
               
               
                 including application of member 
                   
                 pricing methodology. 
               
               
                 contributions, provider 
                   
                   
               
               
                 advances, deduction of liens and 
                   
                   
               
               
                 recoupments. 
                   
                   
               
               
                 Waiver program and a-typical 
                 State Medicaid agency can 
                 For example, a new pricing rule: 
               
               
                 provider services are manually 
                 support payment of waiver  
                 “Pay the amount billed or the 
               
               
                 priced. 
                 program and a-typical providers.  
                 regional average (Region = ME, 
               
               
                   
                   
                 NY, VT), whichever is lower” . . . 
               
               
                   
                   
                 or, “Pay the regional per diem no  
               
               
                   
                   
                 matter what is billed”. 
               
               
                   
                 The agency uses MITA standard 
                   
               
               
                   
                 interfaces to price claims 
                   
               
               
                   
                 and value encounters. 
                   
               
               
                   
                 Flexible business rules allow 
                   
               
               
                   
                 maximum flexibility in changing 
                   
               
               
                   
                 pricing algorithms. 
                   
               
               
                   
                 Pricing formulas are agency 
                   
               
               
                   
                 specific. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 73 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability:  
               
               
                 Cost Avoidance 
                 Perform Cost Avoidance Functions 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 10.8.1.1 Identify and verify other 
                   
                   
               
               
                 insurance/third party  
                   
                   
               
               
                 resource information according 
                   
                   
               
               
                 to clams received 
                   
                   
               
               
                 10.8.1.2 Send collection letters  
                   
                   
               
               
                 to other responsible parties for 
                   
                   
               
               
                 payment due to Medicaid 
                   
                   
               
               
                 10.8.1.3 Provide and process 
                   
                   
               
               
                 reports to monitor cost  
                   
                   
               
               
                 avoidance effort 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 74 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment  
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability:  
               
               
                 Cost Recoveries 
                 Manage Drug Rebate 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the business 
                 The business process uses 
                 Drug rebate is replaced by a new  
               
               
                 process is primarily paper 
                 electronic interchange and 
                 strategy where care management 
               
               
                 invoice processing. 
                 automated processes to support 
                 and disease management interact 
               
               
                   
                 state generation of rebate  
                 with provider EHRs.  
               
               
                   
                 information.  
                   
               
               
                 Rebate information is manually 
                 The business process uses  
                 Data exchange is on a national 
               
               
                 validated.  
                 MITA standard interfaces. 
                 scale. 
               
               
                 Programs are siloed so rebate 
                 Agencies centralize drug 
                 Through peer-to-peer  
               
               
                 process may be uncoordinated 
                 utilization data from siloed 
                 collaboration, real-time access to 
               
               
                 and shared programs with health 
                 programs as inputs to the drug 
                 source data ensures accuracy, 
               
               
                 departments pay for drugs but 
                 rebate process. 
                 eliminates redundant collection  
               
               
                 may not participate in the state 
                   
                 and interchange of data, and 
               
               
                 drug rebate program. 
                   
                 improves process performance. 
               
               
                 Non-standardized data and 
                 Data is standardized for 
                   
               
               
                 format makes any type of cross 
                 automated electronic interchanges 
                   
               
               
                 program management reporting  
                 (interfaces) between agencies and 
                   
               
               
                 and analysis for drug rebate  
                 drug manufacturers. 
                   
               
               
                 purposes is difficult and costly. 
                   
                   
               
               
                 Access to data is limited by 
                 Communications are more 
                   
               
               
                 legacy systems and CMS 
                 consistent, timely and appropriate. 
                   
               
               
                 reporting cycles 
                   
                   
               
               
                 Reporting, analysis, and 
                   
                   
               
               
                 responses to inquiries are not 
                   
                   
               
               
                 timely and data may not be 
                   
                   
               
               
                 accurate. 
                   
                   
               
               
                 Cost-effectiveness is impacted 
                   
                   
               
               
                 by lack of data accuracy and 
                   
                   
               
               
                 completeness, manual 
                   
                   
               
               
                 processing, and need for CMS 
                   
                   
               
               
                 quarterly reporting of rebate 
                   
                   
               
               
                 information. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 75 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: 
               
               
                 Cost Recoveries  
                 Manage Estate Recovery 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the business 
                 The business process has almost 
                 The data exchange necessary for  
               
               
                 process is primarily a mix of 
                 eliminated its use of nonelectronic 
                 estate recovery is accessed for 
               
               
                 paper, phone, fax and  
                 interchange and has automated  
                 member and third party resources 
               
               
                 proprietary EDI. 
                 most processes to the extent  
                 on a national scale. 
               
               
                   
                 feasible.  
                   
               
               
                 Nonstandardized data and 
                 Agencies are standardizing data to 
                 Through peer-to-peer  
               
               
                 format from multiple sources 
                 increase coordination and 
                 collaboration between the agency 
               
               
                 requires manual compilation of 
                 consistency. 
                 and provider EHRs or other 
               
               
                 data. 
                   
                 program applications. 
               
               
                 Access to data is limited by the 
                 MITA standard interfaces are used 
                 e.g.. For example, health 
               
               
                 sporadic, inconsistent, and  
                 for electronic interchanges 
                 departments for date of death  
               
               
                 untimely receipt of data and 
                 (interfaces) between agencies. 
                 matches, realtime access to source 
               
               
                 updates to member eligibility. 
                   
                 data ensures accuracy, eliminates  
               
               
                   
                   
                 redundant collection and 
               
               
                   
                   
                 interchange of data and improves 
               
               
                   
                   
                 performance. 
               
               
                 Generating correspondence is 
                 Communications to stakeholders  
                   
               
               
                 not timely. 
                 and member&#39;s personal 
                   
               
               
                   
                 representatives are consistent, 
                   
               
               
                   
                 timely and appropriate. 
                   
               
               
                 Cost effectiveness is impacted 
                   
                   
               
               
                 by lack of data accuracy and 
                   
                   
               
               
                 completeness, and manual 
                   
                   
               
               
                 processing. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 76 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform:  
                 Capability:  
               
               
                 Cost Recoveries 
                 Manage Recoupment 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the process is 
                 The process has almost eliminated  
                 The process interfaces with other  
               
               
                 likely primarily a manual 
                 its use of nonelectronic 
                 processes via federated 
               
               
                 process. 
                 interchange and has automated 
                 architectures and collaborates 
               
               
                   
                 most processes to the extent feasible. 
                 with other processes in a 
               
               
                   
                   
                 peer2peer environment, 
               
               
                   
                   
                 eliminating redundant collection 
               
               
                   
                   
                 and interchange of data, and 
               
               
                   
                   
                 improving realtime, multi-axial 
               
               
                   
                   
                 processing. 
               
               
                 Communications to providers 
                 More of the formatting is HIPAA 
                   
               
               
                 and other payers are 
                 compliant resulting in 
                   
               
               
                 accomplished via phone and 
                 standardizing data to increase its 
                   
               
               
                 mail. 
                 usefulness for performance 
                   
               
               
                   
                 monitoring, management 
                   
               
               
                   
                 reporting, fraud detection, and 
                   
               
               
                   
                 reporting and analysis. 
                   
               
               
                 Format is not HIPAA complaint, 
                 There is more application-to- 
                   
               
               
                 recouping of monies in third 
                 application communications 
                   
               
               
                 party liability situations is 
                 which results in less manual 
                   
               
               
                 accomplished from payer to 
                 intervention resulting in less 
                   
               
               
                 provider rather than payer to  
                 maintenance and time savings. 
                   
               
               
                 payer. 
                   
                   
               
               
                 Non-standardized data makes  
                 Data is standardized for  
                   
               
               
                 any type of cross program  
                 automated electronic interchanges 
                   
               
               
                 performance monitoring, 
                 and interoperability. 
                   
               
               
                 management reporting, fraud 
                   
                   
               
               
                 detection, or reporting and  
                   
                   
               
               
                 analysis difficult and costly. 
                   
                   
               
               
                   
                 Communications to providers are  
                   
               
               
                   
                 consistent, timely and appropriate. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 77 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: 
               
               
                 Cost Recoveries  
                 Manage Settlement 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the business 
                 The business process has almost 
                 The business process interfaces  
               
               
                 process is likely primarily paper 
                 eliminated its use of nonelectronic 
                 with other processes via federated 
               
               
                 based processing and some 
                 interchange and has automated 
                 architectures and collaborates  
               
               
                 proprietary EDI. 
                 most processes to the extent 
                 with other processes in a 
               
               
                   
                 feasible. 
                 peer2peer environment, 
               
               
                   
                   
                 eliminating redundant collection 
               
               
                   
                   
                 and interchange of data. 
               
               
                 Nonstandardized data makes 
                 Data is standardized for 
                 The business process interfaces 
               
               
                 any type of reporting and 
                 automated electronic interchanges 
                 with other processes via federated 
               
               
                 analysis difficult and costly. 
                 (interfaces). 
                 architectures and collaborates  
               
               
                   
                   
                 with other processes in a peer-to- 
               
               
                   
                   
                 peer environment, improving 
               
               
                   
                   
                 realtime, multi-axial processing. 
               
               
                 Programs create inconsistent 
                 Agencies centralize common 
                   
               
               
                 rules across the Agency and 
                 processes to achieve economies  
                   
               
               
                 Agencies apply their own rules 
                 of scale, increase coordination, 
                   
               
               
                 inconsistently. 
                 improve rule application 
                   
               
               
                   
                 consistency, and standardizing 
                   
               
               
                   
                 data to increase its usefulness for 
                   
               
               
                   
                 performance monitoring, 
                   
               
               
                   
                 management reporting and 
                   
               
               
                   
                 analysis. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 78 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: 
               
               
                 Cost Recoveries  
                 Manage TPL Recovery 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The process is primarily a mix 
                 The process uses agency specified 
                 COB is automatically coordinated  
               
               
                 of paper, phone, fax and 
                 electronic interchange and 
                 through the RHIO registry. 
               
               
                 proprietary EDI.  
                 automated processes. 
                   
               
               
                 Information regarding third- 
                 The business process uses MITA 
                 Data exchange for COB occurs on 
               
               
                 party resources is manually 
                 standard interfaces for payer-to- 
                 a national scale. 
               
               
                 validated. 
                 payer COB process. 
                   
               
               
                 TPL recovery is accomplished 
                 Electronic or magnetic tape  
                 Response and payment outcomes 
               
               
                 primarily via paver-to-provider 
                 downloads from other agencies  
                 are immediate. 
               
               
                 COB. 
                 are used for data matches support 
                   
               
               
                   
                 access to member eligibility data. 
                   
               
               
                 Inconsistency in the rules 
                 Data is standardized for 
                 Regional stakeholders are  
               
               
                 applied to TPL recoveries vary 
                 automated electronic interchanges 
                 interoperable and payment  
               
               
                 from agency to agency. 
                 (interfaces) between agencies and 
                 determinations or denials are  
               
               
                   
                 other payers. 
                 entirely a payer-to-payer process 
               
               
                   
                   
                 making the data immediate, 
               
               
                   
                   
                 accurate and consistent. 
               
               
                 Programs are siloed so the 
                 Communications are consistent, 
                 Through peer-to-peer  
               
               
                 recovery process may be  
                 timely, and appropriate. 
                 collaboration, member and 
               
               
                 uncoordinated.  
                   
                 provider data is accessible 
               
               
                   
                   
                 through RHIO relays across the 
               
               
                   
                   
                 country. 
               
               
                 Non-standardized data and 
                   
                   
               
               
                 format makes any type of cross 
                   
                   
               
               
                 program management reporting, 
                   
                   
               
               
                 and analysis difficult and costly. 
                   
                   
               
               
                 Access to data is limited by  
                   
                   
               
               
                 inter-agency and other payer 
                   
                   
               
               
                 legacy systems. 
                   
                   
               
               
                 Cost-effectiveness is impacted 
                   
                   
               
               
                 by lack of data accuracy and 
                   
                   
               
               
                 completeness, as well as 
                   
                   
               
               
                 inconsistency in how the rules 
                   
                   
               
               
                 and/or policies are applied to 
                   
                   
               
               
                 TPL recoveries, manual 
                   
                   
               
               
                 processing and timeliness. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 79 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Payment and 
                 Capability: 
               
               
                 Reporting Management  
                 Prepare COB 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Medicaid agency identifies 
                 The agency uses MITA standard 
                 The previous COB process  
               
               
                 claims subject to COB prior to 
                 interfaces for claim adjudication 
                 is replaced by payer to payer 
               
               
                 payment (Cost Avoidance) 
                 and COB. The prepare COB 
                 communications. 
               
               
                 based on defined criteria. 
                 process is completely automated 
                   
               
               
                   
                 and only in rare exceptions 
                   
               
               
                   
                 requires manual intervention. 
                   
               
               
                 The claim subject to COB is 
                 Cost avoided claims are  
                 The agency can query registries 
               
               
                 denied and returned to the  
                 immediately forwarded to primary 
                 across the country for pointers to 
               
               
                 provider indicating requirement 
                 payers. Some claims are flagged 
                 repositories of member&#39;s third 
               
               
                 to bill the primary payer first. 
                 manually for forwarding to a third 
                 party resources. 
               
               
                   
                 party on an exception basis.  
                   
               
               
                 Post payment recovery (Pay and 
                 Post payment recovery (Pay and 
                 Meta-data is used to locate the 
               
               
                 Chase) claims are sent to third 
                 Chase) claims are submitted to 
                 records and to ensure data 
               
               
                 party payers using a mix of 
                 third party payers using MITA 
                 interoperability. 
               
               
                 paper and EDI claims with non- 
                 national standards. 
                   
               
               
                 standard data resulting in 
                   
                   
               
               
                 inconsistent application of rules, 
                   
                   
               
               
                 delays, and labor intensive  
                   
                   
               
               
                 efforts. 
                   
                   
               
               
                 It is difficult to adapt to new 
                 Flagging of post payment 
                 Real-time access to source data 
               
               
                 policies for COB. COB 
                 recovery claims is completely 
                 ensures accuracy and improves 
               
               
                 processes are closely integrated 
                 automated and only requires 
                 process performance. 
               
               
                 with claims adjudication,  
                 manual identification of recovery 
                   
               
               
                 pricing, and remittance advice, 
                 claims under limited 
                   
               
               
                 so changes affect all the 
                 circumstances. Optimizing 
                   
               
               
                 interrelated processes. 
                 automation improves error rates 
                   
               
               
                   
                 and timeliness of this process. 
                   
               
               
                 Maintenance is expensive 
                 Post payment recovery processing  
                   
               
               
                 and time-consuming. 
                 is highly flexible and supports 
                   
               
               
                   
                 complex algorithms. 
                   
               
               
                   
                 Related processes are decoupled,  
                   
               
               
                   
                 allowing changes to be made in 
                   
               
               
                   
                 the Prepare COB process with 
                   
               
               
                   
                 reduced impact on related  
                   
               
               
                   
                 business processes. 
                   
               
               
                   
                 All COB is coordinated among  
                   
               
               
                   
                 data sharing partner agencies in 
                   
               
               
                   
                 the state. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 80 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: 
               
               
                 Payment and Reporting Management 
                 Prepare EOP 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Medicaid agency complies with 
                 Medicaid agency enhances the  
                 EOMB is replaced by a Personal  
               
               
                 federal regulations to produce 
                 sampling process to target 
                 Health Record. 
               
               
                 random samples of EOMBs 
                 selected populations. 
                   
               
               
                 quarterly and mail to members. 
                   
                   
               
               
                 Members are asked to read the 
                   
                   
               
               
                 EOMB and report on any 
                   
                   
               
               
                 discrepancies. 
                   
                   
               
               
                 Sensitive services are  
                 Member responses are  
                 Personal Health Records are  
               
               
                 suppressed. 
                 automatically tabulated. 
                 accessible anywhere in the U.S. 
               
               
                   
                   
                 via the NHIN. 
               
               
                   
                 Cultural and linguistic  
                 The agency has access to clinical  
               
               
                   
                 adaptations are introduced. 
                 data and can directly analyze 
               
               
                   
                   
                 services recorded and reported. 
               
               
                   
                 The agency uses MITA standard  
                 The agency can communicate  
               
               
                   
                 interfaces for the EOMB. 
                 with individuals who appear to 
               
               
                   
                   
                 need special attention. 
               
               
                   
                 Other agencies collaborate with  
                   
               
               
                   
                 Medicaid in the EOMB process. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 81 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Payment 
                 Capability: Prepare Home 
               
               
                 and Reporting Management  
                 and Community-Based Services Payment 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The Prepare Home &amp; 
                 The Medicaid agency works with  
                 HCBS programs benefit from  
               
               
                 Community-Based Services 
                 HCBS programs to share 
                 payer system to provider system 
               
               
                 Payment business process is 
                 Medicaid processes. 
                 communications for immediate 
               
               
                 primarily paper/phone/fax based 
                   
                 approval of payment. 
               
               
                 processing with limited EDI. 
                   
                   
               
               
                 HCBS programs are separated 
                 Medicaid agencies and sister  
                 Payments can be made anywhere  
               
               
                 and uncoordinated. There is no  
                 agencies agree to use MITA 
                 in the U.S. 
               
               
                 standardized data. 
                 standard interfaces for payment 
                   
               
               
                   
                 transactions. 
                   
               
               
                 Payments are non-standard and 
                 Some HCBS programs use 
                   
               
               
                 cover a variety of atypical  
                 Medicaid business processes for 
                 Payment authorization is  
               
               
                 providers. Some payments are 
                 service authorization and service 
                 embedded in the provider to payer 
               
               
                 salary-based. 
                 payment. 
                 system communication. As the 
               
               
                   
                   
                 provider enters service data into 
               
               
                   
                   
                 the clinical data record, 
               
               
                   
                   
                 authorization is immediately 
               
               
                   
                   
                 established by the payer 
               
               
                   
                   
                 application. 
               
               
                   
                 HCBS providers agree to use  
                   
               
               
                   
                 Medicaid standards for price 
                   
               
               
                   
                 authorization and claims 
                   
               
               
                   
                 adjudication and payment. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 82 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Payment 
                 Capability: Prepare 
               
               
                 and Reporting Management  
                 Premium EFT-Check 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Medicaid agency or Department 
                 Medicaid agency complies with 
                 Payments are made directly to  
               
               
                 of Finance produces the EFT 
                 state or industry standards for 
                 provider bank accounts triggered 
               
               
                 transaction or a paper check 
                 EFT transactions and conforms 
                 by entries into clinical records 
               
               
                 using Medicaid agency or state 
                 with HIPAA where appropriate. 
                 maintained by the provider and 
               
               
                 DOF standards for format and 
                   
                 accessed by the payer. 
               
               
                 data content. 
                   
                   
               
               
                   
                 Agency encourages electronic  
                 EFT payments are distributed to  
               
               
                   
                 billers to adopt EFT payment. 
                 any location in the country via the 
               
               
                   
                   
                 NHIN. 
               
               
                   
                 The agency uses MITA standard  
                 Premium payments are made  
               
               
                   
                 interfaces for EFT transactions 
                 directly to MCO, insurance 
               
               
                   
                 Paper checks are produced where 
                 company. Medicare buy-in, et al 
               
               
                   
                 required for exceptional  
                 bank accounts based on 
               
               
                   
                 circumstances. 
                 enrollment information. 
               
               
                   
                 All electronic billers receive EFT  
                   
               
               
                   
                 payment. 
                   
               
               
                   
                 Through inter-agency  
                   
               
               
                   
                 coordination, multiple agencies 
                   
               
               
                   
                 share the same EFT process. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 83 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Payment 
                 Capability: Prepare 
               
               
                 and Reporting Management  
                 Provider EFT-Check 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Medicaid agency or Department 
                 Medicaid agency complies with 
                 Payments are made directly to  
               
               
                 of Finance produces the EFT 
                 state or industry standards for 
                 provider bank accounts triggered 
               
               
                 transaction or a paper check 
                 EFT transactions and conforms 
                 by entries into clinical records 
               
               
                 using Medicaid agency or state 
                 with HIPAA where appropriate. 
                 maintained by the provider and 
               
               
                 DOF standards for format and 
                   
                 accessed by the payer. 
               
               
                 data content. 
                   
                   
               
               
                   
                 Agency encourages electronic  
                 EFT payments are distributed to  
               
               
                   
                 billers to adopt EFT payment. 
                 any location in the country via 
               
               
                   
                   
                 the NHIN. 
               
               
                   
                 The agency uses MITA standard  
                 Premium payments are made  
               
               
                   
                 interfaces for EFT transactions 
                 directly to MCO, insurance 
               
               
                   
                 Paper checks are produced where 
                 company, Medicare buy-in, et al 
               
               
                   
                 required for exceptional 
                 bank accounts based on 
               
               
                   
                 circumstances. 
                 enrollment information. 
               
               
                   
                 All electronic billers receive  
                   
               
               
                   
                 EFT payment. 
                   
               
               
                   
                 Through inter-agency  
                   
               
               
                   
                 coordination, multiple agencies 
                   
               
               
                   
                 share the same EFT process. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 84 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Payment 
                 Capability: Prepare  
               
               
                 and Reporting Management  
                 Remittance Advice-Encounter Report 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Medicaid agency produces the 
                 The Medicaid agency complies  
                 With provider clinical system to  
               
               
                 paper Remittance Advice using 
                 with HIPAA to supply an 
                 payer system communication, the 
               
               
                 state Medicaid agency specific 
                 electronic RA that meets state 
                 RA is replaced by a new 
               
               
                 format and data content. 
                 agency Implementation Guide 
                 accounting mechanism, (TBD). 
               
               
                   
                 requirements. 
                   
               
               
                 Explanations of codes are 
                 The agency uses MITA  
                 Payment information can be sent  
               
               
                 comprehensive and agency  
                 standard interfaces for the RA.  
                 to any location in the country via 
               
               
                 specific. 
                 Paper RAs are still supported  
                 the NHIN. 
               
               
                   
                 on an exception basis. 
                   
               
               
                   
                 All electronic billers receive  
                   
               
               
                   
                 ERAs. 
                   
               
               
                   
                 Through inter-agency  
                   
               
               
                   
                 coordination, multipleagencies 
                   
               
               
                   
                 can use the same ERA data  
                   
               
               
                   
                 standard. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 85 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Payment Information Management 
                 Capability: Inquire Payment Status 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The claim status inquiry process 
                 Programs employ AVR, legacy 
                 Claims processing is replaced by 
               
               
                 is primarily a manual process 
                 direct data entry, and point of 
                 direct communication between the 
               
               
                 and is associated with a specific 
                 service devices for electronic 
                 provider&#39;s CLINICAL DATA 
               
               
                 service. 
                 claim status responses. Staff may 
                 system and the payer system. 
               
               
                   
                 still manually handle inquires that 
                 Adjudication results are known 
               
               
                   
                 are not resolved with automated 
                 immediately, eliminating the need 
               
               
                   
                 response. 
                 for claim status inquires. 
               
               
                 Providers inquire about the 
                 The data uses agency standards 
                 Inquiries can be launched and 
               
               
                 current adjudication status of a 
                 and access is less timeconsuming, 
                 responded to nationally through 
               
               
                 claim by phone, fax, or paper. 
                 less burdensome, and requires 
                 the NHIN. 
               
               
                 Staff performs search on the 
                 fewer agency resources. 
                   
               
               
                 claims history data store (for 
                   
                   
               
               
                 claims in process) or the claims 
                   
                   
               
               
                 history repository for claims that 
                   
                   
               
               
                 have been adjudicated. 
                   
                   
               
               
                 Search may be based on the 
                 All programs use a centralized 
                 Provider system collaborate with 
               
               
                 claim ICN, date of service, or 
                 automated electronic claim status 
                 the MMIS during an episode of 
               
               
                 patient name. Staff locates the 
                 process. Interfaces use MITA 
                 care. The providers&#39; systems alert 
               
               
                 data and relay it to the provider 
                 standards. Providers send 
                 the provider to any clinical 
               
               
                 by phone, fax or paper. Process 
                 HIPAAX12 276 or use online 
                 protocols and to any business 
               
               
                 is timeconsuming for providers 
                 direct data entry and receive 
                 rules required by the agency in 
               
               
                 and resource intensive for 
                 HIPAAX12 277 response or find 
                 order for the service to be paid. 
               
               
                 agency. 
                 the claim status online. 
                   
               
               
                   
                 Data is standardized; access is 
                 When the episode of care has 
               
               
                   
                 24 × 7, and is completely 
                 concluded, the service is 
               
               
                   
                 automated for the provider. 
                 reimbursed or not and the 
               
               
                   
                   
                 provider knows the payment 
               
               
                   
                   
                 status immediately, eliminating 
               
               
                   
                   
                 the need for payment status 
               
               
                   
                   
                 inquiry. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 86 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Payment Information Management 
                 Capability: Manage Payment Information 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 At this level, the business 
                 The business process is now an 
                 The business process interfaces 
               
               
                 process is focused primarily on 
                 enterprise resource that provides 
                 with external business processes 
               
               
                 meeting traditional FFS program 
                 real time access to quality, 
                 via regional record locator 
               
               
                 needs as reflected in MMIS 
                 complete and semantically 
                 services. 
               
               
                 certification requirements. 
                 interoperable data via record 
                   
               
               
                   
                 locator services that federate all 
                   
               
               
                   
                 programs&#39; payment history. 
                   
               
               
                 Data is largely nonstandardized 
                 Data sources are primarily 
                 The business process collaborates 
               
               
                 and vary by siloed programs. 
                 electronic interchange. 
                 with other processes in a 
               
               
                   
                   
                 peer2peer environment, 
               
               
                   
                   
                 eliminating redundant collection 
               
               
                   
                   
                 and interchange of data, and 
               
               
                   
                   
                 improving realtime, multi-axial 
               
               
                   
                   
                 processing. 
               
               
                 Payment data is not timely. 
                 All programs use HIPAA 837 data 
                 Claims are no longer sent or 
               
               
                   
                 for claims history records. 
                 compiled by the Agency, and 
               
               
                   
                   
                 instead, users of claims history 
               
               
                   
                   
                 data locate and compile clinical 
               
               
                   
                   
                 episode of care data within EHRs 
               
               
                   
                   
                 via record locator services or 
               
               
                   
                   
                 search engines on a real time, as 
               
               
                   
                   
                 need basis. 
               
               
                 Data availability is limited by 
                 Claims attachments are compliant 
                 Profiles of Medicaid enterprise 
               
               
                 siloed systems&#39; reporting 
                 with the X12 275. 
                 payment history by member, 
               
               
                 capabilities. 
                   
                 provider, service or condition are 
               
               
                   
                   
                 accessible to authorized external 
               
               
                   
                   
                 users. 
               
               
                 Using payment data for 
                 Premium payment data is 
                 Record locator services may be 
               
               
                 profiling members, providers, 
                 compliant with the HIPAA 834. 
                 provided by semantic Web search 
               
               
                 program analysis, or outcome 
                   
                 engines. 
               
               
                 measures requires costly and 
                   
                   
               
               
                 untimely statistical 
                   
                   
               
               
                 manipulation. 
                   
                   
               
               
                   
                 All payment history data is stored 
                 Emerging use of online publish 
               
               
                   
                 internally in accordance with a 
                 and subscribe capabilities or other 
               
               
                   
                 standards-based UML data model. 
                 information content management 
               
               
                   
                   
                 capabilities enable push and pull 
               
               
                   
                   
                 of data to EHRs, PHRs and public 
               
               
                   
                   
                 health. 
               
               
                   
                 Claims may be processed in real 
                 Applications pull and consume 
               
               
                   
                 time, and automation of most 
                 data available via URIs provided 
               
               
                   
                 adjudication and processes 
                 by semantic Web search engines. 
               
               
                   
                 markedly improves the 
                   
               
               
                   
                 availability, quality, completeness 
                   
               
               
                   
                 and timeliness of payment data. 
                   
               
               
                   
                 Decision support and 
                   
               
               
                   
                 sophisticated analytic tools enable 
                   
               
               
                   
                 users to compile member, 
                   
               
               
                   
                 provider, service or condition 
                   
               
               
                   
                 specific profiles and perform 
                   
               
               
                   
                 complex ad hoc analysis and 
                   
               
               
                   
                 reporting in real time. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 87 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Capitation and  
                   
               
               
                 Premium Payment 
                 Capability: Prepare Capitation Premium Payment 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The agency identifies members 
                 The agency implements HIPAA- 
                 Payments are made directly to 
               
               
                 who have elected or have been 
                 compliant standards for electronic 
                 managed care bank account via 
               
               
                 auto-assigned to a managed care 
                 premium payments, however, the 
                 RHIO registries. 
               
               
                 organization, a benefit manager, 
                 other insurance companies impose 
                   
               
               
                 or a primary care physician, and 
                 their specific Implementation 
                   
               
               
                 matches them to appropriate rate 
                 Guide requirements. 
                   
               
               
                 cells, to calculate monthly 
                   
                   
               
               
                 payments. 
                   
                   
               
               
                 Agency may use a modified 
                 The agency uses MITA standard 
                 Agency can make premium 
               
               
                 claims adjudication process to 
                 interfaces which incorporate 
                 payments to any managed care 
               
               
                 support capitation payment 
                 HIPAA premium payment schema 
                 organization or insuring 
               
               
                 preparation. 
                 for identification of managed care 
                 organization at any location in the 
               
               
                   
                 program enrollees, and 
                 country via the NHIN. 
               
               
                   
                 preparation of the capitation 
                   
               
               
                   
                 premium payments. 
                   
               
               
                 Adjustments are manually 
                 Business rules used to identify 
                 Clinical information is accessed 
               
               
                 applied. 
                 candidates are automated on a 
                 directly from the MCO/PCP if the 
               
               
                   
                 state-specific basis. 
                 capitation payment is 
               
               
                   
                   
                 supplemented for special 
               
               
                   
                   
                 circumstances, e.g., high risk 
               
               
                   
                   
                 pregnancy. 
               
               
                 These steps are mostly manual. 
                 Some transactions continue to be 
                   
               
               
                   
                 manually processed at the request 
                   
               
               
                   
                 of the other insurer. 
                   
               
               
                 Standards for the capitation 
                 The agency has the flexibility to 
                   
               
               
                 payment transaction are agency- 
                 easily change the criteria for rate 
                   
               
               
                 specific. 
                 cells. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 88 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Capitation and  
                   
               
               
                 Premium Payment 
                 Capability: Prepare Health Insurance Premium 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The agency identifies members  
                 The agency implements HIPAA- 
                 Payments are made directly to 
               
               
                 who meet criteria for buy-into  
                 compliant standards for electronic 
                 other insurer bank accounts via 
               
               
                 other insurance coverage 
                 premium payments, however, the 
                 RHIO registries. 
               
               
                 through primarily manual  
                 other insurance companies impose 
                   
               
               
                 processes including a 
                 their specific implementation 
                   
               
               
                 cost-benefit analysis of the  
                 Guide requirements. 
                   
               
               
                 individual case. 
                   
                   
               
               
                 The agency enrolls the member  
                 The agency uses MITA standard 
                 Agency can make premium 
               
               
                 and receives premium payment  
                 interfaces for identification of 
                 payments to any insurer at any 
               
               
                 information. 
                 candidates for other payer buy-in, 
                 location in the country via the 
               
               
                   
                 analysis of cost/effectiveness, and 
                 NHIN. 
               
               
                   
                 health insurance premium 
                   
               
               
                   
                 payments. 
                   
               
               
                 The agency pays the premium  
                 Business rules to identify 
                 Access to clinical information 
               
               
                 according to the insurance  
                 candidates and analyze 
                 helps to identify members eligible 
               
               
                 company requirements. 
                 cost/effectiveness are automated 
                 for other insurance programs. 
               
               
                   
                 on a state-specific basis. 
                   
               
               
                 These steps are mostly manual  
                 Some transactions continue to be 
                   
               
               
                   
                 manually processed at the request 
                   
               
               
                   
                 of the other insurer. 
                   
               
               
                 If there are no standards for these 
                 The agency has the flexibility to 
                   
               
               
                 transactions. 
                 easily change the criteria for 
                   
               
               
                   
                 identification of members eligible 
                   
               
               
                   
                 for other insurance buy-in. 
                   
               
               
                   
                 Medicaid collaborates with other 
                   
               
               
                   
                 payers to use the national 
                   
               
               
                   
                 standards. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 89 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Operations Management 
               
             
          
           
               
                 Sub-Platform: Capitation and  
                   
               
               
                 Premium Payment 
                 Capability: Prepare Medicare Premium Payment 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The agency identifies members 
                 Medicaid agencies and CMS use a 
                 Agency can verify status of buy- 
               
               
                 who meet criteria for buy-in to 
                 standard interface for the 
                 in candidate in other states and 
               
               
                 Medicare Part B. 
                 premium payment. The agency 
                 jurisdictions via the NHIN before 
               
               
                   
                 uses MITA standard interfaces for 
                 generating the premium payment. 
               
               
                   
                 identification of candidates for 
                   
               
               
                   
                 Medicare Buyin. 
                   
               
               
                 The agency exchanges 
                 Agencies use business rules to 
                   
               
               
                 information with the SSA using 
                 improve identification of buy-in 
                   
               
               
                 electronic communication 
                 candidates, prepare the premium 
                   
               
               
                 standards specified by SSA. At 
                 payment calculation, and track the 
                   
               
               
                 this level, tape exchange is the 
                 data exchange. 
                   
               
               
                 primary medium. 
                   
                   
               
               
                 The agency prepares the 
                 The agency has the flexibility to 
                   
               
               
                 Medicare Part B premium buy- 
                 easily change the criteria for 
                   
               
               
                 in report. 
                 identification of buy-in 
                   
               
               
                   
                 candidates. 
                   
               
               
                   
                 The agency collaborates with 
                   
               
               
                   
                 other agencies to identify 
                   
               
               
                   
                 potential buy-ins. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 90 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                   
                 Capability: Develop  
               
               
                 Sub-Platform: Health Informatics 
                 Strategy 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 4.1.2.1 Determine Key Business  
                   
                   
               
               
                 Objectives 
                   
                   
               
               
                 4.1.2.2 Assess Current Business  
                   
                   
               
               
                 Environment against Market  
                   
                   
               
               
                 Evaluation 
                   
                   
               
               
                 4.1.2.3 Assess Current Technical  
                   
                   
               
               
                 Environment 
                   
                   
               
               
                 4.1.2.4 Define Organizational 
                   
                   
               
               
                 and Data Stewardship Needs 
                   
                   
               
               
                 4.1.2.5 Create Informatics  
                   
                   
               
               
                 Vision in alignment with overall  
                   
                   
               
               
                 Business Strategy 
                   
                   
               
               
                 4.1.2.6 Assess gaps between the  
                   
                   
               
               
                 current state environment and  
                   
                   
               
               
                 the Informatics Vision 
                   
                   
               
               
                 4.1.2.7 Define Informatics  
                   
                   
               
               
                 Capabilities and Impact 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 91 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                   
                 Capability: Execution of  
               
               
                 Sub-Platform: Health  
                 Strategic Direction  
               
               
                 Informatics 
                 and Activities 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 4.1.4.1 Perform Data Mining/  
                   
                   
               
               
                 Analysis 
                   
                   
               
               
                 4.1.4.2 Conduct Statistical  
                   
                   
               
               
                 Evaluation/Estimation 
                   
                   
               
               
                 4.1.4.3 Perform Predictive  
                   
                   
               
               
                 Modeling/Stratification 
                   
                   
               
               
                 4.1.4.4 Conduct Reporting  
                   
                   
               
               
                 (Outcomes/Forecast/Risks) 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 92 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public 
               
               
                 Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Health Informatics 
                 Capability: Planning 
               
             
          
           
               
                 Basic 
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 4.1.1.1 Plan and Organize 
                   
                   
               
               
                 4.1.1.2 Collect Industry  
                   
                   
               
               
                 Research and Best Practices 
                   
                   
               
               
                 4.1.1.3 Gather Stakeholder Input 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 93 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                   
                 Capability: Prioritize  
               
               
                 Sub-Platform: Health Informatics 
                 Activities 
               
             
          
           
               
                 Basic 
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 4.1.3.1 Perform Cost Benefit  
                   
                   
               
               
                 Analysis and Financial Impact  
                   
                   
               
               
                 Estimation 
                   
                   
               
               
                 4.1.3.2 Determine Plan for  
                   
                   
               
               
                 Implementation of Capabilities 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 94 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Procurement  
                 Capability: Internal  
               
               
                 Management 
                 Stakeholder Management 
               
             
          
           
               
                 Basic 
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 4.3.5.1 Performance  
                   
                   
               
               
                 Management 
                   
                   
               
               
                 4.3.5.2 Process &amp; Contract  
                   
                   
               
               
                 Compliance 
                   
                   
               
               
                 4.3.5.3 Demand Management 
                   
                   
               
               
                 4.3.5.4 Customer Service 
                   
                   
               
               
                 Oriented 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 95 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model-Public Health Services-Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Procurement  
                 Capability: Requisition  
               
               
                 Management 
                 to Pay Operations 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 4.3.6.1 Transaction Processing 
                   
                   
               
               
                 4.3.6.2 Master Data 
                   
                   
               
               
                 4.3.6.3 Assisted Buying 
                   
                   
               
               
                 4.3.6.4 MIS 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 96 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Procurement Management 
                 Capability: Sourcing and Category Management 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Strategic Sourcing: “Three 
                 Strategic Sourcing 
                 Strategic Sourcing: Process rigor, 
               
               
                 quotes” approach solely done by 
                 Strategic Sourcing: Commodity/ 
                 dictated by common cross- 
               
               
                 procurement 
                 Cross team driven approach 
                 functional, analytical method 
               
               
                   
                 Global Sourcing: deployed global 
                   
               
               
                   
                 sourcing strategy in place, 
                   
               
               
                   
                 penetrating new markets 
                   
               
               
                   
                 eSourcing: Simple reverse 
                   
               
               
                   
                 auction for all commodities 
                   
               
               
                 Global Sourcing: Only done on 
                 Category Policy Setting 
                 Global Sourcing: Total landed 
               
               
                 an ad hoc basis 
                 Departmental policies, processes 
                 cost framework to fully leverage 
               
               
                   
                 and procedures are in alignment 
                 LCC opportunities to reduce TCO 
               
               
                   
                 with corporate policies 
                   
               
               
                 eSourcing: Simple reverse 
                 Category Management 
                 eSourcing: Technology driving 
               
               
                 auctions for a few categories 
                 Framework Disparate category 
                 global collaboration, knowledge 
               
               
                   
                 management structure that vary 
                 management and efficiency 
               
               
                   
                 throughout the organization 
                   
               
               
                   
                 Procurement personnel dedicated 
                   
               
               
                   
                 to specific category management 
                   
               
               
                 Departmental policies establish 
                 Compliance Monitoring 
                 Policies are established and 
               
               
                 standards of conduct and 
                 Compliance strategy in place, 
                 communicated to convey the 
               
               
                 promote compliance with 
                 reviewed periodically 
                 Corporation&#39;s position and 
               
               
                 applicable laws and regulations. 
                   
                 philosophy; additionally, they 
               
               
                   
                   
                 provide governance over 
               
               
                   
                   
                 employees actions. 
               
               
                 No category management 
                   
                 Centrally guided category 
               
               
                 framework established 
                   
                 management structure that cut 
               
               
                   
                   
                 across organizational entities 
               
               
                 Groups of buyers 
                   
                 Dedicated sourcing analyst pool 
               
               
                   
                   
                 that provides support during the 
               
               
                   
                   
                 sourcing and category 
               
               
                   
                   
                 management process 
               
               
                 Significant maverick spend 
                   
                 Discipline, full control with non- 
               
               
                   
                   
                 compliance driving corrective 
               
               
                   
                   
                 actions 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 97 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Procurement Management 
                 Capability: Supplier Relationship Management 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Reactive, only talking to 
                 Supplier Performance 
                 Targeted approach, differentiated 
               
               
                 suppliers when problems occur 
                 Management 
                 by supplier segment 
               
               
                   
                 Supplier performance metrics 
                   
               
               
                   
                 established 
                   
               
               
                 Procurement is involved and 
                 Supplier Integration 
                 Integrated product development 
               
               
                 urges groups to adopt industry 
                 Key suppliers are involved for 
                 involving customer focus groups 
               
               
                 or supplier standards 
                 input on alternate materials and 
                 suppliers and design teams, with 
               
               
                   
                 design for manufacturability 
                 suppliers performing component 
               
               
                   
                 issues 
                 development in line with overall 
               
               
                   
                 Key suppliers are incorporated 
                 business and product strategy 
               
               
                   
                 into planning process, forecast 
                   
               
               
                   
                 shared 
                   
               
               
                 Limited to a few problem 
                 Contract Management 
                 Joint Process/Product 
               
               
                 solving meetings 
                 Some long term contracts in place 
                 Improvements, eSupply Chain 
               
               
                   
                 on “big ticket” items or raw 
                 Integration 
               
               
                   
                 materials 
                   
               
               
                   
                 Single contract management 
                   
               
               
                   
                 solution 
                   
               
               
                 Horizon based on material 
                 Supplier Development 
                 Supplier pricing based on long 
               
               
                 requirements released to 
                 Vendor sharing of actual costs and 
                 term alliance agreements and 
               
               
                 procurement on requisition 
                 profit margins 
                 delivery is based on production 
               
               
                   
                 Supplier development initiative 
                 schedule 
               
               
                   
                 established 
                   
               
               
                 Multiple contract databases and 
                   
                 Centrally logged contracts, pro- 
               
               
                 ad hoc compliance management 
                   
                 active mgmt of contract 
               
               
                   
                   
                 compliance 
               
               
                 Raw materials purchasing based 
                   
                 Sharing of technical expertise to 
               
               
                 on competitive bids versus 
                   
                 improve product performance and 
               
               
                 relationships 
                   
                 reduce costs 
               
               
                 No systemic approach of 
                   
                 Focus on repeatable LCC supplier 
               
               
                 supplier development 
                   
                 development 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 98 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Procurement  
                 Capability: Manage Human  
               
               
                 Management 
                 and Tangible Resources 
               
             
          
           
               
                 Basic 
                 Competitive  
                 Market Leading 
               
               
                   
               
               
                 4.3.1.1 Change Agency 
                   
                   
               
               
                 4.3.1.2 Make vs. Buy 
                   
                   
               
               
                 4.3.1.3 Competitive Awareness 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 99 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Privacy and  
                 Capability: Manage  
               
               
                 Compliance Management 
                 Privacy Compliance 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 4.6.1.1 Maintain Training, 
                   
                   
               
               
                 Whistleblower Program, etc. 
                   
                   
               
               
                 4.6.1.2 Manage Reporting 
                   
                   
               
               
                 Requirements 
                   
                   
               
               
                 4.6.1.3 Manage HIPAA and 
                   
                   
               
               
                 State Privacy Compliance 
                   
                   
               
               
                 Maintain Privacy Office 
                   
                   
               
               
                 Maintain Authorizations 
                   
                   
               
               
                 Manage Disclosure 
                   
                   
               
               
                 4.6.1.3 Manage HIPAA and 
                   
                   
               
               
                 State Privacy Compliance 
                   
                   
               
               
                 Maintain Protected Health 
                   
                   
               
               
                 Information (PHI) 
                   
                   
               
               
                 Manage Trading Partners 
                   
                   
               
               
                 Manage Security 
                   
                   
               
               
                 Manage Quality and 
                   
                   
               
               
                 Performance Privacy and 
                   
                   
               
               
                 Security 
                   
                   
               
               
                 4.6.1.4 Manage Sarbanes-Oxley 
                   
                   
               
               
                 Compliance 
                   
                   
               
               
                 Manage Documentation and 
                   
                   
               
               
                 Data Retention 
                   
                   
               
               
                 Manage Attestation 
                   
                   
               
               
                 4.6.1.5 Manage CMS 
                   
                   
               
               
                 Compliance 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
               
               
             
           
               
                 TABLE 100 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Legal Management 
                 Capability: Manage Legal Issues 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
             
          
           
               
                 4.2.1.1 Manage Legal Services 
                   
               
               
                 4.2.1.2 Ensure Regulatory  
                   
               
               
                 Compliance 
                   
               
               
                 4.2.1.3 Provide Litigation  
                   
               
               
                 Services 
                   
               
               
                 4.2.1.4 Provide Tax Advice 
                   
               
               
                 4.2.1.5 Advise Other Plan  
                   
               
               
                 Departments 
                   
               
               
                 4.2.1.6 Manage Quality and  
                   
               
               
                 Performance of the Legal 
                   
               
               
                 Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 101 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform:  
                 Capability: Manage Human 
               
               
                 Human Resources  
                 and Tangible Resources 
               
             
          
           
               
                 Basic  
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 4.5.1.1 Manage Workforce Capacity 
                   
                   
               
               
                 4.5.1.2 Manage recruiting 
                   
                   
               
               
                 4.5.1.3 Manage Compensation  
                   
                   
               
               
                 and Benefits 
                   
                   
               
               
                 4.5.1.4 Manage Employee Services 
                   
                   
               
               
                 4.5.1.5 Manage Training and Career  
                   
                   
               
               
                 Development 
                   
                   
               
               
                 4.5.1.6 Manage Quality and 
                   
                   
               
               
                 Performance of  
                   
                   
               
               
                 Human and Tangible Resources 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 102 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Architecture 
               
               
                 Information Technology Operations  
                 Management - Application Architecture 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Application suites documented 
                 Components are configurable and  
                 Related software and processes  
               
               
                 but without review and quality  
                 quality assurance practiced 
                 have been defined and actively  
               
               
                 control checkpoints 
                   
                 monitored 
               
               
                 Application architecture 
                 Application suite architected 
                 Supporting software, development 
               
               
                 developed for pockets of  
                 considering planned service 
                 and maintenance processes 
               
               
                 projects only 
                 delivery commitments and  
                 improved to appropriate levels  
               
               
                   
                 tracking 
                 (e.g. best in class) and focus on 
               
               
                   
                   
                 proactive fault prevention 
               
               
                 Some rationalization efforts, 
                 Application architecture defined  
                 Enterprise-wide application  
               
               
                 though fragmented and  
                 for functional groups 
                 architecture is actively managed 
               
               
                 inconsistent across groups 
                   
                 for business value and regularly 
               
               
                   
                   
                 refreshed according to changing 
               
               
                   
                   
                 business and technical needs 
               
               
                 Integration layer is documented 
                 Application architecture is  
                 Application portfolio 
               
               
                 but without any review and  
                 consistently enforced 
                 rationalization opportunities 
               
               
                 quality control checkpoints 
                   
                 integrated into new project 
               
               
                   
                   
                 objectives and planning 
               
               
                 Some standardized interfaces 
                 Application portfolio defined, 
                 Active process management for 
               
               
                 such as EDI or common tools 
                 rationalization process 
                 integration architecture in place 
               
               
                   
                 documented and practiced 
                   
               
               
                   
                 consistently across all groups 
                   
               
               
                   
                 Integration architecture 
                 Integration/interface architecture 
               
               
                   
                 considered across functional  
                 refreshed regularly  
               
               
                   
                 units and quality assurance  
                   
               
               
                   
                 practiced in general 
                   
               
               
                   
                 Integration/interface architecture 
                 Interface re-use is actively  
               
               
                   
                 is consistently enforced 
                 managed and enforced and  
               
               
                   
                   
                 considered in business cases 
               
               
                   
                 Standards with supporting 
                   
               
               
                   
                 common integration tool sets 
                   
               
               
                   
                 (e.g., messaging, interface 
                   
               
               
                   
                 building, data transport) exist 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 103 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: Strategic IT 
               
               
                 Information Technology Operations  
                 Alignment - Business and IT Alignment 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Business and/or IT strategy is 
                 Business and IT strategy exist and  
                 IT strategy priorities are  
               
               
                 unclear and not fully 
                 there is some broad linkage 
                 continuously adjusted to match 
               
               
                 communicated 
                 between the two 
                 business needs 
               
               
                 IT and business work in their 
                 IT and business discuss alignment 
                 IT and business are jointly  
               
               
                 silos with mostly reactive and 
                 for critical projects  
                 responsible for defining IT 
               
               
                 one-way communications 
                   
                 strategy and review the strategy 
               
               
                   
                   
                 on set schedule 
               
               
                 Where a strategy has been 
                 IT strategy is translated to 
                 The strategy is translated to clear  
               
               
                 articulated, it is often not 
                 operational levels at varying 
                 operational plans and for specific 
               
               
                 defined at an operational level 
                 levels of detail generally resulting 
                 audience, and tied to group and 
               
               
                 leaving it open to interpretation 
                 in consistent interpretation 
                 individual goals 
               
               
                 Strategy communication is 
                 Strategy communication  
                 Strategy communication  
               
               
                 ad hoc via varying channels to 
                 frequency, channels, audience are 
                 frequency, content and channels  
               
               
                 a fragmented set of audience 
                 defined, but still inconsistently 
                 are customized to audience and 
               
               
                   
                 executed 
                 regularly managed 
               
               
                 IT has limited involvement in 
                 IT is typically involved in 
                 IT is involved in key Business  
               
               
                 Business Unit discussions, often 
                 Business Unit strategic 
                 strategic discussions to ensure the  
               
               
                 resulting in an incomplete 
                 discussions with the strategy 
                 strategy is comprehensive and 
               
               
                 strategic view and risk of 
                 generally inclusive of IT 
                 correctly executed 
               
               
                 deviation from the strategy 
                 implications and correctly 
                   
               
               
                   
                 executed 
                   
               
               
                 IT initiative prioritization and 
                 IT initiative prioritization and 
                 IT initiative prioritization and  
               
               
                 approval process informally  
                 approval process defined with 
                 approved process proactively 
               
               
                 exists 
                 formal steps for business 
                 managed with business 
               
               
                   
                 objective alignment, compliance 
                 involvement for all IT initiatives 
               
               
                   
                 review and formal sign off by key 
                   
               
               
                   
                 decision makers, but not 
                   
               
               
                   
                 consistently followed 
                   
               
               
                 It has limited influence on 
                 IT is involved in all strategic 
                 IT is a respected strategic partner  
               
               
                 strategic agenda 
                 initiatives consistently across 
                 to business 
               
               
                   
                 enterprise 
                   
               
               
                 Business IT Liaison plays a 
                 Business IT Liaison role is clearly 
                 Business IT Liaison plays a lead  
               
               
                 simple order taker role 
                 defined across business areas  
                 role in IT-enabled business  
               
               
                   
                   
                 transformation and acts as a  
               
               
                   
                   
                 change agent 
               
               
                 Business IT Liaison is equipped 
                 Business IT Liaison demonstrates 
                 Business IT Liaison maintains  
               
               
                 with limited “tools” 
                 knowledge of business processes  
                 deep knowledge of organization- 
               
               
                   
                 and interactions across multiple 
                 wide IT roadmap, objectives, 
               
               
                   
                 functional areas  
                 risks, interactions and issues 
               
               
                 Information feedback 
                 Feedback process on performance 
                 Proactive management of  
               
               
                 mechanism on performance or 
                 and customer satisfaction defined, 
                 performance feedback and 
               
               
                 customer satisfaction in place 
                 but not consistently enforced 
                 customer satisfaction results for 
               
               
                   
                   
                 continuous improvement 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 104 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance Capability Assessment 
               
               
                 Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: 
                 Capability: 
               
               
                 Information Technology Operations  
                 Solutions Delivery - Collaboration 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Informal and ad hoc sharing 
                 Sharing of key knowledge  
                 Proactive and ingrained sharing of  
               
               
                 between teams 
                 documentation exists throughout 
                 key knowledge documentation 
               
               
                   
                 the life-cycle within IT and with 
                 throughout the life-cycle within 
               
               
                   
                 the business customers 
                 IT and with the business 
               
               
                   
                   
                 customers 
               
               
                 No standards or guidelines as 
                 Knowledge sharing tools 
                 IT continuously looks for ways to 
               
               
                 how to store project 
                 deployed to facilitate capture and 
                 improve its knowledge sharing 
               
               
                 documentation 
                 distribution 
                 capabilities and regularly reviews 
               
               
                   
                   
                 its knowledge database 
               
               
                 Lack of adequate infrastructure 
                 Various repositories for project 
                 Knowledge is actively 
               
               
                 and tools to incite 
                 documentation, none used 
                 communicated and updated with 
               
               
                 communication 
                 completely or consistently 
                 feedback from all stakeholders 
               
               
                 Ad hoc and inconsistent 
                 Consistent processes across 
                 Proactive involvement of 
               
               
                 communication of knowledge 
                 groups/locations 
                 technology and business groups in 
               
               
                   
                   
                 optimizing knowledge communication 
               
               
                 Knowledge communication 
                 Communication ownership well 
                   
               
               
                 ownership is loosely defined  
                 defined with leaders assigned by 
                   
               
               
                   
                 group, function or topic 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 105 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information  
                 Capability: Strategic IT Alignment -  
               
               
                 Technology Operations  
                 Communicate IT Strategy 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Ad hoc communications of  
                 IT vision and strategy regularly  
                 IT vision and strategy regularly 
               
               
                 the IT vision and strategy  
                 communicated internally to 
                 communicated internally to 
               
               
                   
                 various stakeholders 
                 and externally to various  
               
               
                   
                   
                 stakeholders 
               
               
                   
                 Communications not aligned to 
                   
               
               
                   
                 the IT strategy refresh cycle 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 106 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information 
                 Capability: IT 
               
               
                 Technology Operations 
                 Governance - Develop/Ad minister IT Budgets 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Informal IT funding model 
                 IT funding model allows for  
                 IT funding model designed to  
               
               
                 exists 
                 increases in IT spending to realize 
                 drive appropriate behaviors in 
               
               
                   
                 defined benefits 
                 business and IT 
               
               
                 The allocation of IT budget is 
                 Allocation of IT budget is 
                 Allocation of IT budget is driven 
               
               
                 ad hoc and reactive 
                 partially influenced by business 
                 by business strategic priorities 
               
               
                   
                 objectives  
                 Business managers participate in  
               
               
                   
                 Business and IT managers work 
                 IT planning, and approve IT 
               
               
                   
                 together throughout the year to  
                 priorities and allocations of funds  
               
               
                   
                 allocate resources on the basis of  
                 on the basis of strategic priorities 
               
               
                   
                 operational priorities 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 107 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information  
                 Capability: Architecture 
               
               
                 Technology Operations  
                 Management - End-User Computing Architecture 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 End-user computing 
                 End-user computing architecture  
                 Active process management for  
               
               
                 requirements are documented  
                 considered across functional units 
                 end-user computing architecture 
               
               
                 but without any review and 
                 and quality assurance practiced in 
                 in place 
               
               
                 quality control checkpoints 
                 general 
                   
               
               
                 Multiple end-user computing 
                 End-user computing architecture 
                 A small number of end-user 
               
               
                 devices, possibly including thin,  
                 is consistently enforced 
                 computing device configurations, 
               
               
                 3270-like and thick clients with 
                   
                 designed to deliver required 
               
               
                 multiple software configurations 
                   
                 service at lower costs. 
               
               
                 Rudimentary business value 
                 End-user computing device set  
                 End-user computing architecture 
               
               
                 implications for end-user  
                 with planned set of hardware 
                 has been designed and 
               
               
                 computing architecture 
                 devices and managed software 
                 implemented with consideration 
               
               
                   
                 configurations 
                 for overall application strategy,  
               
               
                   
                   
                 total cost of ownership and  
               
               
                   
                   
                 service targets, and is refreshed 
               
               
                   
                   
                 regularly 
               
               
                   
                 Defined end-user computing 
                   
               
               
                   
                 configurations sets designed to 
                   
               
               
                   
                 deliver to clear service targets; 
                   
               
               
                   
                 supporting organizational  
                   
               
               
                   
                 structures and training 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 108 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information 
                 Capability: IT Governance - 
               
               
                 Technology Operations  
                 Establish/Manage IT Standards 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 IT standards are in its infancy 
                 Standards established by IT with  
                 Clear, consistent and  
               
               
                 Little enterprise-wide standards  
                 little or no input from business, 
                 comprehensive IT standards 
               
               
                 exist. 
                 with minimal accountability 
                 developed and maintained to 
               
               
                   
                   
                 guide decision making and action 
               
               
                   
                   
                 in accordance with established 
               
               
                   
                   
                 business and IT policies 
               
               
                 IT standards are after-thought 
                 Adherence to standards enforced 
                 Changes in business direction and 
               
               
                 and many business users 
                 periodically depending on budget 
                 strategy assessed to determine 
               
               
                 consider IT standards as 
                 pressures 
                 impact on relevancy of standards 
               
               
                 hindrance 
                   
                   
               
               
                 Unclear how IT standards would 
                 Standards changed often to allow 
                 Impact of business and  
               
               
                 be linked to external/regulatory 
                 for requested exceptions, or not 
                 technology trends on standards 
               
               
                 compliance  
                 examined for change at all 
                 assessed 
               
               
                   
                 Internal and external audits are 
                 Changes to existing standards  
               
               
                   
                 conducted to ensure standards 
                 clearly documented and 
               
               
                   
                 compliance to external 
                 communicated to all affected 
               
               
                   
                 regulations 
                 parties 
               
               
                   
                   
                 Dedicated compliance resources  
               
               
                   
                   
                 continuously monitors IT 
               
               
                   
                   
                 standards in lieu of changing 
               
               
                   
                   
                 external regulations 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 109 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information 
                 Capability: Architecture Management - 
               
               
                 Technology Operations  
                 Infrastructure Architecture 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Infrastructure requirements are 
                 Infrastructure architecture  
                 Active process management  
               
               
                 documented but without any 
                 considered across functional units 
                 for infrastructure architecture in 
               
               
                 review and quality control 
                 and quality assurance practiced in 
                 place 
               
               
                 checkpoints  
                 general 
                   
               
               
                 Infrastructure architecture 
                 Configuration management and 
                 Architectures designed, managed 
               
               
                 requirements are not well 
                 quality assurance applied to 
                 and regularly refreshed to meet 
               
               
                 defined 
                 architectures 
                 financial and service targets 
               
               
                   
                 Infrastructure architecture is 
                 Tiered architectures 
               
               
                   
                 consistently enforced 
                 (Infrastructure and Data Center) 
               
               
                   
                   
                 have been defined and are being 
               
               
                   
                   
                 measured and tested for 
               
               
                   
                   
                 availability, recoverability and 
               
               
                   
                   
                 performance 
               
               
                   
                 Distributed architecture set  
                 Architectures have been on  
               
               
                   
                 considered and implemented to 
                 harmonized to maximized Return 
               
               
                   
                 deliver planned service delivery 
                 Investment and minimize 
               
               
                   
                 commitments with tracking 
                 Total Cost of Ownership 
               
               
                   
                 Data Center hierarchies 
                   
               
               
                   
                 articulated and facilities set up to 
                   
               
               
                   
                 deliver required services with 
                   
               
               
                   
                 requisite physical security 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 110 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information  
                 Capability: Service and Management Operations - 
               
               
                 Technology Operations  
                 Infrastructure Services Governance 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Business requirements for 
                 Availability requirements  
                 Availability requirements  
               
               
                 availability exist but are not 
                 documented but not effectively 
                 determined jointly by business 
               
               
                 documented or communicated 
                 monitored or measured 
                 and service provider, based on 
               
               
                   
                   
                 cost per level of availability 
               
               
                 Ad hoc planning efforts to set 
                 Availability requirements not  
                 Availability requirements balance 
               
               
                 and monitor availability with no 
                 based on baseline data 
                 cost against business need 
               
               
                 plan in place 
                   
                   
               
               
                 Initial efforts at capacity 
                 Availability plan documents 
                 Availability strategy reviewed 
               
               
                 modeling with multiple  
                 components as well as business 
                 regularly for effectiveness and  
               
               
                 inconsistent models in place 
                 services 
                 efficiency 
               
               
                 The capacity plan has 
                 Organization does not have good 
                 Availability planning performed 
               
               
                 fragmented structure, where  
                 data to measure whether 
                 at service level 
               
               
                 roles and responsibilities are not  
                 availability plan is met beyond 
                   
               
               
                 clearly defined 
                 the component level 
                   
               
               
                 Basic service continuity 
                 Capacity model defined and 
                 Capacity modeling is 
               
               
                 includes restore from back up  
                 consistently utilized across all  
                 continuously improved via 
               
               
                 media  
                 groups 
                 incremental changes 
               
               
                 Business owners are not 
                 Capacity modeling personnel 
                 Business users have input to the 
               
               
                 involved to assess the strategy  
                 have access to financial, physical, 
                 capacity model 
               
               
                 based on business impact  
                 operational, software, and vendor 
                   
               
               
                 analysis 
                 requirements in order to complete 
                   
               
               
                   
                 model 
                   
               
               
                 The plan is a paper document 
                 A standard enterprise capacity 
                 Capacity planning is continuously 
               
               
                 that is rarely reviewed 
                 plan exists 
                 improved via incremental changes 
               
               
                   
                   
                 over the course of the year 
               
               
                 The initial builders and testers 
                 Plan updated at 
                 Capacity planning efforts are able 
               
               
                 of the IT service continuity plan 
                 specified intervals 
                 to predict, anticipate, understand, 
               
               
                 are the only ones trained on it 
                   
                 and react rapidly to business 
               
               
                   
                   
                 changes impacting IT services 
               
               
                 Some critical business services 
                 Business demand forecasts are 
                 The strategy is fully supported 
               
               
                 identified, but not consistent 
                 incorporated into the capacity 
                 and sponsored by multiple 
               
               
                 across groups 
                 plan 
                 executives in the organization to 
               
               
                   
                   
                 ensure that during a disaster a 
               
               
                   
                   
                 recovery would be guaranteed 
               
               
                   
                   
                 within the recovery period agreed  
               
               
                   
                   
                 upon 
               
               
                 Service model lacks structure 
                 A well documented strategy exists 
                 Business/disaster recovery 
               
               
                 and is paper based; service 
                 and agreed upon by business 
                 planning and management&#39;s 
               
               
                 dependencies are informally 
                 operations and IT 
                 software is tied to backup/ 
               
               
                 understood 
                   
                 restore/archive system for 
               
               
                   
                   
                 metrics reporting and issues 
               
               
                   
                   
                 tracking 
               
               
                 Some services are documented, 
                 Recovery options have been 
                 IT service continuity director  
               
               
                 but no central catalog exists 
                 agreed upon for each business  
                 and supporting staff have taken 
               
               
                   
                 process 
                 external training to learn the 
               
               
                   
                   
                 industry standards for IT service 
               
               
                   
                   
                 continuity 
               
               
                 End user experience is 
                 The plan is reviewed and audited 
                 Critical business service 
               
               
                 monitored as users report  
                 yearly by business and IT 
                 documentation is regularly 
               
               
                 service problems 
                 stakeholders  
                 reviewed in accordance with 
               
               
                   
                   
                 changes in business imperatives 
               
               
                 No performance measure or 
                 The plan is an electronic  
                 Service model is highly effective 
               
               
                 targets/objectives set beyond  
                 document with links to supporting 
                 in predicting the business impact  
               
               
                 overall costs 
                 documents that are updated  
                 of technology events 
               
               
                   
                 regularly with the change 
                   
               
               
                   
                 management processes.  
                   
               
               
                 Costs tracked, but inconsistently 
                 Training policy is in place for  
                 Comprehensive service catalog 
               
               
                 across groups 
                 new recovery team members and  
                 jointly reviewed and updated  
               
               
                   
                 any other personnel that may be  
                 between IT and business 
               
               
                   
                 required in a disaster  
                   
               
               
                 Risks identified at functional 
                 Critical business services are  
                 Service Catalog automatically 
               
               
                 level and for projects 
                 documented  
                 updated when new configuration 
               
               
                   
                   
                 item is place in the system 
               
               
                 No overall account ability for IT 
                 Service model is documented 
                 End-user experience model 
               
               
                 risks 
                   
                 created and utilized to predict and 
               
               
                   
                   
                 proactively control user  
               
               
                   
                   
                 experience 
               
               
                   
                 Well documented service catalog 
                 Balanced set of performance 
               
               
                   
                 exists 
                 measures set, linked directly to 
               
               
                   
                   
                 business and IT strategy. 
               
               
                   
                 Service goals clearly support  
                 Regular monitoring and proactive 
               
               
                   
                 critical business services 
                 revision of plaan and targets  
               
               
                   
                   
                 through the year 
               
               
                   
                 Automated monitoring of end  
                 Charges based on services, not  
               
               
                   
                 user experience 
                 technology 
               
               
                   
                 Clear objectives set for the IT 
                   
               
               
                   
                 function 
                   
               
               
                   
                 Focus is mainly on efficiency  
                   
               
               
                   
                 measures 
                   
               
               
                   
                 Technology service units costed 
                   
               
               
                   
                 and used as the basis for recharge  
                   
               
               
                   
                 Risk management is defined 
                   
               
               
                   
                 accountability 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 111 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information 
                 Capability: Strategic IT 
               
               
                 Technology Operations  
                 Alignment - IT Innovation 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Limited survey of technologies 
                 Market leading technologies are  
                 Technology scanning is ingrained  
               
               
                 conducted 
                 studied and actively investigated 
                 into overall IT and business 
               
               
                   
                 to potentially enable business 
                 processes 
               
               
                   
                 objectives 
                   
               
               
                 IT is perceived to Order Taker 
                 IT is Solutions Provider  
                 IT is Change Agent, leading 
               
               
                 (“Do what you&#39;re told”) 
                 (“Bring ideas to the table”) 
                 efforts to innovate business  
               
               
                   
                   
                 practices 
               
               
                 Limited innovation thinking and 
                 IT innovations support business 
                 IT serves as Change Agent and 
               
               
                 innovation is either too early or 
                 productivity 
                 Leader (“Drive change - out in 
               
               
                 too late to effectively enable 
                   
                 front”) 
               
               
                 business strategy and growth 
                   
                   
               
               
                 Ideas and innovations lack 
                 Investment levels in innovation  
                 IT innovations enable the 
               
               
                 ownership and follow-through 
                 driven by business performance 
                 business strategy and support 
               
               
                   
                 (varies year to year) 
                 growth 
               
               
                 Innovation ideas prioritized 
                 Fast Follower&#39; in IT direction 
                 Innovation supported by business  
               
               
                 ad hoc or using a ‘squeaky  
                   
                 leadership and direction 
               
               
                 wheel’ approach 
                   
                   
               
               
                 The development lifecycle is 
                 Innovations are identified through 
                 Steady investment as a percentage  
               
               
                 often slow and inflexible in 
                 a range of sources both internal 
                 of total IT cost 
               
               
                 delivering business capability 
                 and external usually by a process 
                   
               
               
                 and often results in reduced 
                 of collection 
                   
               
               
                 benefit capture  
                   
                   
               
               
                   
                   
                 Innovations adopted at the right 
               
               
                   
                   
                 point of time ‘Market Leader’ 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 112 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information 
                 Capability: Architecture Management - 
               
               
                 Technology Operations  
                 Manage EDI and Paper Transactions 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 4.4.3.9.1 Process Web-Based 
                   
                   
               
               
                 Transactions 
                   
                   
               
               
                 4.4.3.9.2 Process EDI 
                   
                   
               
               
                 Transactions 
                   
                   
               
               
                 4.4.3.9.3 Process Paper 
                   
                   
               
               
                 Transactions 
                   
                   
               
               
                 4.4.3.9.4 Manage Quality and 
                   
                   
               
               
                 Performance of the Transactions 
                   
                   
               
               
                 Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 113 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform:  
                 Capability: Architecture  
               
               
                 Information  
                 Management - Manage Information 
               
               
                 Technology Operations  
                 Systems and Technology and Security 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 4.4.3.10.1 Plan and Develop 
                   
                   
               
               
                 Technology Enablement 
                   
                   
               
               
                 Capabilities 
                   
                   
               
               
                 4.4.3.10.2 Manage Application  
                   
                   
               
               
                 Infrastructure 
                   
                   
               
               
                 4.4.3.10.3 Manage Technical 
                   
                   
               
               
                 Infrastructure 
                   
                   
               
               
                 4.4.3.10.4 Manage Hardware 
                   
                   
               
               
                 Infrastructure 
                   
                   
               
               
                 4.4.3.10.5 Manage Quality and  
                   
                   
               
               
                 Performance of the Information  
                   
                   
               
               
                 Systems Process 
                   
                   
               
               
                 4.4.3.10.6 Govern Information  
                   
                   
               
               
                 Management 
                   
                   
               
               
                 4.4.3.10.7 Identify Knowledge  
                   
                   
               
               
                 Requirements, Resources, and  
                   
                   
               
               
                 Gaps 
                   
                   
               
               
                 4.4.3.10.8 Collect and Develop  
                   
                   
               
               
                 Knowledge 
                   
                   
               
               
                 4.4.3.10.9 Manage Knowledge  
                   
                   
               
               
                 Repositories 
                   
                   
               
               
                 4.4.3.10.10 Manage User Access  
                   
                   
               
               
                 &amp; Support of 
                   
                   
               
               
                 Information Management 
                   
                   
               
               
                 4.4.3.10.11 Manage  
                   
                   
               
               
                 Applications Development,  
                   
                   
               
               
                 Production &amp; Delivery of 
                   
                   
               
               
                 Information Management 
                   
                   
               
               
                 4.4.3.10.12 Manage Quality and  
                   
                   
               
               
                 Performance of the Knowledge 
                   
                   
               
               
                 Management Process 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 114 
               
             
             
               
                   
               
               
                 Global Health and Life Sciences High Performance  
               
               
                 Capability Assessment Model Public Health Services - Medicaid 
               
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information 
                 Capability: IT Governance - Manage  
               
               
                 Technology Operations  
                 Initiatives to Realize Benefits 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Investments managed 
                 IT portfolio monitored and  
                 IT portfolio is focused on taking  
               
               
                 independently with minimal 
                 benefits realization calculated 
                 actions to proactively optimize 
               
               
                 consideration of overall IT 
                 consistently for key projects on 
                 performance against target benefits 
               
               
                 portfolio 
                 completion 
                 Investment portfolio actively 
               
               
                 Limited business participation in 
                 Business is engaged in IT 
                 managed and measured jointly by 
               
               
                 IT portfolio management 
                 portfolio management for all 
                 IT and business continuously 
               
               
                   
                 functional areas 
                 IT and Business strategically 
               
               
                 Only handful of benefits 
                 IT scorecard used to drive IT 
                 aligned with focus on identified 
               
               
                 measurement exists and the 
                 steering committee agenda 
                 sources of value from IT 
               
               
                 majority of them are 
                 KPIs, typically financial-based,  
                 Joint Committees of the 
               
               
                 operationally-focused 
                 for IT Delivery are identified and 
                 appropriate senior Business and 
               
               
                   
                 reported regularly  
                 IT leaders are actively engaged in 
               
               
                   
                   
                 guiding the IT Investment 
               
               
                   
                   
                 pipeline, portfolio of in-flight 
               
               
                   
                   
                 projects 
               
               
                   
                 IT scorecard used to drive IT  
                 IT and Business strategically 
               
               
                   
                 steering committee agenda  
                 aligned with focus on identified 
               
               
                   
                 All IT areas define performance 
                 sources of value from IT 
               
               
                   
                 targets and are tracked on their 
                 Joint Committees of the 
               
               
                   
                 ability to meet these targets 
                 appropriate senior Business and 
               
               
                   
                   
                 IT leaders are actively engaged in  
               
               
                   
                   
                 guiding the delivery of day-to-day 
               
               
                   
                   
                 services 
               
               
                   
                 IT scorecard used to drive IT  
                 IT and Business strategically 
               
               
                   
                 steering committee agenda 
                 aligned with focus on identified  
               
               
                   
                 Rewards typically tied to overall 
                 sources of value from IT 
               
               
                   
                 business performance 
                 Joint Committees of the 
               
               
                   
                   
                 appropriate senior Business and  
               
               
                   
                   
                 IT leaders are actively engaged in 
               
               
                   
                   
                 guiding at enterprise, business 
               
               
                   
                   
                 unit and program/project/service 
               
               
                   
                   
                 level 
               
               
                   
                   
                 IT and Business strategically 
               
               
                   
                   
                 aligned with focus on identified  
               
               
                   
                   
                 sources of value from IT 
               
               
                   
                   
                 Refinement of priorities, funding 
               
               
                   
                   
                 and resource is aligned with 
               
               
                   
                   
                 accountabilities in the business 
               
               
                   
                   
                 and with the group&#39;s strategic 
               
               
                   
                   
                 intent 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 115 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: IT Governance - Manage Service Provider Relationships 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Multiple diverse sourcing strategies in place 
                 Enterprise-level sourcing strategy defined, but 
                 Sourcing strategy flexible end regularly 
               
               
                 Little or no controls in place for vendors 
                 not consistently followed 
                 refreshed based on objectives and degree of 
               
               
                 relationship management 
                 Large or key supplier relationships managed in 
                 commoditization 
               
               
                 Limited contracting rules defined 
                 a consolidated manner 
                 Coordinated management of supplier 
               
               
                 Limited vendor performance process and 
                 External contracting process defined and 
                 relationships aligned with the business/IT 
               
               
                 metrics are in place 
                 applied consistently to key projects 
                 sourcing strategy 
               
               
                   
                 Escalation procedures exist, but not 
                 External contracts managed consistently and 
               
               
                   
                 consistently followed 
                 tracked against contracting rules 
               
               
                   
                 Moritoring and controls for vendor 
                 Vendor performance is actively tracked against 
               
               
                   
                 performance defined and managed within IT 
                 external industry performance benchmark 
               
               
                   
                   
                 Actions taken proactively when potential issues 
               
               
                   
                   
                 are identified 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 116 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: Strategic IT Alignment - Measure Value from IT 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Ownership and accountability of benefits 
                 Ownership and accountability of benefits 
                 Ownership and accountability of benefits 
               
               
                 realization are not clearly defined and 
                 realization agreed between the Business and 
                 realization shared and agreed between the 
               
               
                 communicated 
                 IT for key projects only 
                 Business and IT 
               
               
                 Benefits realization is considered by business 
                 Business managers have limited 
                 Responsibilities are clearly defined and well 
               
               
                 managers to be IT responsibility only 
                 responsibility for benefits realization and 
                 communicated 
               
               
                 Some value-based metrics exit for a few 
                 accountability 
                 Ownership and accountability of benefits 
               
               
                 simple to define areas 
                 Business value metrics connected to IT 
                 realization shared and agreed between the 
               
               
                 No formal communication as to value added by 
                 initiatives exist, but not for all functional areas 
                 Business and IT 
               
               
                 IT 
                 IT works to ensure that business is aware of 
                 Benefits realization is jointly tracked and 
               
               
                   
                 IT&#39;s value add to the enterprise, but not on a 
                 managed by IT and the business 
               
               
                   
                 regular basis 
                 Ownership and accountability of benefits 
               
               
                   
                   
                 realization shared and agreed between the 
               
               
                   
                   
                 Business and IT 
               
               
                   
                   
                 Business and IT fully collaborate to ensure 
               
               
                   
                   
                 that projected benefits will be achieved 
               
               
                   
                   
                 IT and business metrics used to evaluate 
               
               
                   
                   
                 business case and impact and serve as input 
               
               
                   
                   
                 to adjusting estimating methods 
               
               
                   
                   
                 IT produces IT scorecard and IT 
               
               
                   
                   
                 quarterly/annual reports to report business 
               
               
                   
                   
                 value added to the organization 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 117 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: Architecture Management - Network Architecture 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Diverse network architecture in place and 
                 Data network architecture in place for WAN, 
                 Financial considerations in place for network 
               
               
                 functional 
                 MAN , LAN and Internet. 
                 architecture design and implementation 
               
               
                 Blended cost of service per user reported 
                 Configuration Management and Quality 
                 Architecture design and management 
               
               
                 annually 
                 Assurance practiced 
                 improved to appropriate levels (e.g. best in 
               
               
                   
                 Network architecture is consistently enforced 
                 class) and focus on design, operation 
               
               
                   
                   
                 optimization and Total Cost of Ownership 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 118 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: Architecture Management - Operations Architecture 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Operations architecture requirements are 
                 Operations architecture considered across 
                 Active process management for infrastructure 
               
               
                 documented but without ary review and quality 
                 functional units and quality assurance 
                 architecture in place 
               
               
                 control checkpoints 
                 practiced in general 
                 ITIL fully implemented to manage Technical 
               
               
                 Patchy architecture decisions mostly individual 
                 Operations architecture is consistently 
                 Operations, Service Desk and Service Control 
               
               
                 driven 
                 enforced 
                 with measurement and adjustments completed 
               
               
                 Documented inventory of hardware and 
                 Integration of hardware and software 
                 Service strategy and design process revisited 
               
               
                 software components 
                 components practiced, but still inconsistent 
                 annually 
               
               
                 Rudimentary cost analyses accompany 
                 across groups 
                 Financial and service targets as key driver of 
               
               
                 operational architecture development 
                 ITIL processes defined and implemented for 
                 hardware end software portfolio design 
               
               
                   
                 Incident, Capacity*, Availability, Operations, 
                   
               
               
                   
                 Problem, Configuration and Change 
                   
               
               
                   
                 Hardware and software components are 
                   
               
               
                   
                 managed to a limited set of service level 
                   
               
               
                   
                 targets 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 119 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: IT Governance - Plan/Prioritize Initiative Portfolio 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 The are only informal and verbal business 
                 Basic initiative prioritization and approval 
                 Initiatives are continuously examined by IT and 
               
               
                 cases for initiatives before they are 
                 processes defined and consistently followed 
                 Business stakeholders to ensure that 
               
               
                 implemented 
                 Initiatives are defined and evaluated in a 
                 investments and budgets are used 
               
               
                 Risks identified at functional level and for 
                 consistent manner 
                 appropriately 
               
               
                 projects. No overall accountability for IT risks 
                 Basic initiative prioritization and approval 
                 Potential Investments are tracked and 
               
               
                 Attention to IT-related risks is reactive based 
                 processes defined and consistently followed 
                 managed through a multi-stage demand 
               
               
                 on current issues with no overall consideration 
                 Initiatives and projects are evaluated 
                 pipeline with clear decision gates 
               
               
                 for magnitude 
                 independently with minimal consideration for 
                 Initiatives are continuously examined by IT and 
               
               
                   
                 overlap, resource constraints or conflicts 
                 Business stakeholders to ensure that 
               
               
                   
                 Potential high risk scenarios are identified and 
                 investments and budgets are used 
               
               
                   
                 risk mitigation plans developed 
                 appropriately 
               
               
                   
                 Risk checklist is used in sizing projects and 
                 provides a view of future demand and allows 
               
               
                   
                 initiatives. 
                 level of effort invested to scope and shape 
               
               
                   
                 IT asset inventory is complete and accurate. 
                 initiatives to be managed 
               
               
                   
                 Proactive asset management practices in 
                 Initiatives are continuously examined by IT 
               
               
                   
                 place 
                 and Business stakeholders to ensure that 
               
               
                   
                   
                 investments and budgets are used 
               
               
                   
                   
                 appropriately 
               
               
                   
                   
                 Clear visibility of emerging dem and, status 
               
               
                   
                   
                 and interrelationship of in-flight projects. 
               
               
                   
                   
                 Initiatives are continuously examined by IT and 
               
               
                   
                   
                 Business stakeholders to ensure thet 
               
               
                   
                   
                 investments and budgets are used 
               
               
                   
                   
                 appropriately 
               
               
                   
                   
                 Clear visibility of service delivery performance 
               
               
                   
                   
                 IT risk management is an integral part of all IT 
               
               
                   
                   
                 processes. External risk audits are conducted 
               
               
                   
                   
                 and immediately acted upon 
               
               
                   
                   
                 Potential risks are anticipated well in advance 
               
               
                   
                   
                 of their occurrence, and systematic changes 
               
               
                   
                   
                 are instituted to actively manage and mitigate 
               
               
                   
                   
                 risks based on exposure and potential severity 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 120 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: Strategic IT Alignment - Plan and Manage IT Capability 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 IT capabilities are not well documented 
                 IT capabilities are well documented and are 
                 IT continuously evaluates its application and 
               
               
                 Minimal capability assessment performed or 
                 updated through the change control process 
                 infrastructure capabilities to optimize business 
               
               
                 performed against an inadequate information 
                 Capability assessment performed based on the 
                 performance for opportunities to reduce costs 
               
               
                 base 
                 current view of the asset portfolio and 
                 and improve time to market 
               
               
                   
                 architecture 
                 IT capabilities are cortinuously evaluated end 
               
               
                   
                   
                 adjusted based on performance against the 
               
               
                   
                   
                 targeted state and/or changes in progress 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 121 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: Solutions Delivery - Program Management 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Entirely IT driven; limited to no business 
                 Project management is equally shared by IT 
                 Control over the application of information 
               
               
                 involvement 
                 and business management 
                 technology is fully integrated with company&#39;s 
               
               
                 Programs are considered a superset of 
                 A separate charter approved by business 
                 principal functional units 
               
               
                 projects 
                 exists for the program 
                 Joint business and IT steering committee 
               
               
                 Same processes and deliverables for program 
                 Systematic program approval process exists 
                 performs program management 
               
               
                 management as for project management 
                 and generally followed 
                 Program management part of company 
               
               
                 No explicit or formal approval at program level 
                 Master schedule is clearly delineated into 
                 culture, integrating multiple functional 
               
               
                 Rudimentary master schedule developed 
                 releases that are business capability based 
                 disciplines to achieve business outcomes 
               
               
                 Informal program metrics exists, but not well- 
                 Program management metrics include some 
                 Approval process and evaluation criteria 
               
               
                 understood 
                 value realization 
                 actively managed and improved with business 
               
               
                 Same processes and deliverables for program 
                 Program management processes are defined 
                 inputs 
               
               
                 management as for project management - just 
                 and focused on interdependence between 
                 Proactive planning, review end packaging of all 
               
               
                 summarized 
                 projects 
                 projects 
               
               
                 Program-level reporting is informal 
                 Program communications more than simple 
                 Business value-based program metrics 
               
               
                   
                 aggregation- reports progress to achievement 
                 continuously monitored jointly with business 
               
               
                   
                 of overall vision and business results; 
                 Program management processes are ingrained 
               
               
                   
                 separation of project versus program risks and 
                 as a part of the enterprise-wide processes 
               
               
                   
                 issues 
                 Program management processes focus on 
               
               
                   
                 Program reporting at times inconsistent 
                 realizing business value and actively managed 
               
               
                   
                   
                 and improved with business inputs 
               
               
                   
                   
                 Program milestones and deliverables actively 
               
               
                   
                   
                 monitored jointly with business 
               
               
                   
                   
                 Program reporting prompts C-level executives 
               
               
                   
                   
                 to take appropriate actions 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 122 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: Solutions Delivery - Quality Management 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Quality assurance process is informal 
                 Key Processes defined and implemented: 
                 Engrained management of stakeholders and 
               
               
                 Implementation of improvement initiatives not 
                 Process Quality Assurance 
                 development of stakeholder goals and 
               
               
                 coordinated or prioritized 
                 Solution Quality Management 
                 expectations as a guide to process 
               
               
                 Informal quality standards exists 
                 Management of key stakeholders performed 
                 improvement 
               
               
                 Informal quality targets set 
                 Planned and coordinated implementation of 
                 Process and product QA consistently 
               
               
                 Customer, client, and employee surveys 
                 improvement initiatives 
                 managed and tracked. Regular scheduled 
               
               
                 conducted rarely, survey results inconsistently 
                 Quality standards exist, but not consistently 
                 reviews of process and product quality. Non- 
               
               
                 analyzed to and interpreted to guide immediate 
                 followed 
                 compliance issues is formally communicated 
               
               
                 improvement activities only 
                 Various naming conventions and templates 
                 and resolution is implemented 
               
               
                   
                 Program/project management is evaluated 
                 Existence of an organization wide Software 
               
               
                   
                 based on a balanced scorecard that captures 
                 Quality Assurance (SQA) group with a quality 
               
               
                   
                 productivity and outcome information 
                 assure or assigned to each project to ensure 
               
               
                   
                 Customer, client, end employee surveys 
                 process compliance for processes 
               
               
                   
                 conducted on an ad hoc basis; survey results 
                 Standardized set of naming conventions, 
               
               
                   
                 analyzed and interpreted to guide immediate 
                 templates and quality standards exists and 
               
               
                   
                 improvement activity 
                 regularly updated 
               
               
                   
                   
                 Advanced metrics collected and actively 
               
               
                   
                   
                 managed with all stakeholders involved 
               
               
                   
                   
                 Regular customer, client, and employee 
               
               
                   
                   
                 surveys administered by clear 
               
               
                   
                   
                 communications; survey results analyzed and 
               
               
                   
                   
                 interpreted to guide immediate and future 
               
               
                   
                   
                 improvemert activity 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 123 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology 
                 Capability: Architecture Management - Security Architecture 
               
               
                 Operations 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Security architecture is loosely documented 
                 Frameworks such as GIM TS (ISO 13335), 
                 Security architecture designed within 
               
               
                 without quality standards 
                 COBIT, and ISO 17799 defined and applied to 
                 frameworks to enable and facilitate business 
               
               
                 One or additional diverse security 
                 infrastructures, policies, services and 
                 value and provide effective risk management 
               
               
                 infrastructures, services, policies, standards, 
                 operations as well as their management 
                 Harmonized security architectures for 
               
               
                 administration and operations in place 
                 Security architecture is consistently followed 
                 Infrastructures, policies, services and 
               
               
                 No cohesion with industry standards or 
                 Enterprise security architecture consistently 
                 operations acccrding to published frameworks 
               
               
                 frameworks 
                 practiced across groups 
                 Business Continuity/Disaster Recovery plans 
               
               
                 Limited Business Continuity and Disaster 
                 Cohesion between utilized standards such as 
                 are managed and regularly refreshed to ensure 
               
               
                 Recovery considerations 
                 ISO 17799, for services, policies, operations 
                 business success 
               
               
                   
                 and infrastructure. 
                   
               
               
                   
                 Business Continuity/Disaster Recovery for 
                   
               
               
                   
                 defined critical set of applications 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 124 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology Operations 
                 Capability: Service and Management Operations - Service Delivery 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Informal, reactive service provided. 
                 Service desk is established and processes are 
                 Service support process and policies are 
               
               
                 Fragmented technology, if it exists at all 
                 standardized and documented 
                 regularly monitored and refreshed using 
               
               
                 Escalation process may exist, but is 
                 Service desk functionality supported by 
                 customer input end performance statistics 
               
               
                 undocumented and is not monitored 
                 software and technology that streamlines 
                 Tools and technology are regularly reviewed 
               
               
                 Communication process may exist, but is 
                 service and minimizes human involvement 
                 and technology scan performed to refresh 
               
               
                 haphazard, individual effort based 
                 Escalation processes are documented and 
                 existing tools 
               
               
                 Ad hoc measurement of service performance 
                 applied informally and inconsistently 
                 Escalation processes are well structured and 
               
               
                 No formal agreements on SLAs/OLAs 
                 Customer communication process 
                 monitored for adherence 
               
               
                 Availability monitoring is informal and no 
                 documented and articulated to the organization 
                 Escalation results conveyed back to customer 
               
               
                 accountability for performance exists 
                 Efforts made to inform customers of current 
                 Customers are surveyed regularly regarding 
               
               
                 Ad hoc measurement of service performance 
                 service availability 
                 overall satisfaction with the service desk 
               
               
                 Informal reviews of SLAs/OLAs 
                 Service requirements for OLAs and SLAs are 
                 Customers are surveyed to confirm 
               
               
                   
                 established 
                 satisfaction upon call resolution 
               
               
                   
                 SLAs/OLAs are measured inconsistently, 
                 SLA/OLA monitoring plan specified as part of 
               
               
                   
                 organization makes the effort but automation 
                 contract 
               
               
                   
                 not developed to the point where 
                 Comprehensive service catalog linked to 
               
               
                   
                 measurements are accurate 
                 hierarchy of howservices are related 
               
               
                   
                 Organization able to catalog services offered 
                 OLAs/SLAs for particular service consistent 
               
               
                   
                 by IT 
                 across providers 
               
               
                   
                 Organization has SLAs/OLAs in place, does 
                 End to end monitoring enables accurate 
               
               
                   
                 not know for certain whether or not they are 
                 measurement of business services, bath from 
               
               
                   
                 met 
                 an availability and a performance perspective 
               
               
                   
                 Service breaches are usually identified, but not 
                 Incidents can be linked to services 
               
               
                   
                 always related back to SLA 
                 SLA/OLA monitoring plan specified as part of 
               
               
                   
                 SLAs/OLAs are written, review schedule is set 
                 contract 
               
               
                   
                 out nobody is responsible for actually following 
                 Comprehensive service catalog linked to 
               
               
                   
                 up. Consequently, updates often do not occur 
                 hierarchy of howservices are related 
               
               
                   
                 or are late 
                 OLAs/SLAs for particular service consistent 
               
               
                   
                   
                 across providers 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 125 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology Operations 
                 Capability: Service and Management 
               
               
                   
                 Operations - Service Support 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Little to no assessment performed prior to 
                 Impact analysis performed, service analysis 
                 Service introduction approach proactively 
               
               
                 service introduction and is mostly informal 
                 conducted and operability acceptance criteria 
                 reviewed with key stakeholders for sign off 
               
               
                 Support organization readiness assessment 
                 defined 
                 A service readiness plan is created and 
               
               
                 informal and ad hoc, mostly individual efforts 
                 Support organization is base lined (people, 
                 managed detailing a timeline of the key 
               
               
                 based 
                 process, commercial, financial end operational) 
                 readiness activities that will need to be 
               
               
                 Ad hoc development of service related 
                 and service readiness assessment performed 
                 performed to make organization ready for go- 
               
               
                 documents, mostly individual efforts based 
                 for critical service introductions 
                 live of the new services 
               
               
                 Informal and ad hoc to define configuration 
                 Service delivery handover matrix developed 
                 Service documents are jointly reviewed with 
               
               
                 items and processes 
                 and documented 
                 customers and service introduction team 
               
               
                 Configuration items loosely identified via ad 
                 Business problem identified, process 
                 Continuous feedback from customers and 
               
               
                 hoc methods and are not documented 
                 requirements identified and implementation 
                 support group utilized to optimize the matrix 
               
               
                 Initial efforts to identify dependency between 
                 approach documented and articulated 
                 Configuration management plan proactively 
               
               
                 configuration management and other functional 
                 All configuration items, labels, data sources, 
                 reviewed with key stakeholders for sign off and 
               
               
                 processes with no outcomes 
                 data owners and selection criteria clearly 
                 is updated on a regular basis 
               
               
                 Releases done informally, no preplanning 
                 identified, documented and articulated 
                 Configuration manager assigned to manage 
               
               
                 except for staff discussions and some testing 
                 Efforts to integrate configuration management 
                 definition process and involve key stakeholders 
               
               
                 at individual or group level 
                 with some key service management processes 
                 for input and sign-off 
               
               
                 Ad hoc release plans and schedules created 
                 Standard procedures for building, 
                 Configuration management database 
               
               
                 and communicated upon request 
                 implementing, and configuring of releases are 
                 maintained and actively managed 
               
               
                 Ad hoc release testing performed if any 
                 documented and used across the organization 
                 Functional processes an integral part of 
               
               
                 Rollouts done informally, processes vary 
                 Release plans and schedules communicated 
                 configuration management process, entire 
               
               
                 between groups 
                 across organization 
                 process proactively managed for 
               
               
                 Change process exists, but not formalized 
                 Clearly, defined release testing procedures 
                 improvements 
               
               
                 Changes are scheduled, usually according to 
                 exist 
                 Management review of release plans done on a 
               
               
                 “scheduled maintenance” windows 
                 Rollout plans documented, communicated and 
                 regular basis 
               
               
                 Change discussed informally. Groups meet to 
                 utilized throughout the organization 
                 Extensive use of tools for work flow, 
               
               
                 discuss impending changes, but no formal 
                 Formal process specified, documented and 
                 documentation and builds streamline build 
               
               
                 methodology for approval 
                 enforced 
                 process and improve reliability 
               
               
                 Post implementation check done informally 
                 Schedule of changes exists and is available 
                 Customers kept aware of impending releases 
               
               
                 Software licenses are reactively controlled and 
                 across the organization 
                 along with schedules and work plan 
               
               
                 renewed only when licenses expire 
                 Projected service availability is updated with 
                 Release testing feedback proactively integrated 
               
               
                 Informal audits on an “As Needed” basis 
                 scheduled downtime and distributed across 
                 to optimize process 
               
               
                 Problem detection is reactive with process 
                 organization 
                 Comprehensive rollout plans include dates, 
               
               
                 initiated by affected users 
                 Formal process specified and documented 
                 times, back out procedures, components 
               
               
                 No formalized method far recording reported 
                 Change Advisory Board or similar structure is 
                 affected, etc. 
               
               
                 problems 
                 designated to approve changes 
                 Rollout schedule flexible, can be changed to 
               
               
                 Escalation process may exist, but it is 
                 Standard methodology documented for post 
                 accommodate problems identified doing 
               
               
                 haphazard, undocumented and is not 
                 implementation reviews. 
                 testing 
               
               
                 monitored 
                 Evaluation criteria for post implementation 
                 Changes are prioritized according to industry 
               
               
                 Incident detection is reactive with process 
                 review is identified and established 
                 accepted priority levels 
               
               
                 initiated by affected users 
                 Defined and well documented software 
                 Proactive change process management using 
               
               
                 No single point of contact 
                 licenses management policies and procedures 
                 performance data and user input 
               
               
                 Incidents resolution is done reactively utilizing 
                 across organization. 
                 Change schedules proactively reviewed and 
               
               
                 resources available 
                 Software is tracked for license expiration and 
                 optimized using performance metrics and user 
               
               
                 Escalation process may exist, but it is 
                 illegal use 
                 input 
               
               
                 haphazard, undocumented and is not 
                 Responsibility for tracking and acquiring 
                 Users proactively notified of impending 
               
               
                 monitored 
                 licenses is specific and limited to a single 
                 changes 
               
               
                   
                 person or team 
                 Change process is proactively monitored and 
               
               
                   
                 Some audits performed using auto discovery 
                 reviewed for enhancements 
               
               
                   
                 or other tools 
                 Financial, technical, business and customer 
               
               
                   
                 Clear processes defined as to when/how 
                 considerations are considered before approval 
               
               
                   
                 audit are to be performed 
                 is granted 
               
               
                   
                 Problem management system and associated 
                 Post implementation review process 
               
               
                   
                 staffing identified and budget for staffing, 
                 continuously reviewed and updated 
               
               
                   
                 training and support is allocated 
                 Post implementation review includes evaluation 
               
               
                   
                 Problems logged centrally in a database 
                 of customer satisfaction derived from customer 
               
               
                   
                 A formal process for problem escalation 
                 feedback 
               
               
                   
                 emerging, but still inconsistent across groups 
                 Organization has processes in place to moritor 
               
               
                   
                 Incident management system and associated 
                 licenses across vendors and operating 
               
               
                   
                 staffing identified and budget for staffing, 
                 systems 
               
               
                   
                 training and support is allocated 
                 Active enforcement of system software 
               
               
                   
                 Incidents reported reactively to single point of 
                 inventory and ability to track down software 
               
               
                   
                 contact 
                 that is not authorized or that does not meet 
               
               
                   
                 Formal resolution process exists, with 
                 security specifications 
               
               
                   
                 appropriate recording of each step in incident 
                 Software inventories on individual systems 
               
               
                   
                 database 
                 monitored via automated technology 
               
               
                   
                 Responsibilities of each support group are 
                 Audits scheduled at intervals specified by 
               
               
                   
                 documented and well understood across 
                 needs of organization 
               
               
                   
                 organization 
                 Mostly automatic, automation runs across 
               
               
                   
                 Responsibilities of each support group are 
                 operating systems and software 
               
               
                   
                 documented and well understood across 
                 Problem management function is integrated 
               
               
                   
                 organization 
                 with incident management and categories, 
               
               
                   
                 Some form of knowledge base assists 
                 impact levels, urgency levels and priority levels 
               
               
                   
                 resolution process 
                 are consistent between the two 
               
               
                   
                 A formal process of problem escalation exists, 
                 Problem resolution process is proactively 
               
               
                   
                 but not consistently followed across groups 
                 reviewed for enhancements 
               
               
                   
                   
                 Escalation processes are well structured and 
               
               
                   
                   
                 moritored for adherence 
               
               
                   
                   
                 The organization tracks problems throughout 
               
               
                   
                   
                 the lifecycle and knows status at any given 
               
               
                   
                   
                 time 
               
               
                   
                   
                 The incident management function is 
               
               
                   
                   
                 established and operational responsibilities are 
               
               
                   
                   
                 clearly defined and documented 
               
               
                   
                   
                 Incidents captured in incident database for 
               
               
                   
                   
                 reporting and trending 
               
               
                   
                   
                 Resolution process is reviewed regularly for 
               
               
                   
                   
                 effectiveness and efficiency 
               
               
                   
                   
                 Staff is highly trained and cross-trained, with 
               
               
                   
                   
                 no single person who is the sole expert in a 
               
               
                   
                   
                 particular area 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 126 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology Operations 
                 Capability: Solutions Delivery - Systems Building 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Informal methods exist with loosely defined 
                 Systems Development methodolgy exists 
                 The standard methodology is flexible enough to 
               
               
                 requirements 
                 and is adhered to at across all projects 
                 encompass the full range of project sizes, 
               
               
                 Each project has a charter and plan 
                 Stakeholder expectations formally involved in 
                 types and complexities 
               
               
                 Planning and requirements due diligence is IT 
                 planning 
                 Incremental benefits explicitly linked to specific 
               
               
                 driven 
                 Requirements are tracked and controlled with 
                 requirements and actively managed 
               
               
                 Build techniques and environment at team 
                 change control 
                 Post deployment validation a part of enterprise 
               
               
                 discretion 
                 Design documents are tracked and controlled 
                 deployment methodology and actively 
               
               
                 Projects often begin detailed and technical 
                 and reviewed with enterprise architecture 
                 managed 
               
               
                 design with limited requirements due diligence 
                 board 
                 Business realization and linkage of systems 
               
               
                 Few templates exist and are used 
                 Formal reviews/steering meetings at the end of 
                 products to benefits integrated into 
               
               
                 inconsistently 
                 each phase 
                 methodology 
               
               
                 Projects have their own processes 
                 Unit and system testing formalized and 
                   
               
               
                   
                 standardized with sign-off 
                   
               
               
                   
                 Formal development guidelines in place and 
                   
               
               
                   
                 consistently followed 
                   
               
               
                   
                 Formal stage gating factors in place 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 127 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology Operations 
                 Capability: Solutions Delivery - Systems Maintenance 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Informal systems maintenance processes and 
                 Defined service processes for applications 
                 Applications assessed for optimal performance 
               
               
                 standards 
                 Consistently followed across groups 
                 on a regular basis 
               
               
                 Only reactive maintenance performed 
                 Break-fix activity is separated from 
                 Application tiering is frequently reviewed with 
               
               
                 Large problem back log, no prioritization, no 
                 enhancements 
                 business regarding business impact 
               
               
                 maintenance releases 
                 Work load is prioritized and triaged weekly 
                 SLA metrics are actively tracked and managed 
               
               
                 No periodic assessment of application portfolio 
                 Emergency changes are expedited, other 
                 with business implications 
               
               
                 Informal SLAs exist, but rot-well understood 
                 changes are assigned to maintenance or 
                 Systems design, operations and user 
               
               
                 Documentation limited; discretionary 
                 development releases 
                 documentation is automatically updated as a 
               
               
                   
                 SLAs exist for critical applications 
                 part of configuration management 
               
               
                   
                 Controlled approach assures documentation is 
                 Documentation stored electronically and readily 
               
               
                   
                 normally updated during projects and 
                 available to all groups 
               
               
                   
                 maintenance 
                   
               
               
                   
                 No coordination of effort to ensure updates are 
                   
               
               
                   
                 consistent 
                   
               
               
                   
                 Document includes functional and technical 
                   
               
               
                   
                 information 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 128 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Information Technology Operations 
                 Capability: Strategic IT Alignment - Value Proposition Development 
               
               
                   
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 IT is viewed generally as a cost of doing 
                 Business executives are looking to enhance 
                 IT funds and resources are allocated to 
               
               
                 business, to automate respective business 
                 the use of IT beyond basic process 
                 strategic and value-creating operational 
               
               
                 functions 
                 automation, into decision support and patient 
                 initiatives 
               
               
                 There are only informal and verbal business 
                 services areas 
                 CEO and Board Members actively discuss the 
               
               
                 cases for initiatives before they are 
                 Discretionary spending is usually a percentage 
                 IT agenda 
               
               
                 implemented 
                 of IT budget 
                 Business case is jointly owned and managed 
               
               
                   
                 A detailed Business Case is developed at the 
                 by business and IT 
               
               
                   
                 outset with financial measures and metrics 
                   
               
               
                   
                 (e.g. target run-rate savings) identified, tracked 
                   
               
               
                   
                 and updated on an ongoing basis 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
           
               
                 TABLE 129 
               
               
                   
               
               
                 Global Health and Life Sciences High Performance 
               
               
                 Capability Assessment Model - Public Health Services - Medicaid 
               
               
                   
               
             
             
               
                 Enterprise 
               
             
          
           
               
                 Sub-Platform: Facilities Management 
                 Capability: Manage 
               
               
                   
                 Facilities and Mail 
               
               
                   
               
               
                 Basic 
               
               
                   
               
               
                 4.7.1.1 Manage Facilities 
                   
               
               
                 4.7.1.2 Manage Mail Functions 
                   
               
               
                 Manage Intake 
                   
               
               
                 Manage Internal Distribution 
                   
               
               
                 Manage Privacy and Security of Mail 
                   
               
               
                 Manage Processing and Distribution to 
                   
               
               
                 Postal Service, Private Carriers, etc.