FM14 Manage Accounts Payable Disbursement Linda Gonzales, John Padilla Medical Assistance Division – Systems Bureau FM15 Manage 1099s Linda Gonzales, John Padilla Medical Assistance Division – Systems Bureau FM16 Formulate Budget Anna Nolasco, Lucinda Sydow Medical Assistance Division - Budget Planning & Reporting Bureau FM17 Manage Budget Information Angie Carlton Administrative Services Division - Grants Management Bureau FM18 Manage Fund Donna Sandoval Administrative Services Division - Grants Management Bureau FM19 Generate Financial Report Lucinda Sydow Medical Assistance Division - Budget Planning & Reporting Bureau Member Management (ME) ME01 Manage Member Information Roy Burt Medical Assistance Division – Eligibility Bureau ME02 Manage Applicant and Member Communication Roy Burt Medical Assistance Division – Eligibility Bureau ME03 Perform Population and Member Outreach Roy Burt Medical Assistance Division – Eligibility Bureau ME08 Manage Member Grievance and Appeal Roy Burt Medical Assistance Division – Eligibility Bureau Operations Management (OM) OM04 Submit Electronic Attachment Linda Gonzales, John Padilla Medical Assistance Division – Systems Bureau OM05 Apply Mass Adjustment Linda Gonzales, John Padilla Medical Assistance Division – Systems Bureau OM07 Process Claim Linda Gonzales, John Padilla Medical Assistance Division – Systems Bureau
In the context of this assessment Other State Agencies referenced below include but are not limited to ALTSD, BHSD, CYFD, and DOH. Table - Stakeholder Data Exchange Inventory Business Area Stakeholders Business Relationship Management Other State Agencies, Trading Partners, Business Associates, Federal Agencies Care Management Vendors, MCOs, Members, Providers, Other State Agencies and Facilities Contractor Management Contractors Eligibility and Enrollment Management Members, Vendors, MCOs Financial Management TPL Contractor, Providers, Members, State Treasurer, DFA, Drug Manufacturers, CMS, Contractors, MCOs, Estate Recovery Contractor, IRS, Legislators Member Management Members Operations Management Vendors, MCOs, Providers, Members, State Treasurer, DFA Performance Management Members, Providers, Attorney General Plan Management Members, Providers, Legislature, MCOs, Vendors Provider Management Vendors, Providers, Attorney General Systems and Applications Inventory The PMO Team created a preliminary system inventory and application list by reviewing State-supplied documents, including the New Mexico MITA 2.01 SS-A and the SMHP. As Business Capability Matrices (BCMs) were created, applications that were used to perform the MITA Business Processes were identified. The System Inventory was then mapped to the MITA Business Processes that utilize the systems to establish a complete crosswalk between those systems and their respective MITA Business Process and Business Area. The completed system inventory, validated by appropriate State SMEs, is presented in the table below.
CO07 Manage Contract No Systems Identified CO08 Close Out Contract No Systems Identified CO09 Manage Contractor Grievance and Appeal No Systems Identified Eligibility and Enrollment Management (EE) Eligibility and Enrollment Management (EE) EE01Determine Member Eligibility ASPEN EE02 Enroll Member Omnicaid EE03 Disenroll Member Omnicaid EE04 Inquire Member Eligibility Omnicaid, ASPEN, AVRS, Member Portal EE05 Determine Provider Eligibility Provider Portal, Omnicaid EE06 Enroll Provider Provider Portal, Omnicaid EE07 Disenroll Provider Omnicaid EE08 Inquire Provider Information Omnicaid, ASPEN, AVRS, Provider Portal Financial Management (FM) Financial Management (FM) FM01 Manage Provider Recoupment Omnicaid FM02 Manage TPL Recovery Omnicaid FM03 Manage Estate Recovery Omnicaid FM04 Manage Drug Rebate Omnicaid, SHARE, DRAMS, PDCS OS+ FM05 Manage Cost Settlement Omnicaid, SHARE FM06 Manage Accounts Receivable Information Omnicaid, SHARE FM07 Manage Accounts Receivable Funds Omnicaid, SHARE FM08 Prepare Member Premium Invoice Not performed in NM currently FM09 Manage Contractor Payment Omnicaid FM10 Manage Member Financial Participation Omnicaid, SHARE FM11 Manage Capitation Payment Omnicaid, SHARE
information using an integrated voice response system Work toward enhancing ASPEN to determine eligibility using real-time case processing functionality Refine nationally-recognized process of triage intake at field offices at the start of each day Implement the MMIS Modular Framework approach to achieve interstate data and system interoperability through standardization, reuse, and sharing Integrate New Mexico’s behavioral health system within the changing healthcare environment (Develop seamless and integrated systems that communicate effectively to achieve common Medicaid goals through interoperability and common standards) Collaborate with and support development of Medicaid “health homes” for chronic conditions that integrate community behavioral health and primary care services and emphasize health promotion, addressing the integration of care for people with serious mental illness and substance abuse problems Develop and facilitate the implementation of Behavioral Health “Health Homes” in collaboration with Core Services Agencies (CSAs) Further develop Wellness Centers that offer support, education, information, and opportunities to assist consumer recovery Strengthen the development of behavioral health services for adults and children Expand and improve the capacity of the behavioral health workforce in New Mexico Implement the MMIS Modular Framework approach to achieve interstate data and system interoperability through standardization, reuse, and sharing Upgrade and/or replace IT systems for improved simplicity and better efficiencies (Develop seamless and integrated systems that communicate effectively to achieve common Medicaid goals through interoperability and common standards) Continue planning activities for the MMIS replacement project Implement workflow technology to streamline activities Implement technology that improves the quality of data, access to data, and the ability to share data with other entities Implement technology that encourages the performance of standardized processes across the Enterprise and State
Recipients – NM residents who apply for or who receive Medicaid Enterprise benefits Applicants submit applications either by phone, fax, mail, or entered directly through YES-NM Recipients submit eligibility verifications in electronic and paper format Recipients receive multiple notices regarding eligibility from the Medicaid Enterprise and the MCO Medicaid identifies individuals, based on standardized criteria, who qualify for cost-sharing reductions, Medicaid or CHIP, and other insurance affordability programs Medicaid conducts near-real time verification of application information and, where possible, enrolls the individual into coverage real-time and notifies the issuer of new enrollment Centers for Medicare & Medicaid Services (CMS) - A branch of the U.S. Department of Health and Human Services (HHS). CMS is the federal agency that administers Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). CMS provides information for health professionals, regional governments, and consumers. Medicaid Enterprise submits invoices and Medicaid Statistical Information System (MSIS) reports via email Medicaid Enterprise electronically submits CMS budget reports using MBES/CBES CMS systems exchange information with Medicaid agencies and the Health Information Exchange (HIE) to populate MSIS and derive other budget information in real-time For administrative reporting, CMS systems interface with the State Medicaid Enterprise to derive records needed for reports Other Payers – Other benefit programs with liability to cover medical costs for Medicaid recipients. Includes private insurers Benefit information is exchanged prospectively Other benefit programs share benefit coverage with Medicaid Automated business rules perform coordination of benefits, preferably utilizing data exchanges focused on a cost avoidance mode, rather than pay and chase
identified in the Workforce Impact Analysis. The plan also includes any policy, procedure and training changes that need to be made Develop regional standards (industry, MITA and/or national) Data standards are necessary when two or more parties exchange information. The key elements of a data standard are data element names, definitions, qualifiers, data types, relationships, semantics, and contextual rules. From a business point of view, data standards represent agreements on the format and description of the shared data used by the Medicaid Enterprise. Data standards describe objects, features, or items collected, automated, or affected by the business processes of a State Medicaid Enterprise 707 Policy Rules Management (Rules Engine) A mechanism that employs a business rules engine or business process management software to record business rules for many business functions, including but not limited to, provider enrollment, claims processing, and service authorization 599 Technology Web Services A software system designed to support interoperable interaction over a network 469 Technology Develop regionally standardized processes and policies A statement of intent that is used to implement or adopt processes 380 Process/Policy Document Management and supporting policy Software that controls and organizes documents throughout an organization. It incorporates document and content capture, workflow, document repositories, COLD/ERM, and output systems, and information retrieval systems. Also, 293 Technology/Policy machine