Table : ACA Impacts on Eligibility Determination ACA Section Requirement 4004 Education and outreach campaign regarding preventive benefits and obesity-related care. OM07 – Audit Claim/Encounter Table : ACA Impacts on Audit Claim/Encounter ACA Section Requirement 6507 Requires compliance with National Correct Coding Initiative (NCCI). OM16 – Prepare Health Insurance Premium Payment OM21 – Prepare Member Premium Invoice In these processes, the Commonwealth is covering the member’s share of the premium for medical coverage. The premium billing, collections, and reconciliation processes for member premiums may be handled through the HBE process/system/vendor depending on the Commonwealth’s solution. The Division for Medicaid Services (DMS) could realize some gains in efficiency by eliminating a manual Medicaid process and incorporating it into the HBE. OM20 – Calculate Spend Down Amount The Spend Down process typically covers clients with incomes slightly higher than Medicaid eligibility limits. In these cases, the HBE will offer increasing health care subsidies for health insurance coverage leading up to full Medicaid coverage. The participants would likely qualify for coverage which may eliminate the need for the Spend Down process. OM26 – Manage Recovery Table : ACA Impacts on Manage Recovery Process ACA Section Requirement 6411 The ACA requires the contracting of a Recovery Audit Contractor (RAC). 6506 This provision extends the period of time for recovery to one year from the time of discovery. PG02 – Develop and Maintain Benefit Package Table : ACA Impacts on Benefit Packages ACA Section Requirement 2001 States must create and maintain benchmark plans as well as the “newly eligible” benefit category. 2001 Beginning in 2014, benchmark and benchmark-equivalent plans must begin providing at least essential health benefits, as described in Section 1302(b).
BR02 Manage Business Relationship The business process is supported by proprietary Electronic Data Interchange (EDI) and standardized data and format from multiple sources. Industry Standard Condition Internal data standards have been implemented and HIPAA standards for transactions are in use. BR02 Manage Business Relationship Manual communication and processing are not timely. Industry Standard Condition Some use of electronic interchange, automation of some steps, and internal (and HIPAA) data standards have increased coordination and consistency, thus improving end-to-end time frames for communication and processing. BR03 Terminate Business Relationship The process requires up to 30 days. Business Results Condition Improve process time to average 10 days or less BR03 Terminate Business Relationship Manual operation results in subjective selection of data to be used. Business Results Condition Implement standards BR03 Terminate Business Relationship The process relies primarily on manual activities. Business Results Condition Implement automation to improve efficiency BR04 Manage Business Relationship Communication The business process is supported by proprietary EDI and non-standardized data and format from multiple sources. Industry Standard Condition Adopt HIPAA standards for transactions BR04 Manage Business Relationship Communication There is lack of data accuracy and completeness. Industry Standard Condition Use of HIPAA data exchange standards, and increased use of automation reduces inaccuracies
CM03 Manage Medicaid Population Health Using census, vital statistics and other data sources, information should be distributed to targeted groups Interoperability Condition Proposed systems need to support interoperability with HIE, public health agencies, and other human service programs. CM04 Manage Registry Process promotes connection with health care organizations and other States with respect to managing the exchange of information Industry Standard Condition Expansion and adherence to HIE standards and practices will improve this process CM04 Manage Registry Current registry is growing and expanding connectivity Business Results Condition Expand KHIE access to include all health care providers CM04 Manage Registry Process includes management of laboratory information, claim information from Medicaid, hospitals and health care practitioners Interoperability Condition Exchange of information between involved parties is critical to the process
Table : Contractor Management Detailed Results Business Process Kentucky MITA Capability Gap Condition/Standard Action to Meet MITA To Be and 7C&S CO01 Produce Administrative or Health Services RFP Contract data are centralized and maintained electronically. There is coordination between agencies. Requirements tracking and maintenance are centralized. Industry Standard Condition Centralized contract data should utilize automation where possible. MITA standards need to be integrated into the RFP process. Improve coordination between agencies to eliminate duplication of contracted services. CO01 Produce Administrative or Health Services RFP Completed RFPs are available for response by potential vendors Reporting Condition Publish completed RFPs in various formats CO01 Produce Administrative or Health Services RFP Manual means are primarily used to create RFPs Leverage Condition Complete RFPs utilizing current MITA standards that serve as models for additional RFPs CO02 Award Administrative or Health Services Contract The process complies with state and federal regulations however; manual processes adversely affect cost effectiveness. Business Results Condition Utilize defined data and content standards; centralization reduces process costs and allows staff to shift some attention to cost management and ongoing quality improvement. CO02 Award Administrative or Health Services Contract Proposal information is received and verified in various methods Reporting Condition Results of the proposal process should be published and available for inquiry CO03 Manage Administrative or Health Services Contract Monitoring tools are used to track adherence to contract requirements Modularity Standard Use of a separate rules engine would facilitate contract monitoring (especially administrative)
CO05 Manage Contractor Information Updates to the contractor master file are made from many different fax and paper sources. Staff members rely upon manual and subjective validation methods. Business Results Condition Process should use requests that are standardized and automated which increases the efficiency and accuracy CO06 Manage Contractor Communication Process is primarily manual using electronic forms of communication Business Results Condition Inquiries should be received and processed by centralized contract monitoring group CO06 Manage Contractor Communication Information regarding potential changes and contract activities is distributed Reporting Condition Communications targeting prospective vendors must be made available CO07 Perform Contractor Outreach Staff manually verifies that the information is accurate. Reporting Condition Electronic communications should have built-in verifications of accuracy. CO07 Perform Contractor Outreach Information for the outreach is manually accessed. This adds to the time requirements for this process. Business Results Condition Some information for the process should be accessible electronically. This reduces the time requirements for launching the outreach. CO08 Support Contractor Grievance and Appeal Process is (and includes documents required to be paper), and may take an extended period of time to complete Business Results Condition Incorporate automation tools such as document imaging and Workflow.
ME02 Enroll Member The system makes rules-based decisions to determine the program for which an individual qualifies; completion of the process is a collaborative activity Business Results Condition Process is a combination of automated and manual processes; manual steps are not efficient, Rules Engine would automate some of the process. ME02 Enroll Member Process requires the interaction of systems for various stakeholders. Workers in remote offices use KAMES to process application data. Interoperability Condition Ensure that open interfaces are established and maintained. ME03 Disenroll Member Decisions on programs and levels of eligibility are initially determined by system rules Modularity Standard Separate business rules from core programming. ME03 Disenroll Member The process is primarily manual. Disenrollment information is manually entered and automatically updates to the eligibility/ enrollment data store. Business Results Condition Automate the process where possible with some data still manually entered. Automate the application of business rules to increase overall efficiency.
ME03 Disenroll Member Process requires the interaction of systems for various stakeholders. Workers in remote offices use KAMES to process application data. Interoperability Condition Automate the disenrollment of members based on State business rules or Federal regulations. Members should also be automatically disenrolled from Waiver and Managed Care programs if program rules require it. ME04 Inquire Member Eligibility Requests are received in various formats, primarily electronic transactions Modularity Standard Implement standard SOA based services to make the process modular and standardized across the enterprise. ME04 Inquire Member Eligibility Process is a combination of several inquiry technologies and systems. Automated inquiries currently use HIPAA transactions and AVRS functionality. Interoperability Condition Convert the process to exposed services using open interfaces ME05 Manage Applicant and Member Communication Requests are received in various formats, primarily electronic transactions Modularity Standard Implement electronic communication methods to merge inquiries into a single stream and maintain electronic copies of communications. ME05 Manage Applicant and Member Communication Most inquiries are researched manually, leading to inconsistent results and efficiency Business Results Condition Implement automated tools for workflow management to streamline response process.
ME06 Manage Member Grievance and Appeal This is an all-manual process. Grievances and appeals are filed via fax and USPS. Confidential documents are transferred by certified mail. Business Results Condition Documents should be scanned and the case file automated and shared among case workers. ME06 Manage Member Grievance and Appeal No standards beyond general requirements for establishing a case. Industry Standard Condition Establish local documentation standards and work towards MITA standards ME07 Manage Member Information A member’s data store record will include all eligibility and enrollment spans, and support flexible administration of benefits from multiple programs so that a member may receive a customized set of services Reporting Condition Enable the data store to be used to provide information and statistics for a variety of activities ME07 Manage Member Information This process is associated with many other processes which utilize Member Information Modularity Standard Develop open interfaces and expose standard services ME08 Perform Population and Member Outreach Process is high costs reduce frequency of outreach. Business Results Condition Use automation to improve results in targeting populations needing outreach and education.
Table : Operations Management Detailed Results Business Process Kentucky MITA Capability Gap Condition/Standard Action to Meet MITA To Be and 7C&S OM02 Authorize Service Manual processes are used by the Commonwealth for authorization for FFS claims needing preapproval or post approval Business Results Condition Implement automation to be more effective and efficient OM02 Authorize Service The Authorize Service request may take many days. Accessing the data required to make the decision may take days. Modularity Standard Implement a separate Rules Engine to automate processes OM02 Authorize Service Authorization of service is communicated to other health care agencies and participants Interoperability Condition Improve the exchange of data by automating the approval/denial notifications. OM03 Authorize Treatment Plan Authorize Treatment Plan requests are manually validated against state specific business rules. Modularity Standard Implement a separate Rules Engine to automate processes
OM19 Manage Payment Information Provides data to other business processes Reporting Condition Accurate data should be maintained and exposed to authorized processes within the organization OM20 Calculate Spend Down Amount System manages spend down rules Modularity Standard Rules engine should be separate OM21 Prepare Member Premium Invoice Premium amounts are calculated based upon a variety of factors Modularity Standard Implement a separate rules engine OM21 Prepare Member Premium Invoice Calculation process is manual and relies of data external to MMIS Business Results Condition Automate the calculation process, possibly integrate with the HBE OM21 Prepare Member Premium Invoice Invoices are created manually Reporting Condition Make invoice information available to other systems OM22 Manage Drug Rebate System calculates amounts for rebate for each manufacturer using internal rules Modularity Standard Separate the business rules from the hard-coded system OM23 Manage Estate Recovery Process uses data and communication avenues Business Results Condition Standardize the data and communication avenues to make the process more efficient OM24 Manage Recoupment Process uses data and communication avenues Industry Standard Condition Implement the use of standard data and communication avenues OM26 Manage Recovery Process uses data and communication avenues Industry Standard Condition Use standardized data for data exchange and reduce administrative burden
Table : Program Integrity Management Detailed Results Business Process Kentucky MITA Capability Gap Condition/Standard Action to Meet MITA To Be and 7C&S PI01 Identify Candidate Case Cases to be evaluated are identified Modularity Standard Work with Department of Fraud, Waste, Abuse Identification and Prevention (DFWAIP) to implement system upgrades to improve automation between systems PI01 Identify Candidate Case Process uses manual method to identify, and system resources for investigation Business Results Condition Modify process to allow electronic referrals only (eliminate hard copy) PI02 Manage Case Process begins with a referral Business Results Condition Implement automation to improve consistency in reporting and tracking
Table : Program Management Detailed Results Business Process Kentucky MITA Capability Gap Condition/Standard Action to Meet MITA To Be and 7C&S PG01 Designate Approved Service/Drug Formulary Process seeks and uses input from various sources Business Results Condition Automate input gathering activities to promote greater efficiency and effective data sharing PG01 Designate Approved Service/Drug Formulary Process involves utilization and implementation of current service codes and schemes Industry Standard Condition Use MITA standards and interfaces to increase efficiency and consistency PG02 Develop and maintain benefit package Process utilizes input from Federal and State agencies, and interacts with multiple external agencies Business Results Condition Automate review of electronic sources (in order to alert Commonwealth personnel of changes) PG02 Develop and maintain benefit package Process involves utilization and implementation of current service codes and schemes Industry Standard Condition Use MITA standards and interfaces to increase efficiency and consistency PG02 Develop and maintain benefit package Performance and utilization of benefit plans is evaluated Reporting Condition Automate and schedule the comparison of benefit plan performance and utilization PG03 Manage Rate Setting Process is initiated by regularly scheduled rate modifications and ad-hoc requests Business Results Condition Automate the gathering of information (within the Medicaid Enterprise system) and rate calculation
PG03 Manage Rate Setting Modified rates must be available for each program covered by Medicaid Interoperability Condition Use MITA standards and interfaces to increase efficiency and consistency; publish rates online (with appropriate security) for evaluation by related agencies and entities PG04 Develop Agency Goals and Initiatives Process is initiated by regularly scheduled reviews and ad-hoc needs Business Results Condition Automate research steps (whenever possible) so that execution coincides with scheduled reviews PG05 Develop and maintain program policy Process utilizes input from Federal and State agencies, and interacts with multiple external agencies Business Results Condition Adhere to current MITA standards and interfaces to increase efficient data sharing and communication PG05 Develop and maintain program policy Changes in policy must be communicated to MCOs Industry Standard Condition Implement a formal monitoring process to ensure adherence to policy changes PG06 Maintain State Plan Process utilizes input from State agencies and feedback from CMS Business Results Condition Modify interfaces to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats) PG07 Formulate Budget Process utilizes input from State agencies (Cabinet, DMS and the Governor’s Office for Policy and Management GOPM), along with PricewaterhouseCoopers (PwC)) Business Results Condition Modify interfaces to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats)
PG11 Manage 1099s Copies of 1099s (and results of requests for corrections) must be distributed in a timely manner Interoperability Condition Modify interfaces to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats) PG12 Generate Financial and Program Analysis/Report Process involves the receipt of a request for information or response to a schedule Modularity Standard Automate summary and calculation of financial data within the DSS to coincide with reporting schedules; use rules engine to change parameters when necessary PG12 Generate Financial and Program Analysis/Report Preparers utilize various automated processes and perform manual steps Business Results Condition Automate summary and calculation of financial data within the DSS to coincide with reporting schedules PG12 Generate Financial and Program Analysis/Report Data is shared with other agencies and commercial sources Interoperability Condition Modify interfaces to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats) PG12 Generate Financial and Program Analysis/Report Reports are generated to comply with Federal requirements, along with those necessary for audit Reporting Condition Automate the creation of scheduled reports; use MITA standards and interfaces PG13 Maintain Benefits/Reference Information Data is input from other sources using an automated process Modularity Standard Edit incoming data using a rules engine PG13 Maintain Benefits/Reference Information Data is entered into the system in a manual process Business Results Condition Increase automation of data gathering by utilization of interfaces built on open architecture (SOA)
PG16 Develop and Manage Performance Measures and Reporting Process is performed in a primarily automated fashion, and produces Federal, state and standardized industry measures to reflect performance Business Results Condition Utilize MITA standards and interfaces; automate review of electronic sources to alert the Commonwealth of changes to existing standards PG16 Develop and Manage Performance Measures and Reporting Measures are available in the data warehouse and to other systems Interoperability Condition Modify interfaces to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats); automate notification (and distribution, where appropriate) of reports PG17 Monitor Performance and Business Activity Effectiveness of the MMIS or vendor is measured against key operational values Modularity Standard Utilize MITA standards and interfaces; automate review of electronic sources to alert the Commonwealth of changes to existing standards PG17 Monitor Performance and Business Activity Process is performed in with a mix of automated and manual procedures Business Results Condition Automate calculations when monitoring report is scheduled PG17 Monitor Performance and Business Activity Information to perform this process resides primarily in the data warehouse Reporting Condition Modify interfaces to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats); automate calculation of data within DSS and notification (and distribution, where appropriate) of reports PG18 Draw and Report FFP State prepares report by pulling information from MMIS and applying rules based upon the State Plan Business Results Condition Automate calculation of data within MMIS and notification (and distribution, where appropriate) of reports when activity is scheduled
Table : Provider Management Detailed Results Business Process Kentucky MITA Capability Gap Condition/Standard Action to Meet MITA To Be and 7C&S PM01 Enroll Provider Automated processes within this business process include the handling of application, application changes, and verification of data Modularity Standard Implement separate rules engine to verify/validate submitted information and subsequent provider communications PM01 Enroll Provider Provider enrollment is monitored by outside organizations Industry Standard Condition Implement MITA standards and interfaces to improve efficiency and consistency PM01 Enroll Provider MCOs perform a major portion of the enrollment process; finalization of enrollment is done by State Business Results Condition Implement a formal monitoring process to ensure adherence to MITA standards and interfaces PM01 Enroll Provider Competition of the enrollment process involves communication with credentialers, the provider, MCOs, and other State agencies Interoperability Condition Modify interfaces with MCOs and other related agencies to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats) PM02 Disenroll Provider Both voluntary and involuntary disenrollments are processed Modularity Standard Implement separate rules engine to verify/validate submitted information and associated provider communications PM02 Disenroll Provider Provider disenrollment is monitored by outside organizations Industry Standard Condition Implement MITA standards and interfaces to improve efficiency and consistency
PM02 Disenroll Provider Disenrollments may be caused by a variety of reasons, including loss of license, retirement, or desire to no longer participate Business Results Condition KYHealth Choices and DFWAIP may be involved in the process of disenrollment; Implement a formal monitoring process to ensure adherence to MITA standards and interfaces PM02 Disenroll Provider Results of disenrollment activities are communicated to MCOs, providers, and other related agencies Interoperability Condition Modify interfaces with MCOs and other related agencies to utilize open architecture (SOA, Enterprise Service Bus, MITA standard interface formats) PM03 Inquire Provider Information Information requests are received from a variety of sources; most are responded to by phone, FAX or USPS Business Results Condition Use more online request processing (with verification/validation performed against a user-controlled rules engine) and electronic/automated methods to distributing the information PM04 Manage Provider Communication Information requests are received from a variety of sources Business Results Condition Implement automation to improve consistency in reporting and tracking PM04 Manage Provider Communication Completed communications, after research and creation, are distributed Reporting Condition Expand Decision Support database to store completed communications in order to allow inquiry and reuse easily PM05 Manage Provider Grievance and Appeal Transitions are received in various manners, including inbound transactions; steps are primarily manual Business Results Condition Implement automation to improve consistency in reporting and tracking
PM05 Manage Provider Grievance and Appeal Completed decisions, after research and due process is completed, are communicated and stored Reporting Condition Coordinate with other agencies performing reporting of results of this process to adhere to MITA standards PM05 Manage Provider Grievance and Appeal The transaction received by Receive Inbound Transaction process is logged and tracked Modularity Standard Expand tracking capabilities (and automated reminders from the tracking function) thru the use of a rules engine PM06 Manage Provider information Process is responsible for managing all aspects of the provider registry for both current and prospective providers; uses several manual paper-based processes Business Results Condition Use more online application processing (with verification/validation performed against a user-controlled rules engine) PM06 Manage Provider information The Registry includes contractual terms, such as the services the provider is contracted to provide, related performance measures, and the reimbursement rates for those services; information is communicated and received from various sources including MCOs Reporting Condition Use of MITA standards and interfaces will increase efficiency and consistency
PM06 Manage Provider information This process is associated with many other processes which utilize Provider Information; requirements and regulations may change based upon Federal mandate, State legislation, etc. Modularity Standard Implement a user-controlled, separate rules engine allowing efficient and cost-effective application of required changes PM07 Perform Provider Outreach Outreach process is initiated for both current providers and potential providers thru manual methods and processes Business Results Condition Implement automation in the identification of Providers to improve efficiency
A: Table 32: CMS MITA Maturity Capability Table mita business state business mita business process state business process as is level of business capability to be level of business capability Business Relationship Management Business Relationship Management Business Relationship Management BR Establish Business Relationship BR01 Establish Business Relationship 1 2 Business Relationship Management Business Relationship Management BR Manage Business Relationship BR02 Manage Business Relationship 1 2 Business Relationship Management Business Relationship Management BR Terminate Business Relationship BR03 Terminate Business Relationship 1 2 Business Relationship Management Business Relationship Management BR Manage Business Relationship Communication BR04 Manage Business Relationship Communication 1 2 Care Management Care Management Care Management CM Establish Case CM01 Establish Case 1 2 Care Management Care Management CM Manage Case CM02 Manage Case 1 2 Care Management Care Management CM Manage Medicaid Population Health CM03 Manage Medicaid Population Health 1 2 Care Management Care Management CM Manage Registry CM04 Manage Registry 1 2 Contractor Management
Contractor Management Contractor Management CO Produce Administrative or Health Services RFP CO01 Produce Administrative or Health Services RFP 2 3 Contractor Management Contractor Management CO Award Administrative or Health Services Contract CO02 Award Administrative or Health Services Contract 1 2 Contractor Management Contractor Management CO Manage Administrative or Health Services Contract CO03 Manage Administrative or Health Services Contract 1 2 Contractor Management Contractor Management CO Close-out Administrative or Health Services Contract CO04 Administrative or Health Services Contract 1 2 Contractor Management Contractor Management CO Manage Contractor Information CO05 Manage Contractor Information 1 2 Contractor Management Contractor Management CO Manage Contractor Communication CO06 Manage Contractor Communication 1 2 Contractor Management Contractor Management CO Perform Contractor Outreach CO07 Perform Contractor Outreach 1 2 Contractor Management Contractor Management CO Support Contractor Grievance and Appeal CO08 Support Contractor Appeal 1 2 Contractor Management Contractor Management CO Inquire Contractor Information CO09 Inquire Contractor Information 1 2 Member Management
Member Management Beneficiary Management ME Determine Eligibility ME01 Determine Eligibility 2 2 Member Management Beneficiary Management ME Enroll Member ME02 Enroll Beneficiary 1 2 Member Management Beneficiary Management ME Disenroll Member ME03 Disenroll Beneficiary 1 2 Member Management Beneficiary Management ME Inquire Member Eligibility ME04 Inquire Beneficiary Eligibility 2 2 Member Management Beneficiary Management ME Manage Applicant and Member Communication ME05 Manage Applicant and Beneficiary Communication 1 2 Member Management Beneficiary Management ME Manage Member Grievance and Appeal ME06 Manage Beneficiary Grievance and Appeal 1 2 Member Management Beneficiary Management ME Manage Member Information ME07 Manage Beneficiary Information 1 2 Member Management Beneficiary Management ME Perform Population and Member Outreach ME08 Perform Population and Beneficiary Outreach 1 2 Operations Management Operations Management Operations Management OM Authorize Referral OM01 Authorize Referral 1 2
Operations Management Operations Management OM Authorize Service OM02 Authorize Service 1 2 Operations Management Operations Management OM Authorize Treatment Plan OM03 Authorize Treatment Plan 1 2 Operations Management Operations Management OM Apply Attachment OM04 Apply Attachment 1 2 Operations Management Operations Management OM Apply Mass Adjustment OM05 Apply Mass Adjustment 1 2 Operations Management Operations Management OM Edit OM06 Edit 1 2 Operations Management Operations Management OM Audit OM07 Audit 1 2 Operations Management Operations Management OM Price Claim-Value Encounter OM08 Price Claim-Value Encounter 2 2 Operations Management Operations Management OM Prepare Remittance Report OM09 Prepare Remittance Report 2 2 Operations Management Operations Management OM Prepare Provider OM10 Prepare Provider 2 2 Operations Management Operations Management OM Prepare OM11 Prepare COB 1 2 Operations Management Operations Management OM Prepare EOB OM12 Prepare EOB 1 2
Operations Management Operations Management OM Prepare Home and Community Based Services Payment OM13 Prepare Home and Community Based Services Payment 2 2 Operations Management Operations Management OM Prepare Premium EFT OM14 Prepare Premium EFT 2 2 Operations Management Operations Management OM Prepare Capitation Premium Payment OM15 Prepare Capitation Premium Payment 1 2 Operations Management Operations Management OM Prepare Health Insurance Premium Payment OM16 Prepare Health Insurance Premium Payment 1 2 Operations Management Operations Management OM Prepare Medicare Premium Payments OM17 Prepare Medicare Premium Payments 2 2 Operations Management Operations Management OM Inquire Payment Status OM18 Inquire Payment Status 2 2 Operations Management Operations Management OM Manage Payment Information OM19 Manage Payment Information 2 2 Operations Management Operations Management OM Calculate Spend-Down Amount OM20 Calculate Spend-Down Amount 2 2 Operations Management Operations Management OM Prepare Member Premium Invoice OM21 Prepare Beneficiary Premium Invoice 1 2 Operations Management Operations Management OM Manage Drug Rebate OM22 Manage Drug Rebate 2 2 Operations Management Operations Management OM Manage Estate Recovery OM23 Manage Estate Recovery 1 2
Operations Management Operations Management OM Manage Recoupment OM24 Manage Recoupment 1 2 Operations Management Operations Management OM Manage Cost Settlement OM25 Manage Cost Settlement 1 2 Operations Management Operations Management OM Manage Recovery OM26 Manage Recovery 1 2 Program Integrity Management Program Integrity Management Program Integrity Management PI Identify Candidate Case PI01 Identify Candidate Case 1 2 Program Integrity Management Program Integrity Management PI Manage Case PI02 Manage Case 1 2 Program Management Program Management Program Management PG Designate Approved Services/ Drug Formulary PG01 Designate Approved Services/ Drug Formulary 1 2 Program Management Program Management PG Develop and Maintain Benefit Package PG02 Develop and Maintain Benefit Package 2 2 Program Management Program Management PG Manage Rate Setting PG03 Manage Rate Setting 1 2 Program Management Program Management PG Develop Agency Goals and Objectives PG04 Develop Agency Goals and Objectives 1 2 Program Management Program Management PG Develop and Maintain Program Policy PG05 Develop and Maintain Program Policy 1 2
Program Management Program Management PG Maintain State Plan PG06 Maintain State Plan 1 2 Program Management Program Management PG Formulate Budget PG07 Formulate Budget 1 2 Program Management Program Management PG Manage for MMIS PG08 Manage for MMIS 1 2 Program Management Program Management PG Manage F-MAP PG09 Manage F-MAP 1 2 Program Management Program Management PG Manage State Funds PG10 Manage State Funds 1 2 Program Management Program Management PG Manage 1099s PG11 Manage 1099s 2 2 Program Management Program Management PG Generate Financial and Program Analysis PG12 Generate Financial and Program Analysis 2 2 Program Management Program Management PG Maintain Information PG13 Maintain Information 1 2 Program Management Program Management PG Manage Program Information PG14 Manage Program Information 1 2 Program Management Program Management PG Perform Accounting Functions PG15 Perform Accounting Functions 2 2 Program Management Program Management PG Develop and Manage Performance Measures and Reporting PG16 Develop and Manage Performance Measures and Reporting 1 2
Program Management Program Management PG Monitor Performance and Business Activity PG17 Monitor Performance and Business Activity 1 2 Program Management Program Management PG Draw and Report PG18 Draw and Report 1 2 Program Management Program Management PG Manage for Services PG19 Manage for Services 1 2 Provider Management Provider Management Provider Management PM Enroll Provider PM01 Enroll Provider 1 2 Provider Management Provider Management PM Disenroll Provider PM02 Disenroll Provider 1 2 Provider Management Provider Management PM Inquire Provider Information PM03 Inquire Provider Information 1 2 Provider Management Provider Management PM Manage Provider Communication PM04 Manage Provider Communication 1 2 Provider Management Provider Management PM Manage Provider Grievance and Appeal PM05 Manage Provider Appeal 1 2 Provider Management Provider Management PM Manage Provider Information PM06 Manage Provider Information 1 2 Provider Management Provider Management PM Perform Provider Outreach PM07 Perform Provider Outreach 1 2