Business Process Steps Receive alert that there a request for outreach has been entered in the DMS OR 1. Receive a request for outreach Enter request into Document Management System Workflow/alert generated to approver Approve or deny (or modify) decisions to develop outreach communications If Yes, approved, continue to Step 6 If No, disapproved, go to Step 5 Alert is generated to notify requestor of results/alteratives Determine development approach (internal and external or both) of outreach materials and success measures Identify target population Develop materials in DMS Circulate materials for approval If Yes approved, continue to Step 10 If No, disapproved, go to Step 8 Distribute multi-lingual outreach materials or communications through various mediums Track production/distribution of outreach communications and archive materials Shared Data None Predecessor Program Quality Management process results in need to perform outreach Identified gaps Successor None Constraints None Failures Untimely notification Notification to the wrong population Performance Measures None Perform Provider Outreach “To-Be” Business Capability Matrix Business Capability Descriptions 2 The Perform Provider Outreach process is used to provide information to targeted groups of providers. Documents would be distributed via secure and public website and regular mail. Groups of providers would be identified by such parameters as taxonomy, address, and claims volume, participation in networks such as Coordinated Care Networks or Managed Care Organizations. Timeliness of Process Level 2 The use of a Document Management System (DMS) would greatly reduce the time it currently takes to have a document commented on, updated, returned for review, and approved. Data Access and Accuracy Level 2 Targeting of providers would be more accurate because there would be more parameters to use to define the group.
Prescription Medical Documentation Predecessor Member has medical need that requires the service to be authorized Prescription Denied Claim Successor Audit Claim/Encounter process Member Grievance and Appeal Process Constraints PA requests have a contracted turn-around limit by the PA contractor or FI Failures None Performance Measures Number of post authorizations per member; per PCP Authorize Service “To-Be” Business Capability Matrix Business Capability Descriptions 3 The Agency receives EDI transactions via electronic means that support even small, rural, and waiver providers. Web portals support error free submissions with data field masks, client-side edits, and pre-populated fields, thereby eliminating the need for these submissions to go through manual validation. The Authorize Service process is completely automated and only rare exceptions must be manually reviewed. Optimizing automation improves error rates and timeliness, thereby enabling support of real-time processing. Authorize Service processing is highly flexible so that rule changes can be made quickly and inexpensively in response to need for new or different rules. . Timeliness of Process Level 3 Time is greatly improved due to electronic PA approvals on a portal and reviews verses the mail. The approval process is automated and decisions are made systematically and with consistency. Data Access and Accuracy Level 3 Access and accuracy is improved through the ease of access to data through the portals. The approval process is automated and decisions are made systematically and with consistency. Effort to Perform; Efficiency Level 3 Effort is decreased due to the elimination of mailing information. Cost Effective Level 3 Postage is saved due to electronic communication. Staff is not needed for mailing and processing of postage. Accuracy of Process Results Level 3 Benefits of results are shown through the accuracy of information and the speed of PA approval. Member will be satisfied due to accurate information between the specialty provider or Hospital and the PCP. Utility of Value to Stakeholders Level 3 Provider will be able to diagnose and manage health better due to accuracy and efficiency of health information. Speed of information between providers will increase, which will create tighter and more efficient networks.