Document Information Revision # Revision Date Section(s) Revised Revision Description 1.0 12/12/2008 Initial Submission 2.0 1/9/2009 Second Submission 3.0 1/30/2009 Submission 4.0 2/13/2009 Submission 5.0 2/18/2009 Fifth Submission 6.0 2/19/2009 Sixth Submission Executive Summary The MAXIMUS IV&V Team began work on the LA MMIS Replacement Project in September 2008. This Project is scheduled for 36 months duration and includes four (4) key project Phases, which have clearly defined tasks and subtasks: I: Planning/Pre-Implementation Phase II: Design and Development Phase III: Testing and Implementation IV: Preparation for CMS certification Initially, the MAXIMUS focus has been on Phase I activities and the project’s first objectives: to prepare and develop the Solicitation for Proposal (SFP) for the MMIS Procurement for Fiscal Intermediary (FI) services and MMIS Replacement Project and the associated Implementation Advance Planning Document (IAPD). The “As Is” Business Process Validation is a key Phase I deliverable and the information and data gathered from the “As-Is” JAD sessions provide the basis for this validation. The intent of this “As-Is” Business Process Validation has changed since the start of the project as the original approach was based upon the existence of a completed DHH prepared “As-Is” and “To-Be” MITA State (SS-A). With only an “As-Is” business process model in place, the approach for the “As-Is” Gap Analysis was changed to validating the “As-Is” business process model (prepared by DHH prior to the start of the MMIS IV&V Project) and comparison to MITA business processes and required SS-A content. In November and December 2008, MAXIMUS conducted an assessment of the current Medicaid business processes and business processes through a series of “As Is” and “To Be” Joint Application Design (JAD) sessions. The focus of the “As-Is” sessions was to review the MITA “As-Is” business process model prepared by DHH; determine the accuracy of the information provided; and refine the business process models. These additions/clarifications will be documented by MAXIMUS in the format of the final “As-Is” Business Process Validation deliverable. The Business Process Models from this document will be used as the “As-Is” MITA
Determine Member Eligibility Workflow Enroll Member Enroll Member Process Model Item Details Description The Enroll Member business process receives eligibility data from the Determine Eligibility process or sources, determines additional qualifications for enrollment in programs for which the member may be eligible, loads the enrollment outcome data into the Member and Contractor (TPA) Registries, and produces notifications to the member and the contractor Trigger Event Receive member eligibility data and enrollment application from the Determine Eligibility process or other sources Result Member is enrolled in specific programs Business Process Steps Receive referral via internal/external sources in either paper or electronic: LaHIPP – internal and external referrals Hospice – external referrals OGB – Office of Group Benefits referrals FOA – Family Opportunity Act referrals LAP – LA Affordable plan referrals CommunityCare system generates run in MMIS on individual record Send application to individual or policy holder Verify program requirements are met If Yes, continue to Step 4 If No, go to Step 6 Make enrollment decision Enter decision into TPA registries Generate and send notices Shared Data Verify: INS, Medical Reports, Employers Predecessor Determine Eligibility process approves applicant as eligible for one or more program and benefit packages. Outreach MA eligible Successor Manage Applicant and Member Communication Manage Contractor Communication Phone Call, Fax, Mail and/or Internet Manage Member Information Manage Provider Communication Recipient receiving hospice care. Manage Employer Sponsored Insurance Phone Call, Fax, Mail and/or Internet Provider/MEDS and records updated Constraints State and Federal Rules and Regulations Failures None Performance Measures None
Successor Contractor Grievance and Appeal process Manage Contractor Information Constraints and Federal Rules and Regulations Failures Fail to obtain approvals Performance Measures NONE Close Out Workflow Manage Contract Manage Contract Business Process Model Item Details Description The Manage Contract business process receives the contract award information, implements contract monitoring procedures, and updates contract if needed, and continues to monitor the terms of the contract throughout its duration. Trigger Event Receive finalized signed contract. Result Contractor is in compliance with requirements of the contract. Business Process Steps Receive signed contract Provide copy to contractor Implement contract Monitor the contract for compliance with requirements If Yes, compliance with requirements, go to Step 6 If No, go to Step 5 Notify contractor and withhold payment until compliance is achieved Approve/Pay appropriate invoices Report variances, if any If Yes, a variance is identified, go to Step 9 If No, go to Step 8 Continue to monitor the contract Notify contractor of non-compliance with requirements Reevaluate contractor performance following implementation of corrective actions Update contract with amendments (if any) Contract expires Shared Data Contract Variables ( from Contract Financial Management System) Predecessor Award Contract Process Successor Manage Contractor Communications Manage Contractor Information Close out Contract
Business Process Steps Post status on AVRS/REVS of provider payment information for the most recent weekly processing cycle Calculate payment status Display payment status on an aggregate on REVS with its assigned check-digit provider ID Post Provider claim detail information on a daily and weekly basis – with claim adjudication status – on e-CSI (electronic Claims Status Inquiry) Shared Data Provider security data Predecessor Completion of weekly claims processing and payment cycle Successor Provider communications Constraints Federal and Rules and Regulations Failures Systems constraints Performance Measures Provider check information is required to be posted on REVS and made available each Monday morning. Claims status information is required to be posted every evening on e-CSI after each daily CP cycle and weekly after each weekly CP cycle. Inquire Payment Status Workflow Manage Payment Information Manage Payment Information Business Process Item Details Description The Maintain Payment Information business process supports the maintenance of provider payment information. Trigger Event Weekly Check write process Result Database is updated and reconciled with correct payments have access to payment information Business Process Steps Receive data from Operations Management Area business processes Load data into the STAT file and other MMIS payment files, building new records and updating, or status changes Archive data in accordance with state and federal record retention requirements Shared Data None Predecessor Financial payment process/run Successor Inquire on payment status information Generate reports
Successor Approved matched funding from the Feds Provider Communication & Outreach Member Communication Constraints State & Federal Laws, regulations and initiatives Failures None Performance Measures None Maintain State Plan Business Workflow Formulate Budget Formulate Budget Business Process Model Item Details Description The Formulate Budget business process examines the current budget, revenue stream and trends, and expenditures, assesses external factors affecting the program, assesses agency initiatives and plans, models different budget scenarios, and yearly produces a new budget. Trigger Call letter – Time to do budget New Program or Service – A “BA-7” Result New budget appropriation (funds) received to administer the Medicaid Program.
Shared Data Contractual Data National Measures Data from External Registries Predecessor Approval of the operational plan or budget Federal or State Initiatives Establishment/revision of a performance measure Successor Performance Standards Rewards or Penalties Constraints Federal and State Regulations and Policies Buy-in from Stakeholders Failures None Performance Measures and Federal deadlines Monitor Performance and Business Activity Workflow Generate Financial and Program Analysis Report Generate Financial and Program Analysis Report Business Process Model Item Details Description The Generate Financial & Program Analysis/Report business process is essential for Medicaid agencies to be able to generate various financial and program analysis reports to assist with budgetary controls. Additionally to ensure that the benefits and programs established meet the needs of the member population and are performing according to the intent of the legislative laws or federal reporting requirements. Trigger Request that financial and/or reporting information be produced Pre-determined time-table for scheduled report generation Result New or revised report is established