CM: Screening and Assessment Process

							                                        Operations Management (OM)
                                             Inquire Payment Status
       Item                                                       Details
Description            The Inquire Payment Status business process begins with receiving a claim
                       status inquiry via paper, phone, fax or 276 EDI transaction for the current status of
                       a specified claim(s), calling the payment history data store and/or repository,
                       capturing the required claim status response data, formatting the data set into the
                       277 Claim Status Response, and sending claim status response data set.
MITA                   Source Process Name: Inquire Payment Status
Reference              Source Process Business Area: Operations Management
                       References: Part 1 Appendix C, Business Process Model Details
                       Part 1 Appendix D, Business Process Capability Matrix Details
                       http://www.cms.hhs.gov/MedicaidInfoTechArch/04_MITAFramework.asp
Sample Data            Claims and encounter adjudication log,          Premium and capitation request
                       edit and audit exceptions, claim                processing log, exceptions, and
                       attachment, and claim’s disposition             payment data
                       Claims, encounter reporting, EFT/check
                       preparation and transmitta

                                     OM: Inquire Payment Status: Maturity Levels
       Level 1                Level 2                  Level 3                 Level 4                Level 5
This business          The process              All programs use a      Payment status is      Payment status is
process is primarily   incorporates direct      centralized web         accessible to any      available through
via paper,             connectivity to          based automated         authorized party       HIEs nationally.
telephone, & fax;      provider/contractor;     electronic claim        through HIEs           This Level adds
inquiries are          Web interfaces for       status process.         statewide.             nationwide technical
received from          inquiries; basic         BHspecific              Provider/contractor    interoperability.
various sources        business rules; and      invoicing               systems collaborate
using non-standard     state agency             formats and data        with the payer
formats. The           specific standards.      are phased out as       system during an
process is             Routine inquiries for    the funding/payment     episode of care, so
inconsistent in the    provider/contractor      requirements are        the
application of the     information are          aligned with national   provider/contractor
rules and in           standardized and         standards, allowing     knows the payment
response timing.       automated within         process sharing with    status immediately,
                       the agency.              other systems.          eliminating the need
This Level complies                             Interfaces use          for payment status
with agency            This Level includes      BHMITA                  inquiry.
requirements.          additional data and      standards that
                       quality edits.           are compatible with     This Level adds
                                                Medicaid MITA.          clinical data.
                                                Providers/
                                                contractors send
                                                HIPAA X12 276 or
                                                use online direct
                                                data entry and
                                                receive HIPAA X12
                                                277 response or find
                                                the claim status
                                                online.

                                                At this Level data is
                                                standardized
                                                against HL7 RIM.
                                                     Automation
      Level 1                 Level 2                  Level 3                Level 4                Level 5
All/mostly paper       Internal processes       Internal agency         External agency        Non-state entity
                       mostly automated         processes/interfaces    processes/interfaces   processes/interfaces
                                                mostly automated        mostly automated       mostly automated


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VA As Is
VA To Be
                                                    Standards
      Level 1                 Level 2                 Level 3                Level 4                 Level 5
Use few or no          Internal processes      Internal agency         External agency         Non-state entity
national standards     use national            processes/interfaces    processes/interfaces    processes/interfaces
                       standards               mostly use national     mostly use national     mostly use national
                                               standards               standards               standards
VA As Is
VA To Be
                                               Cross Coordination
        Level 1               Level 2                 Level 3                Level 4                 Level 5
Little/no              Internal agency         Internal agency         External agency         Non-state entity
coordination across    operational             program processes       program and             program and
processes or with      processes               coordinated             operational             operational
other programs         coordinated                                     processes               processes
                                                                       coordinated             coordinated
VA As Is
VA To Be
                                                    Client Data
        Level 1               Level 2                 Level 3                 Level 4                 Level 5
Little/no access to    Internal processes      Internal agency         External agency         Non-state entity
client specific data   have access to          processes have          processes have          processes have
                       client                  access to client        access to client        access to client
                       specific data           specific data           specific data           specific data
VA As Is
VA To Be
                                                  Interoperability
       Level 1                Level 2                 Level 3                 Level 4                 Level 5
None                   Limited                 Interoperability with   Interoperability with   Interoperability with
                       interoperability        internal agency         external agency         non-state entity
                       internally or limited   systems other than      systems other than      systems
                       to                      claims processing       claims processing
                       claims processing
                       systems
VA As Is
VA To Be




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