MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS) by ngs20854

VIEWS: 0 PAGES: 19

									                           MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS)

CLIENT ELIGIBILTY INFORMATION
     Recipient File Subsystem (RFS) - Client Medicaid eligibility, managed care participation, lock-in and service authorizations.

PROVIDER INFORMATION
     Medical Provider Subsystem (MPS) - Supports enrollment and maintenance of Medicaid providers, provider-specific pricing
     methodologies, and claims processing.

CLAIMS PROCESSING
     Medical Claims Processing Subsystem (MCP) - Claim processing, payment, remittance advice, claim adjustments and claims history.
     Claims are processed daily through MCP, where they are edited for processing exceptions. Claims failing the edits are suspended for
     review and remain in a suspended status until they are reviewed and the proper resolution steps are performed or they are deleted and
     removed from further processing. At the end of each processing week, claims remaining in suspended status are processed through MCP
     and re-edited. Claims clearing the edits are held, pending payment, until the next warrant and remittance advice generation date.

DRUG CLAIMS PROCESSING (Outsourced)
     Contracted through ACS. Point of sale, online, real-time pharmacy system. ACS receives and processes pharmacy drug claims, provides
     technical and provider helpdesk support, authorization, and drug utilization review functions. Payment is made by the MMIS.

MANAGED CARE
    Nebraska Managed Care (NMC) and Managed Care Documentation System - Supports and maintains managed care client enrollment,
    plan/provider selection, health assessment and outreach.

REFERENCE FILES
     Reference File Subsystem (RSS) – Maintains reference and pricing files, such as procedure and diagnosis codes, used to support claims
     processing.

THIRD PARTY LIABILITY
     Third Party Liability Subsystem (TPL) – Maintains client third party resources, including private health insurance and casualty resources.
     Supports cost avoidance and recoveries for claims for clients with third party resources.

SURVEILLANCE AND UTILIZATION REVIEW
     Surveillance and Utilization Review Subsystem (SURS) – Consolidates, organizes and reports on selected data to reveal and aid in the
     investigation of potential Medicaid provider abuse or misuse. Creates profiles to identify utilization patterns.




Revised March 23, 2007                                      Nebraska MMIS Overview                                                   Page 1 of 19
                          MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS)

MANAGEMENT REPORTING
    Management and Reporting Subsystem (MARS) – Creates financial reports for fiscal planning, management, control, and state/federal
    reporting requirements.

DATA MANAGEMENT (Outsourced)
     Contracted through Thomson Medstat, Inc. Decision Analyst software is a decision support system (DSS), a management &
     administrative reporting system (MRS), and a surveillance and utilization review system (SURS) used for management, collection and
     analysis of Medicaid data, including managed care encounter data. Includes NetEffect, an executive management system (EIS).
     Generates federal Medicaid Statistical Information System (MSIS) report.

SCREENING ELIGIBLE CHILDREN
     Screening Eligible Children Subsystem (SEC) – Produces EPSDT screening/treatment tracking reports and client outreach.

DRUG REBATE
     Medicaid Drug Rebate System (MDR) – Tracks, invoices and receives rebate payments from drug manufacturers.

NURSING FACILITY CASEMIX
     Casemix System – Receives and maintains nursing facility assessments and determines care levels used during claims processing.

MEDICAL NON-FEDERAL
     Medical Non-Federal Subsystem (MNF) – Ensures that Medicaid federal funds are not claimed for services otherwise available through
     the Medicare Program for those individuals who do not participate in Medicare Part B.

NEBRASKA DISABILITY PROGRAM
     Nebraska Disability Program Subsystem (NDP) – Accounts for separate funding of services for persons with disabilities who do not meet
     all the Medicare eligibility requirements but who are eligible for Medicaid. Also tracks funding for State-funded Refugee Resettlement
     Program.

NEBRASKA MEDICAID ELIGIBILITY SYSTEM – INTERACTIVE VOICE RESPONSE
     Nebraska Medicaid Eligibility System (NMES) – Telephone voice-response system for use by providers to determine Medicaid client
     eligibility.

TRANSLATOR SERVICES (Outsourced)
     Contracted through Sybase, Inc. Provides translator software to assure that HIPAA X12 compliant transactions are conducted through the
     MMIS.




Revised March 23, 2007                                    Nebraska MMIS Overview                                                Page 2 of 19
                                                CLIENT ELIGIBILITY INFORMATION
                                   Client Medicaid eligibility, managed care participation, lock-in and service authorizations.


INPUTS                                                                       MMIS                                                 OUTPUTS
                                                                                                                                               Eligibility
                                                                                                                                             Response (271)
    Eligibility
                              Translator/
  Inquiry (270)
                               Interface
                               Database
                                                            Nursing                  NMC                                                      Authorization
                                                            Facility                Nebraska                                                 Response (278)
  Authorization                                             Casemix                 Managed
  Request (278)                                             System                    Care
                                                                                                                                                TPL Data
                                                                                                                                                Matches


                                                                                                                                             Eligibility Files
      Prior                                                                                                                                         to:
                                                             RFS
  Authorization                                                                                                                             -ACS Drug
                                                         Recipient File
                                                                                                               MCP                          Processing
                                                                                                             Medical                        -Managed Care
                                                                                                              Claims                        Plans
                                                                                                            Processing                      -Medicare
                                                                                                                                            -DEERS
  Absent Parent
                                                                                                                                            -Others
   Information
      from
    CHARTS                                                                                                                                   Absent Parent
                                                                                                                                             Information to
                               NMES                                                                                                            CHARTS
                              Nebraska               Data                    SURS                 SEC                 MARS
                              Medicaid            Management              Surveillance          Screening           Management
                              Eligibility           System                 Utilization           Eligible              and
                               System                                       Review              Children             Reporting          Level of Care to
     Client                                                                                                                               N-FOCUS
   Eligibility
      from
   N-FOCUS                                                                                                                               N-FOCUS
                                                                                                                                        Medicaid Card



     Revised March 23, 2007                                        Nebraska MMIS Overview                                                    Page 3 of 19
                                                          PROVIDER INFORMATION
                        Enrollment and maintenance of Medicaid providers, provider-specific pricing methodologies, and claims processing.


INPUTS                                                                     MMIS                                                             OUTPUTS


                                              EDI Trading
                                                Partner
                                                System



                                                                                                                                             Provider Files to:
    Medicaid
    Provider                                                                                                                                 -ACS Drug
   Enrollment                                                                                                                                Processing
     Forms                                                   MPS                                                                             -Managed Care
                                                        Medical Provider                                                                     Plans
                                                                                                                                             -Others

                                                                                                           MCP
                                                                                                         Medical
                                                                                                          Claims
                                                                                                        Processing



    Provider
     Pricing



                               NMES
                              Nebraska                  Data                  NMC                      SURS                 MARS
                              Medicaid               Management              Nebraska               Surveillance          Management
                              Eligibility              System                Managed                 Utilization             and
                               System                                          Care                   Review               Reporting




    Revised March 23, 2007                                         Nebraska MMIS Overview                                                       Page 4 of 19
                                                                 CLAIMS PROCESSING
                                           Claim processing, payment, remittance advice, claim adjustments and claims history.


INPUTS                                                                       MMIS                                                   OUTPUTS
                                                                                                                                           Electronic
                                  Translator/
                                                                                                                                           Remittance
                                   Interface
                                                                                                                                          Advice (835)
                                   Database
   Electronic
  Claims (837)                                                 MPS                    RSS             NMC
                                                              Medical               Reference        Nebraska                           Electronic Claim
                                                              Provider                File           Managed                            Status Response
                                                                                                       Care                                   (277)
   Electronic
  Claim Status
  Request (276)
                                                                                                                                           Electronic
                                                                                                                                          Remittance
                                                                                                                                        Advice (835/820)


  Drug Claims
   from ACS                                      MCP                                     RFS                TPL                          Paper Warrants
                                       Medical Claims Processing                       Recipient         Third Party                     and EFT (NIS)
                                                                                         File             Liability
     Paper
     Claims                                                                                                                                 Paper
                                                                                                                                          Remittance
                                                                                                                                           Advice
   Electronic
  Claims (Pre-
    HIPAA
    format)
                                NDP                                   MDR
                              Nebraska                              Medicaid                                                              Data
                              Disability                           Drug Rebate                                           MARS          Management
    Referral/                 Program             MNF                                    SURS                          Management        System
  Authorization                                  Medical                              Surveillance                        and
      from                                      Non-Federal                            Utilization       SEC            Reporting
   Managed                                                                              Review         Screening
   Care Plans                                                                                           Eligible
                                                                                                       Children




     Revised March 23, 2007                                              Nebraska MMIS Overview                                          Page 5 of 19
                                                    DRUG CLAIMS PROCESSING
            Contracted through ACS. Point of sale, online, real-time pharmacy system. ACS receives and processes pharmacy drug claims, provides
                 technical and provider helpdesk support, authorization, and drug utilization review functions. Payment is made by the MMIS.


INPUTS                                                                                                            OUTPUTS

                                 Drug Claims
                                    from
                                  Pharmacy
                                  Providers
                                                                                                                                       Claim
                                                                                                                                    Information
                                                                                                                                    to Nebraska
                                                                                                                                     Pharmacy
        Client                                                                                                                      Association
     Information                                                                                                                      for DUR
      from RFS                                                                     ACS
      Recipient                                                            Pharmacy Drug Claims
         File                                                                Processing System
                                 TPL                                                                                                Claims for
                             Information                                                                                              MMIS
                              from TPL                                                                                              processing
                             Third Party                                                                                           and payment
                               Liability
       Provider
     Information
      from MPS
       Medical
       Provider
                                                                                                                                   Management
                             Paid Claim                                                                                             Reports
                             Information
                              from MCP
                                Medical
                                Claims
                              Processing




    Revised March 23, 2007                                   Nebraska MMIS Overview                                                 Page 6 of 19
                                                              MANAGED CARE
                                 Managed care client enrollment, plan/provider selection, health assessment and outreach.


INPUTS                                                                 MMIS                                                 OUTPUTS
                                                                                                                                          Benefit
    Encounter                                                                                                                         Enrollment (834)
    Data from                  RFS                    TPL                       MPS                         Translator/
    Managed                  Recipient             Third Party                 Medical                       Interface
    Care Plans                 File                 Liability                  Provider                      Database
                                                                                                                                         Premium
                                                                                                                                       Payment (820)




                                                                                                                                       Managed Care
                                            NMC                                                                                        ID Documents
                                       Managed Care
                                     Enrollment/Provider
                                           System



                                                                                                                                       Managed Care
                                                                                                                                       Data to Quality
                                                                                                                                         Assurance
                                                                                                                                        Contractor
                                                                    MCP                  NMES
      Client                                                       Medical              Nebraska              Data
    Eligibility                                                    Claims               Medicaid           Management
       from                                                      Processing             Eligibility          System
    N-FOCUS                          NMC                         (Cap/Mgmt               System
                                 Managed Care                      Claims)
                                 Documentation
                                    System
                                                                                                                                            Client
                                                                                                                                          Outreach
                                                                                                                                         Information




    Revised March 23, 2007                                       Nebraska MMIS Overview                                                Page 7 of 19
                                                              REFERENCE FILES
                         Maintains reference and pricing files, such as procedure and diagnosis codes, used to support claims processing.


INPUTS                                                                      MMIS                                                OUTPUTS




    Entry of
   Reference
     Data
  (Manual and
  Automated)


                                                                       RSS
                                                                   Reference File




    Entry of
    Pricing
  (Manual and
  Automated)


                                     MCP                    SURS                      MARS                   Data
                                   Medical               Surveillance               Management            Management
                                    Claims                Utilization                  and                  System
                                  Processing               Review                    Reporting




    Revised March 23, 2007                                      Nebraska MMIS Overview                                                      Page 8 of 19
                                                         THIRD PARTY LIABILITY
                             Maintains client third party resources, including private health insurance and casualty resources.
                                Supports cost avoidance and recoveries for claims for clients with third party resources.


INPUTS                                                                     MMIS                                               OUTPUTS




   Client TPL
  Information
      from
   N-FOCUS
                                                                                                                                         Client TPL
                                                          TPL                                                                           Information
                                                   Third Party Liability                                                                to CHARTS
                                                                                                        MCP
  Client TPL                                                                                          Medical
  Information                                                                                          Claims
     from                                                                                            Processing
   CHARTS
                                                                                                                                            TPL
                                                                                                                                        Data Matches


   Client TPL
  Information
  from Claims                                                                                                                           Client TPL
                                                                                                                                        Information
                                                                                                                                         to ACS for
                                                                                                                                        Drug Claim
  Client TPL                       NMES                                                                                                  Processing
  Information                     Nebraska                NMC                    MARS                 Data
   from Data                      Medicaid               Nebraska              Management          Management
    Matches                       Eligibility            Managed                  and                System
                                   System                  Care                 Reporting
                                                                                                                                        Client TPL
                                                                                                                                        Information
                                                                                                                                         to Defense
                                                                                                                                         Eligibility
                                                                                                                                        Enrollment
                                                                                                                                          Reporting
                                                                                                                                           System
                                                                                                                                          (DEERS)


    Revised March 23, 2007                                       Nebraska MMIS Overview                                                  Page 9 of 19
                                           SURVEILLANCE AND UTILIZATION REVIEW
            Consolidates, organizes and reports on selected data to reveal and aid in the investigation of potential Medicaid provider abuse or misuse.
                                                         Creates profiles to identify utilization patterns.


INPUTS                                                                     MMIS                                                OUTPUTS




                                 RFS                     MCP                       MPS                    RSS
                               Recipient               Medical                    Medical               Reference
                                 File                   Claims                    Provider                File
                                                      Processing




                                                                                                                                          Surveillance
                                                       SURS                                                                              and Utilization
                                            Surveillance and Utilization                                                                    Review
                                                      Review                                                                                Reports




                                                   SEC
                                                 Screening
                                                  Eligible
                                                 Children




    Revised March 23, 2007                                         Nebraska MMIS Overview                                                  Page 10 of 19
                                                         MANAGEMENT REPORTING
                             Creates financial reports for fiscal planning, management, control, and state/federal reporting requirements.


INPUTS                                                                       MMIS                                               OUTPUTS




                                   RFS                    TPL                      MPS                      RSS
                                 Recipient             Third Party                Medical                 Reference
                                   File                 Liability                 Provider                  File




                                                                                                                                               Third Party
                                                                                                                                                Resource
                                                                                                       MCP                                    Questionnaires
                                                                                                     Medical
                                                                                                      Claims
                                                                                                    Processing

      MRS                                             MARS
   Adjustments                                  Management Reporting
                                                      System

                                                                                                                                               Management
                                                                                                                                                Reports




    Revised March 23, 2007                                           Nebraska MMIS Overview                                                  Page 11 of 19
                                                           DATA MANAGEMENT
        Contracted through Thomson Medstat, Inc. Decision Analyst software is a decision support system (DSS), a management & administrative
     reporting system (MRS), and a surveillance and utilization review system (SURS) used for management, collection and analysis of Medicaid data,
                          including managed care encounter data. Includes NetEffect, an executive management system (EIS).
                                       Generates federal Medicaid Statistical Information System (MSIS) report.


INPUTS                                                                                                               OUTPUTS
                                Prior Auth
                               Information
      Provider                     from
    Information
                                N-FOCUS
        from
     N-FOCUS

                                  Client                                                                                               Management
                               Information                                                                                              Reports
      Waiver
                                   from
      Claims
                                N-FOCUS
       from
     N-FOCUS                                                         THOMSON MEDSTAT

                                                                     Decision Support System
                                                                        (Decision Analyst)
                                  Client                           Executive Information System
     Third Party             Information from                               (NetEffect)                                                 Medicaid
      Liability               RFS Recipient                                                                                             Statistical
  Information from                System                                                                                               Information
   TPL Third Party
                                                                                                                                         System
  Liability System
                                                                                                                                         Federal
                                                                                                                                        Reporting
                                 Provider
                             Information from
   Managed Care
                               MPS Medical
  Information from
                             Provider System
   NMC Managed
    Care System
                                                                                                                                        Centers for
                                                                                                                                       Medicare and
                                Prior Auth                                                                                               Medicaid
                               Information                                                                                               Services
  Claim/Encounter
                                   from
  Data from MCP
                             Client Eligibility
  Medical Claims
     Processing


    Revised March 23, 2007                                      Nebraska MMIS Overview                                                 Page 12 of 19
                                               SCREENING ELIGIBLE CHILDREN
                             Produces HEALTH CHECK Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
                                           screening and treatment tracking reports and client outreach.

INPUTS                                                              MMIS                                        OUTPUTS



                                                                                           SURS
                                 RFS                          MCP                       Surveillance
                               Recipient                    Medical                          and
                                 File                        Claims                      Utilization
                                                           Processing                     Review




       Client
      EPSDT                                                                                                                EPSDT
    information                                                   SEC                                                     Outreach
        from                                           Screening Eligible Children                                        Letters to
     N-FOCUS                                                                                                               Clients




    Revised March 23, 2007                                  Nebraska MMIS Overview                                        Page 13 of 19
                                                     DRUG REBATE
                              Tracks, invoices and receives rebate payments from drug manufacturers.


INPUTS                                                             MMIS                                OUTPUTS




                                                               MCP
                                                             Medical
                                                              Claims
   Drug and
                                                            Processing
  Rebate File
  from CMS
                                                                                                                 Invoice to Drug
                                                                                                                  Manufacturers




                                                              MDR
                                                       Medicaid Drug Rebate


    Rebate
 Payment from
     Drug                                                                                                         Management
 Manufacturers                                                                                                     Reports




     Revised March 23, 2007                          Nebraska MMIS Overview                                      Page 14 of 19
                                                    NURSING FACILITY CASEMIX
                     Receives and maintains nursing facility assessments and determines care levels used during claims processing.


INPUTS                                                                       MMIS                                           OUTPUTS


    Assessment
   Minimum Data
     Set (MDS)
   from Nursing
      Facilities




       CMS
     Repository                                                                                          RFS
                                                          Casemix System                               Recipient
   (HHSS Server)
                                                                                                         File




                                                                                                         MCP
                                                                                                       Medical
                                                                                                        Claims
                                                                                                      Processing




    Revised March 23, 2007                                     Nebraska MMIS Overview                                                 Page 15 of 19
                                                        MEDICAL NON-FEDERAL
                   Ensures that Medicaid federal funds are not claimed for services otherwise available through the Medicare Program
                                            for those individuals who do not participate in Medicare Part B


INPUTS                                                                  MMIS                                              OUTPUTS




                                        MCP
   Beneficiary                        Medical
  Data Exchange                        Claims
   (BDE) with                        Processing
      CMS




                                                                                                                                   Finance and
                                                                     MNF
                                                                                                                                   Management
                                                              Medical Non-Federal
                                                                                                                                     Reports




    Revised March 23, 2007                                     Nebraska MMIS Overview                                                  Page 16 of 19
                                                  NEBRASKA DISABILITY PROGRAM
             Accounts for separate funding of services for persons with disabilities who do not meet all the Medicare eligibility requirements
                        but who are eligible for Medicaid. Also tracks funding for State-funded Refugee Resettlement Program.


INPUTS                                                                    MMIS                                               OUTPUTS




                                        MCP
                                      Medical
                                       Claims
                                     Processing




                                                                                                                                      Finance and
                                                                      NDP
                                                                                                                                      Management
                                                            Nebraska Disability Program
                                                                                                                                        Reports




    Revised March 23, 2007                                       Nebraska MMIS Overview                                                   Page 17 of 19
                                           NEBRASKA MEDICAID ELIGIBILITY SYSTEM
                                                        Interactive Voice Response (IVR)
                             Telephone voice-response system for use by providers to determine Medicaid client eligibility.


INPUTS                                                                    MMIS                                                OUTPUTS




                                 RFS                    MPS                       TPL                    NMC
                               Recipient               Medical                 Third Party              Nebraska
                                 File                  Provider                 Liability               Managed
                                                                                                          Care




      Provider
    Phone Calls                                          Nebraska Medicaid Eligibility                                                   Client
     Regarding                                                 System (NMES)                                                           Eligibility
       Client                                                       IVR                                                             Information To
     Eligibility                                                                                                                       Providers




    Revised March 23, 2007                                        Nebraska MMIS Overview                                                Page 18 of 19
                                                        TRANSLATOR SERVICES
                                                              Contracted through Sybase, Inc.
                     Provides translator software to assure that HIPAA X12 compliant transactions are conducted through the MMIS.


INPUTS                                                                           MMIS                                 OUTPUTS

   Electronic                                                                                                                         Electronic
   Eligibility                                                                                                                        Eligibility
 Benefit Inquiry                                                                                                                       Benefit
     (270)                                                                                                                            Response
                                                                          SYBASE                                                        (271)
                                                                          Translator
   Electronic
    Claim –                                                                                                                         Claim Payment
  Professional                                                                                                                        Remittance
    (837P)                                                                                                                              Advice
                                                                                                                                        (835)


   Electronic                                                                                                                         Premium
    Claim –                                                                                                                           Payment
                                                                  MMIS Interface Database
  Institutional                                                                                                                         (820)
     (837I)


   Electronic                                                                                                                          Benefit
    Claim -                                                                                                                         Enrollment and
    Dental                                                                                                                           Maintenance
    (837D)                              NMC                                                                                             (834)
                                       Nebraska
                                       Managed
                                       Care (for
   Electronic                          820/834)                                                                                       Electronic
  Claim Status                                                                              MCP                                      Claim Status
    Request                                                  RFS Recipient                Medical                                     Response
     (276)                                                         File                    Claims                                       (277)
                                                             (for 271, 278)              Processing
                                                                                       (for 277, 820,
                                                                                         835, 837)
  Electronic                                                                                                                         Electronic
 Authorization                                                                                                                      Authorization
   Request                                                                                                                           Response
    (278)                                                                                                                              (278)



     Revised March 23, 2007                                    Nebraska MMIS Overview                                               Page 19 of 19

								
To top