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					                                     TMHP MITA Business Process Mapping




   Texas Medicaid & Healthcare Partnership

       MITA State Self-Assessment Phase 1
             (Provider Management)




                                                              Version 1.1
                                                        July 13, 2007




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MITA State Self-Assessment Phase 1 (Provider Management) ......................... 1
 1.0 Overview .................................................................................................................. 4
   1.1      MITA Mi ssion .........................................................................................................4
   1.2      MITA Goals.............................................................................................................4
   1.3      MITA Objective s .....................................................................................................4
   1.4      What Is a State Self-Asse ssment? .........................................................................5
 2.0 MITA Maturity Model............................................................................................... 5
   2.1      Purpose..................................................................................................................5
 3.0 Business Process Model ....................................................................................... 6
   MITA Busine ss Proce ss Model Hierarchy ........................................................................6
   3.1      (PM) Provider Management As I s Busine ss Proce ss .............................................7
         3.1.1      Provider Enrollment Process Group (PM1) ............................................................................. 9
         3.1.2      (PM2) Provider Information Management Process Group ................................................ 13
         3.1.3      (PM3) Provider Support Process Group ................................................................................ 17

 4.0 Summary ................................................................................................................ 23
 5.0 As Is Application Information.............................................................................. 24
 6.0 To Be Business Processes.................................................................................. 25
 7.0 To Be Information and Technical Architecture ................................................. 25
Appendix A: Provider Management Business Capabilities Matrix ................ 26
   PM Enroll Provider: Busi ness Capabilities.....................................................................27
   PM Disenroll Provider: Busine ss Capabilities [TBD]......................................................32
   PM Manage Provider Information: Business Capabilities ..............................................33
   PM Inquire Provider Information: Busine ss Capabilities................................................36
   PM Manage Provider Communication: Busine ss Capabilities .......................................39
   PM Manage Provider Grievance & Appeal: Busine ss Capabilities .................................42
   PM Perform Provider Outreach: Busine ss Capabilities..................................................45
Appendix B: Contract Requirements..................................................................... 49
Appendix C: Assessment Details ............................................................................ 65
   PM1 – Enroll Provider ....................................................................................................66
   PM1 – Di senroll Provider (TBD)......................................................................................67
   PM2 – Inquire Provider Information ...............................................................................68
   PM3 Manage Provider Grievance and Appeal ................................................................69


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  PM3 Manage Provider Communication ..........................................................................71
  PM3 Perform Provider Outreach ....................................................................................73




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1.0 Overview
The Medicaid Information Technology Architecture (MITA) is an initiative intended to
stimulate an integrated business and IT transformation affecting the Medicaid enterprise
in all States. It is designed to improve Medicaid program administration by establishing
national guidelines for technologies and processes, and it includes an architectural
framework, processes, and planning guidelines that enable State Medicaid enterprises
to meet their objectives within the MITA framework while still supporting unique local
needs.

1.1      MITA Mission
The MITA mission is to establish a national framework of enabling technologies and
processes that support improved program administration for the Medicaid enterprise and
for stakeholders dedicated to improving healthcare outcomes and administrative
procedures for Medicaid beneficiaries.

1.2      MITA Goals
The MITA initiative seeks to accomplish the following goals.
     Develop seamless and integrated systems that communicate effectively to achieve
      common Medicaid goals through interoperability and common standards.
     Promote an environment that supports flexibility, adaptability, and rapid response to
      changes in programs and technology.
     Promote an enterprise view that supports enabling technologies that are aligned with
      Medicaid business processes and technologies.
     Provide data that is timely, accurate, usable, and easily accessible in order to
      support analysis and decision making for healthcare management and program
      administration.
     Provide performance measurement for accountability and planning.
     Coordinate with public health and other partners, and integrate health outcomes
      within the Medicaid community.

1.3      MITA Objectives
The MITA goals translate into the following objectives:
     Adopt data and industry standards.
     Promote reusable components; modularity.
     Promote efficient and effective data sharing to meet stakeholder needs.

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     Provide a beneficiary-centric focus.
     Support interoperability, integration, and an open architecture.
     Promote secure data exchange (single entry point).
     Promote good practices (e.g., the Capability Maturity Model [CMM] and data
      warehouse).
     Support integration of clinical and administrative data.
     Break down artificial boundaries between systems, geography, and funding (within
      the Title XIX Program).

1.4      What Is a State Self-Assessment?
The State Self-Assessment (SS-A) is a process that a State uses to review its strategic
goals and objectives, to measure its current business processes and capabilities against
MITA business capabilities, and ultimately to develop target capabilities to transform its
Medicaid enterprise to be consistent with MITA pr inciples.


2.0 MITA Maturity Model
2.1      Purpose
The purpose of the MITA Maturity Model (MMM) is to serve as a reference model for
grounding the definitions of business capabilities and technical capabilities. The MMM
establishes boundaries and measures to be used in determining whether a business
capability is correctly and sufficiently defined.
The MMM applies to the State Medicaid enterprise only. The Medicaid enterprise
encompasses all administrative services for which CMS supplies Federal matching
funds, including interfaces with stakeholders. States can choose to encourage their data
exchange partners (e.g., providers, managed care organizations, benefit managers,
other agencies, and other payers) to follow these guidelines. Some definitions
associated with Maturity Levels 4 and 5 are dependent on regulations that do not
currently exist or technology that is envisioned but not yet proven. It is a constant
principle of the MITA Framework that all its contents are subject to change. MITA is
always a work in progress.
A maturity model measures the improvement and transformation of a business across
the two dimensions — time and space.




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3.0 Business Process Model
A Business Process Models (BPM) describes what an organization or business does,
including the events that initiate those processes (i.e., the trigger event). The BPM
hierarchy consists of four tiers. The lowest level business process appears in different
tiers depending on the complexity of the business area. In less complex business areas,
the business process appears at Tier 2: or 3.


                        MITA Busine ss Proce ss Model Hierarchy




The BPM is organized in the following eight Business Areas:
      Member Management (ME)
      Provider Management (PM)
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          Contractor Management (CO)
          Operations Management (OM)
          Program Management (PG)
          Business Relationship Management (BR)
          Program Integrity Management (PI)
          Care Management (CM)
The Provider Management (PM) Business Area services the provider network through
outreach, enrollment, information management, communications, and support services.
The Business Objective for this Business Area are to improve quality of provider
network, match needs of the population with availability of appropriate services, satisfy
providers and consumers, prevent illness, and improve outcomes.
Business processes that have a common purpose and share data are grouped together
in Process Groups The following chart illustrates the structure of the PM Business Area,
Process Groups and Business Processes.
                             Provider Management Busine ss Area
      Busine ss Area               Process Group                        Busine ss Proce sse s
Provider Management         PM1 Provider Enrollment           PM1 Enroll Provider
                                                              PM1 Disenroll Provider
                            PM2 Provider Information          PM2 Inquire Provider Information
                            Management                        PM2 Manage Provider Information
                            PM3 Provider Support              PM3 Manage Provider Gri evance and
                                                              Appeal
                                                              PM3 Manage Provider Communication
                                                              PM3 Perform Provider Out reac h


3.1        (PM) Provider Management As Is Business Process
The table below provides a representation of the table contents in the following Provider
Management Business Processes.
          Item                             Details                                     Link
  Description       A brief description of the complete business process   Location in the Model
 Trigger Event      An occurrence that triggers a business process         Sources of Trigger
                    (e.g., receipt of a request, phone call, or a          events in Business
                    scheduled date).                                       Process (BP) Model
                    The Trigger is a defined dat a set.
      Result        One or more outcomes from the execution of the         BP affected by the
                    Business Logic (results are defined as data in         Result
                    motion and are the immediate output from the
                    business process, not the ultimate, downstream

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                result).
                The Result is a defined data set.
  Busine ss     A sequence of steps that execute the successful          N/A
Process Steps   completion of the business process (steps start with
                a verb).
 Shared Data    Shared data is data at rest (i.e., data stores           Referenc e other
                accessed to complete a step in the business              Business Areas and
                process).                                                BP share the same
                Shared data is a defined data set.                       data
 Predecessor    The preceding business process, the Result of            Other BP
                which becomes an input Trigger to this business
                process.
  Succe ssor    The Results of this business process, which may          Other BP
                become a Trigger for another business process.
 Constraints    Conditions that must be met for this generalized         N/A
                process to execute (e.g., enrolling institutional
                providers requires different information from
                enrolling pharmacies ).
   Failures     An identification of the exit points throughout the      N/A
                business process where the Business Logic
                specifies that the process must terminate because
                of failure of one or more steps.
 Performance    Measures that describe what can be measured but          N/A
  Measure s     that are not specific measures in themselves, such
                as the following:
                1. Time to complete process (e.g. real -time
                   response = within ___ seconds; batch response
                   = within ___ days)
                2. Accuracy of decisions = ___%.
                3. Consistency of decisions and disposition =
                   ___%.
                4. Error rate = ___% or less.
                The MITA template specifies the type of measure
                but not the actual measure.




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   3.1.1 Provider Enrollment Process Group (PM1)

       3.1.1.1       Enroll Provider (PM1)

    Item                                     Details                                           Links
 Description     The Enroll Provider business process is responsible for              Business Process
                 managing providers’ enrollment in programs including:                Model loc ation:
                    Receipt of provider applications                                 Tier 1: Provider
                                                                                      Management
                    Processing of provider applications and verification of          Tier 2: Provider
                     applications                                                     Enrollment
                    If applicable, credentialing cont ract providers for Primary
                     Care Case Management (PCCM) and verification of
                     applications on the Provider Master File
                    Updating the Provider Master File with new enrollment
                     data
                    Communicating enrollment status to Providers
Trigger Event       Receipt of verbal or written request of Provider                 Tier 1: Provider
                     Enrollment Application                                           Management
                    Receipt of written request of Contract Credentialing             Tier 2: Provider
                     Application                                                      Enrollment

   Result        Provider enrolled                                                    N/A
  Busine ss      1. Scan application into provider enrollment queue                   Tier 1: Provider
  Process        2. Assign application to specialist for review                       Management
   Steps                                                                              Tier 2: Perform
                 3. Send completed form to Office of the Inspector General
                                                                                      Provider Outreach,
                    (OIG) or send letter to provider requesting corrected
                                                                                      Tier 3: Manage
                    information
                                                                                      Provider
                 4. Perform criminal history investigation (by OIG)                   Communication
                 5. Enroll provider by entering information int o Phoenix
                    and/or CaseTrakker
                 6. Send letter to provider: acceptance, conditional
                    approval, or denial
Shared Data      Master Provider File                                                 Tier 1: Provider
                                                                                      Management
                                                                                      Tier 2: Perform
                                                                                      Provider Outreach
                                                                                      Tier 3: Manage
                                                                                      Provider
                                                                                      Communication
Predecessor         Provider Enrollment Application                                  Tier 1: Provider
                    Texas Standardized Credentialing Application                     Management
                                                                                      Tier 2: Perform
                                                                                      Provider Outreach
                                                                                      Tier 3: Manage

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                                                                                 Provider
                                                                                 Communication

 Succe ssor        Provider notification letters                                Tier 1: Provider
                   Provider Bulletins                                           Management
                                                                                 Tier 2: Provider
                   Primary Care Case Management Bulletins                       Information
                   Children with Special Health Care Needs Services             Management
                    Program (CSHCNSP) Provider Bulletins                         Tier 3: Manage
                                                                                 Provider Information
                                                                                 Tier 2: Provider Support
                                                                                 Tier 3: Manage
                                                                                 Provider
                                                                                 Communication




Constraints        Provider Enrollment Forms must have an original              Tier 1: Provider
                    signature per the Office of the Inspector General (OIG);     Management
                    therefore, they must be mailed to TMHP.                      Tier 2: Provider Support
                   A separat e Provider Enrollment Form is required for         Tier 3: Manage
                    each program desired for enrollment.                         Provider
                                                                                 Communication
                   Intensive, manual validation process is time consuming
                    and costly
                   Providers cannot enroll in the CS HCNSP without first
                    having enrolled in Acute Care.
                   All provider credentials must be approved by HHS C
                    prior to finalizing the enrollment.
  Failures    N/A                                                                N/A
Performance        Accuracy rate for processing provider applications and       N/A
 Measure s          entering provider information into the system
                   Completion of provider applications for enrollment within
                    specified time frames
                   Credentialing of providers within the time frames
                    allowed




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       3.1.1.2        Disenroll Provider (PM1)

    Item                                     Details                                        Links
 Description     The Disenroll Provider process terminates providers bas ed         Business Process
                 on failure to maintain enrollment requirements or requests         Model loc ation:
                 from providers to voluntarily disenroll.                           Tier 1: Provider
                                                                                    Management
                                                                                    Tier 2: Provider
                                                                                    Enrollment
                                                                                    Tier 3: Disenroll
                                                                                    Provider
Trigger Event         Receipt of Provider Information Change (P IC) form           N/A
                      Receipt of notification from Office of the Inspector
                       General (OIG) or Medicaid Program Integrity (MPI) to
                       disenroll provider
   Result             Updated Provider Master File                                 Tier 1: Provider
                      Updated Contracting and Credentialing database               Management
                       (Cas eTrakker)                                               Tier 2: Provider
                                                                                    Support
                                                                                    Tier 3: Manage
                                                                                    Provider
                                                                                    Communication
  Busine ss      1.   Update the provider termination dat a within the Master       N/A
  Process             Provider File.
   Steps         2.   Update credentialing database to reflect termination
                      data.
                 3.   Verify that the provider is due for mandatory termination.
                 4.   Send provider notification of dis enrollment and reasons
                      for disenrollment.
Shared Data      Provider Dat a                                                     Tier 1: Provider
                                                                                    Management
                                                                                    Tier 2: Provider
                                                                                    Support
                                                                                    Tier 3: Manage
                                                                                    Provider
                                                                                    Communication
Predecessor           Provider sends Provider Information Change (P IC) form       Tier 1: Provider
                      State Action Report (SAR) from OIG or MPI                    Management
                                                                                    Tier 2: Provider
                      Provider File weekly report                                  Support
                                                                                    Tier 3: Manage
                                                                                    Provider
                                                                                    Communication
 Succe ssor           Provider receives a termination letter.                      Tier 1: Provider

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                   Discontinuation of publications and additional mailings.     Management
                                                                                 Tier 2: Provider
                                                                                 Support
                                                                                 Tier 3: Manage
                                                                                 Provider
                                                                                 Communication
Constraints   Manual process of comparing weekly report against data             N/A
              against licensure website data is time consuming and costly.
  Failures    N/A                                                                N/A
Performance   N/A                                                                N/A
 Measure s




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   3.1.2 (PM2) Provider Information Management Process Group

      3.1.2.1   Inquire Provider Information (PM2)

     Item                              Details                                    Link
 Description    The Inquire P rovider Information business process       Business Process
                receives requests for provider enrollment verification   Model loc ation:
                from authorized providers, programs or business          Tier 1: Provider
                associates and performs the inquiry and responds.        Management
                                                                         Tier 2: Provider
                                                                         Enrollment
                                                                         Tier 3: Disenroll
                                                                         Provider
Trigger Event      Receipt of inquiry from provider, provider           Tier 1: Provider
                    representative or HHS C                              Management
                   Receipt of internal request for information          Tier 2: Provider
                                                                         Support
                                                                         Tier 3: Manage
                                                                         Provider
                                                                         Communication
    Result      Provider request is researched and a response is         Tier 1: Provider
                returned via phone call, correspondence or TMHP          Management
                Initiated Memo (TIM). Electronic requests receive        Tier 2: Provider
                acceptance or rejection reports.                         Support
                                                                         Tier 3: Manage
                                                                         Provider
                                                                         Communication
  Busine ss     1. Receive call or SAR                                    N/A
Process Steps   2. Log all inquires
                3. Research inquiry
                4. Create TIM in response to inquiry
                5. Respond to inquiry via phone, fax, TIM, or
                   mailed letter


 Shared Data       Electronic Operational Procedures Manual             Tier 1: Provider
                    (eOPM )                                              Management
                   Provider Dat a                                       Tier 2: Provider
                                                                         Support
                                                                         Tier 3: Manage
                                                                         Provider
                                                                         Communication
 Predecessor    Requests for provider enrollment verification and        Tier 1: Provider
                information authorized providers, programs or            Management
                business associates                                      Tier 2: Provider
                                                                         Support

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                                                                        Tier 3: Manage
                                                                        Provider
                                                                        Communication
  Succe ssor         Provider inquiries tracked electronically         Tier 1: Provider
                     Provider inquiries resulting in additional        Management
                      research are processed                            Tier 2: Provider
                                                                        Support
                                                                        Tier 3: Manage
                                                                        Provider
                                                                        Communication
 Constraints    Data updates must be made in several systems for        N/A
                various programs.
   Failures     N/A                                                     N/A
 Performance    Respond to specified percentage of provider             N/A
  Measure s     inquiries within receipt of the inquiry.



      3.1.2.2   Manage Provider Information (PM2)

     Item                               Details                                  Link
 Description    The Manage Provider Information business            Business Process Model
                process is responsible for managing all provider    location:
                information to include outgoing information;        Tier 1: Provider
                banners, bulletins, manuals, applications           Management
                (traditional and managed care-credentialing)        Tier 2: Provider Enrollment
                and licensure information related to a claims       Tier 3: Manage Provider
                payment, a grievanc e and/or an appeal.             Communication


Trigger Event        Receipt of PIC Form from Provider             Tier 1: Provider
                     Receipt of provider demographic,              Management
                      reimbursement methodology, licensure,         Tier 2: Provider Enrollment
                      patient panel and contract changes            Tier 3: Enroll Provider
                                                                    Tier 3: Disenroll Provider
                     Receipt of Provider Inquiry                   Tier 2: Provider Support
                     Receipt of SAR                                Tier 3: Manage Provider
                                                                    Communication
    Result           Provider data updated                         Tier 1: Provider
                     Policy revision                               Management
                                                                    Tier 2: Provider Enrollment
                     Educational notification or clarification     Tier 3: Enroll Provider
                     Outgoing phone call or letter                 Tier 3: Disenroll Provider
                     SAR/TIM                                       Tier 2: Provider Support
                                                                    Tier 3: Manage Provider
                                                                    Communication



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  Busine ss     1.    Scan all requests for change in Kintana.        N/A
Process Steps   2.    Enter dat a manually into the Provider
                      Master File from the PIC form.
                3.    Enter dat a manually for credentialing into
                      CaseTrakker.
                4.    Update data within P rovider Master File.
                5.    Update manual, banner, bulletin, web.
                6.    Respond to inquiry.
 Shared Data         Master Provider File                           Tier 1: Provider
                     Texas State Board of Medical/Dental            Management
                      Examiners license file                         Tier 2: Provider Enrollment
                                                                     Tier 3: Enroll Provider
                     On-line manuals, web content                   Tier 3: Disenroll Provider
                                                                     Tier 2: Provider Support
                                                                     Tier 3: Manage Provider
                                                                     Communication
 Predecessor         Master Provider File                           Tier 1: Provider
                     Texas State Board of Medical/Dental            Management
                      Examiners license file                         Tier 2: Provider Enrollment
                                                                     Tier 3: Enroll Provider
                     On-line manuals, web content, outgoing         Tier 3: Disenroll Provider
                      education                                      Tier 2: Provider Support
                                                                     Tier 3: Manage Provider
                                                                     Communication
  Succe ssor         Provider notification                          Tier 1: Provider
                     Operations Management: Claims are              Management
                      processed according to provider                Tier 2: Provider Enrollment
                      information in the Master Provider File        Tier 3: Enroll Provider
                                                                     Tier 3: Disenroll Provider
                     HHS C and other state agencies                 Tier 2: Provider Support
                     Enrollment brokers and vendors using data      Tier 3: Manage Provider
                      from the Provider Master File                  Communication
                                                                     Tier 1: Operations
                                                                     Management
                                                                     Tier 2: Payment
                                                                     Management
                                                                     Tier 2: Member Payment
                                                                     Management
 Constraints         Provider forms must be submitted on            N/A
                      paper.
                     Research must be performed in several
                      different systems.
                     Lack of policy clarification and direction
                      from state causes delay in implement ation
   Failures     N/A                                                  N/A




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 Performance      Accuracy rate for processing provider           N/A
  Measure s        applications
                  Completion perc entage of all provider
                   applications for enrollment or credentialing
                  Number of delivered written and/or
                   electronic reports to each vendor or broker
                   each month
                  System reporting on inquiries and
                   responses and timeframes




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   3.1.3 (PM3) Provider Support Process Group

      3.1.3.1   Manage Provider Grievance and Appeal (PM3)

     Item                             Details                                       Link
 Description    The Manage Provider Grievance and Appeal               Business Process Model
                business process handles provider appeals of           location:
                adverse decisions or communications of a               Tier 1: Provider
                grievance.                                             Management
                                                                       Tier 2: Provider Support
                                                                       Tier 3: Manage Provider
                                                                       Grievance and Appeal
Trigger Event        Receipt of an appeal request for                 Tier 1: Provider
                      authorization with additional information        Management
                      from provider                                    Tier 2: Provider Support
                     Receipt of Administrative Appeal or              Tier 3: Manage Provider
                      Exception request from HHS C                     Grievance and Appeal


    Result          Authorization det ermination letter is sent to    Tier 1: Provider
                     the provider.                                     Management
                    Research findings and recommendations on          Tier 2: Provider Support
                     Administrative Appeals & Exception request        Tier 3: Manage Provider
                     are sent to HHS C.                                Grievance and Appeal

  Busine ss     Authorizations:                                        N/A
Process Steps   1. Review Authorization appeals request by
                   Prior Authorization staff
                2. Make a determination to approve or deny the
                   appeal.
                3. Send a provider letter by Prior Authorization
                   staff.
                Admini strative Appeals & Exception
                   Requests:
                1.   Review the request from HHSC.
                2.   Research request and mak e
                     recommendations based on findings.
                3.   Submit to HHS C.


 Shared Data        Client Data                                       Tier 1: Provider
                    Provider Data                                     Management
                                                                       Tier 2: Provider
                    Claims Data                                       Information Management
                                                                       Tier 3: Management
                                                                       Provider Information

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                                                                     Tier 1: Member
                                                                     Management
                                                                     Tier 2: Member
                                                                     Information Management
                                                                     Tier 3: Manage Member
                                                                     Information
                                                                     Tier 1: Operations
                                                                     Management
                                                                     Tier 2: Payment
                                                                     Management
                                                                     Tier 3: Claim/Encounter
                                                                     Adjudication
 Predecessor         Provider receives adverse decision             Tier 1: Provider
                      regarding an aut horization                    Management
                     HHS C receives request from Provider           Tier 2: Provider Support
                                                                     Tier 3: Manage Provider
                                                                     Grievance and Appeal
  Succe ssor    The provider can file an appeal with the HHSC        N/A
                after exhausting the appeals process with
                TMHP.
 Constraints    N/A                                                  N/A
   Failures     N/A                                                  N/A
 Performance         Percentage of provider authorization           N/A
  Measure s           determination letters sent in a timely
                      manner
                     Percentage of authorizations processed in a
                      timely manner
                     Administrative appeals and exception
                      requests must be processed within
                      specified time



      3.1.3.2   Manage Provider Communication (PM3)

     Item                                Details                                    Link
 Description    The Manage Provider Communication business                 Business Process
                process receives requests for information, provider        Model loc ation:
                publications, and assistance from prospective and          Tier 1: Provider
                current providers’ communications such as inquiries        Management
                related to eligibility of provider, covered services,      Tier 2: Provider
                reimbursement, enrollment requirements etc.                Enrollment
                Communications are researched, developed and               Tier 3: Enroll Provider
                produced for distribution.                                 Tier 3: Disenroll
                                                                           Provider
                                                                           Tier 2: Provider

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                                                                          Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication
Trigger Event       Receipt of provider enrollment form request          Tier 1: Provider
                    Receipt of policy changes                            Management
                                                                          Tier 2: Provider
                    Receipt of notification of changes to claims         Support
                     payment                                              Tier 3: Manage
                    Receipt of request for provider training or          Provider
                     problem resolution                                   Communication
                    Receipt of provider inquiries
                    Receipt of provider check or refund
                    Receipt of provider inquiry
    Result          Recruitment/ret ention of new providers              Tier 1: Provider
                    Texas Medicaid Provider Procedures Manual is         Management
                     updated.                                             Tier 2: Provider
                                                                          Support
                    Notices of policy and claims payment changes         Tier 3: Manage
                     are given in Provider Bulletins, Banner              Provider
                     Messages and Newsletters.                            Communication
                    Problem resolution or escalation for state
                     direction
                    Training
  Busine ss     1.   Conduct provider workshops and training              N/A
Process Steps        sessions to adequately train all provider types
                     and all geographical areas.
                2.   Send a notification packet containing all
                     information and required forms for participation
                     in the program and list of resources for inquiry
                     and resolution, including location of publications
                     for program participation.
                3.   Notify providers of changes to policy,
                     reimbursement methodology or claims
                     payments via banner messages, provider
                     bulletins and/ or newsletters; or TMHP website.


 Shared Data        Provider Dat a                                       Tier 1: Provider
                    Web Application                                      Management
                                                                          Tier 2: Provider
                                                                          Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication
 Predecessor        Provider outreach                                    Tier 1: Provider
                    Provider inquiries, to include but not limited to    Management
                                                                          Tier 2: Provider
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                      enrollment, grievanc es and appeals                 Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication
  Succe ssor    Providers are notified of outcome of inquiry.             Tier 1: Provider
                                                                          Management
                                                                          Tier 2: Provider
                                                                          Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication
 Constraints    Providers may change their contact information that       N/A
                may not be communicated to TMHP in a timely
                manner.
   Failures     N/A                                                       N/A
 Performance         Number of provider notification packets sent        N/A
  Measure s          Number of workshops performed




      3.1.3.3   Perform Provider Outreach (PM3)

     Item                               Details                                    Link
 Description    The Perform Provider Outreach business proc ess is        Business Process
                in response to multiple activities. For prospective       Model loc ation:
                providers out reach information is developed to           Tier 1: Provider
                target providers identified to recruit, from various      Management
                tools such as licensed provider tools. For providers      Tier 2: Provider
                currently enrolled, information to educate on             Support
                appropriate policies and billing guidelines occur         Tier 3: Manage
                through various venues such as banners, bulletins,        Provider
                web port al other association publications, public        Communication
                health alerts, public service announcements and
                other objectives are provided.
Trigger Event   Recruitment of health care providers                      Tier 1: Provider
                                                                          Management
                                                                          Tier 2: Provider
                                                                          Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication




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    Result      Recruited or retained providers                           Tier 1: Provider
                                                                          Management
                                                                          Tier 2: Provider
                                                                          Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication
  Busine ss     1.   Cont act non-participating providers and assist      N/A
Process Steps        with issues.
                2.   Communicate periodically with various provider
                     groups to evaluate the ongoing training needs of
                     the provider community.
                3.   Meet with HHS C groups, medical societies,
                     regional managed care groups, and
                     associations to form partnerships to care for all
                     Medicaid providers.
                4.   Cont act providers in a face-to-face meeting or
                     via phone, or letter for the purpose of
                     recruitment, education or problem resolution.
 Shared Data        Active provider lists                                Tier 1: Provider
                    Geo-access maps for client ratio to provider         Management
                     ratio per county                                     Tier 2: Provider
                                                                          Support
                    Significant Traditional Provider (S TP) reports in   Tier 3: Manage
                     recruitment activities                               Provider
                    Newly enrolled provider lists                        Communication
                    Licensed provider lists
 Predecessor        Provider requests enrollment, or problem             Tier 1: Provider
                     resolution                                           Management
                    Provider communication                               Tier 2: Provider
                                                                          Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication
  Succe ssor    Increased provider enrollment or provider retention       Tier 1: Provider
                                                                          Management
                                                                          Tier 2: Provider
                                                                          Enrollment
                                                                          Tier 3: Enroll Provider
                                                                          Tier 2: Provider
                                                                          Support
                                                                          Tier 3: Manage
                                                                          Provider
                                                                          Communication
 Constraints        Provider Enrollment Form must be submitted on        Tier 1: Provider
                     paper.                                               Management
                    Frequent changes to policy make updates to           Tier 2: Provider
                                                                          Support
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                     workshops material burdensome.                   Tier 3: Manage
                    Frequent changes to program policies or          Provider
                     benefits need to be communicat ed to providers   Communication
                     and incorporated into their billing practices.
   Failures    N/A                                                    N/A
 Performance   Provider enrollment numbers                            N/A
  Measure s




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4.0 Summary
This section provides a high-level summary of the current assessment for each business
process. Detailed information supporting the assessment can be found in Appendix C –
Assessment Details. The details included are not an all-inclusive representation of all
business processes within a business process area.
The Process Group Level will be determined by HHSC
                            State Self-Asse ssment Profile

    Process           Busine ss Proce ss       Level   Level    Level   Level     Level
     Group                                       1       2        3       4         5
PM1 Provider     PM1 Enroll Provider          As Is
Enrollment
                 PM1 Disenroll Provider       As Is
LEV EL _         (MITA TB D)
PM2 Provider     PM2 Inquire Provider                  As Is
Information      Information


                 PM2 Manage Provider          As Is
LEV EL _
                 Information
PM3 Provider     PM3 Manage Provider          As Is
Support          Grievance and Appeal
                 PM3 Manage Provider                   As Is
                 Communication

LEV EL _         Perform Provider Outreach    As Is




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5.0 As Is Application Information




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6.0 To Be Business Processes
(Future MITA SS-A Phase)


7.0 To Be Information and Technical Architecture
(Future MITA SS-A Phase)




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                              Appendix A:
              Provider Management Business Capabilities Matrix




MITA SS-A                                                               Appendix A

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                                     PM Enroll Provider: Busi ness Capabilities




MITA SS-A                                                                                               Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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                                     PM Disenroll Provider: Busine ss Capabilities [TBD]




MITA SS-A                                                                                                        Appendix A

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                                     PM Manage Provider Information: Business Capabilities




MITA SS-A                                                                                                      Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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                                     PM Inquire Provider Information: Busine ss Capabilities




MITA SS-A                                                                                                            Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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                                 PM Manage Provider Communication: Busine ss Capabilities




MITA SS-A                                                                                                   Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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                               PM Manage Provider Grievance & Appeal: Busine ss Capabilities




MITA SS-A                                                                                                    Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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                                     PM Perform Provider Outreach: Busine ss Capabilities




MITA SS-A                                                                                                         Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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MITA SS-A                                                  Appendix A

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                        Appendix B:
                   Contract Requirements




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Vendor Responsibilities
Unless otherwise specified, all Provider Management functions apply to both Medicaid
providers and PCCM primary care providers (PCPs).

Provider Management Contract Requirements
 CSC-25      Provide a representative at all Fair Hearings for the purpose of defending Vendor
             decisions regarding appeals, adjustments, and/or complaints. The Vendor’s
             representative must have specific knowledge of the policies and rules used in
             making the decision, and of the case file materials pertaining to the fair hearing.
 CSC-28      Develop a comprehensive file containing all relevant materials, with all
             supporting documentation describing the issue and the resolution, for all
             appeals, adjustments, and/or complaints. The file must contain the Vendor’s final
             determination. This file must be forwarded in its entirety to the State if the
             member chooses to appeal or file a complaint with the State.
 FPC-22      Develop, maintain, and provide technical and user training packages for family
             planning providers. Conduct family planning-specific training annually or more
             frequently if needed, for providers across the state.
 LCC-15      Process appeals in conjunction with TDHS regarding denied Medical Necessity
             for Medicaid clients or applicants. The Vendor must participat e in an appeal
             hearing within five weeks of receipt of the call from the hearing officer requesting
             the hearing.
 LTC-17      Train providers on claims processing procedures. The Vendor must offer 12
             training sessions each Contract year. The training includes sessions on both
             electronic and paper filing.
 LTC-18      Conduct up to ten seminars per year for various LTC provider associations. The
             TDHS and TDMHMR identify the appropriate associations.
 LTC-22      Receive and process the electronic files mentioned above on a nightly basis.
             When operational problems occur, the Vendor must have technical staff
             available on call to immediately resolve the problem.
 MCC-33      Monitor P CP activities associated with member outreach to encourage the use of
             the preventive health services available through the EPSDT/ THSteps program.
             The Vendor will assist in this effort by including THSteps information in eac h
             PCP’s quart erly profile.
 MCC-34      Propose recommendations to HHS C on how to enhance the number of
             EPSDT/ THSteps check ups and immunizations accomplished.
 MCC-35      Review PCP compliance with THSteps activities at all site visits and through a
             review of claims dat a.
 MCC-36      Determine, in conjunction with HHSC, an acceptable percent age of check ups
             and immunizations that each EPSDT/ THSt eps provider must achieve for their
             enrollees and establish corrective action protocols when these percentages are
             not achieved.
 MCC-37      Submit a quarterly report of EPSDT/ THSteps findings and corrective actions to
             HHS C.



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MCC-38      Encourage PCCM PCPs to enroll in the THSteps and Vaccine for Children
            programs.
MMC-10      The Provider Enrollment, Contracting and Credentialing (PECC) Department is
            required to process PCP disenrollment from Primary Care Case Management
            (PCCM) Provider network in two categories, Voluntary Provider Disenrollment
            and Mandatory Provider Disenrollment.
PAC-36      Provide staff to represent the State through written and personal testimony at
            Client Fair Hearings and court cases. The majority of client fair hearings are held
            telephonically. The Vendor will be required to participate via telephone
            conference call. The Vendor PA staff must be knowledgeable about the Medical
            Policy used to make the PA determination and must be able to reference all sites
            to Medical Policy pertaining to the decision.
PAC-37      Provide research and document ation to support administrative hearings and
            court cases.
PRC-01      Establish a provider recruitment unit at the Vendor’s Austin, Texas operations
            site. The unit will use a proactive and effective approach in the ongoing effort to
            develop and implement strategies to recruit qualified providers into the Medicaid
            and CSHCN programs and to increase the participation of those providers
            already enrolled in these programs. Monitor the effectiveness of provider
            recruitment/retention strategies and report the results on a monthly basis.
PRC-02      Conduct research to identify all enrolled providers who have ceased to
            participat e in the Medicaid and CS HCN programs supported by the Cont ract and
            reasons for non-participation.
PRC-03      Develop and implement strategies to increase participation and recruit new
            providers. The Vendor must give particular attention to provider types/specialties
            with low participation rates, and to underserved areas of Texas.
PRC-04      Meet with the State on a regular basis and before preparing the Annual Business
            Plan to discuss recruitment focus areas for the upcoming year and recruitment
            goals.
PRC-05      Perform targeted provider recruitment, enrollment, and training as needed, by
            provider type, to encourage participation and increase access to care (e. g.,
            EPSDT/ THSteps, dental, waiver).
PRC-06      Ensure that provider recruitment is reflective, to the extent possible, of the area’s
            cultural and THN client composition.
PRC-07      Provide recruitment on-site, at the provider’s location, as pa rt of the recruitment
            process.
PRC-08      Set up booths or make presentations every year during the meetings or
            conventions of at least nine different provider groups or organizations, including
            the Texas Medical Association, Texas Hospital Association, Texas Osteopathic
            Medical Association, Texas Optometric Association, Tex as Dent al Association,
            Texas Academy of Pediatric Dentists, Texas Hearing Aid Association, Texas
            Pediatric Society, Texas Academy of Family Physicians, and Texas Association
            of Home Health Agencies. Other provider groups or organizations may be
            substituted or added upon mutual agreement with the State or when there is a
            shortage of providers in a particular geographic area of the state.
PRC-09      Make presentations at a minimum of six medical schools and all dental
            professional schools every year. The subject of the presentations will be general
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            information about the Medicaid program, Medicaid Managed Care, CSHCN and
            THSteps. Emphasis must be placed on recruiting providers completing post -
            graduate training programs.
PRC-10      Establish a provider enrollment unit and a provider relations unit at the Vendor’s
            Austin, Texas operations site. The units will be responsible for provider
            enrollment, communications, relations, and training.
PRC-11      Perform enrollment activities for all provider types. The Vendor must maint ain
            knowledge of all applicable Federal and State provider enrollment, licensing, and
            certification requirements, and develop and establish detailed procedures to
            ensure proper enrollment, licensing, and certification of all provider types.
PRC-12      Obtain and maintain, both electronic and hard copy, a signed provider
            agreement for each provider enrolled in the programs supported by the Cont ract
            prior to actual enrollment. The provider a greement must be signed prior to actual
            enrollment.
PRC-13      Allow for the enrollment and payment of State approved out -of-state providers.
PRC-14      Prior to enrollment, and on an ongoing basis, verify that provider is Medicare
            enrolled (if required) and licens ed and/or certified for procedures for which they
            will be billing under their enrolled specialty. This will involve verification from any
            and all licens ure boards and certific ation agencies responsible for these
            activities. If licensing and certification verification cannot be done electronically,
            then it must be done manually.
PRC-15      Ensure that CSHCN providers are enrolled in the Medicaid program in order to
            maintain CSHCN provider status.
PRC-16      Ensure that only properly licensed/certified providers are reimbursed only for
            eligible services provided to eligible clients.
PRC-17      Update provider rec ords and ensure that provider recertification requirements
            are met in a timely fashion after a provider is enrolled.
PRC-18      Collect and update provider demographic information annually.


PRC-19      Receive telephone or written requests for enrollment applications, eligibility
            criteria, and instructions, and mail these materials within five business days of
            the Vendor’s rec eipt of request. The Vendor must maintain a log, by date, of all
            requests made and enrollment packets sent. The log will be used to monitor
            compliance with this standard. The Vendor must prepare and submit a monthly
            report summarizing information maint ained in this log.
PRC-20      Ensure that the provider application process gathers all provider information
            required for the P rovider Master File.
PRC-21      Process and track all provider enrollment applications, including pended
            applications, and maintain an automated tracking system that supports and
            monitors compliance of thes e functions. The Vendor must prepare and submit a
            monthly report summarizing the information maintained in the tracking system.
PRC-22      Enroll providers eligible to provide medical assistance servic es, in accordance
            with Federal and State statutes, rules, and regulations.
PRC-23      Maintain a 98% accuracy rate for processing provider applications and entering
            provider information into the system.


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PRC-24      Process to completion 98% of all complete provider applications for enrollment
            into the Medicaid and CS HCN programs, including verification of required
            licensure and certification, within five business days of receipt. The remaining
            two percent must be processed to completion within ten business days of
            receipt.
PRC-25      Notify providers that submit incomplete applications for enrollment into the
            Medicaid and CSHCN programs (e.g., the applications are missing information)
            what is required to complete the application within two business days of
            determining the information is missing. The Vendor will complete processing of
            the application upon receipt of the necessary information.
PRC-26      Terminate the application process and notify the provider if required information
            is not received within 30 days.
PRC-27      Data enter approved and denied enrollment applications into the system daily.
PRC-28      Send notification letters of acceptance/ rejection of enrollment application within
            five business days of data entry of provider enrollment decision.
PRC-29      Send accept ed providers notific ation packets containing all information and
            forms for participation in the program within ten days of enrollment confirmation.
PRC-30      Send a provider manual and all relevant provider bulletins issued since the last
            provider manual update to providers within ten calendar days of enrollment
            confirmation.
PRC-31      Maintain an electronic file, via document imaging, on all approved, denied, and
            terminat ed providers. The file for approved providers must contain certification
            applications, provider agreements, and all correspondence relating to
            certification or enrollment or resulting in provider data updates. Files for denied
            providers will include applications and documentation regarding the reason for
            the denial. Files for terminated providers will include documentation on reasons
            for termination. Subsequent updates or additions to the file will be date-stamped
            and initialed by Vendor staffs who update the file. Audit trails need to clearly
            track updates to enrollment files.
PRC-32      Maintain, and revise as necessary, all provider agreements/contracts to conform
            to all applicable Federal and State statutes, rules, and regulations. Revisions will
            be made within 30 calendar days of the request by the State. The Vendor will
            notify providers in writing of any changes made. Old agreements may be used
            until the supply is exhausted unless revisions must be implemented by a specific
            date.
PRC-33      Ensure that the State’s Authorized Repres entative signs contracts for all
            participating THN PCPs.
PRC-34      Mail termination notices to providers within five business days of termination
            from the Medicaid Program.
PRC-35      Mail CSHCN termination notices within five business days of Medicaid program
            provider termination.
PRC-36      Prior to initial enrollment in the Medicaid and CSHCN program or enrollment of a
            new provider number for an enrolled provider or provider’s owner, the Vendor
            must verify electronically that the provider and the provider’s business owner are
            not listed on the Medicaid and CSHCN and Medicare Exclusion listings nor are
            they listed on the HHSC Medicaid Program Integrity (MPI) list of providers under
            investigation. In addition, the Vendor must verify electronically that a pot ential
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            provider’s physical or billing address, SSN, and tax ID are not associated with
            any of the providers on any of the above-mentioned lists. If the Vendor
            determines that the potential provider is on these lists or has any of the
            associations listed above, the Vendor will not approve the application request
            and will refer the application to HHS C MPI.
PRC-37      Assign a singular unique TP I core number to each individual enrolled in any
            TMAS program. Assign a singular TP I core number to ot her provider entities
            including groups, hospit als, DME suppliers, etc.
PRC-38      Enroll only group providers with associated performing providers. A group TPI
            number cannot belong to an individual within the group or subsequently be
            assigned to an individual. Conversely, a single provider TP I cannot subsequently
            be used as a group TP I.
PRC-39      Maintain automated electronic audit trails to all aspects of the provider
            subsystem to track changes, when changed, and who made the change.
PRC-40      Maintain all provider records on-line for a minimum of 36 months from the date of
            provider termination/disenrollment, unless otherwise specified by the State.
PRC-41      Archive all provider records for an additional 24 mont hs thereaft er, unless
            otherwise specified by the State. The Vendor must maintain the ability to retrieve
            archived records within five business days of request and restore those records
            to active status within ten days of reactivation.
PRC-42      Process and track all THN PCP enrollment applications, including pended
            applications, and maintain an automated tracking system that supports and
            monitors compliance of thes e functions. Prepare and submit a monthly report
            summarizing the information maintained in the tracking system.
PRC-43      Process to completion 100% of all provider applications for enrollment into the
            THN, to include the credentialing process, within the timeframes allowed for
            provider credentialing established by the laws of the State of Texas, the National
            Committee for Quality Assurance standards, the Quality Assurance Reform
            Initiative Standards, and general medical standards, unless otherwise directed
            by the State.
PRC-44      Notify providers that submit incomplete applications for enrollment into the THN
            what is required to complete the application within two business days of
            determining the information is missing. The Vendor will complete p rocessing of
            the application upon receipt of the necessary information.
PRC-45      Terminate the application process and notify the provider if requested
            information is not received within the timeframes described above.
PRC-46      Maintain a 98% accuracy rate for processing provider applications and entering
            provider information into the system.
PRC-47      Data enter approved and denied THN enrollment applications into the system
            daily.
PRC-48      Send notification letters of acceptance/ rejection of THN enrollment application
            within five business days of data entry of provider enrollment decision.
PRC-49      Send accept ed providers notific ation packets containing all information and
            forms for participation in the THN program, within ten calendar days of
            enrollment confirmation.
PRC-50      Ensure that PCPs meet all THN PCCM agreement requirements, including 24 -

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            hour accessibility.
PRC-51      Develop and maintain a PCP network in sufficient numbers and geographic
            distribution to meet established accessibility standards for t he geographic region.
            As specified by the State, a member will not be required to travel more than 30
            miles to access a PCP, and not more than 75 miles to access specialty care,
            unless an exception to the distance requirement is made by the HHSC SMO.
PRC-52      Provide monthly reports to the State describing the status of coverage from an
            access perspective, and provide an analysis of pot ential gaps in coverage. A
            network coverage gap is defined as a member having to travel more than 30
            miles to access a PCP, or more than 75 miles to access specialty care. Where
            gaps are identified, the Vendor must describe the efforts it plans to undertake to
            recruit additional providers of the types required to remedy potential access
            problems.
PRC-53      Include significant traditional providers (S TP 's), including community health
            centers, federally qualified health centers (FQHC 's), Rural Health Centers
            (RHC's), and city/county public health departments in the THN when they meet
            the pertinent criteria.
PRC-54      Credential and re-credential THN PCPs, according to the laws of the State of
            Texas, the National Committee for Quality Assurance standards, the Quality
            Assurance Reform Initiative Standard, and general medic al standards, unless
            otherwise directed by the State. The State may request that other Medicaid
            providers be credentialed in the future.
PRC-55      Notify the State whenever its evaluation suggests that an individual provider
            materially fails to meet the State’s criteria, or may be engaged in activities that
            threat en the integrity of the program or the health and well being of the public.
PRC-56      Establish appropriate Peer Review functions for the THN.
PRC-57      Enter pertinent information and the terms of the agreement into a consolidat ed
            Network Provider File as each provider agreement is executed for PCPs
            enrolling in the Texas Health Network.
PRC-58      Maintain an electronic provider file that contains: The provider’s name, practice
            address, and, if different, the billing addresses, telephone, and fax numbers.
            The type of provider and the Tax ID number.
            The provider’s license number and Texas Provider Identification (TP I) numbers.
            A copy of the executed provider agreement.
            All credentialing and re-credentialing information obtained and whether it meets
            the requirements for provider participation.
            Patient Panel Notific ation on patients enrolled with the provider for each program
            month (from inception through the last month for whic h effective enrollment
            information is available). The roster must include the following information:
            Total number of members.
            Languages spoken in the PCP’s office.
            Information on whet her the provider is accepting new Medicaid clients and if
            there are any restrictions (e.g., previous clients only, sibling of current client).
            Any special information that will be useful to recipients as they make a PCP
            choice, such as whether a PCP sees newborns.

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            Information regarding the results of contract compliance reviews.
            The date-sensitive specific payment terms negotiated under the agreement
            between the provider and the State for providers subject to negotiated
            contracting.
PRC-59      Update and expand the electronic files to reflect changes in any and all provider
            information, including rate information for contracted hospitals, and to
            accommodate new requirements for information collection established by the
            State.
PRC-60      Produce THN Patient Panel Reports to inform eac h PCP of the members
            assigned to them for each month.
PRC-61      Deliver the written and/or electronic Patient Panel Reports to each PCP within
            five business days of the Vendor receiving the Monthly Enrollment File from the
            Enrollment Broker each month.
PRC-62      Display the begin date of the enrollment.
PRC-63      Generat e and deliver letters to PCPs informing them of newly enrolled or re -
            enrolled THN members within two business days of receiving the weekly
            Member Enrollment File from the Enrollment Broker. The letter must contain the
            member’s effective dat e with the P CP.
PRC-64      Provide an interface to ensure the Enrollment Broker has access to a list of
            current PCPs participating in the THN, on a daily basis.
PRC-65      Provide an interface to ensure the Enrollment Broker has access to PCP
            changes made by members, on a daily basis.
PRC-66      Furnish the technical means by which the Enrollment Broker c an determine the
            number of patients that each enrolled PCP will accept as new patients at that
            time, and rec ord beneficiary elections regarding PCP assignment for the
            forthcoming month.
PRC-67      Provide the E nrollment Brok er with accurate and up-to-date THN provider
            directories, on a quarterly basis, unless otherwise directed by the State.
PRC-68      Provide the State with an electronic copy of the provider directory each quarter.
PRC-69      Interface with the Enrollment Broker and receive the monthly Enrollment File and
            the monthly Capitation File to generate PCP Patient Panel Reports.
PRC-70      Update and maintain provider data in the Provider Master File for enrolled
            providers, including bot h active and inactive providers. File formats describing
            the contents of the Provider Master File are available to bidders in the
            Procurement Library.
PRC-71      Maintain an electronic audit trail, available on -line, of all changes made to the
            Provider Master File. Both batch and on-line audit trails are required.
PRC-72      Ensure that a proper provider file is used for each processing run.
PRC-73      Maintain control totals and processing dat es to ensure that all data processing
            records are accounted for on each processing run.
PRC-74      Establish methods to edit and verify all data elements for completeness and
            consistency before the P rovider Master File is updated.
PRC-75      Correct all erroneous data in the Provider Master File with notification to the
            State of this action.


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PRC-76      Monitor the error suspense file to ensure that all errors are corrected daily.
PRC-77      Produce and review error reports identifying trans actions to the Provider Master
            File that have experienced an error eac h time file maintenance is performed.
PRC-78      Provide separate reports to identify errors to provider transactions for each
            program (e.g., Medicaid, CSHCN, etc.). Each report will identify the error with the
            date of input and type of error.
PRC-79      Establish a process to ensure that all errors identified on thes e reports are
            corrected on a timely basis. The Vendor must maintain error information and
            steps taken to resolve the errors on the Provider Master File for the audit trail.
PRC-80      Maintain an audit trail of all provider type, specialty, and pricing locality
            information to be us ed for appropriate dates of service on all new claims and
            adjustments to paid or denied claims. This information will be used to determine
            payment on the services both initially and on all fut ure adjustments.
PRC-81      Generat e a trans action listing to provide an audit trail to account for every
            change made to a provider’s record. Both batch and on-line audit trails are
            required.
PRC-82      Generat e a control report to balance against manual totals of dat a to ensure that
            all data is processed.
PRC-83      Match provider transaction records to the provider master record by means of
            the unique TP I number.
PRC-84      Process Provider Affiliation Update Files from other programs on an up to daily
            basis and updat e the Master Provider File accordingly.
PRC-85      Process the Monthly Provider A ffiliation Reconciliation File from other programs
            and update the Master P rovider File accordingly.
PRC-86      Process the Daily Provider Affiliation Update File concerning Medicaid providers
            participating in the THN and update the Master Provider File accordingly.
PRC-87      Process the Monthly Provider A ffiliation Reconciliation File concerning Medicaid
            providers participating in the THN and update the Master Provider File
            accordingly
PRC-88      Process Provider Affiliation Update Files on an up to daily basis from HMOs
            concerning Medicaid providers participating in their networks and update the
            Master Provider File accordingly.
PRC-89      Process the Monthly Provider A ffiliation Reconciliation File from HMOs
            concerning Medicaid providers participating in their networks and update the
            Master Provider File accordingly.
PRC-90      Update the Provider Master File with institutional provider percentage factors,
            per diem rat es, selective contracting amounts, and/or other applicable payment
            methodologies. The Vendor must also maintain this information in a date-
            sensitive manner to ensure that all claims processed initially and adjustments
            applied later use the proper rate(s) applicable for the date of service. The Vendor
            must update institutional rat es whenever the cost audit and settlement with a
            particular provider indicates the need for an adjustment.
PRC-91      Update the provider file with the Texas State Board of Medical/ Dent al Examiners
            license file provided by the State.
PRC-92      Provide terminal/P C screen inquiry access to all available information on each

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            individually enrolled provider.
PRC-93      Provide the State with on-line access to each Provider’s data and the change
            date.
PRC-94      Maintain the ability to produce subsystem and masters file reports and address
            labels. The Vendor must produc e all reports in electronic (e.g., on magnetic tape
            or file) and/or hard copy form, as designated by the State.
PRC-95      Produce a mont hly pending application report.
PRC-96      Produce a mont hly report of active, enrolled providers and indicate the provider’s
            enrollment date.
PRC-97      Perform a monthly review to identify which Medicaid providers have not
            submitted any claims within a consecutive six-month period, and place thes e
            providers on inactive status.
PRC-98      Ensure inactive providers are placed back on active status upon the submission
            of a paper or electronic claim.
PRC-99      Perform a monthly review to identify providers on inactive status for six
            consecutive months and terminate thes e providers.
PRC-100     Produce an annual report to identify providers terminated because of inactive
            status for the previous 12 mont hs.
PRC-101     Notify the State when providers are suspended, placed on payment hold, or
            terminat ed from the Medicaid program.
PRC-102     Produce a mont hly report of excluded, suspended, or terminated providers who
            submit claims for payment with dates of services within the exclusion period.
PRC-103     Update the Provider Master File with an action reason code and the dat e on
            which the action occurred to identify providers who are suspended, excluded,
            placed on payment hold, terminated, or placed on inactive status. This must be
            done within five business days of receipt of the information.
PRC-104     Produce a provider listing by:
            - Program affiliation.
             - Benefit plan affiliation.
             - Provider type.
             - Category of services.
             - Provider specialty.
             - County within State region.
             - Group affiliation.
PRC-105     Produce a provider listing of physicians willing to be primary lock -in physicians.
PRC-106     Maintain a list of specialty providers who are willing to be PCPs for clients with
            special healt h care needs (e.g., Pediatric or Adult Cancer Specialists may be
            appropriate P CPs for clients with cancer).
PRC-107     Produce a candidate provider listing for each HMO of Medicaid providers who
            are not enrolled in that HMO.
PRC-108     Produce ad hoc provider reports on an as needed basis.
PRC-109     Produce provider address labels for all providers and/or by specific criteria.
PRC-110     Purge inactive provider records, on a schedule specified by the State.
PRC-111     Provide the ability to place providers on payment hold either at the nine digit or

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            seven digit core number.
PRC-112     Provide the ability to set up accounts receivables or extract percentage of
            payments on providers either at the nine digit or seven digit core number.
PRC-113     Provide an extract of the provider file to the State in accordance with State
            specifications.
PRC-114     Provide a full provider file extract to MFADS in accordanc e with HHSC OIE
            approved requirements.
PRC-115     Develop provider education materials to include manuals, program bulletins, and
            training materials.
PRC-116     Develop, and submit to the State for approval, a provider -training plan within 30
            days of contract implementation or renewal and annually thereafter.
PRC-117     Develop training materials and arrange and conduct annual provider workshops
            and training sessions. The information in the training mat erials, provider
            workshops, and training sessions includes, but is not limited to:
            - Medicaid program policies, procedures, and benefits.
            - THN policies, proc edures, and benefits.
            - CSHCN and other program’s policies, procedures, and benefits.
            - Any other special areas designated by the State.
            - Provider workshops and training sessions must be conducted in sufficient
            numbers, as approved by the State, to adequately train all provider types,
            including but not limited to targeted providers such as EPSDT/ THSteps, CS HCN,
            and Family Planning (Titles V, X, and XX) providers. In addition, provider
            trainings and workshops must be conducted in a sufficient number of locations to
            cover all geographic areas.
PRC-118     Ensure that, whenever possible, these education and training functions qualify
            the attendees for pertinent professional continuing educat ion hours at no
            additional charge.
PRC-119     Provide qualified and knowledgeable staff to consult with providers, providers’
            staff, and providers’ billing agents, conduct in-service trainings, and ans wer
            provider questions regarding the Medicaid and CSHCN programs and the THN,
            at the provider’s, the provider’s staff, or the provider’s billing agent’s request.
            This requirement applies to bot h network and out -of-network providers.
PRC-120     Meet providers’ training needs through telephone contact or scheduled training
            sessions, whichever the provider, the providers’ staff, or the providers’ billing
            agents prefer.
PRC-121     Make qualified staff available to visit providers, providers’ staff, and providers’
            billing agents for educational purposes, including educ ation on possible policy
            violations.
PRC-122     Maintain an automated tracking system to record all contacts with providers,
            providers’ staff, and providers’ billing agents that includes a summary of the
            nature and outcome of the visits.
PRC-123     Forward a copy of the visit documentation not ed above to the State if visits are
            made at the State’s request.
PRC-124     Designate sufficient provider field consultants for the State to provide direct
            assistance to providers, providers’ staff, and providers’ billing agents with claims
            payment problems, including on -site appointments. Each field consultant must

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            be knowledgeable regarding Medicaid and CS HCN policy and billing procedures.
PRC-125     Ensure that sufficient field consultants reside in the area in which they serve to
            adequately meet the needs of providers.
PRC-126     Provide the necessary support staff to eac h field consultant to ensure that the
            field consultants will be able to use one hundred percent of working time on
            provider recruitment, retention, and education.
PRC-127     Ensure that provider field consultants and provider communications and relations
            staff are aware of provider training and inquiry needs. Field consultants will
            provide on-site support to providers, providers’ staff, and/or providers’ billing
            agents within ten business days of provider’s request, unless otherwise directed
            by the State.
PRC-128     Inform provider groups and the State about training sessions at least four weeks
            prior to presentation or at other intervals specified by the State. The Vendor
            cannot charge for training sessions or training materials provided to State
            personnel, enrolled providers, prospective providers, or individuals or
            organizations authorized by the State. The Vendor is precluded from conducting
            workshops and training sessions in locations that charge attendees for parking,
            unless otherwise directed by the State.
PRC-129     Develop, distribute, and analyze provider training evaluations from all training
            sessions.
PRC-130     Submit a summary report to the State about the training sessions including the
            number and type of participants, results of participant evaluations, provider
            comments, and Vendor rec ommendations for improving training bas ed on
            training evaluation results.
PRC-131     Develop, print, and distribute materials to providers about the Medicaid, CSHCN
            and Family Planning Titles V, X, and XX programs, their claims proc essing
            system, and the THN. The cost of development, printing, and distribution will be
            borne by the Vendor. Whether printed commercially or in-house, the Vendor’s
            printed material must have the quality of commercial typeset printed material.
            The Vendor must coordinate with the State during the development of all printed
            materials and electronic media, and must submit such materials to the State for
            final approval.
PRC-132     Allow the State to use its professional judgment in determining/defining Vendor
            errors and/or inadequacies.
PRC-133     Develop, maintain, and distribute a Provider Procedures Manual (PPM), which is
            composed of two parts:
            - Administrative Policies and Procedures Manual.
            - Health Care Policies and Proc edures Manual.
PRC-134     The PPM must contain, at a minimum, all information currently found in the 2002
            Texas Medicaid Provider Procedures Manual, the 2002 Texas Medicaid Service
            Delivery Guide, 2002 CSHCN Provider Procedures Manual and any additional
            materials requested by the State.
PRC-135     Ensure that the manuals offers providers detailed information about:
            - Medicaid and CSHCN program policies and procedures.
            - THN policies and procedures.
            Other topics specified by the State.


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PRC-136     Update, reprint, and distribute the PPM by January 15th of each year, unless an
            exception is granted by the State. The PPM must contain all changes requested
            by the State and all policies that will be in place for the next year that were
            communicated to the Vendor by HHS C no lat er than October 1st of each
            calendar year. The Vendor must maintain an adequat e stock level of the PPM for
            use by the State upon request.
PRC-137     Develop and submit a work plan by September 1st of eac h year outlining the
            timelines for distribution of drafts and final version of the PPM.
PRC-138     Coordinate PPM development with all State stakeholders.
PRC-139     Ensure that the development of the PPM, bulletins, and ot her relevant materials
            is coordinated in a manner that ensures inclusion, consistency, and accuracy of
            all policy changes.
PRC-140     Ensure that the physical format of the PPM that is distributed to providers is
            bound.
PRC-141     Ensure that the physical format of the PPM that is distributed to the State
            facilitates routine updat es (e.g. loose leaf).
PRC-142     Make available electronic copies of the PPM, publications, and bulletins. The
            electronic copy must be updated with the same frequency as the hard copies.
PRC-143     Ensure that the electronic format lends itself to research, cross - referencing, and
            indexing.
PRC-144     Ensure that electronic copies and hard copies are made available to the State, in
            the number specified by the State.
PRC-145     Distribute the PPM to other individuals or organizations as directed by the State.
PRC-146     Develop a distribution plan, prior to printing, with input from the State.
PRC-147     Update the PPM via the Texas Medicaid Bulletin and the CS HCN Bulletin within
            90 days of either a benefit change in the Texas Medicaid and CSHCN programs,
            as determined by the State, or a procedural change made by the Vendor and
            approved by the State.
PRC-148     Notify providers of any policy or benefit change in which provider benefits would
            be reduced or eliminated, at least 30 calendar days prior to implementation of
            the policy or benefit change.
PRC-149     Routinely develop and distribute program bulletins at least every 60 days. The
            program bulletins must be made available to providers and t he State via hard
            copy and electronically. Information in the bulletins must include, but is not
            limited to:
            - Information regarding provider manual updates.
            - Claims processing issues.
            - Policy and procedure clarifications.
            - Reminders about claims filing and completion procedures.
            - Information regarding the Medicaid and CSHCN programs.
            - Frequently asked questions.
            - Routine or general information, as directed by the State.
PRC-150     Prepare and distribute up to ten special bulletins per year containing special or
            time sensitive information about program benefit changes, if required by the
            State. Special bulletins must be printed in a format that is significantly different
            from regular program bulletins. The Vendor must distribut e the special bulletins

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            to providers and the State.
PRC-151     Print and distribute special bulletins wit hin ten calendar days following State
            approval.
PRC-152     Develop claims and related forms to include in the provider manual as directed
            by the State. The claims and related forms must be submitted to the State for
            final approval.
PRC-153     Rework and resubmit to the State materials returned to the Vendor by the State
            due to Vendor errors or inadequacies. Delays resulting from Vendor errors or
            inadequacies are the res ponsibility of the Vendor.
PRC-154     The Vendor must develop and mail letters to providers as directed by the State.
PRC-155x    Respond to all provider inquiries.
PRC-156x    Develop, implement, and maintain an automat ed tracking system that will track
            and cons olidate all inquiries and correspondence related to an individual
            provider into a single, easily accessible file.
PRC-157x    Form, under the direction of the State, ad -hoc and permanent work groups of
            providers and State staff to review provider issues and proposed solutions.
PRC-158x    Fully respond to 95% of provider inquiries within 30 days of receipt of the inquiry
            and respond to the remaining five percent within 60 days.
PRC-159     Report the statistics on the number of provider inquiries, requests, and/or
            complaints received to the State on a monthly basis. The report must include
            provider, type of inquiry, request, or complaint; status of inquiry, request, or
            complaint; the percent of provider correspondence fully ans wered within 30
            calendar days of rec eipt; the percent fully answered within 60 days, and the
            percent of corres pondence pending bey ond 60 calendar days.
PRC-160     Receive written or email authorization from the State before the Vendor releases
            information about an individual provider that is on the s tate investigation list.
PRC-161     Ensure that provider correspondence pert aining to issues outside the purview of
            the Vendor, such as recipient eligibility and claims exception requests, are
            forwarded to the State.
PRC-162     Image all provider correspondence.
PRC-163     Provide a Corres pondence Imaging application to allow retrieval, display, and
            printing of correspondence images.
PRC-164     Provide the State with up to 20 Correspondence Imaging Clients to support
            viewing and printing of images maintained within the Correspondence Imaging
            application. The Vendor must install the Correspondence Imaging Clients on
            PCs provided by the State. The Vendor must also provide maintenance and
            support services for the Correspondence Imaging application, including
            telephone support Monday through Friday from 8:00 a.m. to 5:00 p.m.,
            investigation and resolution of reported problems, and the furnishing of any
            maintenance releases or upgrades.
PRC-165     Furnish a provider toll free phone line staffed with personnel who are
            knowledgeable about the Medicaid program, the THN, the CS HCN program, and
            the Family Planning program. The phone line must be available for providers
            from Monday through Friday, 7 a.m. to 7 p.m., Central Standard Time (excluding
            State-approved holidays), to obtain information about these programs, and to

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            register comments and concerns. Personnel must be knowledgeable, helpful and
            customer service oriented. Provider toll-free line staff must be capable of
            contacting the Vendor’s Medical Director.
PRC-166     Ensure that after hours and on weekends and holidays the line is ans wered by
            an aut omated system with the capability to provide callers wit h operating hours.
PRC-167     The Vendor must ensure that the toll free line meets the following performance
            standards:
            - At least 99% of all calls are answered on or before the fourt h ring.
            - A call-pick up system that places the call in queue may be used.
            - No more than one percent of incoming calls receive a busy signal.
            - At least 80% of calls must be answered by Vendor toll-free line staff within five
            minutes.
            - Call abandonment rate is less than 15%.
            - Call length is sufficient to ensure adequat e information is imparted to the caller.
            - First call resolution rate is at least 85%.
            - Annual traffic studies are conducted to assess the need for additional lines.
PRC-168     Submit a report to the State summarizing call cent er performanc e for the
            provider toll-free line for the previous month by the 15th of each month.
PRC-169     Develop and implement a comprehensive training program for provider toll -free
            line staff to ensure that accurate, complete, and consistent ans wers are provided
            to all inquiries.
PRC-170     Furnish hardware, software, and telecommunications linkages for all toll-free
            lines.
PRC-171     Obtain State approval before limiting the number of topics that may be
            addressed by the caller.
PRC-172     Implement and maintain an aut omated system for all toll-free lines for tracking
            and reporting written and telephone inquiries. The system must ensure on -line
            retrieval of information regarding the call (e.g., provider name and number, date,
            nature of the call, and reply).
PRC-173     Monitor calls on a regular basis to ensure quality customer service and that
            complete and accurate information is imparted to the caller.
PRC-174     Notify providers of the appeal and complaint resolution process.
PRC-175     Establish and maintain a provider complaint tracking system using a model that,
            at a minimum, meets the HHS C and Texas Department of Insurance (TDI)
            adopted model as required by State law. The Vendor must be able to track all
            provider complaints by category, as specified by the State.
PRC-176     Propose, establish, and implement an appeal, adjustment, and complaint
            resolution process in accordance with State policies and proc edu res.
PRC-177     Provide written documentation of the appeal, adjustment, and/or complaint
            resolution and follow the prospectively established procedures for appeals,
            adjustments, and complaints resolution, as specified by the State.
PRC-178     Provide the State with a monthly and quarterly report on the status of all provider
            complaints to include resolution.
PRC-179     For THN providers, follow up on appeals that indicate a contract compliance
            issue using prospectively established contract compliance protocols. The
            provider may file an appeal with the State if the appeal is outside of the Vendor’s

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            purview or cannot be resolved by the Vendor.
PRC-180     Establish a process and furnish sufficient resources to provide support for the
            State’s processing of provider appeals, adjustments, and complaints, per
            guidelines established by the State.
PRC-181     Develop a comprehensive file containing all relevant materials, with all
            supporting documentation describing the issue and the resolution, for all
            appeals, adjustments, and complaints. The file must contain the Vendor’s final
            determination. Upon request by the State, this file must be forwarded in its
            entirety to the State should the provider choos e to appeal or file a complaint with
            the State.




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                              Appendix C: Assessment Details




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                                                           PM1 – Enroll Provider
                                                       As-I s Asse ssment: Level 1
             Level 1                   Level 2                    Level 3                    Level 4                  Level 5
      Because an original      The provider may
       provider signature is     download the
       required the Provider     Provider Enrollment
       Enrollment Form and       Form from the
       Cont ract                 TMHP.com website.
       Credentialing            The Phoenix
       Application, they are     Enrollment Wizard
       submitted on paper        automatically
       via US mail.              enforces some
      The enrollment form       business rules.
       is manually reviewed
       for validity and
       entered into the
       Phoenix Enrollment
       Wizard.
      The provider is
       notified of
       discrepancies in the
       enrollment form in a
       letter via US mail.
      Decisions may be
       inconsistent.


Enroll Provider As Is Assessment is at Level 1 according to the Capability Matrix Levels. Staff rec eives and p roces ses paper enrollment
applications and manually apply the agency’s business rules (including credentialing, verifying information). Providers, memb ers and state
enrollment staff have secure access to appropriate data on demand. Some business rules are automated improving the accuracy of validation and
verification. C21 is the single provider registry where enrollment records are stored. C21 sends provider data to V21 and enc ount ers.


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                                                           PM1 – Di senroll Provider (TBD)
                                                            As-I s Asse ssment: Level 1
              Level 1                    Level 2                      Level 3                    Level 4                     Level 5
        The actual              Verification of current
         disenrollment           medical licenses is
         process in C21 is       possible via websites.
         manual.
        Provider
         notifications are
         submitted on paper
         via mail or fax
        State notifications
         are submitted on
         paper through the
         SAR proc ess


Disenroll Provider As Is Assessment is at Level 1. The Disenrollment process meets state and federal law and policy. Changes to the provider’s
information are submitted on paper, state requests are submitted on paper, and updates are manually ent ered into the Provider Master File.
Notification letters must be manually verified before being sent out. Thes e manual processes are time and labor intensive and require a large staff.
This As Is assessment is based on the MITA vision detailed in the MITA Maturity Model Description and Characteris tics Table found in section 2.1
of this document as there is no defined MITA capability matrix for the process at this time.




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                                                       PM2 – Inquire Provider Information
                                                           As-I s Asse ssment: Level 2
             Level 1                     Level 2                    Level 3                    Level 4                    Level 5
      Inquires are primarily    Providers may inquire
       received via phone.        about claim status via
       However, they may          TDHConnect, the
       also be received by        Web Portal and
       correspondence, fax        AVRS.
       and SAR.                  Claim status inquiries
      Research is                may be submitted
       performed manually         individually or by
      Responses to inquires      batch.
       are performed             Responses to
       manually                   inquiries may be
                                  received individually
                                  or by batch.
                                 Providers may view
                                  R&S reports, panel
                                  reports and
                                  certification of funds
                                  reports via the Web
                                  Portal.


Inquire Provider information As Is Assessment is at Level 2 according to the MITA Capability Matrix. Provider inquires are a mixture of manual and
electronic requests and res pons es. Automated electronic inquires improves the ac curacy and immediate receipt of responses.




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                                                     PM2 – Manage Provider Information
                                                          As-I s Asse ssment: Level 1
             Level 1                    Level 2                    Level 3                   Level 4                    Level 5
     All changes to provider    Reprocessing of claims
     information are            based on a change in
     submitted on a Provider    provider information is
     Information Change         automat ed.
     (PIC) form and manually
     entered into Compass21
     and/or CaseTrakker.



Manage Provider Information As Is Assessment is at Level 1 according to the MITA Business Capability Matrix. The provider can not perform
changes electronically. Updates are made to data manually.


                                                  PM3 Manage Provider Grievance and Appeal
                                                          As-I s Asse ssment: Level 1
             Level 1                    Level 2                    Level 3                   Level 4                    Level 5
      Providers submit a
       formal written request
       for a Level II appeal.
      Documents are
       imaged and manually
       sent to a registered
       nurse for manual
       adjudication.

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      Level II appeals are
       manually entered int o
       the TRA C system.
      Providers are notified
       of resolution of appeal
       by letter.
      A Grievance Hearing
       is scheduled if the
       original adjudication is
       upheld.


Manage Provider Grievance and Appeal As Is Assessment is at Level 1 according to the MITA Business Capability Matrix. The Lev el II provider
appeal process is all-manual. Appeals are formal written documents submitted via US mail. All acknowledgements of receipt and notifications
regarding dis position of appeal or date of Grievance Hearing are done via US mail. Research is done manually whic h may result in inconsistencies
in responses.




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                                                 PM3 Manage Provider Communication
                                                         As-I s Asse ssment: Level 2
            Level 1                   Level 2                     Level 3                   Level 4           Level 5
     Hard copies of           Provider Procedures
      Provider Procedures       Manuals are available
      Manuals, Bulletins        on CD.
      and Newsletters and      Electronic copies
      Banner Messages are       Provider Procedures
      distributed via US        Manuals, Bulletins
      mail                      and Newsletters are
     Policy changes are        available on the Web
      frequent and updates      Portal.
      to the Provider          Banner Messages are
      Procedures Manuals        included on the
      are distributed on an     Electronic Remittance
      annual basis.             and Status Reports
     Research requests         (ER&S)
      via correspondence,      Provider may sign-up
      fax and phone is          for provider
      manually performed        workshops on the
      by the TMHP Contact       Web Portal, view
      Cent er and Provider      R&S, (client) panel
      Representatives and       and certification of
      may take several          funds reports via the
      days to respond.          Web Portal.
                              The Web Portal
                                provides TMHP
                                Cont act Center phone
                                numbers, provider
                                services
                                representatives and
                                information on various

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                                                                        TMHP MITA Business Process Mapping


                                 programs, e.g. Long
                                 Term Care, CSHCN,
                                 THSteps and Family
                                 Planning.




Manage Provider Communication As Is Assessment is at Level 2 according to the MITA Business Capabilities Matrix. Provider commu nication is a
mixture of both manual and electronic proc esses. Communic ation via US mail, fax and phone researched manually can be inconsistent and an
immediat e response is not always possible. Frequent policy updates can be viewed on the Web Portal.




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                                                                       TMHP MITA Business Process Mapping




                                                       PM3 Perform Provider Outreach
                                                        As-I s Asse ssment: Level 1
            Level 1                   Level 2                    Level 3                   Level 4           Level 5
     Provider Relations       Electronic copies
      Representatives           Provider Procedures
      schedule provider in-     Manuals, Bulletins
      services using the        and Newsletters are
      ―scheduled provider       available on the Web
      visit‖ process.           Portal
     Periodic meetings        Providers may enroll
      with various provider     in Provider
      groups are conducted      Workshops via the
      to evaluate the           Web Portal.
      ongoing training
      needs of the provider
      community
     TMHP Provider
      Relations Field-based
      staff meets with
      TDH/ HHS C groups,
      medical societies,
      regional managed
      care groups, and
      associations to form
      partnerships to care
      for all Medicaid
      providers
     Provider workshop
      materials are
      prepared manually.


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Perform Provider Outreach As Is Assessment is at Level 1 according to the MITA Business Capability Matrix. Outreach is primar ily an all-manual
process. TMHP Provider Representatives attend periodic meetings with various provider groups such as Texas Medical Association; Texa s
Hospital Association, County Medic al Societies are conducted to evaluat e the ongoing training needs of the provider community . Provider
Procedures Manuals and Bulletins are posted on the Web Portal and are available for downloading by enrolled providers. The pr ovider and TMHP
benefit from the introduction of automat ed provider enrollment in provider workshops via the Web Portal whic h speeds up the out reac h and
education process.




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DOCUMENT INFO
Description: Texas Application for Medicaid document sample