Information Systems Infrastructure
The CI Information system
Piedmont recognizes that having a responsive information system is critical to effective and
efficient management of state, federal and Medicaid resources. Information that allows Piedmont
to track key indicators and monitor performance in real time provides the data that allows us to
manage for a quality, responsive system of care at the community level.
The PBH information system must support both consumers and providers. A web page that
provides information to consumers about available services, individual provider agencies, provider
performance, LME events and operations, and links to other websites has been developed to
ensure that information is readily available to consumers and families. This web page includes a
provider search function so that consumers can select criteria (such as county, disability, service),
and identify providers that offer these services. The PBH Consumer Family Advisory Committee
has a section on the PBH web page that provides information to the community about their
activities and contact information for those needing information or advocacy.
On October 27, 2005 PBH implemented the Cardinal Innovations System (CI System). This
information system was designed by the PBH Information Systems Department to uniquely
support our business operations and role as a local-regional manager of care. A secure web
based billing system is available for providers to submit their billing, review status of claims
submitted, and request/obtain authorizations. This supports small providers in their billing and
only requires the use of a personal computer and high speed internet connection. High volume
providers can submit claims through HIPAA Standard Electronic Transaction Sets, either directly
or through a clearinghouse, and PBH can respond electronically to let them know whether the
claim was approved, pended or denied.
PBH Connectivity with providers is imperative for smooth operations, quick turn around on
admissions, authorizations, and payments. Comprehensive Community Providers (CCP’s) function
as access points of the system will depend on this connectivity between the LME and CCP’s.
The Call Center, which is the heart of the Access process, depends entirely on a responsive
information system, which can quickly process enrollments, admissions, and authorizations as
well as provide information that can direct callers to community resources or choices of
providers. Having accurate information on network provider availability to respond to consumer
needs results in quick access to care, and provides information that will be used in evaluating and
planning network capacity.
Below is a summary of the critical functionalities that our new CI System provides:
The CI system interfaces electronically with our case management system (EZ System,
also an in-house product) to allow for electronic creation of the Person Centered Plan.
Case Managers can create a Person Centered Planning data sheet that has the goals and
Information Systems Infrastructure
involved parties as well as the services requested. This will build the budget. The case
manager can then attach a narrative document that can then be electronically submitted
to the PBH Utilization Management System for review and approval. All Utilization
Management and case manager communication happens electronically.
The CI system has a module called Provider Direct that is a portal for providers to search
for clients, submit billing, enroll new clients and request authorizations. Those
authorization requests are reviewed and can be approved or sent back to the provider for
revision through the CI system. Authorization/Denial letters are sent to the provider
download section in Provider Direct, where providers can access these through a secure
connection to their “mailbox”.
98.7% of all PBH claims are submitted electronically. Providers can send standard HIPAA
compliant claims, or they can use the PBH web based billing system and enter their
All calls are answered by a “live” person. When a client or family member calls our 1-800
Access Center, the Customer Service Representative in the Access center uses the CI
system to log the call, gather information on the consumer and the person’s problems
and concerns. The Customer Service Representative is able to assess the consumer’s
needs based on a scripted survey and then offer the consumer/family provider options
based on the service needed. There are protocols that the Customer Service
Representative follows to determine whether and when calls are transferred to a licensed
clinician via a “warm transfer”…consumers are never put on hold. There is always a
licensed clinician available to handle calls that require a clinician’s involvement.
The Customer Service Representative offers a choice of providers to the consumer. All
providers offered are documented as well as the provider selected by the consumer.
Unless the consumer prefers to make their own arrangements, the Customer Service
Representative will contact the provider and requests an appointment and adds that to
the call record. The representative can call the provider while the consumer is still on the
line. Referral record is then printed or saved to PDF and can be sent to the provider.
From the Call Center the consumer can be enrolled in the PBH system and authorization
The CI system manages authorizations, receives, and processes claims for payment.
The CI system also interfaces with our general ledger, and transfers information to
update the general ledger, and that allows payments to be made out of the general
ledger software (Great Plains Software).
PBH continues to develop the CI system to refine and enhance its capabilities to support our