Concept of Operations



Department of Health Care ServicesCA-MMISConcept of Operations (COO)March 7, 2014Version 2.0Table of Contents TOC \o "3-3" \h \z \t "Heading 1,1,Heading 2,2,Heading 1_no_num,1,Heading 2_no_num,2,Appendix Heading 1,2,Appendix Heading 2,3" Preface PAGEREF _Toc379890503 \h 6Executive Policies PAGEREF _Toc379890504 \h 6Professional Responsibility PAGEREF _Toc379890505 \h 6Revision History PAGEREF _Toc379890506 \h 61.Introduction PAGEREF _Toc379890507 \h 101.1Business Architecture (BA) – Alignment to MITA PAGEREF _Toc379890508 \h 111.1.1Business Architecture Artifacts PAGEREF _Toc379890509 \h 121.1.2Business Process Model (BPM) PAGEREF _Toc379890510 \h 131.1.3MITA Maturity Model (MMM) PAGEREF _Toc379890511 \h 151.1.4Business Capability Matrix (BCM) PAGEREF _Toc379890512 \h 151.2Document Assumptions PAGEREF _Toc379890513 \h 161.3Document Scope PAGEREF _Toc379890514 \h 171.4Document Constraints PAGEREF _Toc379890515 \h 181.5Referenced Documents PAGEREF _Toc379890516 \h 191.6Definitions PAGEREF _Toc379890517 \h 212.CA-MMIS Actors Catalog PAGEREF _Toc379890518 \h 303.As-Is CA-MMIS PAGEREF _Toc379890519 \h 323.1As-Is CA-MMIS Business Processes PAGEREF _Toc379890520 \h 333.2As-Is CA-MMIS Context Diagram PAGEREF _Toc379890521 \h 353.2.1Business Associates PAGEREF _Toc379890522 \h 393.3As-Is CA-MMIS COO PAGEREF _Toc379890523 \h 403.3.1As-Is CA-MMIS COO – Inbound/Outbound Transactions PAGEREF _Toc379890524 \h 404.To-Be CA-MMIS PAGEREF _Toc379890525 \h 574.1The CA-MMIS Health Enterprise System Information Exchange and Access Environment PAGEREF _Toc379890526 \h 574.2To-Be CA-MMIS COO PAGEREF _Toc379890527 \h 594.3To-Be Environment of CA-MMIS Business Process Implementation in System Replacement Project PAGEREF _Toc379890528 \h 614.4Transition from As-Is to To-Be PAGEREF _Toc379890529 \h 624.4.1Effectiveness – Increase Business Maturity PAGEREF _Toc379890530 \h 634.4.2Effectiveness – Improved Performance Standards PAGEREF _Toc379890531 \h 664.5Compliance PAGEREF _Toc379890532 \h 664.5.1Security and Confidentiality PAGEREF _Toc379890533 \h 664.5.2System Security and Privacy PAGEREF _Toc379890534 \h 664.5.3Other Standards for Compliance PAGEREF _Toc379890535 \h 674.6Critical Business Processes PAGEREF _Toc379890536 \h 674.7Business Architecture – Assumptions, Constraints, and Risks PAGEREF _Toc379890537 \h 67Appendices PAGEREF _Toc379890538 \h 81A.CA-MMIS Actors Catalog PAGEREF _Toc379890539 \h 81B.CA-MMIS Business Process Maturity Level PAGEREF _Toc379890540 \h 123C.Actor Primary Interactions with CA-MMIS Business Process PAGEREF _Toc379890541 \h 133D.Medi-Cal Enterprise PAGEREF _Toc379890542 \h 142E.Planned Releases Roadmap PAGEREF _Toc379890543 \h 143List of Tables TOC \h \z \t "Table Caption" \c Table 1: Explanation of Global Definitions PAGEREF _Toc379890468 \h 16Table 2: Referenced Documents PAGEREF _Toc379890469 \h 19Table 3: Definitions PAGEREF _Toc379890470 \h 21Table 4: CA-MMIS Primary Entities PAGEREF _Toc379890471 \h 37Table 5: CA-MMIS Business Associates PAGEREF _Toc379890472 \h 40Table 6: As-Is CA-MMIS COO Table (Care Management) PAGEREF _Toc379890473 \h 41Table 7: As-Is CA-MMIS COO Table (Contractor Management) PAGEREF _Toc379890474 \h 42Table 8: As-Is CA-MMIS COO Table (Financial Management) PAGEREF _Toc379890475 \h 43Table 9: As-Is CA-MMIS COO Table (Member Eligibility and Enrollment Management) PAGEREF _Toc379890476 \h 47Table 10: As-Is CA-MMIS COO Table (Member Management) PAGEREF _Toc379890477 \h 47Table 11: As-Is CA-MMIS COO Table (Operations Management) PAGEREF _Toc379890478 \h 48Table 12: As-Is CA-MMIS COO Table (Plan Management) PAGEREF _Toc379890479 \h 50Table 13: As-Is CA-MMIS COO Table (Provider Eligibility Management) PAGEREF _Toc379890480 \h 52Table 14: As-Is COO Table (Performance Management) PAGEREF _Toc379890481 \h 55Table 15: As-Is COO Table (Provider Management) PAGEREF _Toc379890482 \h 56Table 16: Release 1 Business Functionality PAGEREF _Toc379890483 \h 61Table 17: Quality Attributes to Measure Business Process PAGEREF _Toc379890484 \h 64Table 18: Template for Business Capability Matrix (BCM) PAGEREF _Toc379890485 \h 65Table 19: Business Architecture - Assumptions, Constraints, and Risks PAGEREF _Toc379890486 \h 68Table 20: CA-MMIS Actors Catalog PAGEREF _Toc379890487 \h 81Table 21: CA-MMIS As-Is and To-Be Maturity Levels PAGEREF _Toc379890488 \h 123Table 22: CA-MMIS Primary Actor Interactions with Business Processes PAGEREF _Toc379890489 \h 133List of Figures TOC \h \z \t "Caption" \c Figure 1: Relationship Between MITA Business Architecture Artifacts PAGEREF _Toc379890490 \h 13Figure 2: Business Process Model Components PAGEREF _Toc379890491 \h 14Figure 3: Business Processes and Business Capabilities PAGEREF _Toc379890492 \h 16Figure 4: Actors Catalog Diagram PAGEREF _Toc379890493 \h 31Figure 5: As-Is CA-MMIS Business Processes PAGEREF _Toc379890494 \h 34Figure 6: As-Is CA-MMIS Context Diagram PAGEREF _Toc379890495 \h 36Figure 7: The CA-MMIS Health Enterprise System Exchange and Access Environment PAGEREF _Toc379890496 \h 58Figure 8: To-Be COO Diagram (CA-MMIS HE System) PAGEREF _Toc379890497 \h 60Figure 9: As-Is and To-Be CA-MMIS Transformation Characteristics PAGEREF _Toc379890498 \h 62Figure 10: COO (Business Architecture Transition) PAGEREF _Toc379890499 \h 63Figure 11: MITA Maturity Level PAGEREF _Toc379890500 \h 65Figure 12: Medi-Cal Enterprise PAGEREF _Toc379890501 \h 142Figure 13: Roadmap for Releases 1 – 5 PAGEREF _Toc379890502 \h 143PrefaceExecutive PoliciesThe Project Policies document, which is stored in the Process Library document folder on the California Medicaid Management Information System (CA-MMIS) SharePoint site, contains policies that apply directly to the CA-MMIS System Replacement Project and tasks to develop, maintain, convert, or re-engineer computer software and services. The Project Policies document is applicable to subcontractors and vendors by including a requirement in the applicable contract, Statement of Work, or task order.Professional ResponsibilityThe project management team has a responsibility to maintain ethical and professional conduct in the management of projects. This obligation includes producing quality products or services within the project’s scope, with consideration to time and cost. Cooperation and good faith are the professional responsibility of stakeholders.Revision HistoryVersionDateDescriptionAuthor0.019/17/2012Initial draft of COOAlok Kumar, Bonnie Lam0.029/20/2012Revised draftLeyla Avila0.039/26/2012QM initial review of COO documentSharisse Baltikauskas0.049/27/2012-9/28/2012Update based on QM initial reviewAlok Kumar, Barbara Jones, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh0.0510/3/2012-10/5/2012Update based on DHCS commentsAlok Kumar, Barbara Jones, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh0.0610/09/2012EPMO ReviewTanya Sachdeva0.0710/11/2012QM ReviewSharisse Baltikauskas0.0810/12/2012-10/14/2012Update based on QM reviewDenise Walsh, Bonnie Lam0.0910/15/2012Final QM ReviewSharisse Baltikauskas0.1010/15/2012Updated Figures 4 & 14 and removed “PA” from Definitions TableBonnie Lam, Denise Walsh0.1110/29/2012Updated based on additional findings from DHCS’ final review.Alok Kumar, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh0.1211/7/2012QM Review for resubmissionSharisse Baltikauskas0.1311/08/2012Updated based on QM review of responses to DHCS’ final review.Denise Walsh0.1411/09/2012Final QM Review for resubmissionSharisse Baltikauskas1.0011/20/2012DHCS approvedTanya Sachdeva1.0110/16/2013 – 12/03/2013Updated document according to CR issued by DHCS.Updated document throughout to align with list of 66 BPs in scope for CA-MMIS versus previous list of 39 BPs.Added CDA and CDSS to Actors Catalog and diagram.Removed Appendix D (Business Improvements/Operational Scenarios).Removed Tables 4 and 16-19.Added new section titled “Business Architecture – Alignment to MITA.”Added new section titled “Business Architecture – Assumptions, Constraints, and Risks.”Alok Kumar, Barbara Jones, Denise Walsh, Jeff Strand, Lisa Cruz1.0212/04/2013Accepted track changes and distributed draft for peer review.Denise Walsh1.0312/04/2013Incorporated peer review comments. Updated Terms/Acronyms table. Added File Maintenance and Service Delivery to Actors Catalog.Updated Appendix D according to internal SME review comments.Denise Walsh, Lisa Cruz, Alok Kumar, John Hunziker, Barbara Jones, Jeff Strand, John Stewart1.0412/10/2013Accepted track changes and prepared document for submission to DHCS for informal review.Denise Walsh1.0501/09/2014Deleted the “Configuration of This Document” statement, as it is no longer applicable to CA-MMIS deliverables.Added a new section titled “Critical Business Processes.”Deleted Appendix D.Deleted Figure 1 and the preceding paragraph.Modified Figure 9 so it only includes Business Architecture details.Removed Information and Technical Architecture details from Figure 11.Added explanation regarding the difference between sections 1.2/1.4 and section 4.6 (now 4.7).Updated the Actor UMD to CAAS per DHCS directive. This change was effective January 1, 2014.Expanded the descriptions of the impacts listed in the Actors Catalog.Alok Kumar, Denise Walsh, Barbara Jones1.0601/27/2014Updated CAAS to CAASD.Added SBP161 (67th BP in-scope for CA-MMIS) to applicable tables and figures.Updated based on CRF received from DHCS for Version 1.05.Alok Kumar, Denise Walsh1.0702/06/2014Added a discussion of the modified agile approach. Added Appendix E (Roadmap for Releases).Alok Kumar, John Stewart, Denise Walsh1.0802/11/2014Updated Actor Impacts table. Added statement before Table 19 for clarity.General formatting cleanup.Prepare document for final submission.Alok Kumar, Barbara Jones, Denise Walsh1.0903/04/2014Updated the definition of “stakeholder” throughout document, based on feedback received from the DHCS Transition Team.Denise Walsh2.003/07/2014DHCS ApprovalDeirdre SmithIntroductionA COO is an abstract model that describes how an organization intends to operate to achieve its goals and objectives and meet the Federal Seven Conditions and Standards to achieve Enhanced Federal Financial Participation funding. It provides a structure that helps organizations document their As-Is (current) operations and define the To-Be (future) transformations. The COO helps frame the vision and showcase the target To-Be environment, independent of technology. It is a well-thought-out vision of the future with actors and other stakeholder interactions in mind. The COO also satisfies Standard 2: Medicaid Information Technology Architecture (MITA) Condition of Centers for Medicare & Medicaid Services (CMS) Enhanced Funding Requirements.As part of the State Self-Assessment (SS-A), the Office of HIPAA Compliance (OHC) developed an Enterprise Medi-Cal COO that included business processes within Medi-Cal. The CA-MMIS COO (i.e., this document) is a part of the Enterprise Medi-Cal COO, and it covers the business processes in scope for the CA-MMIS System Replacement Project.The COO supports the furtherance of the Department of Health Care Services (DHCS) goals and objectives as identified in the California Department of Health Care Services Strategic Plan (2013-2017) and its mission “… to provide Californians with access to affordable, high-quality health care, including medical, dental, mental health, substance use treatment services, and long-term care.”The goals for the State of California in the CA-MMIS System Replacement Project are:Achieve a Medicaid Management Information System (MMIS) that moves the State Medi-Cal program administration higher in the MITA maturity model.Exhibit the interoperability and reusability required by MITA.Create an environment for integrating the business and information technology (IT) environments to improve the management of the Medi-Cal Program.Provide a solid platform for future growth with scalable architecture that can grow and change with the Medi-Cal Program.Support DHCS’ move toward Health Information Exchange (HIE)/Health Information Technologies (HIT) to support improved outcomes and quality services for Medi-Cal members.Support enhanced fraud detection and prevention strategies.Align CA-MMIS with current industry MITA and Service Oriented Architecture (SOA) guidelines.Meet current federal regulation for reporting in compliance with Health Information Portability and Accountability Act (HIPAA).Provide easier access for the Provider community to submit and correct claim documents and retrieve status information, help and billing information electronically.Rapid response to change in terms of adaptability and flexible user functionality. Each change in a law or regulation often means multiple changes to system software. A major goal of this replacement effort is to reduce the time and cost associated with future system enhancementsMeet the Seven Conditions and Standards to qualify for Enhanced Federal Financial Participation (FFP).Technology that supports DHCS programs into the future, in such a manner that business requirements drive enhancements rather than system limitations driving business decisions.Effective management of Medicaid with a system that supports data analysis, performance measurement, and planning. It also requires the ability to share data with providers and other stakeholders.Rules-based configuration through Business Rules Management Systems (BRMSs) that allows authorized users to update business rules in response to changing legislative requirements, regulatory policy, and evolutions in Medicaid and the health care industry.A system that interfaces with other systems in a seamless framework that supports coordination with providers and other stakeholders.A system that supports web-based self-service for provider/pharmacist processing needs.A system that supports multi-payer capability – California, like most states, has several programs that have business requirements almost identical to Medicaid. In addition, members move in and out of these programs as their financial circumstances change.A system that meets the above-listed goals without substantially increasing operating costs.The COO documents the As-Is operations and the To-Be vision of the future for CA-MMIS. It helps DHCS determine business improvements and changes to the current operations and processes to achieve the long term vision of moving the State Medi-Cal program administration higher in the MITA Maturity Model (MMM).The COO is produced early in the requirements analysis process of the CA-MMIS System Replacement Project to describe what the system will do (not how it will do it) and why (rationale). It sets the foundation for developing the Business Process Template (BPT) and is used for the Requirements Elicitation sessions.The COO is updated in each System Replacement release to reflect corrections and approved changes. It is also maintained during system operations and maintenance of the CA-MMIS Health Enterprise (HE) System and thereby serves as a future “As-Is” view. Once the COO is approved and baselined, it is governed by the CA-MMIS Architecture/MITA Workgroup for management of future updates. Changes to the number of business processes in scope for CA-MMIS are governed by the Change Control Board (CCB).The COO is also aligned to The Open Group Architecture Framework (TOGAF) Phase B – Business Architecture which has been adopted as the framework to elaborate the architecture for CA-MMIS System Replacement.Business Architecture (BA) – Alignment to MITAThe CA-MMIS System Replacement Project allows for MITA business capability improvement for impacted business processes. The MITA Framework defines a future in which health care stakeholders (e.g., policy makers, public health and oversight agencies, taxpayers, consumers, and providers) participate in achieving the objectives of improving health outcomes of the population served in a timely and accountable way. Stakeholders are able to apply for health assistance and receive an eligibility determination in real-time. Stakeholders benefit from improvements in information sharing and exchange that enable caregivers, payers, and members to view appropriate clinical information immediately and use this information to make appropriate health care decisions. Providers and payers are able to focus on their primary functions of care giving, benefit plan monitoring, and evaluation as most of the administrative burden of information capture, processing, and reporting are obsolete with the usage of direct messaging between data exchange partners. Business Architecture ArtifactsThe BA is a conceptual construct comprised of models, matrices, and templates. These components are derived from a variety of industry standards because no single methodology exists that meets the scope of MITA.The BA provides the foundation for defining a vision for improvements in Medicaid program operations that result in better outcomes for the stakeholders. The BA contains models of typical Medicaid Business Processes and describes how these processes can improve over time. This allows states to use the BA to assess their own current business capabilities and determine future targets for improvement.The BA is comprised of the following artifacts:COOBusiness Process Model (BPM)Business Capability Matrix (BCM)The BA is comprised of the following tool:MMM-2952751108075The following diagram describes the relationships among the various BA components (artifacts). This diagram helps determine the dependencies (incoming as well as outgoing) for the BA artifacts and other tasks, activities, and related artifacts such as the SS-A and MITA Roadmap.Figure SEQ Figure \* ARABIC 1: Relationship Between MITA Business Architecture ArtifactsThe following sections describe the MITA artifacts and tool that comprise the BA.Business Process Model (BPM)The MITA BPM presents a hierarchy of Medicaid Business Processes organized into categories of Business Areas that are high-level groupings of Business Processes, which share common focus and information.The BPM offers a hierarchy of business areas and sub-tier business areas that lead to the individual Business Process at the lowest level included in the model. The State BPM addresses each of the MITA BPMs and adds some state-specific processes. The State has described, sub-divided, and provided definitions of these state-specific processes unique from the hierarchy presented in the BPM. The BPM for CA-MMIS is the subset of processes that the State has identified through its SS-A.The Business Process is defined as a series of activities that are triggered by one or more events and result in one or more results. The Business Processes contained in the MITA BPM and the state-specific BPM are described in a standard template that captures the Trigger, Result, and Business Logic. The Trigger is the initiating event. It is defined in terms of data or a time/schedule. The Result is the output of the process. It is described as data produced by the Business Process. Business Logic is defined by the individual steps/activities. The following figure illustrates the components of the Business Process.40957541275Figure SEQ Figure \* ARABIC 2: Business Process Model ComponentsOHC provides the Business Processes and their descriptions or variances to the CMS MITA 3.0 Business Processes for DHCS. CMS provided the actual BPMs that include triggers and other model elements. Xerox is responsible for incorporating those models into the overall architecture design guidelines. Xerox develops the To-Be BPM for the business processes defined for CA-MMIS in the COO. The To-Be BPMs are updated in each release and as needed to reflect corrections and approved changes. Each CA-MMIS Business Process is represented both as a narrative as well as in a Business Process Model and Notation (BPMN) diagram.?BPMN is a flowchart based notation for defining business processes and is a visual language for describing “process logic” in a diagram.Individual BPMs and BPMN diagrams are being developed for each BP through several collaborative sessions with DHCS. MITA Maturity Model (MMM)The purpose of the MMM is to serve as a reference model for defining the business capabilities as described in the BCM. The BCM is discussed further in the following section. The MMM establishes boundaries and measures to use in determining whether a business capability definition is clear and concise. The MMM is used as a tool to illustrate how Business Processes are planned to mature over time from a current level to a future level.The scope of the MMM is to define the maturity levels (1 through 5) using business capability quality and technical capability quality attributes. The SS-A helps determine the current maturity level (As-Is) of Medicaid business operations and sets the groundwork to establish a To-Be vision for the evolution of the State Medicaid Program’s MITA maturity level over time.Recognizing that Business Processes form the core activities of the Medicaid Program, and in keeping with the guiding principle that MITA “represents a business-driven enterprise transformation,” the SS-A draws primarily on the BA component of the MITA Framework. The SS-A sets forth specific objectives for reaching a higher maturity level in each Business Process identified in the MITA Framework; the actual steps needed to achieve these objectives are developed as part of the transition planning process. The MMM is a MITA tool; therefore, an artifact is neither developed nor subject to an update cycle.Business Capability Matrix (BCM)The BCM is created from several sources – the BPM, the MMM, and the State’s As-Is and To-Be Medi-Cal Business Processes for the CA-MMIS. Applying the MMM to each Business Process yields the BCM, which shows how the Business Process matures over time. The BCM assigns a Level 1 through 5 to each Business Process.The following figure is an extension of the figure “Business Process Model Components” from the BPM section above and shows how the BPM is the focus of the BCM.285750-247650 Figure SEQ Figure \* ARABIC 3: Business Processes and Business CapabilitiesBCM details will be captured by the State in their BCM artifact to gauge the maturity levels obtained by each of the business process.Document Assumptions The following assumptions pertain specifically to this document. For assumptions related to business processes, refer to Section 4.7, Business Architecture – Assumptions, Constraints, and Risks.The colors and varying shades on the various figures/diagrams throughout the COO document are primarily for aesthetic purposes, unless stated in the legend or associated section. For example, the two different shades of the “To-Be Context Diagram” are representative of the MITA Business Areas and HE components as stated in the legend. To clarify important terms that are used throughout the COO, refer to the table below. It is critical for readers to understand the concept of these terms and how they relate to each other in order to gain a foundational and complete understanding of the COO. For consistency, these terms also appear in the Definitions table.Table SEQ Table \* ARABIC 1: Explanation of Global DefinitionsTermExplanationActorRefers to a specific user group, organization, or system that interacts with CA-MMIS directly or indirectly. These actors belong to one of the three categories (i.e., DHCS, Xerox, and External entities).“DHCS actors” refer to user groups, agencies, and divisions within DHCS.“Xerox actors” refer to user groups, teams, and departments within Xerox.“External actors” refer to Federal agencies, other State agencies, counties and other ancillary groups, submitters and other intermediaries, providers, and members.CA-MMIS Business ProcessRefers to CA-MMIS business processes that are derived from the Medi-Cal Business Processes in the SS-A. Currently, there are 67 CA-MMIS business processes out of the 141 Medi-Cal business processes.Medi-Cal Business ProcessRefers to the DHCS Enterprise Medi-Cal business processes that are identified in the SS-A performed by OHC in June, 2013. Currently, there are 141 Medi-Cal business processes. The Medi-Cal business processes are aligned to the MITA business processes by the MITA 2.0 and 3.0 crosswalk developed by DHCS. This crosswalk illustrates the mapping of MITA 2.0 to MITA 3.0, including the Medi-Cal Business Areas, Business Categories, and Business Processes.The crosswalk is available on SharePoint using the link/path below: CA-MMIS System Replacement > Draft Deliverables and Work Products > Workgroup: SR-Architecture/MITA > Topic: Business Architecture > DHCS MITA Business Processes 2.0 to 3.0 Crosswalk CatalogMITA Business ProcessRefers to the MITA 3.0 business processes that are defined by CMS under the BA. StakeholderThe term “stakeholder” in this document refers to one or more Actors performing in a common role [or common set of roles], who are impacted by the transition from the Legacy CA-MMIS System to the CA-MMIS Health Enterprise System, or who need to be kept informed of its progress, from the broadest perspective. “Internal stakeholders” refer to DHCS and Xerox, and are trained by Xerox Operations Training Department (OTD). “External stakeholders” refer to providers, provider associations, ancillary groups (health plans, counties, etc.), intermediaries (vendors, clearinghouses, CMS, etc.), members, and the public. The Provider Outreach and Education (O&E) Department conducts the outreach activities to these external stakeholders.Document Scope The purpose of this COO is to document the current state of CA-MMIS, the Medicaid Enterprise vision of the future as it relates to the CA-MMIS HE System, and describe the impact of planned improvements on stakeholders, information exchanges, Medicaid operations, and health care outcomes. It satisfies the requirements for a MITA COO as described within the MITA Business Architecture. This COO includes Medi-Cal business processes for which DHCS has contracted Xerox to provide support for the CA-MMIS System Replacement Project. Medi-Cal business processes that meet at least one of the following criteria are considered in-scope for this deliverable: Medi-Cal business processes that use CA-MMIS to support the business operation, regardless of whether the operation is performed by DHCS, Xerox, or Shared (e.g., Manage Drug Rebate).Medi-Cal business processes which CA-MMIS interfaces with, links with, or provides/consumes a service [e.g., Service to obtain eligibility information from the Medi-Cal Eligibility Data System (MEDS)].The COO is not a requirements document. It is not to be considered as a roadmap, implementation plan, or transition plan, as it does not contain the steps involved in planning for the transition from the current state to the future. The COO does not prescribe or limit the approach or technologies that may be used to reach the vision of moving the State Medi-Cal program administration higher in the MMM.The COO includes the following major sections:CA-MMIS Actors: a list of actors (with brief description) who interact with CA-MMIS directly or indirectly and their impacts.As-Is (Current State) CA-MMIS: identifies in-scope Medi-Cal business processes for CA-MMIS, primary actors, and actor interactions with the CA-MMIS business processes. It also includes the As-Is Context Diagram and the As-Is COO Diagram.To-Be (Future State) CA-MMIS: defines the HE transfer systems and business module/function where in-scope MITA business processes will be implemented, as well as the As-Is and To-Be business maturity levels to depict the desired transition based on the SS-A. It also includes the To-Be Context Diagram and the To-Be COO Diagram.Document ConstraintsThe business processes identified for each release of the CA-MMIS System Replacement Project are subject to change during requirement validations. This document identifies current business processes by release and transfer system, as known at the time of publication. For constraints specific to each business process, refer to Section 4.7, Business Architecture – Assumptions, Constraints, and Risks.Referenced DocumentsThe following table displays a list of documents referenced in this COO.Table SEQ Table \* ARABIC 2: Referenced DocumentsReferenced DocumentDocument LocationVersion # and DateCA-MMIS System Replacement – Architecture PlanXerox Link: Version 3.08July 2, 2013DHCS Link: SharePoint Navigation Path: CA-MMIS Home > Deliverables > Deliverables Library > Del ID : DPP.0003 Architecture Plan > Architecture PlanCalifornia Department of Health Care Services Strategic Plan 2008DHCS Division Descriptions 2012Enhanced Funding Requirements: Seven Conditions and Standards – Medicaid IT Supplement (MITS-11-01-v1.0) 1.0April 2011Medi-Cal Enterprise Business Process DiagramXerox Link: HYPERLINK "" 29, 2013DHCS Link : HYPERLINK "" Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Draft Deliverables and Work Products > Workgroup : SR-Architecture > Project Phase: Phase I > COO-Medi-Cal Enterprise Business Process DiagramCA-MMIS MITA Workgroup SS-A based on MITA 2.0Xerox Link: 1.3May 30, 2008DHCS Link: Navigation Path: CA-MMIS Home > CA-MMIS Sites> System Replacement > Documents > Reference > Category : Architecture > Med-Cal_MITA_SS-A Based on MITA 2.0Medi-Cal MITA SS-A Interim Report (Medi-Cal business processes and maturity level ratings) based on MITA 3.0Xerox Link: August 6, 2013DHCS Link: SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Draft Deliverables and Work Products > Workgroup : SR-Architecture/MITA > Topic: Concept of Operations > State BP Ratings 20130806MITA 3.0 Framework 3.0February 2012MITA 3.0, Part I Business Architecture, Chapter 2 - Concept of OperationsXerox Link: 3.0February 2012DHCS Link: Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Reference > Category : Standards > more… > Part I Chapter 2 Concept of Operations 3.0MITA 3.0, Part I Business Architecture, Appendix A - Concept of Operations DetailsXerox Link: 3.0February 2012DHCS Link: Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Reference > Category : Standards > more… > Part I Appendix A Concept of Operations Details 3.0MITA Workgroup CharterXerox Link: December 7, 2012DHCS Link: SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Draft Deliverables and Work Products > Workgroup : SR-Architecture/MITA > Topic: Charter > Scanned Approved Charter MITA Architecture WGRisks LogXerox Link: ApplicableDHCS Link: Navigation Path: CA-MMIS Home > RisksDefinitionsThis section lists glossary terms and acronyms specifically applicable to this document.Table SEQ Table \* ARABIC 3: DefinitionsTerm/AcronymExplanation/ExpansionA&IAudits & InvestigationsA/RAccounts ReceivableABAssembly BillACAAffordable Care ActACMSAutomated Collection Management SystemActorRefers to a specific user group, organization, or system that interacts with CA-MMIS directly or indirectly. These actors belong to one of the three categories (i.e., DHCS, Xerox, and External entities).“DHCS actors” refer to user groups, agencies, and divisions within DHCS. “Xerox actors” refer to user groups, teams, and departments within Xerox.“External actors” refer to Federal agencies, other State agencies, counties and other ancillary groups, submitters and other intermediaries, and members.ADDHCS Administration DivisionADAAmericans with Disabilities ActADMAdministration DivisionAEVSAutomated Eligibility Verification SystemAIIHIAmerican Indian Infant Health InitiativeAVRSAutomated Voice Response SystemBABusiness Architecture which describes the needs and goals of the State and presents a collective vision of the futureBCMBusiness Capability Matrix. The BCM scale of 1 to 5 assesses the degree of automation, standardization, and integration, with Level 5 representing the highest level of maturityBCMPBusiness Change Management PlanBICBeneficiary Identification CardBPMBusiness Process ModelBPMNBusiness Process Model and NotationBPTBusiness Process TemplateBRMSBusiness Rules Management SystemBWARDBenefits & Waiver Analysis DivisionCAASDClinical Assurance and Administrative Support DivisionCAHCritical Access HospitalCalMENDCalifornia Mental Health Care Management ProgramCalSORHCalifornia State Office of Rural HealthCA-MMISCalifornia Medicaid Management Information SystemCA-MMIS Business ProcessRefers to CA-MMIS business processes that are derived from the Medi-Cal Business Processes in the SS-A. Currently, there are 67 CA-MMIS business processes out of the 141 Medi-Cal business processes.CA-MMIS Health Enterprise SystemThe name of the CA-MMIS Replacement System once it has been fully implemented in CA-MMIS Replacement System Project CA-MMIS Replacement SystemThe name of the approach being designed, developed, and implemented in response to the requirements specified in DHCS Requests for Proposal (RFP) 08-85022.CAQHCouncil for Affordable Quality HealthcareCCBChange Control BoardCCSCalifornia Children’s ServicesCDACalifornia Department of AgingCDPHCalifornia Department of Public HealthCEAPCalifornia Enterprise Architecture ProgramCFRCode of Federal RegulationsCHDPChild Health & Disability Prevention ProgramCMSCenters for Medicare & Medicaid ServicesCMS-DHCSChildren’s Medical Services Branch of DHCSCMSPCounty Medical Services ProgramCOHSCounty Organized Health SystemCOOConcept of OperationsCORECommittee on Operating Rules for Information ExchangeCOTSCommercial Off-The-Shelf. COTS products are not modified and are implemented and integrated as part of the overall system. However, they can be configured to meet CA-MMIS requirements.CRDDCapitation Rates Development DivisionCSCCalifornia Children’s ServicesCTACalifornia Technology AgencyDHCSDepartment of Health Care ServicesDMCDental Managed Care PlanDMCDrug Medi-CalDMHDepartment of Mental HealthDOFDepartment of FinanceDOJDepartment of JusticeDPHPDesignated Public Hospital ProjectDRAMSDrug Rebate Analysis & Management SystemDRGDiagnostic Related GroupDRUDrug Rebate UnitDSHDepartment of State HospitalsDURDrug Use ReviewEDIElectronic Data InterchangeEDUEncounter Data UnitEFTElectronic Funds TransferERAElectronic Remittance AdviceFAUFinancial Analysis UnitFDBFirst Data BankFFBFiscal Forecasting BranchFFPFederal Financial ParticipationFFSFee For ServiceFFSRDDFee-For-Service Rates Development DivisionFIFiscal IntermediaryFIPSFederal Information Processing StandardsFISMAFederal Information Security Management ActFLEXMedicare Rural Hospital FlexibilityFMBFinancial Management BranchFPACTFamily Planning, Access, Care, and Treatment. Family PACT is a program that provides no-cost family planning services to low-income men and women, including teens. Many doctors and clinics throughout California are part of the Family PACT program.FTBFranchise Tax BoardGHPPGenetically Handicapped Persons ProgramHAMHealth Administration ManualHCBSHome & Community Based ServicesHCPCSHealthcare Common Procedure Coding SystemHEHealth EnterpriseHHSDepartment of Health and Human ServicesHIEHealth Information ExchangeHIPAAHealth Insurance Portability and Accountability Act of 1996HIPPHealth Insurance Premium PaymentHITHealth Information TechnologiesHITECHHealth Information Technology for Economic and Clinical Health Act of 1996HIXHealth Insurance Exchange HUCDSHospital/Uninsured Care Demonstration SectionIHIndian HealthIRSInternal Revenue ServiceISOInternational Organization for StandardizationITInformation TechnologyITSDInformation Technology Services DivisionKDEKey Data EntryLEALocal Educational AgencyLGALegislative & Governmental AffairsLGBTLesbian, Gay, Bisexual & TransgenderLIHPLow Income Health Program DivisionLTCDLong Term Care DivisionMARManagement Administrative ReportsMCMedi-Cal ConsultantMCEDMedi-Cal Eligibility DivisionMCOManaged Care OrganizationMCPManaged Care PlanMCPManaged Care PlanMDSDMedi-Cal Dental Services DivisionMedCCCMedi-Cal Claims Customer Service OfficeMedi-CalThe name of the California Medicaid program serving low-income families, seniors, persons with disabilities, children in foster care, pregnant women, and certain low-income adults. It is jointly administered by DHCS and CMS, with many services implemented at the local level mainly by the counties of California.Medi-Cal Business ProcessRefers to the DHCS Enterprise Medi-Cal business processes that are identified in the SS-A performed by OHC. Currently, there are 151 Medi-Cal business processes. The Medi-Cal business processes are aligned to the MITA business processes by the MITA 2.0 and 3.0 crosswalk developed by DHCS. This crosswalk illustrates the mapping of MITA 2.0 to MITA 3.0, including the Medi-Cal Business Areas, Business Categories, and Business Processes.MEDSMedi-Cal Eligibility Data SystemMEDSMedi-Cal Eligibility Data SystemMHPMental Health PlanMITAMedicaid Information Technology ArchitectureMITA Business ProcessRefers to the MITA 3.0 business processes that are defined by CMS under the Business Architecture.MITA ConditionOne of the Seven Conditions and Standards of CMS’ Enhanced Funding Requirements. This condition requires the State to align to and advance increasingly in MITA maturity for business, architecture, and data. The State is required to develop a COO and BPM to satisfy this condition.MITA Maturity LevelThe five levels of maturity and the measurable qualities that each level should demonstrate for the particular business process. The MITA Maturity Model tool is used to determine how a business can mature over time and advance to each level. MMAMedicare Modernization ActMMCDMedi-Cal Managed Care DivisionMMISMedicaid Management Information SystemMMMMITA Maturity ModelMPSGMedical Professional Service GroupMRBMedical Review BranchMSPSMedi-Cal Supplemental Payment SectionNISTNational Institute of Standards and TechnologyNOANotice of ActionO&EProvider Outreach and Education DepartmentOCROffice of Civil RightsOCROptical Character RecognitionOFPOffice of Family PlanningOHCOffice of HIPAA ComplianceOHITOffice of Health Information TechnologyOILOperating Instruction LetterOLSOffice of Legal ServicesOMBOffice of Management and BudgetOMCPOffice of Medi-Cal ProcurementOMHOffice of Multicultural HealthOPAOffice of Public AffairsOTDXerox Operations Training DepartmentOWHOffice of Women’s HealthPAPrior AuthorizationPAVEProvider Application Verification and EnrollmentPBDPharmacy Benefits DivisionPBM OS+Pharmacy Benefit Management Open SystemPCPharmacy ConsultantPEDProvider Enrollment DivisionPHPPrepaid Health PlanPIUProvider Integrity UnitPMFProvider Master FilePOBProgram Operations BranchPRHDPrimary & Rural Health DivisionPRUProvider Review UnitPUBSPublicationsQAFQuality Assurance FeeR&CResearch and CorrespondenceRADRemittance Advice DetailsRAISRebate Accounting and Information SystemRFARequests For ApplicationRFPRequests For ProposalRHSDRural Health Services DevelopmentRSARational Software ArchitectSAMState Administrative ManualSAMWSeasonal Agricultural and Migratory Workers ProgramSARService Authorization RequestSCDSystems of Care for Children and Adults DivisionSCOState Controller’s OfficeSDNSoftware Development NoticeSeven Conditions and StandardsConditions and standards that must be met by the states in order for Medicaid technology investments to be eligible for the enhanced match funding. The seven conditions and standards are: Modularity Standard, MITA Condition, Industry Standards Condition, Leverage Condition, Business Results Condition, Reporting Condition, and Interoperability Condition.SGSystem’s GroupSHIPSmall Rural Hospital Improvement ProgramSIMMState Information Management ManualSLAService Level AgreementSMAState Medicaid AgencySmartPA?Automated authorization tool for pharmacy claimsSMHSpecialty Mental HealthSMSBStatewide Medical Services BranchSNFDSafety Net Financing DivisionSOAService Oriented ArchitectureSPBUSmall Provider Billing UnitSPCPOffice of Selective Provider Contracting ProgramSS-AState Self-AssessmentStakeholderRefers to one or more Actors performing in a common role [or common set of roles], who are impacted by the transition from the Legacy CA-MMIS System to the CA-MMIS Health Enterprise System, or who need to be kept informed of its progress, from the broadest perspective. “Internal stakeholders” refer to DHCS and Xerox, and are trained by Xerox Operations Training Department (OTD). “External stakeholders” refer to providers, provider associations, ancillary groups (health plans, counties, etc.), intermediaries (vendors, clearinghouses, CMS, etc.), members, and the public. The Provider Outreach and Education (O&E) Department conducts the outreach activities to these external stakeholders.SUDSSubstance Use Disorder ServicesSURSSurveillance and Utilization Review SubsystemTARTreatment Authorization RequestTOGAFThe Open Group Architecture FrameworkTPLThird Party LiabilityTPLRDThird Party Liability and Recovery DivisionTransfer SystemsThe Xerox baselined products HE, PBM OS+, Drug Rebate Analysis & Management System (DRAMS), SmartPA?, and Medical Authorization, are termed “transfer systems” and are different from the Commercial Off-The-Shelf (COTS) products such as the Isaac Blaze Rules Engine. Xerox transfer systems are to be configured, customized, and enhanced to meet State requirements. At the end of System Replacement, when the transfer systems have been successfully customized and implemented, the resulting strategy is the CA-MMIS HE System for the State of California.TSCTelephone Service CenterUMDUtilization Management DivisionCA-MMIS Actors CatalogAn Actor is a person or entity external to the system being specified (e.g., another system, a piece of hardware), who interacts with the system to accomplish tasks. Actors correspond to different user roles (not names or formal Human Resources titles) that use the system. Actors are distinguished by the ways in which they interact with the system. Factors that distinguish actors include common responsibilities, skill levels, work activities, and modes of interaction with the system. An individual may serve in the role of one or more actors (e.g., a call center manager may play the role of customer service manager and claims manager), whereas other actors may have distinct operational scenarios for their interactions with the system.The Primary Actor is the actor that initiates the system request and interacts with the system to accomplish a goal. Other involved actors do not directly interact with the system, but have an influence on, or are influenced by, the system.A list of Actors who interact with CA-MMIS directly or indirectly can be found in the CA-MMIS Actors Catalog in Appendix A. The impact(s) to each of the Actors in each System Replacement Release are also provided in Appendix A. The Actors Catalog is available as part of the “Business Architecture – Actors Catalog” within the TOGAF Business Architecture domain developed using Rational Software Architect (RSA).The Actors Catalog Diagram below summarizes the actors listed in the CA-MMIS Actors Catalog (Appendix A) and the entity type (DHCS, Xerox, or External) that they belong to. Actors who are not part of DHCS or Xerox are categorized as “External” entity type in the CA-MMIS Actors Catalog and Diagram. The Diagram uses the Aliases, instead of the formal Actor Name, from the CA-MMIS Actors Catalog. The CA-MMIS Actors Catalog and Diagram are used as a starting point for the Stakeholder Analysis deliverable, the BPT, and the BPMN diagrams. Note: As indicated in the Assumptions section of this document, the term “stakeholders” in this document refers to one or more Actors performing in a common role [or common set of roles], who are impacted by the transition from the Legacy CA-MMIS System to the CA-MMIS Health Enterprise System, or who need to be kept informed of its progress, from the broadest perspective. “Internal stakeholders” refers to DHCS and Xerox, and are trained by Xerox OTD. “External stakeholders” refers to providers, provider associations, ancillary groups (health plans, counties, etc.), intermediaries (vendors, clearinghouses, CMS, etc.), Medi-Cal beneficiaries, and the public. The Provider O&E Department conducts the outreach activities to these external stakeholders.Figure SEQ Figure \* ARABIC 4: Actors Catalog DiagramAs-Is CA-MMISThe CA-MMIS system has been developed under federal guidelines for the development and operation of California Medicaid processing and information retrieval. As a federally certified system, CA‐MMIS receives 90 percent federal funding for development, 75 percent federal funding for systems operation, and 50 percent for claims payments on most federal/state covered services. CA‐MMIS processes Medi-Cal claims other than Dental. Medi‐Cal is California’s Medicaid program and it is administered by DHCS. Medi‐Cal is intended to provide Federal and State financial assistance for the health and medical care of the needy by providing health care coverage for low‐income families, aged, blind, and disabled persons, and individuals whose income and resources are insufficient to meet the costs of necessary medical services.The Medi-Cal MITA SS-A created in 2008 showed process redundancy within the Medi-Cal program (e.g., provider enrollment is performed nine different ways within the Medi-Cal program). The assessment of Medi-Cal’s business capabilities measured using the MITA 2.0 BCM showed the highest level of capability of Medi-Cal business processes was a level 3, with the majority of Medi-Cal business processes achieving a maturity level of 2 or under. Many systems, interfaces, and data sets integral to Medi-Cal program operations are not able to share data in a timely and automated manner. Manual processing of claims still occurs. Multiple proprietary repositories may support a single business area, and these repositories supporting one business area may not be able to share data effectively with other interdependent business areas. The lack of automated interfaces within and between business areas is a common aspect of the Medi-Cal current view found in the 2008 Medi-Cal MITA SS-A.The information presented in this section is based on the Medi-Cal MITA SS-A, which was created in June, 2013 based on MITA 3.0. Refer to Section 4.4.1 for MITA Maturity Level descriptions.As-Is CA-MMIS Business ProcessesThe As-Is Enterprise Medi-Cal business processes include CA-MMIS specific business processes. The As-Is Medi-Cal Enterprise includes Tier 1 Medi-Cal Business Areas and Tier 2 Medi-Cal Business Categories, as well as CA-MMIS related business processes that are derived from the number of Medi-Cal specific business processes that are required by MITA 3.0. For a diagram of the Medi-Cal Enterprise, refer to Appendix F.MITA Business Process: Refers to the MITA 3.0 business processes that are defined by CMS under the Business Architecture.Medi-Cal Business Process: Refers to the DHCS Enterprise Medi-Cal business processes that are identified in the SS-A performed by OHC. Currently, there are 141 Medi-Cal business processes. The Medi-Cal business processes are aligned to the MITA business processes by the MITA 2.0 and 3.0 crosswalk developed by DHCS. This crosswalk illustrates the mapping of MITA 2.0 to MITA 3.0, including the Medi-Cal Business Areas, Business Categories, and Business Processes.CA-MMIS Business Process: Refers to CA-MMIS business processes that are derived from the Medi-Cal Business Processes in the SS-A. Currently, there are 67 CA-MMIS business processes out of the 141 Medi-Cal business processes.The following diagram contains the As-Is CA-MMIS Business Areas and associated Business Processes, based on MITA 3.0. Each business process is denoted as either Xerox, DHCS, or Shared, depending on which entity performs the business process.Figure SEQ Figure \* ARABIC 5: As-Is CA-MMIS Business ProcessesAs-Is CA-MMIS Context DiagramThe As-Is CA-MMIS Context Diagram presents a current-state conceptual view of the external entities with which CA-MMIS interacts. The Context Diagram shows CA-MMIS as a whole, with inputs and outputs at a high level between the external entities and CA-MMIS. It is the intent of the As-Is Context Diagram to provide readers an understanding of the environment in which CA-MMIS is used.The primary purpose of the CA-MMIS system is to process medical claims to support the State of California’s health care programs, particularly the Medi-Cal program. As such, the primary entities identified in the As-Is CA-MMIS Context Diagram directly interface with CA-MMIS due to claims-related and care management transactions. Business associates are not considered primary entities. A more elaborate description of business associates is discussed later in this section.External entities are conceptual groupings of individuals or organizations based on the role the entities have with CA-MMIS (Refer to Entity Type in the CA-MMIS Actors Catalog in Appendix A). While the CA-MMIS Actors Catalog has a large number of entities involved, the context diagram depicted below shows the primary external entities that directly exchange information with CA-MMIS and the type of information they exchange with CA-MMIS.To view the As-Is CA-MMIS Context Diagram with specific inbound and outbound transactions of each primary entity, along with its respective description, refer to the tables below. Figure SEQ Figure \* ARABIC 6: As-Is CA-MMIS Context DiagramTable SEQ Table \* ARABIC 4: CA-MMIS Primary EntitiesActor NameDescriptionInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound & Outbound Interaction to/from CA-MMISProviderRefers to individuals or organizations enrolled by the Medi-Cal program to provide certain services to Medi-Cal members. Includes doctors, hospitals, nursing homes, pharmacies, or durable medical supplies retailers.Part of the Medi-Cal Actor Catalog that functions as a subset of the Provider actor group are the Child Health and Disability Prevention Program (CHDP) Provider, which renders medical services specifically to members under the CHDP program and the Pharmacy Provider, which dispenses drugs to members and submits pharmacy claims.Claims - refers to the claim forms submitted in order to receive payment for the services they rendered or items they dispensed to members.Inquiries/Responses - refers to a general type of Inbound and Outbound information that is exchanged between Providers and CA-MMIS. For instance, inquiry and response on Provider eligibility status or claims payment.Enrollments - refers to the information sent by Providers in order to become eligible for Medi-Cal and other State programs.Eligibilities - refers to Provider and Member eligibility criteria and status that are necessary to adjudicate claims accurately. This information is sent out by CA-MMIS to give providers the ability to know if they will be paid for seeing the member.Payment Information - refers to statements sent to providers to notify them of claims that have been received and processed. It also indicates if the claim has been approved, suspended, or denied. If necessary, this creates a point to start an appeal.Enrollments - in response to information received from Providers, CA-MMIS sends out information regarding the enrollment.Laboratory Services - refers to the information that Providers initiate by requesting lab service reservations and verification of frequency limits prior to performing procedures. Conversely, CA-MMIS conducts outbound transactions in response to the inbound information that providers requested.Prior Authorizations (PA) – refers to the information sent by Providers to authorize a service or procedure for the member. CA-MMIS adjudicates the prior authorization request and provides the response.MemberRefers to beneficiaries of Medi-Cal and other State related programs; specifically, individuals or families who have met eligibility requirements to be enrolled in the Medi-Cal program.N/AN/ABeneficiary Identification Card (BIC) - refers to the identification card that allows providers to determine Members’ eligibility and enrollment status to the Medi-Cal program. Managed Care Organization (MCO)Refers to entities that manage commercial Medicaid programs. They submit encounters which report services provided to members. Medi-Cal Managed Care Health Plans have their own doctors, specialists, clinics, pharmacies, and hospitals.Encounters - refers to the claim forms submitted by MCOs in order to receive reimbursement for the services and/or items they paid for on behalf of Medi-Cal Members. These claims include encounter details that describe the types of service rendered to works – indicates providers authorized to perform services on behalf of the MCO in support of approved Members.N/AN/AMedicare and Other PayersMedicare submits crossover claims to Medi-Cal. “Other Payers” refers to those payers that are responsible in covering Medi-Cal members’ health care costs. This group includes private payers or other third party payers.Claims - refers to the claim forms submitted in order to receive payment for the services that their eligible Providers rendered and/or the items they dispensed to Medi-Cal Members.N/AInquiries/Responses - refers to general types of Inbound and Outbound information that are exchanged between Medicare and/or Other Payers and CA-MMIS (e.g., inquiry and response on claims status).CMSRefers to an agency of the U.S. Department of Health and Human Services (HHS). CMS is the federal agency which administers Medicare, Medicaid, and the Children’s Health Insurance Program. CMS also provides information for health professionals, regional governments, and consumers.Policies and Regulations - refers to legislative mandates that CA-MMIS needs to adhere to in order to receive funding, remain in compliance, and avoid costly penalties.Reports – refers to quantitative and/or qualitative information generated from Medi-Cal and other related State programs that are audited, monitored, and controlled by CMS.Inquiries/Responses - refers to general types of Inbound and Outbound information that are exchanged between CMS and CA-MMIS (e.g., inquiry and response on Medi-Cal Drug Rebate’s CMS-64 quarterly reports).DHCS and Other State AgenciesRefers to the DHCS and other State agencies that report to CMS. DHCS is the single state agency responsible for administration of the Medi‐Cal, County Medical Services Program (CMSP), California Children’s Services (CCS), Genetically Handicapped Persons Program (GHPP), and CHDP programs. It also has responsibility for the administration of other health‐related programs. An example of Other State Agencies mentioned in the CA-MMIS Actors Catalog is the Department of Justice (DOJ). DOJ primarily works together with DHCS to monitor illegal activities.Policies and Regulations - refers to legislative mandates that DHCS and Other State Agencies need to adhere to in order to receive funding, remain in compliance, and avoid costly penalties.Reports – refers to quantitative and/or qualitative information that is generated from Medi-Cal and other related State programs that are required and requested by CMS. These reports are also audited, monitored, and controlled by CMS or state agencies.Payment Data and Claims Reference Files – refers to the data sent from CA-MMIS to DHCS and State divisions. This includes Claims Payment information sent to the State Controller’s Office (SCO).Inquiries/Responses - refers to general types of Inbound and Outbound information that are exchanged between CMS and DHCS and/or Other State Agencies (e.g., inquiry and response on a report that presents data on illegal activities related to fraudulent health care providers).Business AssociatesThe CA-MMIS Actors Catalog includes external entities that are not primary entities. These are considered Business Associates and are excluded from the As-Is Context Diagram. According to the U.S. HHS and 45 Code of Federal Regulations (CFR) 160.103, a “business associate” is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. The types of functions or activities that may make a person or entity a business associate include payment or health care operations activities, as well as other functions or activities regulated by the Administrative Simplification Rules. Business associate functions and activities include: claims processing or administration; data analysis, processing or administration; utilization review; quality assurance; billing; benefit management; practice management; and re-pricing. Business associate services refers to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, and financial. The CA-MMIS Actors Catalog identifies several business associates that are involved with the primary entities mentioned above. The Business Associates for CA-MMIS are defined in the following table.Table SEQ Table \* ARABIC 5: CA-MMIS Business AssociatesActor NameDescriptionFirst Data Bank (FDB)Provides formulary data updates. Note that the formulary file refers to a CA‐MMIS table identifying the drugs or medical supplies, and rates, acceptable for billing under the Medi‐Cal system. These files are established by Title 22, California Code of Regulations.Maximus Performs enrollment and disenrollment of Managed Care Plan (MCP) members. Also referred to as “MCP Eligibility.”Drug Manufacturers/LabelersReceives drug rebate invoices and submits rebates to DHCS. These entities are contracted with CMS and DHCS on drug rebate.SubmittersSends claims to CA-MMIS on behalf of providers. Also known as “Clearinghouses.” As-Is CA-MMIS COOThe As-Is CA-MMIS COO illustrates the information exchanged between CA-MMIS and the external entities (i.e., “DHCS” and “External” under the CA-MMIS Actors Catalog). The external entities consist of the primary entities identified in the As-Is CA-MMIS Context Diagram and the business associates. As-Is CA-MMIS COO – Inbound/Outbound TransactionsThis section discusses the operational view of the inbound and outbound transactions that are exchanged between CA-MMIS and the external entities as it exists at present. These transactions are specific to CA-MMIS business areas and processes that interface with Providers, MCOs, Medicare and Other Payers, CMS, DHCS and Other State Agencies, and Business Associates. Inbound Interaction to CA-MMIS refers to the information that CA-MMIS receives, while Outbound Interaction from CA-MMIS refers to the information that CA-MMIS sends out to the specific Actors identified. There are instances where CA-MMIS receives and sends out the same information, and this scenario is categorized as Inbound/Outbound Interaction.Note: For a more elaborate description of these external entity groups, refer to the previous Section , As-Is CA-MMIS Context Diagram. Care ManagementTable SEQ Table \* ARABIC 6: As-Is CA-MMIS COO Table (Care Management)CA-MMIS Business CategoryCA-MMIS Business ProcessPROVIDERSDHCS & OTHER STATE AGENCIESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionAuthorization DeterminationAuthorize CCS/GHPP ServicesReceive Service Authorization Request (SAR)Send adjudicated SAR responseN/AReceive SAR review result from CMSNetSend SAR for review to CMSNetSend SAR utilization dataN/AMedi-Cal Treatment Authorization Requests (TARs)Receive TARSend adjudicated TAR responseN/AReceive TAR review result from Pharmacy/Medi-Cal ConsultantSend TAR for review to Pharmacy/Medi-Cal ConsultantSend TAR utilization dataN/ACase ManagementAuthorize Treatment PlanReceive treatment planSend authorized treatment planN/AN/AN/AN/AEstablish Case Receive Medi-Cal CaseN/AN/ACreate a Medi-Cal CaseN/AN/AEstablish CCS/GHPP CaseReceive CCS/GHPP CaseN/AN/ACreate a CCS/GHPP CaseN/AN/AManage Case InformationReceive Medi-Cal Case detailsN/AN/AN/AN/ARetrieve and work a Medi-Cal CaseManage CCS/GHPP CaseReceive CCS/GHPP Case detailsN/AN/AN/AN/ARetrieve and work a CCS/GHPP CasePerform Screening and AssessmentReceive TAR or claim for processing and perform clinical screening.Send adjudicated TAR response or adjudicated claim responseN/AN/AN/AN/AManage Treatment Plan and OutcomesN/AN/AN/AReceive electronic recordsN/AN/AState SpecificReserve ServiceReceive reservation requestsN/AN/AN/AN/AN/AContractor ManagementTable SEQ Table \* ARABIC 7: As-Is CA-MMIS COO Table (Contractor Management)CA-MMIS Business CategoryCA-MMIS Business ProcessDHCS & OTHER AGENCIESBUSINESS ASSOCIATESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound Interaction Inbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionContractor SupportManage Medi-Cal Contractor CommunicationN/ACommunicate information to DHCSN/AN/APost documentation and communications to SharePointN/AContract ManagementManage CA-MMIS Fiscal Intermediary (FI) ContractCommunication information from DHCSN/AReceive FI Letters and send response lettersN/AN/AN/AFinancial ManagementTable SEQ Table \* ARABIC 8: As-Is CA-MMIS COO Table (Financial Management)CA-MMIS Business CategoryCA-MMIS Business ProcessPROVIDERSMCOCMSDHCS & OTHER AGENCIESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/Outbound InteractionInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound Interaction to CA-MMISOutbound Interaction from CA-MMISAccounts Payable ManagementManage 1099N/AN/AReceive & send 1099 informationN/ASend 1099 reportsReceive 1099 informationSend 1099 informationManage Incentive PaymentReceive incentive payment requestProcess incentive payment and send payment informationN/AN/AN/AReceive incentive payment requestSend incentive payment informationManage Medi-Cal Accounts Payable InformationN/AN/AN/AN/AN/AReceive warrant numbers for Medi-Cal payments Send Accounts Payable (A/P) informationManage Medi-Cal Payable DisbursementN/AWeekly Check write from CA-MMISN/AN/ASend Weekly Check Write data to SCOReceive Provider disbursement transactionsSend Provider disbursement payment informationManage Contractor PaymentN/ASend payment request to Financial Management Branch (FMB)N/AN/AN/ASend payment request to FMBSend Contract Management / payment ?reports from CA-MMIS Manage Medicare Premium PaymentStore Medicare buy-in Premium Payment informationN/AN/AN/AN/AN/AExecuted by DHCS Third Party Liability and Recovery Division (TPLRD)Manage Health Insurance Premium PaymentsStore Medicare buy-in Premium Payment informationN/AN/AN/AN/AN/AExecuted by DHCS TPLRDAccounts Receivable ManagementManage Cost Reports SettlementN/AN/AN/AN/AN/AReceive Accounts Receivable (A/R) recoupment transaction informationSend Provider payment informationManage Drug RebateN/AN/AN/AReceive MCO information for drug rebateSend CMS reports for drug rebate informationReceive drug claims dataSend drug rebate informationManage Medi-Cal Accounts Receivable FundsN/AN/AN/AN/AReceive funds information to determine provider payments (no budget process)Send check-write informationManage Medi-Cal Accounts Receivable InformationN/AN/AN/AN/AN/AReceive A/R transaction initiation requestSend A/R transaction reportsManage Overpayment RecoupmentN/AN/AN/AN/AN/AAppeals process overpayment / recoupmentCreate Provider recoupment transactionsManage TPL Recovery?N/ASend Third Party Liability (TPL) letters N/AN/AN/AN/ASend TPL analysis results, recoupment transaction informationManage Estate RecoveryStore data in the Automated Collection Management System (ACMS)N/AStore Vital Records Data in CAMMIS Member Subsystem (MEDS)N/AN/AN/AOverseen by DHCS TPLRD State SpecificManage Member Health Care ReimbursementCA-MMIS is used to validate Medi- Cal member/provider eligibility and Service coverage for medical servicesN/AN/AN/AN/ACA-MMIS is used to validate Medi- Cal member/provider eligibility and service coverage for medical servicesMember Reimbursement checks are distributed by the State Controller’s Office Fiscal ManagementManage State FundsN/AN/AN/AN/AN/AN/ASend Contract Management/payment ?reports from CA-MMISFormulate Medi-Cal BudgetN/AWeekly Check write from CA-MMIS N/AN/AN/AN/AWeekly Check write from CA-MMIS Generate Medi-Cal Budget Estimates Financial ReportN/AWeekly Check write from CA-MMIS N/AN/AN/AN/AWeekly Check write from CA-MMIS Member Eligibility and Enrollment Management Table SEQ Table \* ARABIC 9: As-Is CA-MMIS COO Table (Member Eligibility and Enrollment Management)CA-MMIS Business CategoryCA-MMIS Business ProcessPROVIDERSInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionMember EnrollmentInquire Medi-Cal EligibilityReceive member eligibility Inquiry transactionsSend member eligibility responseN/AMember ManagementTable SEQ Table \* ARABIC 10: As-Is CA-MMIS COO Table (Member Management)CA-MMIS Business CategoryCA-MMIS Business ProcessPROVIDERSDHCS & OTHER AGENCIESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/Outbound InteractionInbound Interaction to CA-MMISOutbound Interaction from CA-MMISMember Support ManagementManage Medi-Cal Applicant and Member CommunicationN/AN/AReceive request for TAR in the Field OfficeReceive Notice of Action (NOA) letter from Consultants.NOA letters are printed and mailed out.Operations ManagementTable SEQ Table \* ARABIC 11: As-Is CA-MMIS COO Table (Operations Management)CA-MMIS Business CategoryCA-MMIS Business ProcessPROVIDERSMCOMEDICARE & OTHER PAYERSDHCS & OTHER AGENCIESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound Interaction to CA-MMISInbound Interaction to CA-MMISInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionClaims AdjudicationSubmit Medi-Cal Claim AttachmentReceive claim attachmentsN/AN/AN/AN/AN/AN/AApply Medi-Cal Mass AdjustmentN/AN/AN/AN/AReceive mass adjustment changesN/AN/AProcess Medi-Cal ClaimReceive Medi-Cal ClaimSend Medi-Cal claim adjudication responseN/AReceive Crossover claimsReceive policy changes to process Medi-Cal claimsN/AN/APayment and ReportingGenerate Medical Remittance Advice? N/ASend medical remittance advice details (RAD)N/AN/AN/ASend medical remittance advice information? N/AInquire Medi-Cal Payment StatusReceive Medi-Cal Payment requestSend Medi-Cal payment inquiry responseN/AN/AN/AN/AN/AManage DataN/AN/AN/AN/AReceive reference data [FDB, Healthcare Common Procedure Coding System (HCPCS), etc.]N/ARetrieve data; Update dataProcess EncounterProcess Managed Care EncounterN/AN/AReceive Managed Care encounter dataN/AN/ASend Manage Care Encounter reports?N/APlan ManagementTable SEQ Table \* ARABIC 12: As-Is CA-MMIS COO Table (Plan Management)CA-MMIS Business CategoryCA-MMIS Business ProcessCMSDHCS & OTHER AGENCIESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionPlan AdministrationMaintain Program Policy?N/A?N/A?N/AFI Letter requesting updates to program policyN/AN/AHealth Plan AdministrationManage Medi-Cal Program InformationDefine policies; initiate tasks to update policies?N/A?N/ADefine policies; initiate tasks to update policies in CA-MMIS Update Provider bulletin Web pageN/ADevelop and Manage Performance Measures N/AN/AN/AN/AGenerate/send performance measure reportsN/AHealth Benefits AdministrationMaintain Benefits-Reference InformationDefine policies; Initiate tasks to update policies in CA-MMISN/AN/AReceive policies; Initiate tasks to update policies in CA-MMISN/AN/AManage Benefit InformationN/AN/AN/AReceive policies; initiate tasks to update policies in CA-MMISN/AN/AManage Drug FormularyN/AN/AN/AReceive policies; initiate tasks to update Formulary File and associated tablesN/AN/AManage Rate SettingN/AN/AN/AReceive policies; initiate tasks to update policies in CA-MMISN/AN/AProvider Eligibility ManagementTable SEQ Table \* ARABIC 13: As-Is CA-MMIS COO Table (Provider Eligibility Management)CA-MMIS Business CategoryCA-MMIS Business ProcessProviderDHCS & OTHER AGENCIESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionProvider EnrollmentEnroll Medi-Cal ProviderSubmit enrollment applications (out-of-state Providers)Send approval/denial letter (out-of-state Providers)N/AN/AN/AN/AInquire Medi-Cal Provider InformationN/A N/AReceive/send inquiry transactionsN/AN/AReceive/send inquiry transactionsDetermine Medi-Cal Provider EligibilityN/AN/AN/AProvider Enrollment Division determines the enrollment of providers N/AN/ADetermine Provider Eligibility for Incentive ProgramN/AN/AN/ACA-MMIS Provider Subsystem: Verifies authorized Medi-Cal providers and includes provider data in the Provider Master File (PMF).N/AN/ADetermine CHDP Provider EligibilityN/AN/AN/AProvider Enrollment Division determines the enrollment of CHDP providersN/AN/AEnroll Drug Medi-Cal ProviderN/AN/AProviders are able to access member eligibility through Automated Eligibility Verification System (AEVS), MC Web site etc.Drug Medi-Cal PMF is sent to CA-MMIS to add as a “Other Intermediary” into the Medi-Cal PMF.N/AN/AEnroll Mental Health ProviderN/AN/AProviders are able to access member eligibility through AEVES, Medi-Cal Web site, etc.Mental Health PMF is sent to CA-MMIS to add as a “Other Intermediary” into the Medi-Cal PMFN/AN/AEnroll Dental ProviderN/AN/AN/AN/AN/AN/AEnroll CCS ProviderN/AN/AN/ACMSNet is considered to be part of CA-MMIS and stores provider approvals for CCS and CHDP as well as authorized treatment request for CCS and GHPPN/AN/AEnroll CHDP ProviderN/AN/AN/ACA-MMIS CHDP Subsystem: Stores CHDP provider enrollment information that is accessed during CHDP claims processing. N/AN/ADisenroll Medi-Cal ProviderN/AN/AN/ACA-MMIS Provider Subsystem: Verifies authorized Medi-Cal providers and includes provider data in the PMF. Provider is not removed from the Medi-Cal PMF. Status changes to inactive or their enrollment is end-dated.N/AN/ADisenroll Dental ProviderN/AN/AN/AN/AN/AN/APerformance ManagementTable SEQ Table \* ARABIC 14: As-Is COO Table (Performance Management)CA-MMIS Business CategoryCA-MMIS Business ProcessDHCS & OTHER AGENCIESInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/Outbound InteractionCompliance ManagementDetermine Adverse Action IncidentReceive information to add Providers to Suspect Hold; receive TPL casesSend Suspect Hold reports & Audits & Investigations (A&I) transaction informationN/AIdentify Utilization AnomaliesN/ASend utilization data and reportsN/AEstablish Compliance IncidentN/ASend utilization data and reportsN/AManage Compliance Incident InformationN/ASend utilization data and reportsN/APrepare Beneficiary Confirmation LettersN/ASend utilization data and reportsN/AProvider ManagementTable SEQ Table \* ARABIC 15: As-Is COO Table (Provider Management)CA-MMIS Business CategoryCA-MMIS Business ProcessPROVIDERSMCOInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionInbound Interaction to CA-MMISOutbound Interaction from CA-MMISInbound/ Outbound InteractionProvider Information ManagementManage Medi-Cal Provider InformationReceive Provider data updateN/AN/AReceive network provider dataN/AN/AProvider SupportManage Medi-Cal Provider CommunicationN/APublish provider communicationsN/AN/AN/AN/APerform Medi-Cal Provider OutreachN/AProvides support & trainingN/AN/AN/AN/APerform Family Planning, Access, Care, and Treatment (FPACT) Provider OutreachN/AProvides FPACT trainingN/AN/AN/AN/AManage Medi-Cal Fee-for-Service (FFS) Provider Grievance & AppealReceives appeals & grievanceSend Claims appeals adjudication informationN/AN/AN/AN/ATo-Be CA-MMISIn the future, Medi-Cal business processes are expected to be more automated, standardized, unified, and timely. Stakeholders are not required to access the Medi-Cal program through numerous, disparate channels, and they benefit from new agency interfaces that feature capabilities supporting “single point of entry” or “no wrong door” concepts. In addition, Member, Provider, claims, and other repositories operate in an integrated architecture, transmitting standardized data real-time through shared technology services throughout the Medi-Cal program and other state and federal agencies and programs. The coordination improves the Medi-Cal program’s cost-effectiveness and significantly enhances the value to its key stakeholders.The CA-MMIS Health Enterprise System Information Exchange and Access EnvironmentThe To-Be Context Diagram purposely conveys a setting where the CA-MMIS Health Enterprise System’s business transformation is realized in a new and dynamic enterprise environment with the Member’s relationship central to the enterprise. The To-Be Context Diagram displays the direct interaction between the primary entities and CA-MMIS. The role of the business associates that is evident in the As-Is Context Diagram scenario diminishes on its corresponding To-Be scenario. Due to technological advancement, particularly the HE components that are scheduled to be implemented in CA-MMIS, the primary entities are able to exchange and access information easily. The transactions that are exchanged between the primary entities and CA-MMIS are not limited as compared to the transactions in the As-Is state. This high level of technological sophistication supports operational efficiency and productivity by minimizing administrative costs and the number of processes necessary in order to retrieve and/or send information with key entities. To illustrate the overall business transformation of CA-MMIS in relation to the Member-centric structure of California’s health system, refer to the following figure.Figure SEQ Figure \* ARABIC 7: The CA-MMIS Health Enterprise System Exchange and Access EnvironmentTo-Be CA-MMIS COOThe SS-A conducted by DHCS in June, 2013 was used to formulate the To-Be CA-MMIS Context and COO Diagram. The To-Be view includes consolidated interfaces with program stakeholders instead of multiple program access routes and interfaces. Also, the To-Be vision includes consolidated data repositories and consolidation of business areas and improved coordination between programs and business processes. This leads to higher maturity levels and shows improvement and transformation of the business processes over time. Through the technological advancement that HE brings, the As-Is CA-MMIS business processes are able to align to higher MITA maturity levels and transition into the MITA-driven To-Be CA-MMIS business processes.To view the To-Be COO Diagram (CA-MMIS HE System), refer to the diagram below.center-47625Figure SEQ Figure \* ARABIC 8: To-Be COO Diagram (CA-MMIS HE System)To-Be Environment of CA-MMIS Business Process Implementation in System Replacement ProjectIn the first quarter of 2014, DHCS and Xerox agreed to replace the phased approach with a modified agile approach. The CA-MMIS System Replacement Project will be now implemented in five distinct releases, with each release building on the prior release. The roadmap for the planned releases is provided in Appendix E. Details for each release will be documented as the scope of each release is finalized. The following table provides the business functionality being planned for implementation in Release 1.Table SEQ Table \* ARABIC 16: Release 1 Business Functionality#Business Functionality1Development of the framework to retrieve Member Eligibility data (HIPAA X12 270/271 transactions requests/responses from FAME/MEDS2Development of the framework for making To-Be systems as the system of record for all Reference Data and integration with Legacy3Development of the framework for making To-Be systems as the system of record for all Formulary data and integration with Legacy4Development of the framework for managing rate settings 5Development of the framework for managing benefit plans6Provider Enrollment/Disenrollment functionality; integration with Provider Master Files and PAVE, along with Provider maintenance and inquiry7Building the framework for determining Medi-Cal Provider eligibility, including incentive program8Integration of Legacy RAIS invoices with To-Be Rebate Web to allow manufacturers and labelers to view their invoices9Provider Outreach and Communication Management through correspondences and contact management, and publications to upload static information such as manuals, bulletins, and FAQs10Management of Medi-Cal Program information11Management of Program Policy12HE Portal integration to access Legacy IHO/MCM Case information13HE Portal integration to access Legacy Grievance & Appeal informationTransition from As-Is to To-BeThe current state (As-Is) of the DHCS CA-MMIS is:Multiple program access routes and interfaces for stakeholdersDisparate state repositoriesLimited coordination between business areasMultiple variants for business area processesThe future vision (To-Be) for DHCS CA-MMIS includes but is not limited to:Consolidated interfaces with program stakeholdersConsolidated data repositories accessible throughout the agencyBusiness area consolidationImproved coordination between programs and business processescenter833120The figure below shows the transformation envisioned between the existing CA-MMIS and its processes to the new enhanced CA-MMIS Replacement System and its processes.Figure SEQ Figure \* ARABIC 9: As-Is and To-Be CA-MMIS Transformation Characteristicscenter561975The transition of the CA-MMIS from a MITA Business Architecture perspective is shown in the following diagram.Figure SEQ Figure \* ARABIC 10: COO (Business Architecture Transition)Effectiveness – Increase Business MaturityBusiness capabilities link to enabling technical capabilities and are the principal drivers of business services.As part of the BCM, the business process areas are scored based on different maturity levels. Each general description of a level is supplemented by more specific definitions in a set of qualities. Qualities represent aspects of capabilities that are measurable, such as the following:Timeliness of business processData accuracy and accessibilityEase of performance/efficiencyCost effectivenessQuality of process resultsValue to stakeholdersThe BCM contains maturity levels of functionality for each business process in the BPM. Capabilities are assigned at each Business Process level. It defines the boundaries and behavior for each business process in the context of the five (5) levels of the MMM. The Business Processes identified in the SS-A are scored for the quality attributes. The To-Be BCM must be equal to or surpass the State’s maturity goals. Business processes are assigned a MITA Maturity Level of 1 (lowest level of maturity) through 5 (highest level of maturity) for business capabilities.DHCS uses the BCM to perform a self-assessment to establish their current maturity level for each business process and select higher levels for future improvements. This assessment provides a foundation for DHCS to develop a strategic plan for continuous improvement, targeting to move to higher levels of maturity. Business process improvement may come in different forms such as new technology adoption, business process re-engineering, change in management direction, process obsolescence etc. in order to reduce costs, improve productivity and deliver services more efficiently. Business changes are documented as part of the CA-MMIS System Replacement Business Change Management Plan (BCMP).The first table (Table 15) below describes the quality attributes which are used to measure the maturity level of the business processes. The second table (Table 16) shows the template for capturing the maturity levels for the quality attributes for a given business process.The As-Is and To-Be maturity levels for the CA-MMIS business processes are shown in Appendix B. The MITA Maturity Level is shown in Figure 12.Table SEQ Table \* ARABIC 17: Quality Attributes to Measure Business ProcessQuality AttributeDescriptionTimeliness of Business ProcessTime lapse between the State’s initiation of a Business Process and attaining the desired result (e.g., length of time to enroll a provider, assign a member, pay for a service, respond to an inquiry, make a change, or report on outcomes)Data Accuracy and AccessibilityEase of access to data that the Business Process requires and the timeliness and accuracy of data used by the Business ProcessEase of PerformanceLevel of effort necessary to perform the Business Process given current resourcesCost EffectivenessRatio of the amount of effort and cost to the outcomeQuality of Process ResultsDemonstrable benefits from using the Business ProcessUtility of Value to StakeholdersImpact of the Business Process on individual members, providers, and State staffFigure SEQ Figure \* ARABIC 11: MITA Maturity LevelTable SEQ Table \* ARABIC 18: Template for Business Capability Matrix (BCM)BUSINESS PROCESS : <NAME>Level 1Level 2Level 3Level 4Level 5Quality: Timeliness of Business ProcessQuality: Data Accuracy and AccessibilityQuality: Efficiency, Ease of PerformanceQuality: Cost EffectivenessQuality: Quality of Process ResultsQuality: Utility of Value to StakeholdersEffectiveness – Improved Performance StandardsDHCS has defined performance standards to be measured for the CA-MMIS System Replacement.The performance standards include, but are not limited to, the following:System performance and capacity for current claim volumes and projected growth patternsSupporting current level and future growth in the number of usersSystem availabilitySystem response time for online transactions, reports and interfacesComplianceCA-MMIS System Replacement is compliant to federal and state statutes, regulations, and DHCS security policies. It is compliant with the Electronic Data Interchange (EDI) standards as well as the standards determined under provisions of HIPAA.Security and Confidentiality Security and Confidentiality for System Replacement facilities and applications are compliant to:Federal Information Processing Standards (FIPS) PublicationsState Administrative Manual (SAM) and Health Administration Manual (HAM)Federal and State mandates (including the State Medicaid Manual)Federal and State legislation (including HIPAA and the Information Practices Act (Civil Code section 1798,et. seq.)Office of Management and Budget (OMB) Circular A-130Federal Information Security Management Act (FISMA) ComplianceApplicable International Organization for Standardization (ISO) StandardsSarbanes OxleyCalifornia Civil Code Section 1798.29 & 1798.82Assembly Bill (AB) 1298 (California Civil Code Sections 56.06, 1785.11.2, 1798.29, and 1798.82, relating to personal information)National Institute of Standards and Technology (NIST) PublicationsDHCS IT Project Security Requirements 1 (SR 1)Health Information Technology for Economic and Clinical Health Act of 1996 (HITECH)System Security and PrivacySystem Replacement, as well as activities performed in support of System Replacement, is compliant with applicable federal and state security requirements (including HIPAA, NIST, and MITA Security and Privacy Principles and Standards).Other Standards for ComplianceGUI/Access/Web ServicesCalifornia Enterprise Architecture Program (CEAP)California SOA and Federated Identity Management Technical Vision (January 7, 2008)California Technology Agency (CTA) policies and compliance components, as found in the CA-MMIS/FI Procurement Federal Americans with Disabilities Act (ADA) GuidelinesWeb service standards (Oasis and W3C)NIST 800-95 Guide to Secure Web ServicesMITA Technical Reference ArchitectureState Medicaid Manual: State Information Management Manual (SIMM) – IT Policy: Critical Business ProcessesA process will be developed to identify the criteria for determining the criticality of each business process. These criteria include, but are not limited to, external stakeholder involvement, and the need for a business process to achieve a higher maturity. A business process catalog will be created to identify the critical business processes. The identification of critical business processes helps the Implementation Team perform contingency planning and develop approaches and plans in the event that such business functions are impaired and cannot be carried out as planned.Business Architecture – Assumptions, Constraints, and RisksThe following table describes the assumptions, constraints, and risks identified for each CA-MMIS business process. Several business processes do not have assumptions, constraints, and/or risks listed; these may be identified at later dates as the CA-MMIS System Replacement Project advances and more information is known.Impacts to the actors will be refined with the assistance of the Transition Team during each of the planned releases. Table SEQ Table \* ARABIC 19: Business Architecture - Assumptions, Constraints, and RisksCA-MMIS Business AreaCA-MMIS Business ProcessAssumptionsConstraintsRisksCare ManagementAuthorize Treatment PlanCA will adopt and conform to pending Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) operating rules related to service authorizations.CA will establish and enable policies and processes to support ICD-10 processing.Xerox transfer systems support ICD 9 and 10 processing.As-Is CA-MMIS currently does not make use of X12 278 transaction standard.Health Enterprise supports X12 278 transaction standard.None identified at this time.Care ManagementEstablish CaseTo-Be business process is not anticipating collecting and using clinical data as a part of this business process.MITA 3.0 business process includes the collection and use of clinical data within its baseline.None identified at this time.Establish CCS/GHPP CaseTo-Be business process will allow for some automation with changes to CMSNet. MITA 3.0 business process includes the collection and use of clinical data within its baseline.None identified at this time.Manage Case InformationHIE is outside the scope of CA-MMIS System Replacement requirements.MITA 3.0 baseline capability includes the integration of an HIE.None identified at this time.Manage CCS/GHPP CaseHIE is outside the scope of CA-MMIS System Replacement requirements.MITA 3.0 baseline capability includes the integration of an HIE.None identified at this time.Manage Treatment Plan and OutcomesCA will establish and enable policies and processes to support ICD-10 processing.Xerox transfer systems support ICD 9 and 10 processing.MITA Maturity 3 requires interaction with HIE, outside scope of CA-MMIS. None identified at this time.Medi-Cal Treatment Authorization Requests (TARs)Rule based logic (SmartPA) will auto-generate pharmacy TARs from submitted claims without human intervention.CA will establish and enable policies and processes to support ICD-10 processing.None identified at this time.Perform Screening and AssessmentHIE is outside the scope of CA-MMIS System Replacement requirements.CA will establish and enable policies and processes to support ICD-10 processing.MITA 3.0 baseline capability includes the integration of an HIE.None identified at this time.Care ManagementReserve ServiceNone identified at this time.As this is a state specific business process, the capabilities of this business process will have to be developed for DHCS.None identified at this time.Contractor ManagementManage CA-MMIS FI ContractThe Manage CA-MMIS FI contract business process has no significant enhancements planned in System Replacement requirements. None identified at this time.None identified at this time.Manage Medi-Cal Contractor CommunicationHealth Enterprise will leverage the provider management, communication and contact tracking capabilities for these contractor relationships.All communications must be approved by DHCS prior to being posted or sent out.None identified at this time.Financial ManagementFormulate Medi-Cal BudgetCM64 enhancements will automate some of the reporting to CMS. The Formulate Budget business process is primarily a manual effort performed outside of the system. None identified at this time.Generate Medi-Cal Budget Estimates Financial ReportCM64 enhancements will automate some of the reporting to CMS.None identified at this time.None identified at this time.Manage 1099None through maturity level 2.None identified at this time.None identified at this time.Manage Contractor PaymentCA will adopt and conform to CAQH CORE operating rules related to Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA).None identified at this time.None identified at this time.Financial ManagementManage Cost Reports SettlementNone through maturity level 2.None identified at this time.None identified at this time.Manage Drug RebateRebate Accounting and Information System (RAIS) and all its sub-systems, such as RAIS Datamart , will be decommissioned with the implementation of DRAMS.RAIS Data Mart holds additional CA-MMIS information beyond drug rebate and invoice information.Hardcopy documentation will continue to be scanned in and retained indefinitely.Manage Estate RecoveryNone through maturity level 2.None identified at this time.None identified at this time.Manage Health Insurance Premium PaymentsCA will adopt and conform to pending CAQH CORE operating rules related for Healthcare Premium Payment.None identified at this time.None identified at this time.Manage Incentive PaymentNone identified at this time.None identified at this time.Incentive payment triggers are not defined or may change.Manage Medi-Cal Accounts Payable InformationNone identified at this time.The baseline MITA process includes payroll activities, which may not be applicable to CA.None identified at this time.Manage Medi-Cal Accounts Receivable FundsNone through maturity level 2.None identified at this time.None identified at this time.Manage Medi-Cal Accounts Receivable InformationNone assuming Maturity Level 2None identified at this time.None identified at this time.Manage Medi-Cal Payable DisbursementCA will adopt and conform to CAQH CORE operating rules related to EFT/ERA.SCO will require system changes also related to EFT/ERA.None identified at this time.Manage Medicare Premium PaymentCA will adopt and conform to evolving buy-in, Medicare Modernization Act (MMA) and other CMS data exchange formats.None identified at this time.None identified at this time.Financial ManagementManage Member Health Care ReimbursementCA will adopt and conform to pending CAQH CORE operating rules related for Healthcare Premium Payment.None identified at this time.None identified at this time.Manage Overpayment RecoupmentNone identified at this time.There are no approved national data standards that support MITA Maturity Level 3, nor are most of the automation capabilities described in Maturity Level 3 available to providers.None identified at this time.Manage State FundsNone identified at this time.MITA level 3 requires the use of Nationally Recognized Standards to improve accuracy. These standards are not available.None identified at this time.Manage TPL RecoveryHealth Enterprise is capable of achieving Maturity Level 2.Maturity Level 3 requires undefined data standards and sharing COB information via HIE, which is not supported within CA-MMIS. In California, the MMIS does not perform this function but simply provides data to the State’s TPL department.CA will establish and enable policies and processes to incorporate ICD-10 in the TPL recovery processes.Member Eligibility and Enrollment ManagementInquire Medi-Cal EligibilityVoice Response will not give fully CORE content compliant response. EDI and Web Portal will be able to give compliant responses assuming that CA has adopted and implemented CORE Operating rules.None identified at this time.CA will have established infrastructure and processes to support CORE Operating Rules by the time of implementation of SR.Member ManagementManage Medi-Cal Applicant and Member CommunicationProviders inquire on the status of authorization requests on behalf of Medi-Cal Applicant or Member.None identified at this time.None identified at this time.Operations ManagementApply Medi-Cal Mass AdjustmentMass Adjustment requests will be initiated through Operating Instruction Letters (OILs), Software Development Notices (SDNs) and other communication mechanisms as they are now and not through automated triggers as described in Maturity Level 2.None identified at this time.None identified at this time.Generate Medi-Cal Remittance AdviceCA will adopt and conform to CAQH CORE operating rules related to EFT/ERA.SCO office may have to support system changes. None identified at this time.Inquire Medi-Cal Payment StatusCA will adopt and conform to CAQH CORE operating rules related to Inquire Claim Status.None identified at this time.None identified at this time.Manage DataCA will establish and enable policies and processes to support ICD-10 processing and the appropriate extracts.CA will adapt to evolving RAC recovery audit data formats to support ICD-10.T-MSIS requires data which may be outside of the MMIS. This requires appropriate sourcing, integration and transformation.Operations ManagementProcess Managed Care EncounterHealth Enterprise has the ability to receive and process encounters with similar adjudication capability as regular Fee-for-Service claims. California may only use a subset of the capability within Health Enterprise based on State specific business processes. California does not currently receive encounter data in the 837 format.MCO’s may not implement ICD-10 processing at the same time as CA-MMIS, potentially causing data issues.Process Medi-Cal ClaimCA will adopt and conform to pending CAQH CORE operating rules related to claims.CA will establish and enable policies and processes to support ICD-10 processing.Service Level Agreement (SLA) of 6 seconds needs to be met. None identified at this time.Submit Medi-Cal Claim AttachmentCA will adopt and conform to pending CAQH CORE operating rules related to attachments.None identified at this time.Providers have limited ways to submit attachments and enhancements may be needed to conform to new standards. Plan ManagementDevelop and Manage Performance MeasuresCA will accept and implement national quality standards or will define their own performance measures.None identified at this time.CA currently has defined quality and performance standards that are adhered to which may need to be revised.Maintain Benefits-Reference InformationCA will establish and enable policies and processes to support ICD-10 processing.All transfer systems are enabled for ICD 9 and 10 processing.None identified at this time.None identified at this time.Manage Drug FormularyFirst Data Bank will continue to provide the updates to the formulary file.None identified at this time.None identified at this time.Plan ManagementManage Medi-Cal Program InformationNone identified at this time.None identified at this time.DHCS sends the changes to policy over in an FI letter and Xerox updates the programs and files as appropriate.Manage Benefit InformationThere are no planned changes to the existing business processes. The replacement system will dramatically increase the configurability of benefits.None identified at this time.None identified at this time.Maintain Program PolicyThe replacement system will enable significantly greater policy management through configuration, but not necessarily automation.DHCS sends the changes to policy over in an FI letter and Xerox updates the programs and files as appropriate.None identified at this time.Manage Rate SettingThe replacement system will enable significantly greater rate setting management through configuration but not necessarily automation.DHCS sends the changes to policy over in an FI letter and Xerox updates the programs and files as appropriate. None identified at this time.Program Integrity (Performance) ManagementDetermine Adverse Action IncidentNone identified at this time.MITA Maturity Level 3 requires connectivity to State and Federal law enforcement agencies, as well as regional exchange hubs. None identified at this time.Program Integrity (Performance) ManagementIdentify Utilization AnomaliesCA will establish and enable policies and processes to support ICD-10 processing.MITA Maturity Level 3 includes connection to HIE, Health Insurance Exchange (HIX), and standardized data exchanges which do not currently exist. State Medicaid Agency (SMA) completes a review in 60 seconds or less with 99% accuracy is not currently possible.Identifying utilization anomalies across the ICD-10 processing boundary may not be effective. Provider / billing service ICD-10 strategies may mask /exacerbate utilization anomalies.Establish Compliance IncidentNone identified at this time.MITA Maturity Level 3 requires connectivity to State and Federal law enforcement agencies. Provide Notice of Appeal rights within 15 minutes. Requires External sources of information use MITA Framework and industry standards for information exchange. None identified at this time.Manage Compliance Incident InformationCA will establish and enable policies and processes to support ICD-10 processing.All transfer systems support ICD 9 and 10 processing.MITA Maturity Level 3 requires connectivity to State and Federal law enforcement agencies. Requires External sources of information use MITA Framework and industry standards for information exchange.None identified at this time.Program Integrity (Performance) ManagementPrepare Beneficiary Confirmation LettersNone through maturity level 2None identified at this time.None identified at this time.Provider Eligibility and Enrollment ManagementEnroll Medi-Cal ProviderCA-MMIS System Replacement deals with out-of-state provider enrollment only.New provider types may need to be enrolled to support the Essential Health Benefits required for Medicaid Expansion.DHCS will approve providers and enter their information; this will be provided in the daily PMF. DHCS will also be responsible for all provider related policies and rules, and will manage the review and approval of provider enrollment applications for prospective Medi-Cal providers. All prospective providers must be licensed and accredited. DHCS will continue to develop enrollment policies and respond to provider questions related to enrollment issues.Health Enterprise supports provider enrollment with credentialing supported by Digital Harbor.DHCS has a number of state specific business processes related to Enroll Provider. This analysis is based on the MITA 3.0 definition. Baseline business process identifies HIX notification which is outside the scope of CA-MMIS process. The Affordable Care Act (ACA) has recently defined a number of additional requirements for provider enrollment that are not described within these business process steps. The new Provider Application Verification and Enrollment (PAVE) Project will provide provider enrollment functions. CA-MMIS System Replacement will have to ref-actor code to integrate with PAVE rather than the existing Legacy Provider Master Files.Inquire Medi-Cal Provider InformationAutomated Voice Response System (AVRS) telephone will not be supported to inquire on provider eligibility.Only providers enrolled in the Medi-Cal system will have information available.None identified at this time.Provider Eligibility and Enrollment ManagementDetermine Medi-Cal Provider EligibilityDetermine Medi-Cal Provider eligibility is overseen by DHCS Provider Enrollment Division (PED). Health Enterprise supports provider enrollment with credentialing supported by Digital Harbor.Only providers enrolled in the Medi-Cal system will have information available.The new PAVE Project will provide provider enrollment functions including determine provider eligibility. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files. Determine Provider Eligibility for Incentive ProgramDetermine Incentive Program Provider Eligibility is overseen by the DHCS Office of Health Information Technology (OHIT) once provider have completed the federal registration process to access the Medi-Cal State Level Registry. None identified at this time.None identified at this time.Determine CHDP Provider EligibilityDetermine CHDP l Provider eligibility is overseen by DHCS PED. Only providers enrolled in the CHDP system will have information available.None identified at this time.Enroll Drug Medi-Cal ProviderDetermine Drug Medi-Cal Provider eligibility is overseen by DHCS PED. Only providers enrolled in the Medi-Cal system will have information available.The new PAVE Project will provide provider enrollment functions. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files.Provider Eligibility and Enrollment ManagementEnroll Mental Health ProviderDetermine Mental health Provider eligibility is overseen by DHCS PED. Only providers enrolled in the Medi-Cal system will have information available.None identified at this time.Enroll Dental ProviderDetermine Dental Provider eligibility is overseen by DHCS PED. Only providers enrolled in the Medi-Cal system will have information available.None identified at this time.Enroll CCS ProviderDetermine CCS Provider eligibility is overseen by DHCS PED. Only providers enrolled in the Medi-Cal system will have information available.None identified at this time.Enroll CHDP Provider Determine CHDP Provider eligibility is overseen by DHCS PED. Only providers enrolled in the Medi-Cal system will have information available.None identified at this time.Disenroll Medi-Cal ProviderDisenrolling a Medi-Cal Provider is overseen by DHCS PED. None identified at this time.The new PAVE Project will provide provider disenrollment functions. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files.Provider Eligibility and Enrollment ManagementDisenroll Dental ProviderDisenrolling a Dental Provider is overseen by DHCS PED. None identified at this time.The new PAVE Project will provide provider disenrollment functions. CA-MMIS System Replacement will have to refactor code to integrate with PAVE rather than the existing Legacy Provider Master Files.Provider ManagementManage Medi-Cal Provider CommunicationHIX is outside the scope of this project.The baseline business process includes sharing information with the HIX. None identified at this time.Manage Medi-Cal Provider Grievance & AppealNone identified at this time.None identified at this time.None identified at this time.Manage Medi-Cal Provider InformationOnly providers enrolled in the Medi-Cal system will have information available.Base MITA process includes interaction with HIX and Insurance Affordability Program for provider information. None identified at this time.Perform Medi-Cal Provider OutreachNone identified at this time.None identified at this munication needs to be properly planned, developed, targeted and delivered to specific provider groups or audiences.AppendicesCA-MMIS Actors CatalogThe following table describes the actors who interact with CA-MMIS directly or indirectly. The actors are sorted by Actor Name within the table. The Entity Type defined in the table identifies whether the actor belongs to Xerox, DHCS, or is an external entity. It helps to categorize the actors and is used in the Actors Catalog Diagram (See Figure 5). The following table also includes the impacts to each of the actors across the lifecycle of the CA-MMIS System Replacement Project.Table 20: CA-MMIS Actors CatalogActor NameAliasesEntity TypeDescriptionPharmacy Claims and Drug RebatesPharmacy Prior AuthorizationsMedical Prior AuthorizationsMedical ClaimsAdministration DivisionADMDHCSThe Administration Division provides an array of central support services to achieve DHCS program and operations objectives. Staff provides management information and business control functions for the directorate, helping to confirm that the most effective and efficient level of service is achieved. The Administration Division streamlines and simplifies policies and procedures, stressing collaboration and improved communication with program staff; certifies fiscal accountability of programs by overseeing the financial management of DHCS, including budget development and oversight; provides responsive and reliable employee support and human resource management systems; provides guidance and consultation on contract and purchasing services; responsibly manages DHCS physical resources through facilities and telecommunications business services; supports the protection of DHCS employees through the Health and Safety office; and evaluates business processes with attention to improvements in other department-wide support functions.DHCS supports program operations and will be impacted in all releases of the CA-MMIS System Replacement Project. The Administration Division closely monitors the impacts of any changes to policies and procedures for the DHCS Program. Throughout the project, the Administrations Division will manage information, control business functions, and utilize the information to continually look for ways to streamline policy and procedures. The Administration Division is also responsible for overseeing financial management, which includes budgeting and evaluation of business processes for future improvements. With the System Replacement implementation, the changes to policies and procedures can be implemented in a much shorter timeframe. This would allow for better fiscal accountability. Appeals Unit ExaminerAppealsXeroxPart of Claims Adjudication. Reviews and processes appeals submitted by providers. (See Actor: Provider for more details)Processing Pharmacy Appeals, which may be impacted by the implementation of the Pharmacy Claims system. Processing Pharmacy Appeals, which may include review of TARs/SARs and the use of the SmartPA and Medical Prior Authorization systems.Processing of all Appeals will be impacted when is the entire Appeals Business Process is implemented. Appeals staff will need to be trained in all functionality to support the research of the appeals claims.Audits & Investigations DivisionA&IDHCSThe mission of A&I is to protect and enhance the fiscal integrity of the health programs administered by DHCS and confirm a high quality of care is provided to the beneficiaries of these programs. The overall goal of A&I is to improve the efficiency, economy and effectiveness of DHCS and the programs it administers. To carry out its mission, A&I:Performs various financial and medical audits as well as post-service, post payment utilization reviews to assure Medi-Cal program integrity.Assures accountability of state and federal health care funding and identifies funds for recovery, where appropriate.Identifies and investigates Medi-Cal provider and beneficiary fraud, waste and abuse, emphasizing fraud prevention.Performs internal audits of DHCS programs to assure the adequacy and effectiveness of internal controls.Performs special audits as needed by DHCS executive management, programs, the California Health and Human Services Agency and the Governor’s Office.Provides technical assistance and audited data (internally and externally) on various aspects of health care financing and delivery.Provides technical assistance (financial and medical) for the development, modification and expansion of DHCS health programs and related policy.A&I works closely with Xerox to protect the integrity of the health programs. During each release of system changes, they will closely monitor the claims processing system to ensure that Providers are adhering to the billing standards and that the new system has adequate controls in place to prevent Provider and beneficiary fraud. Benefits & Waiver Analysis DivisionBWARDDHCSThe Benefits & Waiver Analysis Division (BWARD) is responsible for managing and ensuring the uniform application of federal and state laws and regulations regarding Medi-Cal benefits and waiver policies that affect more than 150,000 providers of medical services to Medi-Cal beneficiaries. The division is the primary liaison with the federal CMS for waivers and coordinates with other DHCS divisions and state departments to assure compliance with state and federal requirements under those waivers and the State Plan. The division consists of the Medi-Cal Policy branch and the Benefits and Waiver Analysis branch.BWARD will need to be kept informed of the progress of each release to determine the impact of policy changes that are in process. During each release of the System Replacement changes, policies will continue to be updated or new ones will be implemented as required by CMS or other State agencies. BWARD will need to be aware of any impacts to ensure compliance with federal and state laws, and to determine if any changes to their Departments’ internal process will be necessary. California Department of Public HealthCDPHExternalCalifornia Department of Public Health (CDPH) comprises:Center for Chronic Disease Prevention and Health PromotionCenter for Infectious DiseasesCenter for Family HealthCenter for Environmental Health Center for Health Care QualityHealth Information and Strategic PlanningEmergency Preparedness OfficeAdministrationOffice of Public AffairsThe goals of CDPH are to achieve health equities and eliminate health disparities; eliminate preventable disease, disability, injury, and premature death; promote social and physical environments that support good health for all; prepare for, respond to, and recover from emerging public health threats and emergencies; improve the quality of the workforce and workplace; and promote and maintain an efficient and effective organization. CDPH works toward these goals through its programmatic and operational support activities and in collaboration with local health departments and other organizations throughout the State.CDPH works with Health Departments and provides information for administration. During the System Replacement releases, CDPH will keep the Health Departments informed of changes that may directly impact their claims processing. California Medicaid Management Information System DivisionCA-MMIS DivisionDHCSThe CA-MMIS Division is responsible for activities associated with usage of California’s IT system, which process and pays approximately $19 billion a year in Medi-Cal FFS health care claims, as well as claims for other DHCS health care programs. CA-MMIS processes payments to providers for medical care provided to 7.7 million Medi-Cal beneficiaries in the state. The FI operates and maintains the system. This division is responsible for the administration, management, oversight, and monitoring of the FI contract and services provided under the contract. FI services include the operation of a telephone service center and provider relations functions (publications, outreach and training); system operations, updates and enhancements; processing eligibility inquiry transactions, TARs and service authority requests; and processing more than four million claims per week. Under the CA-MMIS Division’s direction and leadership, the FI is also responsible for planning, developing, designing, testing and implementing a new MMIS that represents current technology and support SOA, consistent with MITA.DHCS Division responsible for oversight of CA-MMIS and contractor activities. The CAMMIS Division will be involved in each release of the System Replacement Project. They will be reviewing and approving all requirements that need to migrate to the new system, as well any new requirements. The CAMMIS-Division will work closely with Xerox during the testing phases , as well as all transition phases from the old to the new systems to ensure that each release is a smooth transition.Capitation Rates Development DivisionCRDDDHCSCapitation Rates Development Division is responsible for the accuracy and integrity of data used to calculate and implement capitation rates in compliance with contractual and regulatory requirements. The Actuary Unit calculates and sets the capitation rates for managed care organizations and performs calculations of budget estimates. The actuaries certify that capitation rates for managed care health plans are determined in compliance with federal requirements. The Financial Management Unit performs research functions and rate calculations on Medi-Cal eligibility data, calculates FFS and managed care data costs for Medi-Cal programs and interprets and analyzes legislative impacts on Medi-Cal managed care programs costs. The Financial Analysis Unit (FAU) assures correct application and payment of capitation rates with regard to contractual agreements and departmental policy. The FAU also acts as the liaison between DHCS’ Fiscal Forecasting Division, the federal CMS, Department of Finance (DOF) and the Legislative Analyst's Office. FAU coordinates the preparation of budget neutrality and quarterly monitoring analyses for managed care programs for federal waivers. The Financial Review Unit assures the timely reporting of financial and accounting data by managed care organizations and provides financial analysis to stakeholders.DHCS Division works closely with CRDD for financial management, rate calculations on Medi-Cal eligibility data, and fiscal forecasting. During each release of the System Replacement Project, the CRDD will be kept informed of any impact to policy implementations, and changes to reporting capabilities which may be used by the CRDD. Cash Control AnalystCash ControlXeroxPart of Research and Correspondence. Manages the processes of check writing, accounts receivable, electronic functions transactions, warrants, 1099's, and overpayments.Xerox Cash Control unit works with claims payment and needs to be aware of changes which may impact the financial system. During Pharmacy Claims implementation, the Cash Control unit will closely review the impact to pharmacy claims payments and adjustments . N/AN/AXerox Cash Control unit works with claims payment and needs to be aware of changes which may impact the financial system. During the implementation of Medical Claims, the Cash Control unit will closely review the impact to all claims payments and adjustments . Centers for Medicare & Medicaid ServicesCMSExternalCMS is a branch of the U.S. HHS. CMS is the federal agency which administers Medicare, Medicaid, and the Children's Health Insurance Program. Provides information for health professionals, regional governments, and consumers.CMS administers programs and provides information which may impact billing of Medi-Cal. During all releases of System Replacement, CMS will be kept informed so that information can be collected and provided to CMS for MMIS certification.Child Health and Disability Prevention Program ProviderCHDP ProviderExternalA subset of the Provider actor group. Provides medical services to members under the CHDP programN/A N/AN/ACHDP Program submits claims to Medi-Cal and works with Medi-Cal Providers. During Release 1, the counties will be kept informed of changes to the CHDP claims processing so that they can provide awareness to their Provider communities. CHDP currently uses non-compliant forms and decisions to go with the standard forms may impact CHDP.Children’s Medical Services CMS-DHCSDHCSThe Children's Medical Services Branch of DHCS (CMS-DHCS) provides an extensive system of health care for children through preventive screening, diagnostic, treatment, rehabilitation, and follow-up services. CMS-DHCS carries out this mission through a variety of programs meeting specific health care needs of targeted population.CMS-DHCS Program submits claims to Medi-Cal and works with Medi-Cal Providers. CMS providers submit claims for services rendered to children under this program. The CMS Branch will need to be kept informed of each release of the System Replacement changes. This will allow CMS-DHCS to communicate to their provider community any impact to claims submission so that payment for services is not interrupted.Claims AdjudicationClaims AdjudicationXeroxPart of Claims Operations. Claims Adjudication verifies and validates claim information to determine if the claim should be paid, denied, or suspended for manual review. Claim Adjudication is made up of the following two areas: Claims Suspense, and Appeals.Xerox Claims Adjudication will process claims that are impacted with the changes. The Claims Adjudication area will work closely with the System Replacement Implementation Team to ensure that all staff are trained in each release. All Claims Adjudication staff will need to become familiar with PBM-OS+ and Health Enterprise system screens and navigation to appropriately adjudicate claims. The staff will also need to understand the changes when Treatment Authorization / Service Authorizations are implemented and how to use the data as needed in claims adjudication.Claims OperationsClaims OpsXeroxThe primary purpose of the Claims Operations is to receive and adjudicate claims. The Claims Operations Department is organized into three major business areas: Front End, Claims Adjudication, and Medical Professional Service Group.Xerox Claims Operations will process claims that are impacted with the changes. The Operations areas will be kept informed of the release implementations; however the impact of the system changes will be to the Claims Adjudication areas and the Medical Professionals who adjudicate the claims. These groups will be trained on all aspects of PBM-OS+ and Health Enterprise system screens and navigation to appropriately adjudicate claims. The staff will also need to understand the changes in Treatment Authorizations / Service Authorizations and how to use the data as needed in claims adjudication.Claims Suspense ExaminerSuspenseXeroxPart of Claims Adjudication. Reviews claims that fail an edit or audit. Makes the determination of the appropriate action to take on the claims.Xerox Claims Operations will process claims that are impacted with the changes. The Claims Adjudication area will work closely with the System Replacement Implementation Team to ensure that all staff are trained in each release. All Claims Adjudication staff will need to become familiar with PBM-OS+ and Health Enterprise system screens and navigation to appropriately adjudicate claims. The staff will also need to understand the changes in Treatment Authorization / Service Authorizations and how to use the data as needed in claims adjudication.Clinical Assurance and Administrative Support DivisionCAASDDHCSCAASD is comprised of five branches, two pharmacy sections and an appeals and litigation section. CAASD provides strong, cost-effective utilization controls by reviewing and adjudicating TARs for certain medical procedures, services and drugs for FFS Medi-Cal beneficiaries prior to payment for services. In 2011, CAASD processed more than 3.2 million TARs. CAASD also responds to TAR appeals submitted by providers and offers program support to the Office of Legal Services for litigation resulting from denied TAR appeals. In addition, CAASD is responsible for the Designated Public Hospital Project (DPHP), which allows public hospitals in California to use an evidence-based standardized tool to determine medical necessity for hospital days and services for Medi-Cal beneficiaries in lieu of submitting a TAR to the field office.Prior to January 1, 2014, this Division was known as the Utilization Management Division (UMD).DHCS – CAASD is responsible for pharmacy sections and appeals and litigations related to TARS and needs to be informed of changes to CA-MMIS. CAASD will be kept informed of all releases of the System Replacement implementation to monitor any impact to the processing of claims that required TARs. During Treatment Authorization / Service Authorizations, CAASD will be closely involved in the system changes that will impact the TAR approval process and the Medical Prior Authorization processing. They will be trained on these releases which may impact the Appeals/litigation of TARs process. Cost Containment Unit AnalystCost ContainmentXeroxPart of Provider Integrity Unit. Analyzes and proposes cost containment ideas to DHCS to save Medi-Cal program dollars.Xerox Cost Containment Unit will analyze claims that may be impacted with the changes. The Xerox Cost Containment Unit will closely monitor all releases for any impact to the Provider Community, claims processing, and reporting process. County OfficeCountyExternalPerforms member enrollment, determines member eligibility, and manages member information.Counties work with DHCS for member enrollment and should be kept informed of changes. The releases should not directly impact the County eligibility offices.N/AN/ACounties work with DHCS for member enrollment and should be kept informed of changes. The releases should not directly impact the County eligibility offices .Department of AgingCDAExternalThe California Department of Aging (CDA) administers programs that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the State. The Department administers funds allocated under the federal Older Americans Act , the Older Californians Act, and through the Medi-Cal program.The Department contracts with the network of Area Agencies on Aging, who directly manage a wide array of federal and state-funded services that help older adults find employment; support older and disabled individuals to live as independently as possible in the community; promote healthy aging and community involvement; and assist family members in their vital care giving role. CDA also contracts directly with agencies that operate the Multipurpose Senior Services Program through the Medi-Cal home and community-based waiver for the elderly, and certifies Adult Day Health Care centers for the Medi-Cal program.CDA works with long-term care facilities under the federal Older Americans Act through the Medi-Cal program and processing changes may impact the services provided. Throughout the releases of the System Replacement Project, the CDA will be kept informed of any changes that may impact the ability of their clients to submit claims or TARs for payment . Department of Health Care ServicesDHCSDHCSThe single state agency responsible for administration of Medi-Cal. DHCS acts for the State of California as the contract entity.DHCS is responsible for the administration of Medi-Cal and will be approving the implementation of each release of the System Replacement Project. DHCS will be involved in gathering requirements and making policy decisions for all releases to help increase business maturity of the business processes.Department of JusticeDOJExternalWorks closely with DHCS in monitoring illegal activity.DOJ works with DHCS and needs to be aware of changes to CA-MMIS for monitoring purposes, as well as changes to reporting that may be used by the DOJ. Department of Mental HealthDMHExternalThe Department of Mental Health (DMH) operates five state hospitals throughout California including: Atascadero State Hospital (San Luis Obispo County), Coalinga State Hospital (Fresno County), Metropolitan State Hospital (Los Angeles County), Napa State Hospital (Napa County), and Patton State Hospital (San Bernardino County). Each state hospital provides inpatient treatment services for Californians with serious mental illnesses. Additionally, DHM operates two correctional programs, Salinas Valley Psychiatric Program and Vacaville Psychiatric Program. As of July 1, 2012, DMH became the new Department of State Hospitals (DSH). As part of the Governor’s goal to give more local control to community mental health functions, many programs formerly under the purview of DMH are transitioned to other state departments and the counties.DMH should be kept informed of changes to CA-MMIS for billing purposes. They will be kept informed during each release to monitor claims processing, as well as the approval of mental health treatment authorizations.Department of Social ServicesCDSSExternalThe California Department of Social Services is comprised of more than 54 offices throughout the State and is the state agency responsible for:Ensuring efficient, accurate, and equitable delivery of payments and benefitsProviding services that foster self-sufficiency and dignityProviding social services to the elderly, blind, disabled and other children and adultsLicensing and regulating foster homes, group homes, residential care facilities, day care facilities, and preschoolsEvaluating eligibility of applicants for federal and State programsCDSS will be kept informed of each release and the changes in the Medi-Cal processing systems that may impact the community they serve. Department of State HospitalsDSHExternalOn December 7, 2011, DMH announced the blueprint to establish the new DSH and reforms to the DMH structure designed to improve the mental hospital system in California.As of July 1, 2012, DMH became the new DSH. DSH focuses on the care of patients in its seven forensic state hospitals: DSH-Atascadero, DSH-Coalinga, DSH-Metropolitan Los Angeles, DSH-Napa, DSH-Patton, DSH-Salinas Valley, and DSH-Vacaville.DSH will be kept informed of changes to CA-MMIS for billing purposes. DSH may be impacted by claims processing changes, as well as the changes to the Treatment Authorization system.Drug Manufacturer / LabelerLabelerExternalContracted with CMS and DHCS on drug rebate. Receives drug rebate invoices and submits rebates to DHCS.Drug Manufacturer/Labeler may be impacted with changes to Drug Rebate.N/AN/AN/ADrug Rebate UnitDRUXeroxPart of Medical Professional Service Group. Responsible for invoicing drug manufacturers for drugs that were dispensed to Medi-Cal members. Manages Drug rebates.Xerox DRU unit may be impacted by changes to forms processing that providers submit. They may also be impacted by the implementation of DRAMS. They will closely monitor the data that is captured to process Drug Rebates.N/AN/AXerox DRU unit may be impacted by changes to forms processing that providers submit.Drug Use ReviewDURXeroxXerox Medical Professional Service Group works to improve the quality and cost effectiveness of drug use by ensuring that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical results.Xerox DUR unit may be impacted by changes to forms, which include TAR processing that providers submit. The DUR review is done based on the data captured at processing and in reporting.Encounter Data UnitEDUXeroxProcesses and analyzes encounter data records.Xerox EDU unit may be impacted in data collection by the changes to forms that Providers will use and any release that directly impacts the data storage for these encounter data records. N/AN/AXerox EDU unit may be impacted in data collection by the changes to forms that Providers will use and any release that directly impacts the data storage for these encounter data records.Fee-For-Service Rates Development DivisionFFSRDDDHCSFFSRRD is responsible for developing Medi-Cal reimbursement rates for non-institutional and long-term care services, performing analysis for General Fund cost savings/avoidance proposals and rate methodologies and assisting the Office of Legal Services in defending DHCS in legal actions. FFSRDD serves as a point of contact on matters pertaining to Medi-Cal non-institutional and long-term care rate setting matters in negotiation and/or meetings with health care provider representatives, patient advocates, external state agencies, representatives of county, state and federal governments, industry representatives, special interests groups, the media and other high-level officials regarding Medi-Cal rate policies and issues. FFSRDD also crafts legislation and submits State Plan Amendments regarding changes to provider reimbursements. In addition, FFSRDD administers a quality assurance fee (QAF) program that collects more than $500 million annually.DHCS FFSRDD area needs to be kept informed of changes to CA-MMIS in order to monitor the impact on claims and Treatment Authorization processing as the changes are implemented and to provide data for future analysis of cost savings/avoidance proposals and rate methodologies. FFSRDD meets with health care Providers’ representatives and patient advocates and will need to understand the many changes to CA-MMIS. File MaintenanceSystems Group (SG)XeroxThe File Maintenance Team is responsible for maintaining, updating, and cross verifying all CA-MMIS files and tables, including the MMIS Tables Files, Procedure Code Master File (RF-F-070), Diagnosis Master File (RF-F-001), and Formulary File.File maintenance will need to understand the PBM OS+ processing of claims for any testing that is required to implement OILs and edit criteria updates related to claims processing.N/AN/AFile maintenance will need to understand the HE system claims processing for any testing that is required to implement OILs and edit criteria updates related to claims processing.Financial Management BranchFMBDHCSPerforms the accounting function within DHCS.FMB should be informed of any changes to the CA-MMIS system that may impact financials, which will include claims processing and reportingN/AN/AFMB should be informed of any changes to the CA-MMIS system that may impact financials, which will include claims processing and reportingFirst Data BankFDBExternalProvides updates to formulary fileFirst Data Bank may be impacted by the PBM OS+ and DRAMS changes. Xerox will need to keep them informed of any impact to weekly files they submit.N/AN/AN/AFiscal Forecasting BranchFFBDHCSFFB looks at current revenue trends and expenditures, assesses external factors impacting the program, models different budget scenarios and produces the budget estimates for the Medi-Cal and CCS/GHPP/CHDP Local Assistance program. N/AN/AN/AN/AFiscal IntermediaryFIXeroxThe contractor who performs Medi-Cal and other health program claims processing and management reporting functions for DHCS. In California, Xerox is the DHCS FI for CA-MMIS.Xerox will be involved in all releases of the System Replacement Project and will work closely with DHCS to ensure that all claims processing for Medi-Cal programs continue to run smoothly and that the changes are transparent to the Provider community.Franchise Tax BoardFTBExternalFTB is responsible for administering two of California’s major tax programs: Personal Income Tax and the Corporation Tax. FTB also has responsibility for administering other nontax programs and delinquent debt collection functions.N/AN/AN/AN/AFront EndFront EndXeroxPart of Claims Operations. Front End is responsible for the receipt and control of hard copy claims. Front End is made up of the following areas: Mailroom, Input Prep, Scanning, and Key Data Entry (KDE).Xerox Frontend Claims Operations will process Pharmacy claims that are impacted by the changes. There will be no direct impact to this area, but they will be knowledgeable in the changes.Xerox Frontend Claims Operations may process TARs that are impacted with changes. There should be no direct impact to the front-end process, but the Department will be made aware of the changes to TAR processing.Xerox Frontend Claims Operations will process claims that are impacted with the System Replacement changes. There will be no direct impact to this area, but they will have knowledge of the rmation Technology Services Division ITSDDHCSITSD provides a secure, reliable IT environment to support the program and administrative objectives of DHCS, Health and Human Services Agency, CDPH, Office of Health Information Integrity and Health Benefit Exchange Board. ITSD establishes IT policy and standards and assures compliance with state and federal laws and regulations regarding the use of IT and the safeguarding of electronic information; supports a complex portfolio of program applications, the largest of which is the MEDS; provides quality application and data services to DHCS programs; facilitates the successful completion of IT projects undertaken by DHCS; and manages the design, installation, upgrade and support of a complex technology infrastructure, including network, servers, desktops, network devices, messaging systems, Web sites, Web applications and databases.DHCS – ITSD furnishes the MEDS eligibility files daily and will need to be informed of program changes and any possible changes to the daily files that are received.ITSD must also be informed of any changes to interfaces that originate/terminate at their end to ensure no impact to the eligibility files that are received daily.ITSD will also help in the development, testing, and deployment of the Member Eligibility Web Service.Input PrepInput PrepXeroxPart of Front End. Prepares hard copy claims, attachments for scanning, completes visual audits.Xerox Input Preparation is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the input prep process, but the Department will be made aware of the changes to the claims processing systems.Internal Revenue ServicesIRSExternalIRS is the United States government agency responsible for tax collection and tax law enforcement.N/AN/AN/AN/AKey Data Entry OperatorKDEXeroxPart of Front End. Manually keys hard copy claim information not recognized by the scanning process Optical Character Recognition (OCR).Xerox Key Data Entry is a part of Claims Operations and may process claims that are impacted by the changes. Key Data may be impacted in the entry of paper claims, and will work closely with the System Replacement teams from all releases to ensure that they are aware of the changes.Legislative & Governmental Affairs DivisionLGADHCSLegislative & Governmental Affairs Division facilitates, coordinates and advocates for the development and enactment of legislation in the interest of public health and health care. As a key player in carrying out DHCS’ mission to protect and advance the health of Californians, LGA assists in the development and refinement of the state's health care laws.DHCS LGA Division should be informed of changes that may impact claims processing for health care. There should be no direct impact to this area, but this Division needs to be informed of the changes to CA-MMIS.Local Educational AgencyLEAExternalLocal Educational Agency delivers services to students receiving special education services and who are on Medi-Cal.LEA should be informed of changes that may impact claims processing for health care. LEA claims are submitted for processing and they will need to understand if there is any specific impact to their programs.Long Term Care DivisionLTCDDHCSLong Term Care Division is an integral component of California’s Olmstead Plan by ensuring the provision of long-term services and supports to Medi-Cal-eligible frail seniors and persons with disabilities to allow them to live in their own homes or community-based settings instead of in facilities. LTCD directly operates and/or administers five home- and community-based services (HCBS) waivers on behalf of DHCS, as the single state Medicaid agency. LTCD also provides monitoring and oversight for four HCBS waivers and the In-Home Supportive Services state plan benefit operated by the Department of Social Services, Department of Aging and Department of Developmental Services. In addition, LTCD operates two managed care programs, Program of All-inclusive Care for the Elderly and Senior Care Action Network, and the California Partnership for Long-Term Care, a long-term care insurance program. In addition, LTCD administers a federal Money Follows the Person grant to transition Medi-Cal-eligible residents from long-term care facilities back to community living arrangements. LTCD works collaboratively with the Medi-Cal Managed Care Division to integrate long-term services and supports for seniors and persons with disabilities and Medicare/Medi-Cal dual eligible beneficiaries in a managed care delivery system.DHCS LTCD Division should be informed of changes that may impact claims processing for health care throughout the releases.DHCS LTCD Division should be informed of changes that may impact TAR processing for health care.DHCS LTCD Division should be informed of changes that may impact claims processing for health care throughout the releases.Low Income Health Program DivisionLIHP DivisionDHCSIn November 2010, California received approval from the federal CMS to implement a new section 1115 “Bridge to Reform” Medicaid demonstration. The demonstration includes several programs that prepare the state for implementation of the Patient Protection and ACA. LIHP is responsible for administering and managing approximately $3 billion in federal funding to implement the LIHP, which is a significant component of the demonstration. The program extends and expands the Health Care Coverage Initiative program to a statewide local program targeting the Medicaid expansion population and the low-income adult population eligible for participation in the Health Benefit Exchange. The division responsibilities include: developing policies and procedures related to the LIHP, reviewing and approving claiming invoices for federal reimbursement to local LIHPs and providing technical assistance. The division also monitors program compliance with contracts, Special Terms and Conditions, and federal requirements; compiles program data for federal and state reporting requirements; and develops contracts and amendments. In addition, the Division collaborates with program stakeholders and other divisions in planning program transition.DHCS LIHP Division will be informed of changes that may impact claims processing for health care during the System Replacement releases.DHCS LIHP Division should be informed of changes that may impact TAR processing for health care.DHCS LIHP Division will be informed of changes that may impact claims processing for health care during the System Replacement releases.MailroomMailroomXeroxPart of Front End. Receives and sorts incoming hard copy claims and form into trays.Xerox Mailroom is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the Mailroom process, but the Department will be made aware of the changes to the claims processing systems.Managed Care OrganizationMCOExternalManages commercial Medicaid programs. Submits encounters to report services provided to members.Managed Care Organization’s may be impacted in data collection by the changes to forms that Providers will use. Communication on scheduled releases will be provided.N/AN/AManaged Care Organization’s may be impacted in data collection by the changes to forms that Providers will use. Medical Claims may impact the Managed Care Organizations who submit encounter data for medical and outpatient claims. Communication on scheduled releases will be provided.MaximusMCP EligibilityExternalPerforms enrolling and dis-enrolling members to MCPs.N/AN/AN/AN/AMedical Case AgentCMIS-MCMDHCSCreates and works cases - Medical Case Management (Systems of Care Division).DHCS CMIS-MCM will be informed of changes that may impact Medical Case Management in all releases of the System Replacement Project. Medi-Cal ConsultantMCDHCSAuthorizes Medi-Cal TARs.N/ADHCS Medi-Cal Consultant should be informed of changes that may impact TAR authorization. Changes in Treatment Authorization / Service Authorizations may impact the review process that is currently used by Medi-Cal Consultants N/AMedi-Cal Dental Services DivisionMDSDDHCSMedi-Cal Dental Services Division is responsible for the provision of dental services to Medi-Cal beneficiaries. Services are provided under FFS and managed care models. The division contracts with a dental FI for FFS and 13 MCPs and prepaid health plans (PHPs) to provide dental care to approximately 7.5 million-plus Medi-Cal beneficiaries. The FFS program is state wide; while the Dental Managed Care Plan (DMC) and PHP are located in Sacramento and Los Angeles counties.DHCS MDSD; Division should be informed of changes that may impact claims processing and reporting. N/AN/ADHCS MDSD; Division should be informed of changes that may impact claims processing and reporting.Medi-Cal Eligibility DivisionMCEDDHCSMedi-Cal Eligibility Division develops statewide policies, procedures and regulations governing Medi-Cal eligibility and assures eligibility is determined accurately and timely in accordance with state and federal requirements. MCED performs Medi-Cal quality control reviews of county compliance with state and federal eligibility requirements for program integrity and works with the county welfare department consortiums and ITSD to develop the business rules necessary to implement eligibility policy and to maintain the records of beneficiaries in both the county eligibility systems and DHCS’ MEDS. MCED provides county public social service agencies policy direction via County Welfare Directors Letters and Medi-Cal Eligibility Information Letters that implement Medi-Cal eligibility policies and procedures. MCED consists of three branches: Policy Development, Policy Operations and Program Review.DHCS – MCED assures that eligibility is determined based on program requirements and should be informed of CA-MMIS changes that may impact any necessary Medi-Cal eligibility policy and procedures implementations during the releases. Medi-Cal Managed Care DivisionMMCDDHCSMedi-Cal Managed Care Division contracts with managed care organizations to arrange for the provision of health care services for approximately 4.4 million Medi-Cal beneficiaries in 30 counties. MMCD has three primary models: Two-Plan, which operates in 14 counties; County Organized Health Systems (COHS), which operate in 14 counties; and Geographic Managed Care, which operates in two counties. MMCD also contracts with a PHP in one additional county and with two specialty plans. In total, Medi-Cal managed care paid health plans approximately $10.6 billion for rate year 2010-11. MMCD has three branches: Plan Monitoring/Program Integrity, Policy and Financial Management and Plan Management.DHCS – MMCD may be impacted in data collection by the changes to forms that Providers will use, and releases that may change the data collection process.N/AN/ADHCS – MMCD may be impacted in data collection by the changes to forms that Providers will use and releases that may change the data collection process.Medical Professional Service GroupMPSGXeroxPart of Claims Operations. The Medical Professional Service Group is responsible for reviewing claims for medical judgment. The group is made up of various professionals including doctors, nurses, and pharmacists. Works closely with DHCS on policy considerations and/or issues. The Medical Professional Service Group consists of two areas: DUR, DRU.Xerox MPSG is part of Claims Medical Professional Service Group and will process claims that are impacted with changes. This team will need to be familiar with how PBM OS+ adjudication works Xerox MPSG is part of Claims Medical Professional Service Group and may review Treatment Authorization/Service Authorizations that are impacted with changes. The changes for TARS/SARS may impact the way that the approved authorizations can be viewed by Consultants when working a claim. The consultants need to be trained in all aspects of these changes.Xerox MPSG is part of Claims Medical Professional Service Group and may process claims that are impacted with changes. This team will need to be familiar with how HE adjudication works in order to review the claims.Medical Review BranchMRBDHCSMedical Review performs medical and financial audits and federally mandated post service, post payment utilization reviews of non-institutional Medi-Cal providers, including laboratories and pharmacies. DHCS MRB supports the medical and financial audits for DHCS which may be impacted due to changes in claims processing. The MRB needs to understand how the PBM OS+ system manages claims processing.N/AN/ADHCS MRB supports the medical and financial audits for DHCS which may be impacted due to changes in processing. The MRB needs to understand how the HE system manages claims processing.MedicareMedicareExternalSubmits crossover claims to Medi-Cal. Medicare supports the submission of crossover claims to Medi-Cal which may be impacted due to changes in processing claims. Medicare will be kept informed of the different releases.N/AN/AMedicare supports the submission of crossover claims to Medi-Cal which may be impacted due to changes in processing of claims. Medicare will be kept informed of the different releases.MemberMemberExternalBeneficiary of the Medi-Cal and associated programs. Individual or family who has met the eligibility requirements to be enrolled in the Medi-Cal program.N/AN/AN/AN/AOffice of Civil RightsOCRDHCSOffice of Civil Rights is responsible for overseeing compliance with various federal and state civil rights laws and implementing regulations and executive orders pertaining to employment and services by DHCS and its contractors to assure nondiscrimination in the access and delivery of health care services provided or administered by DHCS. OCR provides departmental guidance, coordination, monitoring, training and investigation of issues relating to DHCS employees through the Internal Equal Employment Opportunity Program (Title VII), External Civil Rights Compliance Program (Title VI) and Reasonable Accommodation Program. Also, OCR coordinates and develops technical, prevention and sensitivity awareness training that deals with Equal Employment Opportunity and disability issues and resolves complaints of discrimination via counseling, informal reviews, investigations and mediations filed by DHCS applicants and employees.N/AN/AN/AN/AOffice of Family Planning OFPDHCSThe Office of Family Planning administers the FPACT program. Effective July 1, 2012, the Office of Family Planning/Family PACT program transitioned from the CDPH to DHCS.DHCS – OFP may be impacted by the changes to forms that Providers will use and any changes to Family Planning specific reports that may be used by their program.Office of Health Information TechnologyOHITDHCSOHIT is responsible for implementing the Medi-Cal Electronic Health Record Incentive Program. This incentive program shall improve the quality, safety and efficiency of health care by Medi-Cal hospitals and professionals through incentive payments to encourage the meaningful use of electronic health records. OHIT administers a new program that began making incentive payments in 2011 to qualified Medi-Cal health care providers who adopt and use electronic health records in accordance with the American Recovery and Reinvestment Act of 2009. OHIT sets the policies and procedures for the program, in addition to implementing systems to disburse, track and report the incentive payments. It also develops goals and metrics for the program, including the impact of the program on quality, cost and service.DHCS – OHIT incentive program by be impacted due to the changes in claims processing under Pharmacy claims. OHIT will be kept informed of the releases to determine any impact to Medi-Cal Health care providers.N/AN/ADHCS – OHIT incentive program by be impacted due to the changes in claims processing for all other claim types. The OHIT will be kept informed of the releases to determine any impact to Medi-Cal Health care providers.Office of HIPAA ComplianceOHCDHCSOffice of HIPAA Compliance (OHC) is responsible for leadership and oversight related to the implementation and maintenance efforts of a range of federally required initiatives to simplify and standardize the administration of health care while protecting the privacy of patients served by DHCS programs. Federal HIPAA legislation passed in 1996 established national standards for electronic health care transactions and national identifiers for providers, health plans and employers. It also addressed the security and privacy of health data and was adopted to improve the efficiency and effectiveness of the nation’s health care system by encouraging the widespread use of EDI. HIPAA requirements continue to be updated, most recently through administrative simplification provisions included in the ACA. OHC also serves as the DHCS lead for measuring and monitoring progress against the MITA framework, a federal initiative that holds states accountable for federally funded health IT expenditures. An annual operating budget of approximately $50 million is used to fund administrative simplification projects throughout DHCS, primarily for systems maintained by the Medi-Cal program’s FI.DHCS – OHC is responsible for oversight related to implementation and alignment to MITA and needs to be kept informed.Office of Legal ServicesOLSDHCSOffice of Legal Services provides legal services to DHCS and its employees and legal support to departmental programs. OLS's 50 attorneys and nine paralegals are distributed among five large legal teams, each of which focuses on a particular area of departmental legal work:The Administrative Litigation Unit represents DHCS in administrative hearings before the Office of Administrative Hearings and Appeals, the State Personnel Board and other state entities, and handles the bulk of DHCS’ legal personnel functions.The Medi-Cal House Counsel Team serves as DHCS’ primary provider of legal support for programmatic functions, including the drafting and reviewing of much of DHCS’ proposed legislation.The Medi-Cal Litigation Team provides programmatic legal support, but also serves as DHCS’ liaison to the California Attorney General's Office and other external entities about litigation involving DHCS, and this team provides litigation support for active cases.The Special Projects Team handles legal assignments that emanate primarily from the directorate, such as implementation projects related to the ACA.The newly created Medi-Cal Financing and Rates Team specialize in its namesake subject matter.OLS also contains two sub-specialty programs: the Privacy Office, staffed by attorneys dedicated to privacy legal compliance; and the Office of Regulations, which is responsible for ensuring the consistency and accuracy of regulations that DHCS promulgates.DHCS – OLS is responsible for Medi-Cal House Counsel Team and supports the Medi-Cal Litigation Team, which needs to be kept informed of changes to claims processing and reporting.DHCS – OLS is responsible for Medi-Cal House Counsel Team and supports the Medi-Cal Litigation Team, which needs to be kept informed of changes to TARs processing.DHCS – OLS is responsible for Medi-Cal House Counsel Team and supports the Medi-Cal Litigation Team, which needs to be kept informed of changes to claims processing and reporting.Office of Medi-Cal ProcurementOMCPDHCSOffice of Medi-Cal Procurement is an internal consulting and advisory group within DHCS. OMCP’s function is to conduct major procurements and write contracts in support of the various divisions and offices of the Medi-Cal program. These procurements may take the form of Requests for Proposal (RFP) and Requests for Application (RFA), depending upon the services being sought. OMCP is responsible for the entire process from the development of the procurement documents to the evaluation of proposals received in response to those documents through to the development and approval (from the Department of General Services and CMS) of the contract documents. Medi-Cal procurement and contracting procedures are conducted with the highest integrity, with the goal of producing procurement documents and contracts that are effective and cost-efficient for the Medi-Cal program.DHCS – OMCP is responsible for Medi-Cal Procurements and responsible for producing procurement documents and needs to be aware of changes to CA-MMIS claims processing that may impact future procurement efforts.DHCS – OMCP is responsible for Medi-Cal Procurements and responsible for producing procurement documents and needs to be aware of changes to CA-MMIS and the TAR process. DHCS – OMCP is responsible for Medi-Cal Procurements and responsible for producing procurement documents and needs to be aware of changes to CA-MMIS claims processing that may impact future procurement efforts.Office of Multicultural HealthOMHDHCSOffice of Multicultural Health serves as the internal focal point for improved planning and coordination of activities and programs that serve California’s racial and ethnic populations. OMH’s mission is to increase the capacity of DHCS and the CDPH, health care providers and ethnic/racial communities to achieve equity, reduce health disparities and improve access to quality care among racial/ethnic, Lesbian, Gay, Bisexual and Transgender (LGBT) and other underserved populations in California. OMH carries out its mission through the following primary functions:Informing and advocating for policies and practices to increase the effectiveness of programs and services toward reducing health disparities and inequities among diverse racial/ethnic, LGBT and underserved rming and advancing national, state and local discussions on multicultural and LGBT health, cultural and linguistic competence, workforce diversity, health equity and the reduction of disparities in health and health care.Advocating for and using federal, state and community level data to address the issues of health and health care disparities among racial/ethnic, LGBT and underserved populations to monitor and evaluate health outcomes among these population groups.Creating and strengthening information networks among DHCS and CDPH programs and ethnic/racial, LGBT and underserved communities for the inclusion of community participation in decision-making related to health issues.Building internal and external capacity to achieve equity and reduce health disparities through training, technical assistance, consultation and strategic planning.Supporting the development and dissemination of information, strategies and resources contributing to the improved health status of racial/ethnic, LGBT and underserved communities.N/AN/AN/AN/AOffice of Public AffairsOPADHCSOffice of Public Affairs is responsible for overall communications and outreach activities associated with DHCS and serves as the central conduit of information for the department. Staff responds to inquiries, drafts and finalizes approved responses and delivers responses to various stakeholders, the public and media. Staff also assess the impact of actions or situations involving the department and provide guidance on the appropriate message and method of response. OPA crafts statements and press releases, conducts interviews and background briefings and stages press conferences. Staff works to engage the general public and media with compelling, informative features on the home page of the DHCS website and communicates with internal staff primarily through the DHCS Times department newsletter. OPA also assists with DHCS’ public education and outreach programs, such as the California Partnership for Long-Term Care.DHCS – OPA is responsible for oversight related to communication and outreach activities and needs to be kept informed. OPA will need to understand the specific releases and the changes being made in case they receive inquires or need to publish information related to the system changes.Office of Selective Provider Contracting ProgramSPCPDHCSThrough the Office of Selective Provider Contracting Program, DHCS contracts on a competitive basis with those hospitals that desire to provide inpatient services to Medi-Cal beneficiaries at a negotiated per diem rate for hospital inpatient services.DHCS – SPCP is responsible for contracts related to hospital and needs to be kept informed of changes to CA-MMIS. These contracted hospitals will need to be kept informed of changes to claims processing which may impact them. Office of Women’s HealthOWHDHCSOffice of Women’s Health was created in 1993 by Governor's Executive Order W-57-93 and in 1994 was permanently established in statute. In 1997, the Gynecological Cancer Information Program was statutorily created within OWH. OWH is a shared policy and program within DHCS and CDPH that guides women’s public health services in a positive way to promote health and well-being and reduce the burden of preventable disease and injury among women and girls in California. OWH serves as a focal point for DHCS and CDPH policies and programs for setting and monitoring women’s health policies that promote more expansive and effective approaches to improve women’s overall health, including quality assessment, monitoring and improvement, coordination of existing programs and resources, enhancing the visibility and prominence of women’s health problems and developing cost-effective innovative approaches to addressing those problems. OWH has five major functions: women’s health policy, women’s health research, program administration of the Gynecological Cancer Information Program, health education and health literacy and outreach. OWH staffs the Women’s Health Council, which advises both directors and programs within DHCS and CDPH on a wide range of issues. OWH chairs the interagency California Women’s Health Survey and its interagency workgroup that researches women’s health and publishes annual reports and research findings.DHCS – OWH is responsible for Women Public Health services and needs to be kept informed of changes to CA-MMIS. OWH will need to be informed of changes related to Pharmacy claims processing.N/AN/ADHCS – OWH is responsible for Women Public Health services and needs to be kept informed of changes to CA-MMIS. OWH will need to be informed of changes related to System Replacement changes in claims processing.Operations Training DepartmentOTDXeroxResponsible for the development and delivery of Operations trainingXerox OTD is responsible for the delivery of Operations training and will train on the CA-MMIS changes. OTD personnel will need to train in PBM OS+ for Pharmacy claims processing. Xerox OTD is responsible for the delivery of Operations training and will train on the TAR submission changes. OTD personnel will need to train in SmartPA and the Medical Prior Authorization systems to support the future training efforts.Xerox OTD is responsible for the delivery of Operations training and will train on the CA-MMIS changes. OTD personnel will need to train in HE for processing of all claim types.Pharmacy ConsultantPCDHCS Authorizes Pharmacy TARs.DHCS – Pharmacy Consultant is responsible for authorizing Pharmacy TARS and needs to be kept informed of changes to CA-MMIS. They will need to train in the Smart PA and Medical Authorization systems.Pharmacy ProviderPharmacy ProviderExternalA subset of the Provider actor group. Dispenses drugs to members and submits pharmacy claims.Pharmacy Providers who submit pharmacy claims for services provided need to be kept informed of changes to processing. Pharmacy Providers who submit pharmacy TARs for services provided need to be kept informed of changes to processing.N/AN/APharmacy Benefits DivisionPBDDHCSPharmacy Benefits Division is responsible for DHCS’ Medi-Cal FFS drug program and for the management of the Medi-Cal managed care pharmacy program. PBD is comprised of four branches: Pharmacy Policy, Enteral and Medical Supplies, Drug Contracting and Drug Rebates. In addition, the Vision Services program and the California Mental Health Care Management Program (CalMEND) fall under the purview of the division. PBD has primary responsibility for ensuring that prescription drug coverage is provided to FFS Medi-Cal beneficiaries. PBD contracts with drug and medical supply manufacturers and providers to assure they meet specific criteria, including safety, effectiveness and essential need, and to eliminate the potential for misuse. In exchange for the ability to contract with Medi-Cal, manufacturers provide rebates to the program, which in 2010-11 was approximately $1.7 billion in total rebates (federal and state). California’s rebate program is considered one of the most aggressive in the country. PBD is also responsible for the Medi-Cal FFS vision program and CalMEND, funded primarily with funding from the Mental Health Services Act (Prop. 63) and charged with improving the health of Medi-Cal beneficiaries with mental illness.DHCS – PBD are responsible for managed care Pharmacy Policy, Enteral and Medical Supplies, Drug Contracting and Drug Rebates and need to be kept informed of changes to CA-MMIS. Primary & Rural Health DivisionPRHDDHCSThe mission of Primary & Rural Health Division is to improve the health status of diverse population groups living in medically underserved urban and rural areas. PRHD administers seven programs that seek to improve and make accessible primary care services and other public health services for persons at risk, including the uninsured or indigent, and those who otherwise have limited or no access to services due to geographical, cultural or language barriers. Those programs are: Rural Health Services Development (RHSD), Seasonal and Agricultural Workers (SAMW), Indian Health (IH), California State Office of Rural Health (CalSORH), Medicare Rural Hospital Flexibility/Critical Access Hospital (FLEX/CAH), Small Rural Hospital Improvement (SHIP) and J-1 Visa Waiver. The division functions as the primary liaison for providers and other stakeholders concerned with rural health, IH and primary care clinics. PRHD works with rural health constituents to provide training and technical assistance to strengthen the rural health care infrastructure. PRHD has lead responsibility in ensuring that DHCS complies with federal requirements to seek regular and ongoing advice from tribes and IH program designees on proposed changes to the Medi-Cal program that have a direct impact on Indians and IH providers. PRHD also provides training and technical assistance to IH programs as well as administers the American Indian Infant Health Initiative (AIIHI) and Federal Emergency Preparedness activities. Additionally, PRHD assists in the development of Medi-Cal policies affecting Federally Qualified Health Centers, Rural Health Clinics and IH clinics.DHCS-PRHD responsible for Rural Health Care improvements and may need to be kept informed of changes to CA-MMIS and billing for services. Print and DistributionP&DXeroxPart of Provider Relations Organization. Prints and distributes mass quantities of publications affiliated with the Medi-Cal program.Xerox – P&D provide the forms distribution and distributions of bulletins which may include processing changes.N/AN/AXerox – P&D provide the forms distribution and distributions of bulletins which may include processing changes.ProviderProviderExternalIndividual or organization enrolled by the Medi-Cal program to provide certain services to Medi-Cal members, including doctors, hospitals, nursing homes, pharmacies, or durable medical supplies retailers.Pharmacy Providers who submit pharmacy claims for services provided need to be kept informed of changes to processing.Providers who submit TAR/SAR Request for services provided need to be kept informed of changes to prior authorization request as well as claims processing.Pharmacy Providers who submit Medical claims for services provided need to be kept informed of changes to processing.Provider Enrollment DivisionPEDDHCSProvider Enrollment Division is responsible for the review and appropriate action of FFS provider applications seeking to participate in the Medi-Cal program, including ensuring that applicants meet licensure requirements and participation standards defined by federal and state statutes and regulations. PED also conducts re-enrollment functions of current providers to assure continued compliance with program requirements and standards of participation. PED has responsibility for updating and maintaining the Provider Master File database that is used in the claims payment process. PED is actively involved in Medi-Cal anti-fraud efforts aimed at preventing fraud, waste and abuse in the Medi-Cal program.Substance Use Disorder clinics and their satellite sites who participate in the Drug Medi-Cal (DMC) Program are certified via the DMC Provider Certification process, as stipulated in the Drug Medi-Cal Standards for Substance Abuse Clinics of 2004. County Mental Health Plans (MHP) determine initial eligibility for Specialty Mental Health (SMH) program and submit to the MHS Medi-Cal Claims Customer Service office .DHCS – PED Enrolls and updates the provider master file as it relates to Medi-Cal Providers and should be kept informed of changes that may impact the files that are transmitted to CA-MMIS..N/AN/ADHCS – PED Enroll and update the provider master file as it relates to Medi-Cal Providers and should be kept informed of changes that may impact the files that are transmitted to CA-MMIS. Provider Integrity UnitPIUXeroxMonitors the activities of providers and tracks suspicious activity. There are three departments within the Provider Integrity Unit: Provider Review Unit, Surveillance and Utilization Review Subsystem (SURS) Liaison, and Cost Containment.Xerox –PIU unit is responsible for providing SURS reports, and Provider Review on claims processed to State Agencies. The PIU will need to understand PBM OS+ and the HE claims processing systems and the impact to running the SURS reports.Provider Outreach and EducationProvider O&EXeroxPart of Provider Relations Organization. Disseminates program information and provider education. Coordinates educational provider seminars throughout California.Xerox - Provider O & E is responsible for the delivery of program information to Providers and training as needed. O&E will have to reach out to the Provider community to train them on Health Enterprise features, as well as on the differences in how the new system will operate compared to how Legacy currently works.Provider Relations OrganizationPROXeroxThe Provider Relations Organization is organized into five major business areas: Telephone Service Center, Research and Correspondence, Provider O&E, Publications, and Print and Distribution.Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing, reporting, and CA-MMIS to conduct research and answer Provider questions. Provider Review UnitPRUXeroxPart of Provider Integrity Unit. Reviews the activities of providers for suspicious fraudulent or abusive activity.Xerox –PRU unit is responsible for review of suspect Providers and reporting suspicious activity. The PRU team will need to understand the PBM OS+ and the HE claims processing systems and the impact to claims review for fraudulent or abusive activity.PublicationsPUBSXeroxWrites, edits, designs, and routes Medi-Cal content for distribution through both print and the Internet media channels.Xerox –PUBS unit is responsible for distribution of Medi-Cal bulletins or web notifications regarding changes. Research and CorrespondenceR&CXeroxPart of Provider Relations Organization. Researches and resolves billing issues and communicates in writing to providers regarding complex billing questions and issues.Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing or CA-MMIS to conduct research, and answer Provider questions.Safety Net Financing DivisionSNFDDHCSSafety Net Financing Division administers supplemental payments in accordance with the “Bridge to Reform” Section 1115 Medicaid Waiver and the Medicaid State Plan. The Medi-Cal Supplemental Payment Section (MSPS) processes and monitors payments for hospitals and other types of providers for various supplemental programs and administers the QAF program. The Hospital/Uninsured Care Demonstration Section (HUCDS) evaluates designated public hospital costs and rates, oversees the development of California’s new waiver, oversees the implementation of the Diagnostic Related Group (DRG) inpatient hospital’s reimbursement methodology and administers the Sub acute Care Program. The Administrative Claiming, Local and School Services Branch provide federal reimbursement to counties and school districts for administrative activities, targeted case management and certain medically necessary school-based services. The Disproportionate Share Hospital Financing and Non-Contract Hospital Recoupment Branch reimburses eligible hospitals for uncompensated care costs for hospital services and recoups overpayments for inpatient hospital services provided by non-contract hospitals.DHCS – SNFD administers supplemental payments for the DHCS and needs to be kept informed of changes that impact CA-MMIS. ScanningScanningXeroxPart of Front End. Front End scanning is responsible for scanning in hardcopy claims received using the OCR software. The claims then move to the data entry system where the business rules are applied and data entry operators validate fields that fail a business rule, or that the OCR could not read. Xerox Scanning is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the scanning area process, but the Department will be made aware of the changes to the claims processing systems.Xerox Scanning is part of Claims Operations may process TARS that are impacted with changes. There will be no direct impact to the scanning area process, but the Department will be made aware of the changes to the claims processing systems.Xerox Scanning is part of Claims Operations may process claims that are impacted with changes. There will be no direct impact to the scanning area process, but the Department will be made aware of the changes to the claims processing systems.Service DeliverySGXerox The Service Delivery Team is responsible for managing SDNs and System Change Requests that are received from DHCS. They work closely with their DHCS counterpart to understand the changes that need to be made and to meet the implementation timeframes.SDNs and OILs that are implemented during development may impact specific releases. The Service Delivery Team will be kept informed of all system changes.Small Provider Billing UnitSPBUXeroxPart of Provider O&E. Provides support and trains small providers (based on number of claims) until they become proficient in creating and submitting Medi-Cal claims.Xerox - Small Provider Billing Unit needs to be kept informed of any changes to claims processing or CA-MMIS to support the Provider community they support. The SPBU unit will need to be trained on the PBM OS+ system for processing of any Pharmacy claims.Xerox - Small Provider Billing Unit needs to be kept informed of any changes to TAR processing or CAMMIS to support the Provider community they support.Xerox - Small Provider Billing Unit needs to be kept informed of any changes to claims processing or CA-MMIS to support the Provider community they support. The SPBU unit will need to be trained on the HE system for processing of any claims.State Controller's OfficeSCOExternalDisburses payments to providers.SCO needs to be informed of any change to claims processing and reporting in CA-MMIS that may impact Provider Payments. N/AN/ASCO needs to be informed of any change to claims processing and reporting in CA-MMIS that may impact Provider Payments.SubmitterSubmitterExternalSubmits claims to CA-MMIS on behalf of providers. Submitters are also known as Clearing House.Submitters are responsible for submitting claims on behalf of providers and need to be kept informed of changes to claims processing or submission of the electronic files. . N/AN/ASubmitters are responsible for submitting claims on behalf of providers and need to be kept informed of changes to claims processing or submission of the electronic files.Surveillance Utilization Review Subsystem LiaisonSURS LiaisonXeroxPart of Provider Integrity Unit. Assists with SURS, which monitors fraud and abuse activity.Xerox –SURS Liaison is responsible for running reports to support fraud and abuse and need to be informed of changes to CA-MMIS. N/AN/AXerox –SURS Liaison is responsible for running reports to support fraud and abuse and need to be informed of changes to CA-MMIS.Systems of Care for Children and Adults DivisionSCDDHCSSystems of Care for Children and Adults Division creates effective and efficient systems of care for vulnerable populations with chronic conditions to better improve or maintain their health care status and reduce health care costs. SCD is comprised of two major branches: Statewide Medical Services Branch (SMSB) and Program Operations Branch (POB). SMSB is comprised of medical professionals who have oversight of several programs, including: Medical Therapy, serving 27,000 clients; High-Risk Infant Follow-Up; Child Health and Disability Prevention, serving two million children; Genetically Handicapped Persons, serving 1,500 clients; Newborn Hearing Screening, which screens about 425,000 annually; and Health Care Program for Children in Foster Care Programs. The POB has administrative oversight of these same programs. POB is also responsible for the development and implementation of the California Children’s Services (CSC) demonstration pilot program as a component of DHCS’ Section 1115 Medicaid “Bridge to Reform” waiver.DHCS – SCD is responsible for the CSC program and needs to be kept informed of changes that impact CA-MMIS.N/AN/ADHCS – SCD is responsible for the CSC program and needs to be kept informed of changes that impact CA-MMIS.Telephone Service Center AgentTSCXeroxPart of Provider Relations Organization. Researches, resolves, and responds to Medi-Cal provider and member telephone inquiries.Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing or CA-MMIS to conduct research, and answer Provider questions.N/AN/A Xerox - Provider Relations Organization needs to be kept informed of any changes to claims processing or CA-MMIS to conduct research, and answer Provider questions.Third Party Liability and Recovery DivisionTPLRDDHCSThird Party Liability and Recovery Division assures that the Medi-Cal program complies with state and federal laws and regulations requiring that Medi-Cal be the payer of last resort. TPLRD accomplishes this by recovering Medi-Cal expenses from liable third parties and avoiding Medi-Cal cost by identifying or purchasing alternative health care coverage. TPLRD’s recovery programs, Estate Recovery, Personal Injury and Overpayments, account for $300 million in annual revenue. TPLRD cost avoidance programs annually process more than 300 million commercial insurance records and pay Medicare premiums for 1.1 million dual eligible beneficiaries, avoiding more than $3 billion in Medi-Cal costs. In addition to the coordination of benefits programs, TPLRD is also responsible for the collection of the Provider QAF, totaling approximately $4 billion annually.DHCS – TPLRD is responsible for recovering Medi-Cal expenses from liable third parties program and needs to be kept informed of changes that impact CA-MMIS claims processing and reporting.N/AN/ADHCS – TPLRD is responsible for recovering Medi-Cal expenses from liable third parties program and needs to be kept informed of changes that impact CA-MMIS claims processing and reporting.CA-MMIS Business Process Maturity LevelThe table below depicts the As-Is and To-Be maturity levels, where available, based on the SS-A report provided by OHC in October, 2013. Note: Business processes with a To-Be rating of “N/A” indicate they are identified by DHCS as marked for consolidation into another business process. Maturity levels for Inquire Medi-Cal Eligibility are listed as “TBD” because all Eligibility and Member Management business processes are on hold pending the release of the outstanding components of the MITA Framework. The BCM, as explained in Section 1.1.4, will aid in determining if the system meets, exceeds, or does not meet the target To-Be maturity levels.Table SEQ Table \* ARABIC 21: CA-MMIS As-Is and To-Be Maturity LevelsAs-Is Maturity LevelTo-Be Maturity LevelCA-MMIS Business AreaCA-MMIS Business CategoryCA-MMIS Business ProcessOverall TimelinessData Access & AccuracyEffort to PerformCost EffectivenessAccuracy of ProcessUtility or Value to StakeholdersOverall TimelinessData Access & AccuracyEffort to PerformCost EffectivenessAccuracy of ProcessUtility or Value to StakeholdersCare ManagementAuthorization DeterminationAuthorize CCS/GHPP Services1111111N/AN/AN/AN/AN/AN/AN/AMedi-Cal Treatment Authorization Requests222222222?22222Authorize Treatment Plan11111112222222Case ManagementEstablish Case 11111112222222Establish CCS/GHPP Case1111111N/AN/AN/AN/AN/AN/AN/AManage Case Information11111112222222Manage CCS/GHPP Case Information1111111N/AN/AN/AN/AN/AN/AN/APerform Screening and Assessment11111112222222Manage Treatment Plan and Outcomes11111112222222State SpecificReserve Service22222222222222Contractor ManagementContract ManagementManage CA-MMIS FI Contract22222222222222Contractor SupportManage Medi-Cal Contractor Communication12111221211122Financial ManagementAccounts Payable ManagementManage 109922222222222222Manage Contractor Payment11111112222222Manage Health Insurance Premium Payments11111112222222Manage Incentive Payment22222222222222Manage Medi-Cal Accounts Payable Information11111112222222Manage Medi-Cal Payable Disbursement11111112222222Manage Medicare Premium Payment22222222222222Accounts Receivable ManagementManage Cost Reports Settlement11111112222222Manage Drug Rebate12111222222222Manage Estate Recovery11111112222222Manage Medi-Cal Accounts Receivable Funds11111112222222Manage Medi-Cal Accounts Receivable Information11111112222222Manage Overpayment Recoupment11111112222222Manage TPL Recovery11111112222222Fiscal ManagementFormulate Medi-Cal Budget11111112222222Generate Medi-Cal Budget Estimates Financial Report12122222222222Manage State Funds22222222222222State SpecificManage Member Health Care Reimbursement11111112222222Member Eligibility and Enrollment ManagementMember EnrollmentInquire Medi-Cal EligibilityTBDTBDTBDTBDTBDTBDTBDTBDTBDTBDTBDTBDTBDTBDMember ManagementMember Support ManagementManage Medi-Cal Applicant and Member Communication (Based on 2008 SS-A)11111112222222Operations ManagementClaims AdjudicationApply Medi-Cal Mass Adjustment22222222222222Process Medi-Cal Claim22222222222222Submit Medi-Cal Claim Attachment22222222222222Payment and ReportingGenerate Medi-Cal Remittance Advice22222222222222Inquire Medi-Cal Payment Status22222222222222Manage Data22222222222222Process EncounterProcess Managed Care Encounter11122222222222Plan Management Health Benefits AdministrationManage Benefit Information11111121111111Maintain Benefits-Reference Information11111122222222Manage Drug Formulary2222222N/AN/AN/AN/AN/AN/AN/AManage Rate Setting11111112222222Health Plan AdministrationDevelop and Manage Performance Measures11111111111111Manage Medi-Cal Program Information11111111111111Plan AdministrationMaintain Program Policy11111121111112Program Integrity (Performance) Management Compliance ManagementDetermine Adverse Action Incident11111112222222Establish Compliance Incident11111112222222Identify Utilization Anomalies11111112222222Manage Compliance Incident Information11111112222222Prepare Beneficiary Confirmation Letters11111112222222Provider Eligibility Management Provider EnrollmentEnroll Medi-Cal Provider11111113333333Inquire Medi-Cal Provider Information11111113333333Determine Medi-Cal Provider Eligibility11111113333333Determine Provider Eligibility for Incentive Program2222222N/AN/AN/AN/AN/AN/AN/ADetermine CHDP Provider Eligibility1111111N/AN/AN/AN/AN/AN/AN/AEnroll Drug Medi-Cal Provider1111111N/AN/AN/AN/AN/AN/AN/AEnroll Mental Health Provider1111111N/AN/AN/AN/AN/AN/AN/AEnroll Dental Provider1111111N/AN/AN/AN/AN/AN/AN/AEnroll CCS Provider2222222N/AN/AN/AN/AN/AN/AN/AEnroll CHDP Provider1111111N/AN/AN/AN/AN/AN/AN/ADisenroll Medi-Cal Provider11111113333333Disenroll Dental Provider1111111N/AN/AN/AN/AN/AN/AN/AProvider Management Provider Information ManagementManage Medi-Cal Provider Information11111113333333Provider SupportManage Medi-Cal Provider Grievance & Appeal11111111111111Manage Medi-Cal Provider Communication22222222222222Perform Medi-Cal Provider Outreach22222222222222Actor Primary Interactions with CA-MMIS Business ProcessTable SEQ Table \* ARABIC 22: CA-MMIS Primary Actor Interactions with Business ProcessesCA-MMIS Business AreaCA-MMIS Business CategoryCA-MMIS Business ProcessActorsTypes of InteractionCare Management Authorization DeterminationMedi-Cal Treatment Authorization RequestsProviderTARMedi-Cal ConsultantTARAuthorize CCS/GHPP ServicesCMS-DHCSSARAuthorize Treatment PlanProviderTreatment PlanMedical Case AgentTreatment PlanCase ManagementEstablish Case ProviderTreatment PlanEstablish CCS/GHPP CaseSCDMedical CaseManage Case InformationMedical Case AgentMedical CaseManage CCS/GHPP Case InformationSCDMedical CasePerform Screening and AssessmentLTCDCase ManagementManage Treatment Plan and OutcomesLTCDLTCD performs case management for specific waiver programs and special programs.State SpecificReserve ServiceProviderService Reservation RequestContractor Management Contractor SupportManage Medi-Cal Contractor CommunicationFiscal IntermediaryDocumentation and Communications in SharePointManage CA-MMIS FI ContractCA-MMIS DivisionCA-MMIS FI contract management is the same as those performed across the Department for the management of all Medi-Cal contracts.Financial Management Accounts Payable ManagementManage 1099Cash Control Analyst1099 reportsManage Contractor PaymentOverseen by multiple business areas within DHCSInteraction with many business areas, such as inpatient hospitals and managed care health plans, along with program-specific health services contracts include lab, pharmacy, DME, and disease management.Manage Health Insurance Premium PaymentsTPLRDCA-MMIS Recipient Subsystem: MEDS is accessed and updated to support the HIPP process. CAPMAN system automates the capitation payment calculation process, HIPP premium payments, and generates the HIPAA 820 payment and 834 enrollment transactions.Manage Incentive PaymentProviderIncentive paymentManage Medi-Cal Accounts Payable InformationSCOWarrant numbers; Medi-Cal payments & disbursementsManage Medi-Cal Payable DisbursementSCOPayment information & disbursementsManage Medicare Premium PaymentTPLRDCA-MMIS Recipient Subsystem: MEDS is updated with Medicare eligibility and buy-in information resulting from data exchanges with CMS.Accounts Receivable ManagementManage Cost Reports SettlementTPLRDCost settlement amounts; Recoupment requestsManage Drug RebateDRUDrug Rebate reference information; Drug Rebate invoicesManage Estate RecoveryTPLRDEstate recovery referrals are typically received from vital records data and the descendents representativesManage Medi-Cal Accounts Receivable FundsFMBPayments; Provider checksManage Medi-Cal Accounts Receivable InformationCash Control Analyst Accounts Receivable (A/R) transactionsAppeals ExaminerAccounts Receivable (A/R) transactionsManage Overpayment RecoupmentCash Control AnalystProvider recoupment transactionsManage TPL RecoveryTPLRDTPL analysis results; Recoupment transaction information.CA-MMIS DivisionTPL letters Fiscal ManagementManage State FundsDHCS Administration Division (AD)AD Accounting Section is responsible for reconciling state fund allocations and the drawdown and reporting of FFPFormulate Medi-Cal BudgetFinancial Management Branch (FMB) of the Administration Division with input from the FFBBudget Office of FMB is responsible for State Support and non-Medi-Cal Local Assistance while the FFB looks at current revenue trends and expenditures, assesses external factors impacting the program, models different budget scenarios and produces the budget estimates for the Medi-Cal and CCS/GHPP/CHDP Local Assistance program. DHCS Director has final approval authority for the proposed Medi-Cal budget sent to the Governor.Generate Medi-Cal Budget Estimates Financial ReportDHCS Administration Division, FFBFFB prepares the CMS-37 and CMS-21B reports in support of the budget process and the management of FFP.State SpecificManage Member Health Care ReimbursementOverseen by the CA-MMIS DivisionMember reimbursement checks are distributed by the State Controller’s Office. Member Eligibility and Enrollment Management Member EnrollmentInquire Medi-Cal EligibilityCounty OfficeInquiry transactionsMember ManagementMember Support ManagementManage Medi-Cal Applicant and Member CommunicationTAR Office ConsultantsReview the documentation received from Providers on behalf of the Member and make a determination on the TAR request to initiate? the NOA letter.CA-MMISReceive the NOA response letter and print and mail to Provider on behalf of Member.Operations Management Claims AdjudicationApply Medi-Cal Mass AdjustmentCA-MMIS DivisionClaims mass adjustment work orderProcess Medi-Cal ClaimProviderClaimsSubmitterClaimsSubmit Medi-Cal Claim AttachmentProviderClaim attachmentsPayment and ReportingGenerate Medi-Cal Remittance AdviceSCOMedical remittance adviceInquire Medi-Cal Payment StatusProviderMedi-Cal payment status inquiryManage DataProvider Relations OrganizationDataClaims OperationsDataDURDataCash Control AnalystDataProcess EncounterProcess Managed Care EncounterEDUManaged Care encounter data Plan Management Health Benefits AdministrationMaintain Benefits-Reference InformationCA-MMIS DivisionPolicy-triggered transactionsManage Drug FormularyPBDPBD is responsible for developing the policy instructions needed to add or modify drug codes to the CA-MMIS formulary fileManage Rate SettingFFSRDDFFSRDD is responsible for rate setting activities for the majority of Medi-Cal services , there are multiple other program areas responsible for rate setting activities such as PBD, MDSD, SNFD, Hospital contract rates and school-based services, MHSUDS, PED sets rates for certain types of LTC facilities, MHS – Sets rates for mental health services Drug Medi-Cal – Sets rates for the Drug Medi-Cal programHealth Plan AdministrationDevelop and Manage Performance MeasuresCA-MMIS DivisionProgram performance measures Manage Benefit InformationDHCS DirectorateThe various DHCS program areas are responsible for maintaining and updating relevant benefit package information and related changes in Medi-Cal policy.Manage Medi-Cal Program InformationCA-MMIS DivisionPolicy-triggered transactionsPlan AdministrationMaintain Program PolicyDHCS DirectorateVarious DHCS program areas are responsible for maintaining and updating policies related to Medi-Cal approved servicesFile MaintenanceFile Maintenance Team receives FI letters with OILs to update policy per DHCS instructions. They are responsible for implementing the policy related to the DHCS change requests in the allotted time frames.Service DeliveryProcess SDNs and system change requests. Program Integrity (Performance) Management Compliance ManagementDetermine Adverse Action IncidentA&I Division A/R transactions; Suspect hold Providers; TPL cases; Legal activitiesEstablish Compliance IncidentA&IA&I coordinates with other DHCS Divisions and government agencies for referrals, data and investigative supportIdentify Utilization AnomaliesCAASDTARs; TAR denial appeals; Claims review for abnormalities in billing & cost containment ideasManage Compliance Incident InformationA&IA&I coordinates with other DHCS Divisions and government agencies for referrals, data and investigative support. Prepare Beneficiary Confirmation LettersCA-MMIS Division, MDSDFor medical services, the CA-MMIS FI, Xerox, sends out manual confirmation letters to a select number of beneficiaries. For dental services, the CD-MMIS FI, Delta Dental, produces confirmation letters for beneficiaries that received a service that was preauthorizedProvider Eligibility and Enrollment ManagementProvider EnrollmentDetermine Medi-Cal Provider EligibilityPEDPED determines eligibility for the majority of providers requesting enrollment into the Medi-Cal program.Determine Provider Eligibility for Incentive ProgramOHITApplicant providers must first complete the federal registration process prior to being able to access the Medi-Cal State Level Registry for enrollment into the EHR Incentive ProgramDetermine CHDP Provider EligibilitySCDApplicant providers must already be enrolled as a Medi-Cal Provider to apply to be a CHDP provider. CHDP providers are location specific and the determination of eligibility process is performed by the local CHDP county officesEnroll Medi-Cal ProviderProviderEnrollment applications (out-of-state)PEDProvider eligibility & enrollment applications;Approval/denial letter (out-of-state)Enroll Drug Medi-Cal ProviderPED (SUDS)Substance Use Disorder clinics and their satellite sites who participate in the DMC Program are certified via the DMC Provider Certification process as stipulated in the Drug Medi-Cal Standards for Substance Abuse Clinics of 2004.Enroll Mental Health ProviderDMH County MHPs determine initial eligibility for SMH program and submit standard forms to the MHS Medi-Cal Claims Customer Service Office (MedCCC) for processing and enrollment.Enroll Dental ProviderMDSDFiscal Intermediary for the CD-MMIS, Delta Dental, performs the majority of the steps.Enroll CCS ProviderSCDApplicant providers must already be enrolled as a Medi-Cal Provider to apply to be “paneled” as a CCS provider. Application process is online and auto enrolls the provider into the CCS program if all requirements are met. Enroll CHDP ProviderSCDApplicant providers must already be enrolled as a Medi-Cal Provider to apply to be a CHDP provider. CHDP providers are location specific and the enrollment process is performed by the local CHDP county offices.Disenroll Medi-Cal ProviderPEDPED performs the steps for a majority of providers requiring disenrollment from the Medi-Cal program. Some provider types are disenrolled from the Medi-Cal program by other state organizations (e.g., Licensing and Certification for institutional providers), for which PED’s primary responsibility is to perform the steps to have the PMF.Disenroll Dental ProviderMDSDThe Fiscal Intermediary for the CD-MMIS, Delta Dental, performing the majority of the steps. The Customer Service Department is the Delta Dental organizational component that maintains centralized information on Medi-Cal Dental Program providers, and acts as the primary point of communication between providers and the program.Inquire Medi-Cal Provider InformationPEDInquiry transactionsProvider Management Provider Information ManagementManage Medi-Cal Provider InformationPEDProvider informationProvider SupportManage Medi-Cal Provider Grievance & AppealProvider Relations Organization Provider appeals & grievancesManage Medi-Cal Provider CommunicationProvider O&EProgram information;Medi-Cal Provider educationPerform Medi-Cal Provider OutreachProviderCommunicationsProvider O&ECommunications to Medi-Cal Providers Medi-Cal Enterprise center438150For a full view of the diagram on the following page, refer to the Referenced Documents table for the SharePoint link to the Medi-Cal Enterprise Business Process Diagram in SharePoint.Figure SEQ Figure \* ARABIC 12: Medi-Cal EnterprisePlanned Releases RoadmapEffective January, 2014, the following figure depicts the roadmap for the planned releases of the CA-MMIS System Replacement Project based on the modified agile approach. center12700Figure SEQ Figure \* ARABIC 13: Roadmap for Releases 1 – 5 ................
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