Business Architecture 2.02 – Use Cases Enroll Provider For the Medicaid Information Technology Architecture (MITA) Business Enterprise Version 1.0 December 8, 2010 Submitted to: Centers for Medicare & Medicaid Services OAGM/Division of Support Contracts 7500 Security Blvd., M/S C2-21-15 Baltimore, MD 21244-1850

Submitted by:

FOR OFFICIAL USE ONLY Public availability to be determined under 5 USC 552 Exemptions to the Freedom of Information Act may apply to these records. Questions regarding application of this marking/sensitivity determination will be directed to Centers for Medicare & Medicaid Services at 410-786-3314. CMS personnel are also advised of their responsibility to protect this information in accordance with HRPM Volume 4, ER-4.1, Section 4

Distribution is authorized to U.S. government agencies; Reason: Specific Authority, 27 September 2007 Other requests for this document shall be referred to the Centers for Medicare & Medicaid Services OAGM/Division of Support Contracts ATTN: Ms. Leslie Flaherty, Government COTR 7500 Security Blvd., M/S C2-21-15 Baltimore, MD 21244-1850 The materials in this document are categorized as:

For Official Use Only This document contains information exempt from mandatory disclosure under the Freedom of Information Act (FOIA).

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Business Architecture 2.02 – Use Cases Enroll Provider For Enterprise Architect and Technical Support Services for the Medicaid Information Technology Architecture (MITA) Business Enterprise Version 1.0 8 December 2010 SUBMITTED BY Patti Garofalo Team Foxhole, Project Manager

DATE APPROVAL

Leslie Flaherty Centers for Medicare & Medicaid Services, COTR

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DATE

Table of Changes The following table indicates the changes made to this document since its last release. Revision 1.0

Date

Description

12/08/2010 Initial Release

Change Request Origin None

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Table of Contents 1. Overview ................................................................................................................... 8 1.1

Stakeholder Review Orientation Purpose ............................................................ 8

1.2

Review Process ................................................................................................... 9

2. Model Report - Enroll Provider Use Case ................................................................ 10 2.1

Package: Enroll Provider ................................................................................... 10

2.1.1

Usecase: Context Diagram .......................................................................... 10

2.1.2

Actor: Provider ............................................................................................. 11

2.1.3

Actor: Agency Staff ...................................................................................... 12

2.1.4

Component: Provider Registry System ........................................................ 12

2.1.5

Component: Enroll Provider System ............................................................ 12

2.1.6

Component: Enrollment Web Application ..................................................... 12

2.1.7

UseCase: Manage Provider Information ...................................................... 12

2.1.8

UseCase: Maintain Provider Application ...................................................... 12

2.1.9

UseCase: Inquire Provider Information ........................................................ 12

2.1.10 UseCase: Verify Provider Application........................................................... 12 2.1.11 UseCase: Establish Rates ........................................................................... 13 2.1.12 UseCase: Manage Administrative or Health Services Contract .................... 13 2.1.13 UseCase: Notify of Enrollment ..................................................................... 13 2.1.14 Actor: Health Care Provider ......................................................................... 13 2.2

Package: Maintain Provider Enrollment Application ........................................... 13

2.2.1

Usecase: Maintain Provider Enrollment Application ..................................... 13

2.2.2

UseCase: Create Application ....................................................................... 14

2.2.3

UseCase: Modify Application ....................................................................... 14

2.2.4

UseCase: Cancel Application ....................................................................... 14

2.2.5

UseCase: Inquire Application ....................................................................... 15

2.2.6

UseCase: Submit Application ....................................................................... 15

2.2.7

UseCase: Provide Supplement Information.................................................. 15

2.3

Package: Verify Provider Application ................................................................. 15

2.3.1

Usecase: Verify Provider Application ........................................................... 15 Page iv

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2.3.2

Actor: Verification Entity ............................................................................... 16

2.3.3

UseCase: Verify Enumeration ...................................................................... 17

2.3.4

UseCase: Verify Sanctions .......................................................................... 17

2.3.5

UseCase: Verify Credentials ........................................................................ 17

2.3.6

UseCase: Create Enumeration .................................................................... 17

2.3.7

UseCase: Verify Requirements .................................................................... 17

2.3.8

UseCase: Determine Enrollment Status ....................................................... 17

2.3.9

UseCase: Verify Insurance .......................................................................... 17

2.4

Package: Establish Rates .................................................................................. 17

2.4.1

Usecase: Establish Provider Rates .............................................................. 17

2.4.2

UseCase: Assign To Programs .................................................................... 18

2.4.3

UseCase: Assign Provider Rates ................................................................. 18

2.4.4

UseCase: Determine Contract Parameters .................................................. 18

2.5

Package: Notify of Enrollment ............................................................................ 18

2.5.1

Usecase: Notify of Enrollment ...................................................................... 19

2.5.2

UseCase: Prepare Provider EFT/Check ....................................................... 19

2.5.3

UseCase: Prepare Capitation and Premium Payment.................................. 19

2.5.4

UseCase: Perform Provider Outreach .......................................................... 19

2.5.5

UseCase: Manage Provider Communication................................................ 20

2.5.6

UseCase: Send Enrollment Notification ....................................................... 20

2.5.7

UseCase: Send Enrollment Alert.................................................................. 20

2.6

Package: Predecessors ..................................................................................... 20

2.6.1

Usecase: Predecessors ............................................................................... 20

2.6.2

UseCase: Receive Inbound Transaction ...................................................... 21

2.6.3

UseCase: Program Integrity Manage Case .................................................. 21

2.6.4

UseCase: Monitor Performance and Business Activity ................................. 21

2.6.5

UseCase: Enroll Provider ............................................................................. 21

2.7

Package: Successors ........................................................................................ 22

2.7.1

Usecase: Successors .................................................................................. 22

2.7.2

UseCase: Manage Provider Information ...................................................... 22

2.7.3

UseCase: Send Outbound Transaction ........................................................ 23

2.8

Package: Overviews .......................................................................................... 23 Page v

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2.8.1

Usecase: Actors Overview ........................................................................... 23

2.8.2

Freeform: Enroll Provider Use Case Overview ............................................. 23

List of Figures Figure 1 – Enroll Provider Context Diagram .................................................................. 11 Figure 2 – Maintain Provider Enrollment Application Model ........................................... 14 Figure 3 – Verify Provider Model ................................................................................... 16 Figure 4 – Establish Rates Model .................................................................................. 18 Figure 5 – Notify of Enrollment Model ........................................................................... 19 Figure 6 – Predecessor Model ...................................................................................... 21 Figure 7 – Successors Model ........................................................................................ 22 Figure 8 – Actors Overview Model................................................................................. 23 Figure 9 – Use Case Overview Model ........................................................................... 24

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1. Overview The Centers for Medicare & Medicaid Services (CMS) is undertaking efforts to fast track the development of the Medicaid Information Technology Architecture (MITA) Framework 2.0. The goal of the CMS MITA project is to provide States with informative logical business models and definitions which can be used for Medicaid Management Information System (MMIS) planning, design, development, implementation and maintenance. By using the CMS MITA Framework during all stages of the MMIS lifecycle, States will be fully prepared for the federally mandated certification review of a State’s MMIS. CMS has determined the most effective diagrams to use in order to represent the Medicaid enterprise. For this project, the following initial diagrams are provided for review for each of the specific business processes: •

•

Business Architecture: o Use Case Diagram(s) for functionality modeling o Activity Diagram(s) for business modeling o Predecessor and Successor diagram(s) for dependency modeling Information Architecture: o Class Diagram(s) for input and output messaging modeling o Class Diagram(s) for information modeling which include common classes, vocabulary and datatypes.

The MITA Business Architecture models are based on the MITA business process template and business capability matrix. The diagrams are intended to show primary functionality and business operations at a level 3 maturity which are common for most Medicaid enterprises. The MITA Information Architecture models provide descriptions of the information strategy, architecture, and data to a level such that States can define the data needs for the future business processes of their Medicaid enterprise. The MITA Information Architecture is technology-, organization-, and location-neutral. The CMS MITA data model is a Logical Data Model (LDM) rather than a physical data model. The LDM shows data subject areas broken down into the data classes and attributes needed for every drilled-down business process, as well as the relationships between the subject areas. The MITA LDM does not include State-specific data objects and relationships; rather, States will complete the LDM to include State-unique entities, relationships and detailed attributes. States will also be responsible for deriving a physical data model from their LDM. 1.1 Stakeholder Review Orientation Purpose The purpose of the Stakeholder Review is to conduct a validation of the draft business architecture and information architecture models for MITA Framework 2.0 business process. This offers an opportunity to verify the business-driven logical architecture for the Medicaid enterprise. The stakeholders are comprised of individuals knowledgeable about the business activities and the information requirements for conducting Medicaid programs. This gives a multi-faceted look into the models, so a thorough representation is documented in a manner which is easily understood and communicates business and information needs appropriately.

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1.2 Review Process The Stakeholder’s Review process extends over ten business days. During this time the subject matter experts (SMEs) will become familiar with the models and conduct a thorough review of the content. An email message from CMS will be sent with the details of the start and end dates of the review. Additional information to conduct and complete the review will also be provided. A CMS MITA comment collection website has been established as a repository for Stakeholder feedback throughout the process. The website is located at http://fs21.formsite.com/CMSmita/form3/form_login.html. You will be prompted to enter a unique username and password to be used throughout your review. You may compile comments as you evaluate diagrams and documentation. Comments are saved under your unique username, and may be amended at any time during the ten day review period. Note: Architectures are categorized by MITA business process; validate that you are using the correct form for the models you are reviewing. The Business Architecture report contains diagrams and documentation for use case overviews and business process models, while the Information Architecture report contains diagrams and documentation for the logical data models. CMS MITA models are provided as a link in Adobe PDF format for your review. Both a UML Legend and a BPMN Legend are available in the Stakeholder’s Review Orientation document for your reference during the review of models.

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2. Model Report - Enroll Provider Use Case Enroll Provider process involves the activity for Health Care Providers and Providers to submit enrollment application via web-based application and to receive notification of enrollment determination. Most of the verification and validation of application information is automated with some manual effort by Agency Staff required for internal and external verifications with Verification Entities. There are four Provider enrollment variations: institutional Provider, professional Provider, pharmacy and a-typical. The process also includes activity for submission status tracking, determination of applicant type, Provider taxonomy, determination of contracting parameters, assignment of internal identifiers, and establishment of payment rates. The result is the Provider receives enrollment determination notification of enrolled, re-enrolled or denied. 2.1 Package: Enroll Provider Enroll Provider use case involves the activity for Health Care Providers and Providers to submit enrollment application via web-based application and to receive notification of enrollment determination.

2.1.1 Usecase: Context Diagram The Context Diagram depicts the interactions between systems and user or other external systems. The Enroll Provider business process has four use cases to maintain a Provider's application, verify the application information, establish a Provider's rates and enroll the Provider into Medicaid programs. There are three roles (Provider, Agency Staff and Verification Entity) and three subsystems (Web Application, Enroll Provider System and Provider Registry System) which utilize use cases for the Enroll Provider business process.

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Figure 1 – Enroll Provider Context Diagram

2.1.2 Actor: Provider An institution, agency, or person with a signed agreement from a Medicaid Agency. They are to furnish medical care and goods and/or services to clients and eligible to receive payment from the Medicaid Agency. The following are variations of a Provider: o o o o o o o o

Individual Billing Individual Rendering Group Institutional Supplier Pharmacy Medical Transportation Atypical (includes Portable Imaging Provider)

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2.1.3 Actor: Agency Staff A person responsible for the management of state Medicaid operations.

2.1.4 Component: Provider Registry System A system to support Provider information management and inquiry functions. Can be a local, regional or national registry.

2.1.5 Component: Enroll Provider System A system that collects enrollment application information from a Health Care Provider or Provider.

2.1.6 Component: Enrollment Web Application A web application for which Health Care Provider or Provider enters the data elements required to apply for Medicaid enrollment. The Provider's application for enrollment undergoes an entire workflow whose main steps and validation points are identified in MITA Framework 2.0.

2.1.7 UseCase: Manage Provider Information The Manage Provider Information use case is responsible for managing all operational aspects of the Provider Registry, which is the source of comprehensive information about prospective and contracted Providers, and their interactions with the state Medicaid.

2.1.8 UseCase: Maintain Provider Application The Maintain Provider Application use case is responsible for the collection and maintenance of Health Care Provider's or Provider's enrollment application information.

2.1.9 UseCase: Inquire Provider Information The Inquire Provider Information use case receives requests for Provider enrollment verification from authorized Providers, programs or business associates; performs the inquiry; and prepares the response data set for the Send Outbound Transaction process.

2.1.10 UseCase: Verify Provider Application Verification of information in the enrollment application or record with internal and external sources, including: a. Enumerators, including NPI, SSN, EIN, internal enumerators. If lacking, facilitate enumeration. b. Sanction status, e.g., HIPDB, NPDB, Boards, criminal background checks; and Provider performance profiles and State prescription monitoring programs (PMP). c. Credentials, e.g., licensure, specialty boards, and school, affiliations

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2.1.11 UseCase: Establish Rates The establishment of payment rates and funding sources, taking into consideration service area, incentives or discounts.

2.1.12 UseCase: Manage Administrative or Health Services Contract The Manage Administrative or Health Services Contract use case receives the contract award data set, implements contract monitoring procedures, and updates contract if needed, and continues to monitor the terms of the contract throughout its duration.

2.1.13 UseCase: Notify of Enrollment Send notification of approved enrollment to Provider as well to other business processes to initiate additional communications and system configurations. Send an enrollment notification to local, regional and national Provider Registry Systems.

2.1.14 Actor: Health Care Provider A person who is trained and licensed to give health care to patients. Also, a place that is licensed to give health care to patients. Doctors, nurses, and hospitals are examples of Health Care Providers. 2.2 Package: Maintain Provider Enrollment Application The Maintain Provider Application use case is responsible for the collection and maintenance of Health Care Provider's or Provider's enrollment application information.

2.2.1 Usecase: Maintain Provider Enrollment Application The Maintain Provider Enrollment Application use case includes activity to create, inquire, or modify enrollment application and then submit for evaluation. Requestor may also elect to cancel existing enrollment application. Business rules are applied to gather the appropriate information for the type of enrollment being submitted by the Health Care Provider or Provider. Maintain Provider Application also includes activity to attach any supplement information to accompany the enrollment application.

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Figure 2 – Maintain Provider Enrollment Application Model

2.2.2 UseCase: Create Application Health Care Provider or Provider provides information to new Provider enrollment application specific to requestor.

2.2.3 UseCase: Modify Application Health Care Provider or Provider modifies (i.e. add, update, delete) an existing Provider enrollment application specific to requestor.

2.2.4 UseCase: Cancel Application Health Care Provider or Provider cancels an existing Provider enrollment application specific to the requestor.

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2.2.5 UseCase: Inquire Application Health Care Provider or Provider views an existing Provider enrollment application information specific to requestor.

2.2.6 UseCase: Submit Application Health Care Provider or Provider accepts terms and conditions of enrollment agreement(s) and submits enrollment application for evaluation.

2.2.7 UseCase: Provide Supplement Information Health Care Provider or Provider provides supplement information for the Provider enrollment application specific to the requestor. Documents are typically submitted as different file formats including Microsoft Word, Microsoft Excel, Adobe PDF and various image formats (e.g. JPEG, TIFF, GIF, etc.). 2.3 Package: Verify Provider Application Verify Provider Application use case is responsible for verification of information in the enrollment application or record with internal and external sources.

2.3.1 Usecase: Verify Provider Application Verify Provider Application use case includes activity for automatic and manual verification of Provider enrollment application information. The MMIS system automatically verifies enumeration, sanctions, credentials and insurance as well as conformity with federal and state enrollment rules and regulations. The exception is for the Agency Staff to conduct manual verification with Verification Entity when automated interfaces are not available.

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Figure 3 – Verify Provider Model

2.3.2 Actor: Verification Entity Individual or system which performs primary source verification of Provider credentials and sanction status with internal or external entities including: •

Education and training/Board certification

•

License to practice

•

DEA/CDS Certificates

•

Medicare/Medicaid sanctions

•

Disciplinary/sanctions against licensure which may include external States

•

Malpractice claims history

•

NPDB (National Provider Data Bank) and HIPDB (Health Integrity Protection Data Base) disciplinary actions/sanctions

•

Verifying or applying for NPI enumeration with the NPPES

•

Verifying SSN or EIN and other business information

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2.3.3 UseCase: Verify Enumeration Validation of requestor's enumerations, including NPI, SSN, EIN, and internal enumerators.

2.3.4 UseCase: Verify Sanctions Validation of requestor's sanction status, e.g., HIPDB, NPDB, Boards, criminal background checks; and Provider's performance profiles and state Prescription Monitoring Programs (PMP).

2.3.5 UseCase: Verify Credentials Validation of requestor's credentials, e.g., licensure, specialty boards, schools and affiliations.

2.3.6 UseCase: Create Enumeration Create Provider enumerations, including NPI, SSN, EIN, and internal enumerators.

2.3.7 UseCase: Verify Requirements Verification the enrollment application complies with federal and state requirements.

2.3.8 UseCase: Determine Enrollment Status Determination to decline, suspend or accept enrollment request.

2.3.9 UseCase: Verify Insurance Validation of requestor's insurance coverage. 2.4 Package: Establish Rates The Establish Rates use case is responsible for the establishment of payment rates and funding sources, taking into consideration service area, incentives or discounts.

2.4.1 Usecase: Establish Provider Rates Establish Provider Rates use case includes activity for Agency Staff to determine contract parameters, assignment to programs and the automatic assignment of Provider rates.

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Figure 4 – Establish Rates Model

2.4.2 UseCase: Assign To Programs Assignment of Provider to Medicaid Programs they will participant in.

2.4.3 UseCase: Assign Provider Rates Assign Provider's rates use case includes identifying the type of rate, e.g., negotiated, Medicare, percent of charges, case management fee, other via look-ups in the reference and benefit repositories.

2.4.4 UseCase: Determine Contract Parameters Determine contracting parameters, e.g., Provider taxonomy, categories of service for which the Provider can bill, eligible Provider types, payment types, contract terms and maximums, client enrollment levels, panel size, and any contractor specific benefit packages and procedures.

2.5 Package: Notify of Enrollment Notify of Enrollment use case is responsible for sending notification of approved enrollment to Provider as well to other business processes to initiate additional communications and system configurations. Send enrollment notification to local, regional and national Provider Registry Systems.

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2.5.1 Usecase: Notify of Enrollment Notify of Enrollment use case includes activity to send notification of enrollment results to the Provider and send alert of Provider enrollment to other business processes such as Manage Provider Communication, Perform Provider Outreach, prepare Provider EFT/Check and Prepare Capitation and Premium Payment.

Figure 5 – Notify of Enrollment Model

2.5.2 UseCase: Prepare Provider EFT/Check The Prepare Provider EFT/Check use case is responsible for managing the generation of electronic and paper based reimbursement instruments.

2.5.3 UseCase: Prepare Capitation and Premium Payment The Prepare Capitation Premium Payment use case includes premiums for Managed Care Organizations (MCO), Primary Care Case Managers (PCCM), and other capitated programs.

2.5.4 UseCase: Perform Provider Outreach The Perform Provider Outreach use case originates internally within the Agency in response to multiple activities, e.g., identified gaps in medical service coverage, public health alerts, Provider complaints, medical advancements, changes in the Medicaid program policies and procedures.

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2.5.5 UseCase: Manage Provider Communication The Manage Provider Communication use case receives requests for information, Provider publications, and assistance from prospective and current Providers' communications such as inquiries related to eligibility of Provider, covered services, reimbursement, enrollment requirements etc. Communications are researched, developed and produced for distribution via Send Outbound Transaction process.

2.5.6 UseCase: Send Enrollment Notification Send a transaction (e.g. electronic data exchange (EDI)) notifying Provider of their enrollment application results (e.g., enrolled, re-enrolled or denied) using Send Outbound Transaction.

2.5.7 UseCase: Send Enrollment Alert Send a signal of the enrollment of a Provider to the following business processes: Prepare Capitation Premium Payment, Prepare Provider EFT/Check, Perform Provider Outreach and Manage Provider Communication. 2.6 Package: Predecessors The Predecessor diagram depicts the use case activities which precede Enroll Provider.

2.6.1 Usecase: Predecessors The Predecessor diagram depicts the use case activities which precede Enroll Provider and include: • • • •

Manage Provider Communication Receive Inbound Transaction Monitor Performance and Business Activity Program Integrity Manage Case

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Figure 6 – Predecessor Model

2.6.2 UseCase: Receive Inbound Transaction Receive message and validate inbound transaction (e.g., Electronic Data Exchange (EDI)) from internal or external system. Inbound message may be encrypted.

2.6.3 UseCase: Program Integrity Manage Case The Program Integrity Manage Case use case receives a case file from an investigative unit with the direction to pursue the case to closure. The case may result in civil or criminal charges, in corrective action, in removal of a Provider, contractor, or beneficiary from the Medicaid program; or the case may be terminated or suspended.

2.6.4 UseCase: Monitor Performance and Business Activity The Monitor Performance and Business Activity use case utilizes the mechanisms and measures that were developed by the Develop and Manage Performance Measures and Reporting process. The process includes the steps involved in implementing the mechanisms and measures to track agency activity and effectiveness at all levels of monitoring.

2.6.5 UseCase: Enroll Provider Enroll Provider use case involves the activity for Health Care Provider and Provider to submit enrollment application via web-based application and to receive notification of enrollment determination.

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2.7 Package: Successors The Successor package depicts the use case activity which follows Enroll Provider.

2.7.1 Usecase: Successors The Successor diagram depicts the use case activity which follows Enroll Provider which includes the following: • • • • • • •

Monitor Performance and Business Activity Manage Provider Communication Perform Provider Outreach Manage Provider Information Prepare Provider EFT/Check Send Outbound Transaction Prepare Capitation and Premium Payment

Figure 7 – Successors Model

2.7.2 UseCase: Manage Provider Information The Manage Provider Information use case is responsible for managing all operational aspects of the Provider Registry, which is the source of comprehensive about prospective and contracted Providers, and their interactions with the state Medicaid.

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2.7.3 UseCase: Send Outbound Transaction Create message and send outbound transaction (e.g., Electronic Data Exchange (EDI)) to internal or external system. Outbound message may be encrypted.

2.8 Package: Overviews The overviews provide a high-level perpective of the primary activities (i.e., business needs) of the use case as well as the actors and their generalization relationships.

2.8.1 Usecase: Actors Overview The Actors Overview depicts the actors of the Enroll Provider use case and their generalization relationships.

Figure 8 – Actors Overview Model

2.8.2 Usecase: Enroll Provider Use Case Overview The Enroll Provider Use Case Overview provides a high-level look at the primary activity (i.e., business needs) to enroll a Provider into Medicaid participation. The use case includes Maintain Provider Enrollment Application, Verify Provider Application, Establish Rates and Notify of Enrollment.

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Figure 9 – Use Case Overview Model

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