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Department of Health Care ServicesCA-MMISConcept of Operations (COO)
March 7, 2014Version 2.0
Table of ContentsPreface.......................................................................................6
Executive Policies.........................................................................................6Professional Responsibility...........................................................................6Revision History............................................................................................6
1. Introduction.......................................................................101.1 Business Architecture (BA) – Alignment to MITA...............................11
1.1.1 Business Architecture Artifacts.............................................121.1.2 Business Process Model (BPM)...........................................131.1.3 MITA Maturity Model (MMM)................................................151.1.4 Business Capability Matrix (BCM)........................................15
1.2 Document Assumptions......................................................................161.3 Document Scope................................................................................171.4 Document Constraints........................................................................181.5 Referenced Documents......................................................................191.6 Definitions...........................................................................................21
2. CA-MMIS Actors Catalog..................................................303. As-Is CA-MMIS.................................................................32
3.1 As-Is CA-MMIS Business Processes.................................................333.2 As-Is CA-MMIS Context Diagram.......................................................35
3.2.1 Business Associates.............................................................393.3 As-Is CA-MMIS COO..........................................................................40
3.3.1 As-Is CA-MMIS COO – Inbound/Outbound Transactions....404. To-Be CA-MMIS................................................................57
4.1 The CA-MMIS Health Enterprise System Information Exchange and Access Environment...........................................................574.2 To-Be CA-MMIS COO........................................................................594.3 To-Be Environment of CA-MMIS Business Process Implementation in System Replacement Project........................................614.4 Transition from As-Is to To-Be............................................................62
4.4.1 Effectiveness – Increase Business Maturity.........................634.4.2 Effectiveness – Improved Performance Standards..............66
4.5 Compliance.........................................................................................664.5.1 Security and Confidentiality..................................................664.5.2 System Security and Privacy................................................664.5.3 Other Standards for Compliance..........................................67
4.6 Critical Business Processes...............................................................67
Concept of Operations 2
4.7 Business Architecture – Assumptions, Constraints, and Risks.....................................................................................................67
Appendices..............................................................................81A. CA-MMIS Actors Catalog........................................................................81B. CA-MMIS Business Process Maturity Level.........................................123C. Actor Primary Interactions with CA-MMIS Business Process.....................................................................................................133D. Medi-Cal Enterprise..............................................................................142E. Planned Releases Roadmap................................................................143
Concept of Operations 3
List of TablesTable 1: Explanation of Global Definitions................................................16
Table 2: Referenced Documents..............................................................19
Table 3: Definitions...................................................................................21
Table 4: CA-MMIS Primary Entities..........................................................37
Table 5: CA-MMIS Business Associates..................................................40
Table 6: As-Is CA-MMIS COO Table (Care Management).......................41
Table 7: As-Is CA-MMIS COO Table (Contractor Management)..............42
Table 8: As-Is CA-MMIS COO Table (Financial Management)................43
Table 9: As-Is CA-MMIS COO Table (Member Eligibility and Enrollment Management)...........................................................................................47
Table 10: As-Is CA-MMIS COO Table (Member Management)...............47
Table 11: As-Is CA-MMIS COO Table (Operations Management)...........48
Table 12: As-Is CA-MMIS COO Table (Plan Management).....................50
Table 13: As-Is CA-MMIS COO Table (Provider Eligibility Management) 52
Table 14: As-Is COO Table (Performance Management).........................55
Table 15: As-Is COO Table (Provider Management)................................56
Table 16: Release 1 Business Functionality.............................................61
Table 17: Quality Attributes to Measure Business Process......................64
Table 18: Template for Business Capability Matrix (BCM).......................65
Table 19: Business Architecture - Assumptions, Constraints, and Risks. 68
Table 20: CA-MMIS Actors Catalog..........................................................81
Table 21: CA-MMIS As-Is and To-Be Maturity Levels............................123
Table 22: CA-MMIS Primary Actor Interactions with Business Processes................................................................................................................133
List of FiguresFigure 1: Relationship Between MITA Business Architecture Artifacts.....13
Figure 2: Business Process Model Components......................................14
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Figure 3: Business Processes and Business Capabilities........................16
Figure 4: Actors Catalog Diagram............................................................31
Figure 5: As-Is CA-MMIS Business Processes.........................................34
Figure 6: As-Is CA-MMIS Context Diagram..............................................36
Figure 7: The CA-MMIS Health Enterprise System Exchange and Access Environment.............................................................................................58
Figure 8: To-Be COO Diagram (CA-MMIS HE System)...........................60
Figure 9: As-Is and To-Be CA-MMIS Transformation Characteristics......62
Figure 10: COO (Business Architecture Transition)..................................63
Figure 11: MITA Maturity Level.................................................................65
Figure 12: Medi-Cal Enterprise...............................................................142
Figure 13: Roadmap for Releases 1 – 5.................................................143
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Preface
Executive Policies
The 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 Responsibility
The 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 History
Version Date Description Author
0.01 9/17/2012 Initial draft of COO Alok Kumar, Bonnie Lam
0.02 9/20/2012 Revised draft Leyla Avila
0.03 9/26/2012 QM initial review of COO document
Sharisse Baltikauskas
0.04 9/27/2012-9/28/2012
Update based on QM initial review
Alok Kumar, Barbara Jones, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh
0.05 10/3/2012-10/5/2012
Update based on DHCS comments
Alok Kumar, Barbara Jones, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh
0.06 10/09/2012 EPMO Review Tanya Sachdeva
0.07 10/11/2012 QM Review Sharisse Baltikauskas
Concept of Operations 6
Version Date Description Author
0.08 10/12/2012-10/14/2012
Update based on QM review Denise Walsh, Bonnie Lam
0.09 10/15/2012 Final QM Review Sharisse Baltikauskas
0.10 10/15/2012 Updated Figures 4 & 14 and removed “PA” from Definitions Table
Bonnie Lam, Denise Walsh
0.11 10/29/2012 Updated based on additional findings from DHCS’ final review.
Alok Kumar, Bonnie Lam, Leyla Avila, Akon Offiong, Denise Walsh
0.12 11/7/2012 QM Review for resubmission Sharisse Baltikauskas
0.13 11/08/2012 Updated based on QM review of responses to DHCS’ final review.
Denise Walsh
0.14 11/09/2012 Final QM Review for resubmission
Sharisse Baltikauskas
1.00 11/20/2012 DHCS approved Tanya Sachdeva
1.01 10/16/2013 – 12/03/2013
Updated 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 Cruz
1.02 12/04/2013 Accepted track changes and distributed draft for peer review.
Denise Walsh
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Version Date Description Author
1.03 12/04/2013 Incorporated 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 Stewart
1.04 12/10/2013 Accepted track changes and prepared document for submission to DHCS for informal review.
Denise Walsh
1.05 01/09/2014 Deleted 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 Jones
1.06 01/27/2014 Updated 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 Walsh
Concept of Operations 8
Version Date Description Author
1.07 02/06/2014 Added a discussion of the modified agile approach.
Added Appendix E (Roadmap for Releases).
Alok Kumar, John Stewart, Denise Walsh
1.08 02/11/2014 Updated Actor Impacts table. Added statement before Table 19 for clarity.
General formatting cleanup.
Prepare document for final submission.
Alok Kumar, Barbara Jones, Denise Walsh
1.09 03/04/2014 Updated the definition of “stakeholder” throughout document, based on feedback received from the DHCS Transition Team.
Denise Walsh
2.0 03/07/2014 DHCS Approval Deirdre Smith
Concept of Operations 9
1. Introduction
A 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:
1. Achieve a Medicaid Management Information System (MMIS) that moves the State Medi-Cal program administration higher in the MITA maturity model.
2. Exhibit the interoperability and reusability required by MITA.3. Create an environment for integrating the business and information technology (IT)
environments to improve the management of the Medi-Cal Program.4. Provide a solid platform for future growth with scalable architecture that can grow and
change with the Medi-Cal Program.5. Support DHCS’ move toward Health Information Exchange (HIE)/Health Information
Technologies (HIT) to support improved outcomes and quality services for Medi-Cal members.
6. Support enhanced fraud detection and prevention strategies.7. Align CA-MMIS with current industry MITA and Service Oriented Architecture (SOA)
guidelines.8. Meet current federal regulation for reporting in compliance with Health Information
Portability and Accountability Act (HIPAA).9. Provide easier access for the Provider community to submit and correct claim
documents and retrieve status information, help and billing information electronically.10. 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 enhancements
11. Meet the Seven Conditions and Standards to qualify for Enhanced Federal Financial Participation (FFP).
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12. Technology that supports DHCS programs into the future, in such a manner that business requirements drive enhancements rather than system limitations driving business decisions.
13. 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.
14. 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.
15. A system that interfaces with other systems in a seamless framework that supports coordination with providers and other stakeholders.
16. A system that supports web-based self-service for provider/pharmacist processing needs.
17. 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.
18. 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.
1.1 Business Architecture (BA) – Alignment to MITA
The 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
Concept of Operations 11
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.
1.1.1 Business Architecture Artifacts
The 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:
1. COO2. Business Process Model (BPM)3. Business Capability Matrix (BCM)
The BA is comprised of the following tool:
1. MMM
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The 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 1: Relationship Between MITA Business Architecture Artifacts
The following sections describe the MITA artifacts and tool that comprise the BA.
1.1.2 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
Concept of Operations 13
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.
Figure 2: Business Process Model Components
OHC 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.
Concept of Operations 14
1.1.3 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.
1.1.4 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.
Concept of Operations 15
Figure 3: Business Processes and Business Capabilities
BCM details will be captured by the State in their BCM artifact to gauge the maturity levels obtained by each of the business process.
1.2 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.
1. 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.
2. 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 1: Explanation of Global Definitions
Term Explanation
Actor Refers 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 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.
Concept of Operations 16
Term Explanation
Medi-Cal Business Process
Refers 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:
https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/DHCS%20MITA%20Business%20Processes%202.0%20to%203.0%20Crosswalk%20Catalog.xlsx
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 Catalog
MITA Business Process Refers to the MITA 3.0 business processes that are defined by CMS under the BA.
Stakeholder The 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.
1.3 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:
1. 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).
2. 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
Concept of Operations 17
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:
1. CA-MMIS Actors: a list of actors (with brief description) who interact with CA-MMIS directly or indirectly and their impacts.
2. 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.
1.4 Document Constraints
The 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.
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1.5 Referenced Documents
The following table displays a list of documents referenced in this COO.
Table 2: Referenced Documents
Referenced Document
Document Location Version # and Date
CA-MMIS System Replacement – Architecture Plan
Xerox Link: https://cammis.sp.acs-inc.com/sites/lib/Deliverable%20Library/Architecture%20Plan.docx
Version 3.08
July 2, 2013
DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/lib/Deliverable%20Library/Architecture%20Plan.docx
SharePoint Navigation Path: CA-MMIS Home > Deliverables > Deliverables Library > Del ID : DPP.0003 Architecture Plan > Architecture Plan
California Department of Health Care Services Strategic Plan
http://www.dhcs.ca.gov/Documents/DHCS%20Strategic%20Plan.pdf October 2008
DHCS Division Descriptions
http://www.dhcs.ca.gov/Documents/DHCS%20Division%20Descriptions%20May%202012.pdf
May 2012
Enhanced Funding Requirements: Seven Conditions and Standards – Medicaid IT Supplement (MITS-11-01-v1.0)
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Downloads/EFR-Seven-Conditions-and-Standards.pdf
Version 1.0
April 2011
Medi-Cal Enterprise Business Process Diagram
Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/COO%20-%20Medi-Cal%20Enterprise%20Business%20Process%20Diagram.vsd
August 29, 2013
DHCS Link : https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/COO%20-%20Medi-Cal%20Enterprise%20Business%20Process%20Diagram.vsd
SharePoint 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 Diagram
CA-MMIS MITA Workgroup SS-
Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip
Version 1.3
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Referenced Document
Document Location Version # and Date
A based on MITA 2.0
May 30, 2008DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Medi-Cal_MITA_SS-A%20Based%20on%20MITA%202.0.zip
SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites> System Replacement > Documents > Reference > Category : Architecture > Med-Cal_MITA_SS-A Based on MITA 2.0
Medi-Cal MITA SS-A Interim Report (Medi-Cal business processes and maturity level ratings) based on MITA 3.0
Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx
August 6, 2013
DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/State%20BP%20Ratings%2020130806.xlsx
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 20130806
MITA 3.0 Framework
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Medicaid-Information-Technology-Architecture-MITA.html
Version 3.0
February 2012
MITA 3.0, Part I Business Architecture, Chapter 2 - Concept of Operations
Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf
Version 3.0
February 2012
DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Chapter%202%20Concept%20of%20Operations%203.0.pdf
SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Reference > Category : Standards > more… > Part I Chapter 2 Concept of Operations 3.0
MITA 3.0, Part I Business Architecture, Appendix A - Concept of Operations Details
Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf
Version 3.0
February 2012
DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Reference/Part%20I%20Appendix%20A%20Concept%20of%20Operations%20Details%203.0.pdf
SharePoint Navigation Path: CA-MMIS Home > CA-MMIS Sites > System Replacement > Documents > Reference > Category : Standards > more… > Part I Appendix A Concept of Operations Details 3.0
MITA Workgroup Charter
Xerox Link: https://cammis.sp.acs-inc.com/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf
December 7, 2012
DHCS Link: https://cammis-sp.psd.dhs.ca.gov/sites/ddi/Shared%20Documents/Scanned_Approved_Charter_MITA_Architecture_WG.pdf
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 WG
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Referenced Document
Document Location Version # and Date
Risks Log Xerox Link: https://cammis.sp.acs-inc.com/cammis/Lists/Risks/O_P_Risks.aspx
Not Applicable
DHCS Link: https://cammis-sp.psd.dhs.ca.gov/cammis/Lists/Risks/O_P_Risks.aspx
SharePoint Navigation Path: CA-MMIS Home > Risks
1.6 Definitions
This section lists glossary terms and acronyms specifically applicable to this document.
Table 3: Definitions
Term/Acronym Explanation/Expansion
A&I Audits & Investigations
A/R Accounts Receivable
AB Assembly Bill
ACA Affordable Care Act
ACMS Automated Collection Management System
Actor Refers 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.
AD DHCS Administration Division
ADA Americans with Disabilities Act
ADM Administration Division
AEVS Automated Eligibility Verification System
AIIHI American Indian Infant Health Initiative
AVRS Automated Voice Response System
BA Business Architecture which describes the needs and goals of the State and presents a collective vision of the future
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Term/Acronym Explanation/Expansion
BCM Business 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 maturity
BCMP Business Change Management Plan
BIC Beneficiary Identification Card
BPM Business Process Model
BPMN Business Process Model and Notation
BPT Business Process Template
BRMS Business Rules Management System
BWARD Benefits & Waiver Analysis Division
CAASD Clinical Assurance and Administrative Support Division
CAH Critical Access Hospital
CalMEND California Mental Health Care Management Program
CalSORH California State Office of Rural Health
CA-MMIS California Medicaid Management Information System
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.
CA-MMIS Health Enterprise System
The name of the CA-MMIS Replacement System once it has been fully implemented in CA-MMIS Replacement System Project
CA-MMIS Replacement System
The name of the approach being designed, developed, and implemented in response to the requirements specified in DHCS Requests for Proposal (RFP) 08-85022.
CAQH Council for Affordable Quality Healthcare
CCB Change Control Board
CCS California Children’s Services
CDA California Department of Aging
CDPH California Department of Public Health
CEAP California Enterprise Architecture Program
CFR Code of Federal Regulations
CHDP Child Health & Disability Prevention Program
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Term/Acronym Explanation/Expansion
CMS Centers for Medicare & Medicaid Services
CMS-DHCS Children’s Medical Services Branch of DHCS
CMSP County Medical Services Program
COHS County Organized Health System
COO Concept of Operations
CORE Committee on Operating Rules for Information Exchange
COTS Commercial 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.
CRDD Capitation Rates Development Division
CSC California Children’s Services
CTA California Technology Agency
DHCS Department of Health Care Services
DMC Dental Managed Care Plan
DMC Drug Medi-Cal
DMH Department of Mental Health
DOF Department of Finance
DOJ Department of Justice
DPHP Designated Public Hospital Project
DRAMS Drug Rebate Analysis & Management System
DRG Diagnostic Related Group
DRU Drug Rebate Unit
DSH Department of State Hospitals
DUR Drug Use Review
EDI Electronic Data Interchange
EDU Encounter Data Unit
EFT Electronic Funds Transfer
ERA Electronic Remittance Advice
FAU Financial Analysis Unit
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Term/Acronym Explanation/Expansion
FDB First Data Bank
FFB Fiscal Forecasting Branch
FFP Federal Financial Participation
FFS Fee For Service
FFSRDD Fee-For-Service Rates Development Division
FI Fiscal Intermediary
FIPS Federal Information Processing Standards
FISMA Federal Information Security Management Act
FLEX Medicare Rural Hospital Flexibility
FMB Financial Management Branch
FPACT Family 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.
FTB Franchise Tax Board
GHPP Genetically Handicapped Persons Program
HAM Health Administration Manual
HCBS Home & Community Based Services
HCPCS Healthcare Common Procedure Coding System
HE Health Enterprise
HHS Department of Health and Human Services
HIE Health Information Exchange
HIPAA Health Insurance Portability and Accountability Act of 1996
HIPP Health Insurance Premium Payment
HIT Health Information Technologies
HITECH Health Information Technology for Economic and Clinical Health Act of 1996
HIX Health Insurance Exchange
HUCDS Hospital/Uninsured Care Demonstration Section
IH Indian Health
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Term/Acronym Explanation/Expansion
IRS Internal Revenue Service
ISO International Organization for Standardization
IT Information Technology
ITSD Information Technology Services Division
KDE Key Data Entry
LEA Local Educational Agency
LGA Legislative & Governmental Affairs
LGBT Lesbian, Gay, Bisexual & Transgender
LIHP Low Income Health Program Division
LTCD Long Term Care Division
MAR Management Administrative Reports
MC Medi-Cal Consultant
MCED Medi-Cal Eligibility Division
MCO Managed Care Organization
MCP Managed Care Plan
MCP Managed Care Plan
MDSD Medi-Cal Dental Services Division
MedCCC Medi-Cal Claims Customer Service Office
Medi-Cal The 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 Process
Refers 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.
MEDS Medi-Cal Eligibility Data System
MEDS Medi-Cal Eligibility Data System
MHP Mental Health Plan
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Term/Acronym Explanation/Expansion
MITA Medicaid Information Technology Architecture
MITA Business Process
Refers to the MITA 3.0 business processes that are defined by CMS under the Business Architecture.
MITA Condition One 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 Level The 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.
MMA Medicare Modernization Act
MMCD Medi-Cal Managed Care Division
MMIS Medicaid Management Information System
MMM MITA Maturity Model
MPSG Medical Professional Service Group
MRB Medical Review Branch
MSPS Medi-Cal Supplemental Payment Section
NIST National Institute of Standards and Technology
NOA Notice of Action
O&E Provider Outreach and Education Department
OCR Office of Civil Rights
OCR Optical Character Recognition
OFP Office of Family Planning
OHC Office of HIPAA Compliance
OHIT Office of Health Information Technology
OIL Operating Instruction Letter
OLS Office of Legal Services
OMB Office of Management and Budget
OMCP Office of Medi-Cal Procurement
OMH Office of Multicultural Health
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Term/Acronym Explanation/Expansion
OPA Office of Public Affairs
OTD Xerox Operations Training Department
OWH Office of Women’s Health
PA Prior Authorization
PAVE Provider Application Verification and Enrollment
PBD Pharmacy Benefits Division
PBM OS+ Pharmacy Benefit Management Open System
PC Pharmacy Consultant
PED Provider Enrollment Division
PHP Prepaid Health Plan
PIU Provider Integrity Unit
PMF Provider Master File
POB Program Operations Branch
PRHD Primary & Rural Health Division
PRU Provider Review Unit
PUBS Publications
QAF Quality Assurance Fee
R&C Research and Correspondence
RAD Remittance Advice Details
RAIS Rebate Accounting and Information System
RFA Requests For Application
RFP Requests For Proposal
RHSD Rural Health Services Development
RSA Rational Software Architect
SAM State Administrative Manual
SAMW Seasonal Agricultural and Migratory Workers Program
SAR Service Authorization Request
SCD Systems of Care for Children and Adults Division
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Term/Acronym Explanation/Expansion
SCO State Controller’s Office
SDN Software Development Notice
Seven Conditions and Standards
Conditions 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.
SG System’s Group
SHIP Small Rural Hospital Improvement Program
SIMM State Information Management Manual
SLA Service Level Agreement
SMA State Medicaid Agency
SmartPA© Automated authorization tool for pharmacy claims
SMH Specialty Mental Health
SMSB Statewide Medical Services Branch
SNFD Safety Net Financing Division
SOA Service Oriented Architecture
SPBU Small Provider Billing Unit
SPCP Office of Selective Provider Contracting Program
SS-A State Self-Assessment
Stakeholder 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.
SUDS Substance Use Disorder Services
SURS Surveillance and Utilization Review Subsystem
TAR Treatment Authorization Request
TOGAF The Open Group Architecture Framework
Concept of Operations 28
Term/Acronym Explanation/Expansion
TPL Third Party Liability
TPLRD Third Party Liability and Recovery Division
Transfer Systems The 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.
TSC Telephone Service Center
UMD Utilization Management Division
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2. CA-MMIS Actors Catalog
An 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.
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Figure 4: Actors Catalog Diagram
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3. As-Is CA-MMIS
The 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.
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3.1 As-Is CA-MMIS Business Processes
The 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.
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.
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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.
Figure 5: As-Is CA-MMIS Business Processes
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3.2 As-Is CA-MMIS Context Diagram
The 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.
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Figure 6: As-Is CA-MMIS Context Diagram
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Table 4: CA-MMIS Primary Entities
Actor Name Description Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound & Outbound Interaction to/from CA-MMIS
Provider Refers 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.
Member Refers 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/A N/A Beneficiary Identification Card (BIC) - refers to the identification card that allows providers to determine Members’ eligibility and enrollment status to the Medi-Cal program.
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Actor Name Description Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound & Outbound Interaction to/from CA-MMIS
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 Members.
Networks – indicates providers authorized to perform services on behalf of the MCO in support of approved Members.
N/A N/A
Medicare and Other Payers
Medicare 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/A Inquiries/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).
CMS Refers 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).
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Actor Name Description Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound & Outbound Interaction to/from CA-MMIS
DHCS and Other State Agencies
Refers 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).
3.2.1 Business Associates
The 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.
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Table 5: CA-MMIS Business Associates
Actor Name Description
First 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/Labelers Receives drug rebate invoices and submits rebates to DHCS. These entities are contracted with CMS and DHCS on drug rebate.
Submitters Sends claims to CA-MMIS on behalf of providers. Also known as “Clearinghouses.”
3.3 As-Is CA-MMIS COO
The 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.
3.3.1 As-Is CA-MMIS COO – Inbound/Outbound Transactions
This 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.
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3.3.1.1 Care Management
Table 6: As-Is CA-MMIS COO Table (Care Management)
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS DHCS & OTHER STATE AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Authorization Determination
Authorize CCS/GHPP Services
Receive Service Authorization Request (SAR)
Send adjudicated SAR response
N/A Receive SAR review result from CMSNet
Send SAR for review to CMSNet
Send SAR utilization data
N/A
Medi-Cal Treatment Authorization Requests (TARs)
Receive TAR
Send adjudicated TAR response
N/A Receive TAR review result from Pharmacy/Medi-Cal Consultant
Send TAR for review to Pharmacy/Medi-Cal Consultant
Send TAR utilization data
N/A
Case Management
Authorize Treatment Plan
Receive treatment plan
Send authorized treatment plan
N/A N/A N/A N/A
Establish Case
Receive Medi-Cal Case
N/A N/A Create a Medi-Cal Case
N/A N/A
Establish CCS/GHPP Case
Receive CCS/GHPP Case
N/A N/A Create a CCS/GHPP Case
N/A N/A
Manage Case Information
Receive Medi-Cal Case details
N/A N/A N/A N/A Retrieve and work a Medi-Cal Case
Manage CCS/GHPP Case
Receive CCS/GHPP Case details
N/A N/A N/A N/A Retrieve and work a CCS/GHPP Case
Concept of Operations 41
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS DHCS & OTHER STATE AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Perform Screening and Assessment
Receive TAR or claim for processing and perform clinical screening.
Send adjudicated TAR response or adjudicated claim response
N/A N/A N/A N/A
Manage Treatment Plan and Outcomes
N/A N/A N/A Receive electronic records
N/A N/A
State Specific Reserve Service
Receive reservation requests
N/A N/A N/A N/A N/A
3.3.1.2 Contractor Management
Table 7: As-Is CA-MMIS COO Table (Contractor Management)
CA-MMIS Business Category
CA-MMIS Business Process
DHCS & OTHER AGENCIES BUSINESS ASSOCIATES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Contractor Support
Manage Medi-Cal Contractor Communication
N/A Communicate information to DHCS
N/A N/A Post documentation and communications to SharePoint
N/A
Contract Management
Manage CA-MMIS Fiscal Intermediary (FI) Contract
Communication information from DHCS
N/A Receive FI Letters and send response letters
N/A N/A N/A
Concept of Operations 42
3.3.1.3 Financial Management
Table 8: As-Is CA-MMIS COO Table (Financial Management)
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO CMS DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Accounts Payable Management
Manage 1099 N/A N/A Receive & send 1099 information
N/A Send 1099 reports
Receive 1099 information
Send 1099 information
Manage Incentive Payment
Receive incentive payment request
Process incentive payment and send payment information
N/A N/A N/A Receive incentive payment request
Send incentive payment information
Manage Medi-Cal Accounts Payable Information
N/A N/A N/A N/A N/A Receive warrant numbers for Medi-Cal payments
Send Accounts Payable (A/P) information
Manage Medi-Cal Payable Disbursement
N/A Weekly Check write from CA-MMIS
N/A N/A Send Weekly Check
Write data to SCO
Receive Provider disbursement transactions
Send Provider disbursement payment information
Concept of Operations 43
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO CMS DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Manage Contractor Payment
N/A Send payment request to Financial Management Branch (FMB)
N/A N/A N/A Send payment request to FMB
Send Contract Management / payment reports from CA-MMIS
Manage Medicare Premium Payment
Store Medicare buy-in Premium Payment information
N/A N/A N/A N/A N/A Executed by DHCS Third Party Liability and Recovery Division (TPLRD)
Manage Health Insurance Premium Payments
Store Medicare buy-in Premium Payment information
N/A N/A N/A N/A N/A Executed by DHCS TPLRD
Accounts Receivable Management
Manage Cost Reports Settlement
N/A N/A N/A N/A N/A Receive Accounts Receivable (A/R) recoupment transaction information
Send Provider payment information
Manage Drug Rebate N/A N/A N/A Receive MCO information for drug rebate
Send CMS reports for drug rebate information
Receive drug claims data
Send drug rebate information
Concept of Operations 44
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO CMS DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Manage Medi-Cal Accounts Receivable Funds
N/A N/A N/A N/A Receive funds information to determine provider payments (no budget process)
Send check-write information
Manage Medi-Cal Accounts Receivable Information
N/A N/A N/A N/A N/A Receive A/R transaction initiation request
Send A/R transaction reports
Manage Overpayment Recoupment
N/A N/A N/A N/A N/A Appeals process overpayment / recoupment
Create Provider recoupment transactions
Manage TPL Recovery
N/A Send Third Party Liability (TPL) letters
N/A N/A N/A N/A Send TPL analysis results, recoupment transaction information
Manage Estate Recovery
Store data in the Automated Collection Management System (ACMS)
N/A Store Vital Records Data in CAMMIS Member Subsystem (MEDS)
N/A N/A N/A Overseen by DHCS TPLRD
Concept of Operations 45
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO CMS DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
State Specific Manage Member Health Care Reimbursement
CA-MMIS is used to validate Medi- Cal member/provider eligibility and Service coverage for medical services
N/A N/A N/A N/A CA-MMIS is used to validate Medi- Cal member/provider eligibility and service coverage for medical services
Member Reimbursement checks are distributed by the State Controller’s Office
Fiscal Management
Manage State Funds N/A N/A N/A N/A N/A N/A Send Contract Management/payment
reports from CA-MMIS
Formulate Medi-Cal Budget
N/A Weekly Check write from CA-MMIS
N/A N/A N/A N/A Weekly Check write from CA-MMIS
Generate Medi-Cal Budget Estimates Financial Report
N/A Weekly Check write from CA-MMIS
N/A N/A N/A N/A Weekly Check write from CA-MMIS
Concept of Operations 46
3.3.1.4 Member Eligibility and Enrollment Management
Table 9: As-Is CA-MMIS COO Table (Member Eligibility and Enrollment Management)
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Member Enrollment
Inquire Medi-Cal Eligibility
Receive member eligibility Inquiry transactions
Send member eligibility response
N/A
3.3.1.5 Member Management
Table 10: As-Is CA-MMIS COO Table (Member Management)
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Member Support Management
Manage Medi-Cal Applicant and Member Communication
N/A N/A Receive request for TAR in the Field Office
Receive Notice of Action (NOA) letter from Consultants.
NOA letters are printed and mailed out.
Concept of Operations 47
3.3.1.6 Operations Management
Table 11: As-Is CA-MMIS COO Table (Operations Management)
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO MEDICARE & OTHER PAYERS
DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound Interaction to CA-MMIS
Inbound Interaction to CA-MMIS
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Claims Adjudication
Submit Medi-Cal Claim Attachment
Receive claim attachments
N/A N/A N/A N/A N/A N/A
Apply Medi-Cal Mass Adjustment
N/A N/A N/A N/A Receive mass adjustment changes
N/A N/A
Process Medi-Cal Claim
Receive Medi-Cal Claim
Send Medi-Cal claim adjudication response
N/A Receive Crossover claims
Receive policy changes to process Medi-Cal claims
N/A N/A
Payment and Reporting
Generate Medical Remittance Advice
N/A Send medical remittance advice details (RAD)
N/A N/A N/A Send medical remittance advice information
N/A
Inquire Medi-Cal Payment Status
Receive Medi-Cal Payment request
Send Medi-Cal payment inquiry response
N/A N/A N/A N/A N/A
Concept of Operations 48
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO MEDICARE & OTHER PAYERS
DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound Interaction to CA-MMIS
Inbound Interaction to CA-MMIS
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Manage Data N/A N/A N/A N/A Receive reference data [FDB, Healthcare Common Procedure Coding System (HCPCS), etc.]
N/A Retrieve data; Update data
Process Encounter
Process Managed Care Encounter
N/A N/A Receive Managed Care encounter data
N/A N/A Send Manage Care Encounter reports
N/A
Concept of Operations 49
3.3.1.7 Plan Management
Table 12: As-Is CA-MMIS COO Table (Plan Management)
CA-MMIS Business Category
CA-MMIS Business Process
CMS DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Plan Administration
Maintain Program Policy
N/A N/A N/A FI Letter requesting updates to program policy
N/A N/A
Health Plan Administration
Manage Medi-Cal Program Information
Define policies; initiate tasks to update policies
N/A N/A Define policies; initiate tasks to update policies in CA-MMIS
Update Provider bulletin Web page
N/A
Develop and Manage Performance Measures
N/A N/A N/A N/A Generate/send performance measure reports
N/A
Health Benefits Administration
Maintain Benefits-Reference Information
Define policies; Initiate tasks to update policies in CA-MMIS
N/A N/A Receive policies; Initiate tasks to update policies in CA-MMIS
N/A N/A
Manage Benefit Information
N/A N/A N/A Receive policies; initiate tasks to update policies in CA-MMIS
N/A N/A
Manage Drug Formulary
N/A N/A N/A Receive policies; initiate tasks to update Formulary File and associated tables
N/A N/A
Concept of Operations 50
CA-MMIS Business Category
CA-MMIS Business Process
CMS DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Manage Rate Setting
N/A N/A N/A Receive policies; initiate tasks to update policies in CA-MMIS
N/A N/A
Concept of Operations 51
3.3.1.8 Provider Eligibility Management
Table 13: As-Is CA-MMIS COO Table (Provider Eligibility Management)
CA-MMIS Business Category
CA-MMIS Business Process
Provider DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Provider Enrollment
Enroll Medi-Cal Provider
Submit enrollment applications (out-of-state Providers)
Send approval/denial letter (out-of-state Providers)
N/A N/A N/A N/A
Inquire Medi-Cal Provider Information
N/A N/A Receive/send inquiry transactions
N/A N/A Receive/send inquiry transactions
Determine Medi-Cal Provider Eligibility
N/A N/A N/A Provider Enrollment Division determines the enrollment of providers
N/A N/A
Determine Provider Eligibility for Incentive Program
N/A N/A N/A CA-MMIS Provider Subsystem: Verifies authorized Medi-Cal providers and includes provider data in the Provider Master File (PMF).
N/A N/A
Determine CHDP
N/A N/A N/A Provider Enrollment Division
N/A N/A
Concept of Operations 52
CA-MMIS Business Category
CA-MMIS Business Process
Provider DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Provider Eligibility
determines the enrollment of CHDP providers
Enroll Drug Medi-Cal Provider
N/A N/A Providers 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/A N/A
Enroll Mental Health Provider
N/A N/A Providers 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 PMF
N/A N/A
Enroll Dental Provider
N/A N/A N/A N/A N/A N/A
Enroll CCS Provider
N/A N/A N/A CMSNet 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 GHPP
N/A N/A
Concept of Operations 53
CA-MMIS Business Category
CA-MMIS Business Process
Provider DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Enroll CHDP Provider
N/A N/A N/A CA-MMIS CHDP Subsystem: Stores CHDP provider enrollment information that is accessed during CHDP claims processing.
N/A N/A
Disenroll Medi-Cal Provider
N/A N/A N/A CA-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/A N/A
Disenroll Dental Provider
N/A N/A N/A N/A N/A N/A
3.3.1.9 Performance Management
Table 14: As-Is COO Table (Performance Management)
Concept of Operations 54
CA-MMIS Business Category
CA-MMIS Business Process
DHCS & OTHER AGENCIES
Inbound Interaction to CA-MMIS Outbound Interaction from CA-MMIS
Inbound/Outbound Interaction
Compliance Management Determine Adverse
Action IncidentReceive information to add Providers to Suspect Hold; receive TPL cases
Send Suspect Hold reports & Audits & Investigations (A&I) transaction information
N/A
Identify Utilization Anomalies N/A Send utilization data and reports N/A
Establish Compliance Incident N/A Send utilization data and reports N/A
Manage Compliance Incident Information N/A Send utilization data and reports N/A
Prepare Beneficiary Confirmation Letters N/A Send utilization data and reports N/A
3.3.1.10 Provider Management
Table 15: As-Is COO Table (Provider Management)
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Provider Information Management
Manage Medi-Cal Provider Information
Receive Provider data update
N/A N/A Receive network provider data
N/A N/A
Concept of Operations 55
CA-MMIS Business Category
CA-MMIS Business Process
PROVIDERS MCO
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Inbound Interaction to CA-MMIS
Outbound Interaction from CA-MMIS
Inbound/ Outbound Interaction
Provider Support
Manage Medi-Cal Provider Communication
N/A Publish provider communications
N/A N/A N/A N/A
Perform Medi-Cal Provider Outreach
N/A Provides support & training
N/A N/A N/A N/A
Perform Family Planning, Access, Care, and Treatment (FPACT) Provider Outreach
N/A Provides FPACT training
N/A N/A N/A N/A
Manage Medi-Cal Fee-for-Service (FFS) Provider Grievance & Appeal
Receives appeals & grievance
Send Claims appeals adjudication information
N/A N/A N/A N/A
Concept of Operations 56
4. To-Be CA-MMIS
In 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.
4.1 The CA-MMIS Health Enterprise System Information Exchange and Access Environment
The 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.
Concept of Operations 57
Figure 7: The CA-MMIS Health Enterprise System Exchange and Access Environment
Concept of Operations 58
4.2 To-Be CA-MMIS COO
The 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.
Concept of Operations
Concept of Operations 60
Figure 8: To-Be COO Diagram (CA-MMIS HE System)
4.3 To-Be Environment of CA-MMIS Business Process Implementation in System Replacement Project
In 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 16: Release 1 Business Functionality
# Business Functionality
1 Development of the framework to retrieve Member Eligibility data (HIPAA X12 270/271 transactions requests/responses from FAME/MEDS
2 Development of the framework for making To-Be systems as the system of record for all Reference Data and integration with Legacy
3 Development of the framework for making To-Be systems as the system of record for all Formulary data and integration with Legacy
4 Development of the framework for managing rate settings
5 Development of the framework for managing benefit plans
6 Provider Enrollment/Disenrollment functionality; integration with Provider Master Files and PAVE, along with Provider maintenance and inquiry
7 Building the framework for determining Medi-Cal Provider eligibility, including incentive program
8 Integration of Legacy RAIS invoices with To-Be Rebate Web to allow manufacturers and labelers to view their invoices
9 Provider Outreach and Communication Management through correspondences and contact management, and publications to upload static information such as manuals, bulletins, and FAQs
10 Management of Medi-Cal Program information
11 Management of Program Policy
12 HE Portal integration to access Legacy IHO/MCM Case information
13 HE Portal integration to access Legacy Grievance & Appeal information
Concept of Operations 61
4.4 Transition from As-Is to To-Be
The current state (As-Is) of the DHCS CA-MMIS is:
Multiple program access routes and interfaces for stakeholders Disparate state repositories Limited coordination between business areas Multiple variants for business area processes
The future vision (To-Be) for DHCS CA-MMIS includes but is not limited to:
Consolidated interfaces with program stakeholders Consolidated data repositories accessible throughout the agency Business area consolidation Improved coordination between programs and business processes
The 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 9: As-Is and To-Be CA-MMIS Transformation Characteristics
Concept of Operations 62
The transition of the CA-MMIS from a MITA Business Architecture perspective is shown in the following diagram.
Figure 10: COO (Business Architecture Transition)
4.4.1 Effectiveness – Increase Business Maturity
Business 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 process Data accuracy and accessibility Ease of performance/efficiency Cost effectiveness Quality of process results Value to stakeholders
The 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).
Concept of Operations 63
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 17: Quality Attributes to Measure Business Process
Quality Attribute Description
Timeliness of Business Process
Time 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 Accessibility
Ease of access to data that the Business Process requires and the timeliness and accuracy of data used by the Business Process
Ease of Performance Level of effort necessary to perform the Business Process given current resources
Cost Effectiveness Ratio of the amount of effort and cost to the outcome
Quality of Process Results
Demonstrable benefits from using the Business Process
Utility of Value to Stakeholders
Impact of the Business Process on individual members, providers, and State staff
Concept of Operations 64
Figure 11: MITA Maturity Level
Table 18: Template for Business Capability Matrix (BCM)
BUSINESS PROCESS : <NAME>
Level 1 Level 2 Level 3 Level 4 Level 5Quality: Timeliness of Business Process
Quality: Data Accuracy and Accessibility
Quality: Efficiency, Ease of Performance
Quality: Cost Effectiveness
Quality: Quality of Process Results
Quality: Utility of Value to Stakeholders
Concept of Operations 65
4.4.2 Effectiveness – Improved Performance Standards
DHCS 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 patterns Supporting current level and future growth in the number of users System availability System response time for online transactions, reports and interfaces
4.5 Compliance
CA-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.
4.5.1 Security and Confidentiality
Security and Confidentiality for System Replacement facilities and applications are compliant to:
Federal Information Processing Standards (FIPS) Publications State 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-130 Federal Information Security Management Act (FISMA) Compliance Applicable International Organization for Standardization (ISO) Standards Sarbanes Oxley California Civil Code Section 1798.29 & 1798.82 Assembly 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) Publications DHCS IT Project Security Requirements 1 (SR 1) Health Information Technology for Economic and Clinical Health Act of 1996 (HITECH)
4.5.2 System Security and Privacy
System 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).
Concept of Operations 66
4.5.3 Other Standards for Compliance
GUI/Access/Web Services California 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) Guidelines Web service standards (Oasis and W3C) NIST 800-95 Guide to Secure Web Services MITA Technical Reference Architecture
State Medicaid Manual: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html
State Information Management Manual (SIMM) – IT Policy: http://www.cio.ca.gov/Government/IT_Policy/SIMM.html
4.6 Critical Business Processes
A 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.
4.7 Business Architecture – Assumptions, Constraints, and Risks
The 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.
Concept of Operations 67
Table 19: Business Architecture - Assumptions, Constraints, and Risks
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Care Management Authorize Treatment Plan CA 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 Management Establish Case To-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 Case To-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 Information HIE 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 Case HIE 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.
Concept of Operations 68
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Manage Treatment Plan and Outcomes
CA 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 Assessment
HIE 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 Management Reserve Service None 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 Management
Manage CA-MMIS FI Contract The 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.
Concept of Operations 69
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Manage Medi-Cal Contractor Communication
Health 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 Management
Formulate Medi-Cal Budget CM64 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 Report
CM64 enhancements will automate some of the reporting to CMS.
None identified at this time.
None identified at this time.
Manage 1099 None through maturity level 2.
None identified at this time.
None identified at this time.
Manage Contractor Payment CA 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 Management
Manage Cost Reports Settlement
None through maturity level 2.
None identified at this time.
None identified at this time.
Manage Drug Rebate Rebate 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 Recovery None through maturity level 2.
None identified at this time.
None identified at this time.
Concept of Operations 70
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Manage Health Insurance Premium Payments
CA 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 Payment None identified at this time.
None identified at this time.
Incentive payment triggers are not defined or may change.
Manage Medi-Cal Accounts Payable Information
None 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 Funds
None through maturity level 2.
None identified at this time.
None identified at this time.
Manage Medi-Cal Accounts Receivable Information
None assuming Maturity Level 2
None identified at this time.
None identified at this time.
Manage Medi-Cal Payable Disbursement
CA 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 Payment
CA 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 Management
Manage Member Health Care Reimbursement
CA 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.
Concept of Operations 71
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Manage Overpayment Recoupment
None 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 Funds None 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 Recovery Health 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 Management
Inquire Medi-Cal Eligibility Voice 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.
Concept of Operations 72
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Member Management
Manage Medi-Cal Applicant and Member Communication
Providers 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 Management
Apply Medi-Cal Mass Adjustment
Mass 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 Advice
CA 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 Status
CA 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 Data CA 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.
Concept of Operations 73
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Operations Management
Process Managed Care Encounter
Health 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 Claim
CA 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 Attachment
CA 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 Management Develop and Manage Performance Measures
CA 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 Information
CA 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.
Concept of Operations 74
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Manage Drug Formulary First Data Bank will continue to provide the updates to the formulary file.
None identified at this time.
None identified at this time.
Plan Management Manage Medi-Cal Program Information
None 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 Information There 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 Policy The 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 Setting The 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) Management
Determine Adverse Action Incident
None 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.
Concept of Operations 75
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Program Integrity (Performance) Management
Identify Utilization Anomalies CA 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 Incident None 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.
Concept of Operations 76
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Manage Compliance Incident Information
CA 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) Management
Prepare Beneficiary Confirmation Letters
None through maturity level 2
None identified at this time.
None identified at this time.
Concept of Operations 77
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Provider Eligibility and Enrollment Management
Enroll Medi-Cal Provider CA-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 Information
Automated 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.
Concept of Operations 78
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Provider Eligibility and Enrollment Management
Determine Medi-Cal Provider Eligibility
Determine 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 Program
Determine 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 Eligibility
Determine 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 Provider Determine 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.
Concept of Operations 79
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Provider Eligibility and Enrollment Management
Enroll Mental Health Provider Determine 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 Provider Determine 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 Provider Determine 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 Provider Disenrolling 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.
Concept of Operations 80
CA-MMIS Business Area CA-MMIS Business Process Assumptions Constraints Risks
Provider Eligibility and Enrollment Management
Disenroll Dental Provider Disenrolling 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 Management
Manage Medi-Cal Provider Communication
HIX 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 & Appeal
None identified at this time.
None identified at this time.
None identified at this time.
Manage Medi-Cal Provider Information
Only 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 Outreach
None identified at this time.
None identified at this time.
Communication needs to be properly planned, developed, targeted and delivered to specific provider groups or audiences.
Concept of Operations 81
Appendices
A. CA-MMIS Actors Catalog
The 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 Catalog
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Administration Division
ADM DHCS The 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;
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.
Concept of Operations 82
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Appeals Unit Examiner
Appeals Xerox Part 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 Division
A&I DHCS The 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
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.
Concept of Operations 83
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Benefits & Waiver Analysis Division
BWARD DHCS The 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
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
Concept of Operations 84
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
determine if any changes to their Departments’ internal process will be necessary.
California Department of Public Health
CDPH External
California Department of Public Health (CDPH) comprises:
Center for Chronic Disease Prevention and Health Promotion
Center for Infectious Diseases
Center for Family Health
Center for Environmental Health
Center for Health Care Quality
Health Information and Strategic Planning
Emergency Preparedness Office
Administration
Office of Public Affairs
The 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
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.
Concept of Operations 85
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
California Medicaid Management Information System Division
CA-MMIS Division
DHCS The 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
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.
Concept of Operations 86
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
new MMIS that represents current technology and support SOA, consistent with MITA.
Capitation Rates Development Division
CRDD DHCS Capitation 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
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.
Concept of Operations 87
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
stakeholders.
Cash Control Analyst
Cash Control
Xerox Part 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/A N/A Xerox 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 Services
CMS External
CMS 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 Provider
CHDP Provider
External
A subset of the Provider actor group. Provides medical services to members under the CHDP program
N/A N/A N/A CHDP Program submits claims to Medi-Cal and works with Medi-Cal
Concept of Operations 88
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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-DHCS DHCS The 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 Adjudication
Claims Adjudication
Xerox Part 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
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
Concept of Operations 89
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Adjudication is made up of the following two areas: Claims Suspense, and Appeals.
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 Operations
Claims Ops Xerox The 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 Examiner
Suspense Xerox Part 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.
Concept of Operations 90
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Clinical Assurance and Administrative Support Division
CAASD DHCS CAASD 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 Analyst
Cost Containment
Xerox Part 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.
Concept of Operations 91
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
County Office County External
Performs 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/A N/A Counties 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 Aging
CDA External
The 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
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 .
Concept of Operations 92
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Adult Day Health Care centers for the Medi-Cal program.
Department of Health Care Services
DHCS DHCS The 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 Justice
DOJ External
Works 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 Health
DMH External
The 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 Services
CDSS External
The California Department of Social Services is comprised of more than 54
CDSS will be kept informed of each release and the changes in the Medi-Cal processing systems that may impact the community they
Concept of Operations 93
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
offices throughout the State and is the state agency responsible for:
Ensuring efficient, accurate, and equitable delivery of payments and benefits
Providing services that foster self-sufficiency and dignity
Providing social services to the elderly, blind, disabled and other children and adults
Licensing and regulating foster homes, group homes, residential care facilities, day care facilities, and preschools
Evaluating eligibility of applicants for federal and State programs
serve.
Department of State Hospitals
DSH External
On 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 / Labeler
Labeler External
Contracted 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/A N/A N/A
Concept of Operations 94
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Drug Rebate Unit
DRU Xerox Part 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/A N/A Xerox DRU unit may be impacted by changes to forms processing that providers submit.
Drug Use Review
DUR Xerox Xerox 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 Unit
EDU Xerox Processes 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/A N/A 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.
Concept of Operations 95
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Fee-For-Service Rates Development Division
FFSRDD DHCS FFSRRD 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.
Concept of Operations 96
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
File Maintenance
Systems Group (SG)
Xerox The 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/A N/A File 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 Branch
FMB DHCS Performs 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 reporting
N/A N/A FMB should be informed of any changes to the CA-MMIS system that may impact financials, which will include claims processing and reporting
First Data Bank FDB External
Provides updates to formulary file First 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
N/A N/A N/A
Concept of Operations 97
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
submit.
Fiscal Forecasting Branch
FFB DHCS 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.
N/A N/A N/A N/A
Fiscal Intermediary
FI Xerox The 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 Board
FTB External
FTB 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/A N/A N/A N/A
Concept of Operations 98
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Front End Front End Xerox Part 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 changes.
Concept of Operations 99
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Information Technology Services Division
ITSD DHCS ITSD 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 Prep Input Prep Xerox Part 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 Services
IRS External
IRS is the United States government agency responsible for tax collection and tax law enforcement.
N/A N/A N/A N/A
Key Data Entry Operator
KDE Xerox Part 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.
Concept of Operations 100
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Legislative & Governmental Affairs Division
LGA DHCS Legislative & 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 Agency
LEA External
Local 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 Division
LTCD DHCS Long 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
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.
Concept of Operations 101
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Low Income Health Program Division
LIHP Division
DHCS In 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
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.
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Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Mailroom Mailroom Xerox Part 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 Organization
MCO External
Manages 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/A N/A Managed 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.
Concept of Operations 103
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Maximus MCP Eligibility
External
Performs enrolling and dis-enrolling members to MCPs.
N/A N/A N/A N/A
Medical Case Agent
CMIS-MCM DHCS Creates 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 Consultant
MC DHCS Authorizes Medi-Cal TARs. N/A DHCS 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/A
Medi-Cal Dental Services Division
MDSD DHCS Medi-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/A N/A DHCS MDSD; Division should be informed of changes that may impact claims processing and reporting.
Medi-Cal Eligibility Division
MCED DHCS Medi-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
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.
Concept of Operations 104
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Medi-Cal Managed Care Division
MMCD DHCS Medi-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/A N/A 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.
Concept of Operations 105
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Medical Professional Service Group
MPSG Xerox Part 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 Branch
MRB DHCS Medical 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/A N/A DHCS 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.
Medicare Medicare External
Submits crossover claims to Medi-Cal. Medicare supports the submission of
N/A N/A Medicare supports the submission of
Concept of Operations 106
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
crossover claims to Medi-Cal which may be impacted due to changes in processing claims. Medicare will be kept informed of the different releases.
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.
Member Member External
Beneficiary 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/A N/A N/A N/A
Office of Civil Rights
OCR DHCS Office 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
N/A N/A N/A N/A
Concept of Operations 107
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Office of Family Planning
OFP DHCS The 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 Technology
OHIT DHCS OHIT 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/A N/A DHCS – 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 Compliance
OHC DHCS Office of HIPAA Compliance (OHC) is responsible for leadership and
DHCS – OHC is responsible for oversight related to implementation
Concept of Operations 108
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
and alignment to MITA and needs to be kept informed.
Office of Legal Services
OLS DHCS Office 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:
DHCS – OLS is responsible for Medi-Cal House Counsel Team and supports the Medi-Cal Litigation Team, which needs to be kept informed of
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
Concept of Operations 109
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
changes to claims processing and reporting.
needs to be kept informed of changes to claims processing and reporting.
Office of Medi- OMCP DHCS Office of Medi-Cal Procurement is an DHCS – OMCP is DHCS – OMCP is responsible DHCS –
Concept of Operations 110
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Cal Procurement
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.
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.
for Medi-Cal Procurements and responsible for producing procurement documents and needs to be aware of changes to CA-MMIS and the TAR process.
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 Health
OMH DHCS Office 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
N/A N/A N/A N/A
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Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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 populations.
Informing 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
Concept of Operations 112
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Office of Public Affairs
OPA DHCS Office 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.
Concept of Operations 113
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Office of Selective Provider Contracting Program
SPCP DHCS Through 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 Health
OWH DHCS Office 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
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/A N/A 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 System Replacement changes in claims processing.
Concept of Operations 114
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Operations Training Department
OTD Xerox Responsible for the development and delivery of Operations training
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 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 Consultant
PC DHCS 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 Provider
Pharmacy Provider
External
A 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
N/A N/A
Concept of Operations 115
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
processing.
Pharmacy Benefits Division
PBD DHCS Pharmacy 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 Division
PRHD DHCS The mission of Primary & Rural Health Division is to improve the health status of diverse population groups living in
DHCS-PRHD responsible for Rural Health Care improvements and may need to be kept informed of changes to CA-MMIS and billing for
Concept of Operations 116
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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
services.
Concept of Operations 117
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Qualified Health Centers, Rural Health Clinics and IH clinics.
Print and Distribution
P&D Xerox Part 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/A N/A Xerox – P&D provide the forms distribution and distributions of bulletins which may include processing changes.
Provider Provider External
Individual 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 Division
PED DHCS Provider 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
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/A N/A DHCS – 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
Concept of Operations 118
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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 .
CA-MMIS.
Provider Integrity Unit
PIU Xerox Monitors 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 Education
Provider O&E
Xerox Part 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 Organization
PRO Xerox The 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.
Concept of Operations 119
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Provider Review Unit
PRU Xerox Part 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.
Publications PUBS Xerox Writes, 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 Correspondence
R&C Xerox Part 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 Division
SNFD DHCS Safety 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
DHCS – SNFD administers supplemental payments for the DHCS and needs to be kept informed of changes that impact CA-MMIS.
Concept of Operations 120
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Scanning Scanning Xerox Part 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 Delivery SG Xerox 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.
Concept of Operations 121
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
Small Provider Billing Unit
SPBU Xerox Part 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 Office
SCO External
Disburses 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/A N/A SCO needs to be informed of any change to claims processing and reporting in CA-MMIS that may impact Provider Payments.
Submitter Submitter External
Submits 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
N/A N/A Submitters are responsible for submitting claims on behalf of providers and need to be
Concept of Operations 122
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
changes to claims processing or submission of the electronic files. .
kept informed of changes to claims processing or submission of the electronic files.
Surveillance Utilization Review Subsystem Liaison
SURS Liaison
Xerox Part 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/A N/A Xerox –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 Division
SCD DHCS Systems 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
DHCS – SCD is responsible for the CSC program and needs to be kept informed of changes that impact CA-MMIS.
N/A N/A DHCS – SCD is responsible for the CSC program and needs to be kept informed of changes that impact CA-MMIS.
Concept of Operations 123
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
Telephone Service Center Agent
TSC Xerox Part 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/A N/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 Division
TPLRD DHCS Third 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
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/A N/A 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
Concept of Operations 124
Actor Name Aliases Entity Type Description
Pharmacy Claims and Drug Rebates
Pharmacy Prior Authorizations
Medical Prior Authorizations
Medical Claims
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.
processing and reporting.
Concept of Operations 125
B. CA-MMIS Business Process Maturity Level
The 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 21: CA-MMIS As-Is and To-Be Maturity Levels
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Care Management
Authorization Determination
Authorize CCS/GHPP Services
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Medi-Cal Treatment Authorization Requests
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Authorize Treatment Plan
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Case Management
Establish Case 1 1 1 1 1 1 1 2 2 2 2 2 2 2
Concept of Operations 126
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Establish CCS/GHPP Case
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Manage Case Information
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage CCS/GHPP Case Information
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Perform Screening and Assessment
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Treatment Plan and Outcomes
1 1 1 1 1 1 1 2 2 2 2 2 2 2
State Specific Reserve Service
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Contractor Management
Contract Management
Manage CA-MMIS FI Contract
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Contractor Support
Manage Medi-Cal Contractor Communication
1 2 1 1 1 2 2 1 2 1 1 1 2 2
Concept of Operations 127
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Financial Management
Accounts Payable Management
Manage 1099 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Manage Contractor Payment
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Health Insurance Premium Payments
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Incentive Payment
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Manage Medi-Cal Accounts Payable Information
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Medi-Cal Payable Disbursement
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Medicare Premium Payment
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Concept of Operations 128
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Accounts Receivable Management
Manage Cost Reports Settlement
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Drug Rebate
1 2 1 1 1 2 2 2 2 2 2 2 2 2
Manage Estate Recovery
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Medi-Cal Accounts Receivable Funds
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Medi-Cal Accounts Receivable Information
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage Overpayment Recoupment
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Manage TPL Recovery
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Fiscal Management
Formulate Medi-Cal Budget
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Concept of Operations 129
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Generate Medi-Cal Budget Estimates Financial Report
1 2 1 2 2 2 2 2 2 2 2 2 2 2
Manage State Funds
2 2 2 2 2 2 2 2 2 2 2 2 2 2
State Specific Manage Member Health Care Reimbursement
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Member Eligibility and Enrollment Management
Member Enrollment
Inquire Medi-Cal Eligibility
TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD TBD
Member Management
Member Support Management
Manage Medi-Cal Applicant and Member Communication
(Based on 2008 SS-A)
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Operations Management
Claims Adjudication
Apply Medi-Cal Mass Adjustment
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Concept of Operations 130
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Process Medi-Cal Claim
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Submit Medi-Cal Claim Attachment
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Payment and Reporting
Generate Medi-Cal Remittance Advice
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Inquire Medi-Cal Payment Status
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Manage Data 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Process Encounter
Process Managed Care Encounter
1 1 1 2 2 2 2 2 2 2 2 2 2 2
Plan Management
Health Benefits Administration
Manage Benefit Information
1 1 1 1 1 1 2 1 1 1 1 1 1 1
Maintain Benefits-Reference Information
1 1 1 1 1 1 2 2 2 2 2 2 2 2
Concept of Operations 131
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Manage Drug Formulary
2 2 2 2 2 2 2 N/A N/A N/A N/A N/A N/A N/A
Manage Rate Setting
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Health Plan Administration
Develop and Manage Performance Measures
1 1 1 1 1 1 1 1 1 1 1 1 1 1
Manage Medi-Cal Program Information
1 1 1 1 1 1 1 1 1 1 1 1 1 1
Plan Administration
Maintain Program Policy
1 1 1 1 1 1 2 1 1 1 1 1 1 2
Program Integrity (Performance) Management
Compliance Management
Determine Adverse Action Incident
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Establish Compliance Incident
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Identify Utilization Anomalies
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Concept of Operations 132
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Manage Compliance Incident Information
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Prepare Beneficiary Confirmation Letters
1 1 1 1 1 1 1 2 2 2 2 2 2 2
Provider Eligibility Management
Provider Enrollment
Enroll Medi-Cal Provider
1 1 1 1 1 1 1 3 3 3 3 3 3 3
Inquire Medi-Cal Provider Information
1 1 1 1 1 1 1 3 3 3 3 3 3 3
Determine Medi-Cal Provider Eligibility
1 1 1 1 1 1 1 3 3 3 3 3 3 3
Determine Provider Eligibility for Incentive Program
2 2 2 2 2 2 2 N/A N/A N/A N/A N/A N/A N/A
Concept of Operations 133
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Determine CHDP Provider Eligibility
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Enroll Drug Medi-Cal Provider
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Enroll Mental Health Provider
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Enroll Dental Provider
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Enroll CCS Provider
2 2 2 2 2 2 2 N/A N/A N/A N/A N/A N/A N/A
Enroll CHDP Provider
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Disenroll Medi-Cal Provider
1 1 1 1 1 1 1 3 3 3 3 3 3 3
Disenroll Dental Provider
1 1 1 1 1 1 1 N/A N/A N/A N/A N/A N/A N/A
Concept of Operations 134
As-Is Maturity Level To-Be Maturity Level
CA-MMIS Business Area
CA-MMIS Business Category
CA-MMIS Business Process
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
akeh
olde
rs
Ove
rall
Tim
elin
ess
Dat
a A
cces
s &
Acc
urac
y
Effo
rt to
Per
form
Cos
t Effe
ctiv
enes
s
Acc
urac
y of
Pro
cess
Util
ity o
r Val
ue to
St
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Provider Management
Provider Information Management
Manage Medi-Cal Provider Information
1 1 1 1 1 1 1 3 3 3 3 3 3 3
Provider Support
Manage Medi-Cal Provider Grievance & Appeal
1 1 1 1 1 1 1 1 1 1 1 1 1 1
Manage Medi-Cal Provider Communication
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Perform Medi-Cal Provider Outreach
2 2 2 2 2 2 2 2 2 2 2 2 2 2
Concept of Operations 135
C. Actor Primary Interactions with CA-MMIS Business Process
Table 22: CA-MMIS Primary Actor Interactions with Business Processes
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Care Management
Authorization Determination
Medi-Cal Treatment Authorization Requests
Provider TAR
Medi-Cal Consultant TAR
Authorize CCS/GHPP Services CMS-DHCS SAR
Authorize Treatment Plan
Provider Treatment Plan
Medical Case Agent Treatment Plan
Case Management Establish Case Provider Treatment Plan
Establish CCS/GHPP Case SCD Medical Case
Manage Case Information Medical Case Agent Medical Case
Manage CCS/GHPP Case Information SCD Medical Case
Perform Screening and Assessment LTCD Case Management
Manage Treatment Plan and Outcomes
LTCD LTCD performs case management for specific waiver programs and special programs.
Concept of Operations 136
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
State Specific Reserve Service Provider Service Reservation Request
Contractor Management Contractor Support
Manage Medi-Cal Contractor Communication Fiscal Intermediary Documentation and Communications in
SharePoint
Manage CA-MMIS FI Contract CA-MMIS Division
CA-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 Management Manage 1099 Cash Control
Analyst 1099 reports
Manage Contractor PaymentOverseen by multiple business areas within DHCS
Interaction 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 Payments TPLRD
CA-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 Payment Provider Incentive payment
Manage Medi-Cal Accounts Payable Information SCO Warrant numbers; Medi-Cal payments &
disbursements
Manage Medi-Cal Payable Disbursement SCO Payment information & disbursements
Manage Medicare Premium Payment
TPLRD CA-MMIS Recipient Subsystem: MEDS is updated with Medicare eligibility and buy-in information resulting from data exchanges with CMS.
Concept of Operations 137
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Accounts Receivable Management
Manage Cost Reports Settlement TPLRD Cost settlement amounts; Recoupment requests
Manage Drug Rebate DRU Drug Rebate reference information; Drug Rebate invoices
Manage Estate Recovery TPLRDEstate recovery referrals are typically received from vital records data and the descendents representatives
Manage Medi-Cal Accounts Receivable Funds FMB Payments; Provider checks
Manage Medi-Cal Accounts Receivable Information
Cash Control Analyst Accounts Receivable (A/R) transactions
Appeals Examiner Accounts Receivable (A/R) transactions
Manage Overpayment Recoupment
Cash Control Analyst Provider recoupment transactions
Manage TPL RecoveryTPLRD TPL analysis results; Recoupment
transaction information.
CA-MMIS Division TPL letters
Fiscal Management Manage State Funds DHCS Administration Division (AD)
AD Accounting Section is responsible for reconciling state fund allocations and the drawdown and reporting of FFP
Concept of Operations 138
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Formulate Medi-Cal Budget Financial Management Branch (FMB) of the Administration Division with input from the FFB
Budget 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 Report
DHCS Administration Division, FFB
FFB prepares the CMS-37 and CMS-21B reports in support of the budget process and the management of FFP.
State Specific Manage Member Health Care Reimbursement
Overseen by the CA-MMIS Division
Member reimbursement checks are distributed by the State Controller’s Office.
Member Eligibility and Enrollment Management Member Enrollment Inquire Medi-Cal Eligibility County Office Inquiry transactions
Member Management Member Support Management
Manage Medi-Cal Applicant and Member Communication
TAR Office Consultants
Review the documentation received from Providers on behalf of the Member and make a determination on the TAR request to initiate the NOA letter.
CA-MMIS Receive the NOA response letter and print and mail to Provider on behalf of Member.
Operations Management Claims Adjudication Apply Medi-Cal Mass Adjustment CA-MMIS Division Claims mass adjustment work order
Process Medi-Cal ClaimProvider Claims
Submitter Claims
Submit Medi-Cal Claim Attachment
Provider Claim attachments
Concept of Operations 139
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Payment and Reporting
Generate Medi-Cal Remittance Advice SCO Medical remittance advice
Inquire Medi-Cal Payment Status Provider Medi-Cal payment status inquiry
Manage Data
Provider Relations Organization Data
Claims Operations Data
DUR Data
Cash Control Analyst Data
Process Encounter Process Managed Care Encounter EDU Managed Care encounter data
Plan Management
Health Benefits Administration
Maintain Benefits-Reference Information CA-MMIS Division Policy-triggered transactions
Manage Drug Formulary PBD PBD is responsible for developing the policy instructions needed to add or modify drug codes to the CA-MMIS formulary file
Manage Rate Setting FFSRDD FFSRDD 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 program
Health Plan AdministrationDevelop and Manage Performance Measures
CA-MMIS Division Program performance measures
Concept of Operations 140
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Manage Benefit Information DHCS Directorate The 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 Information
CA-MMIS Division Policy-triggered transactions
Plan Administration Maintain Program Policy
DHCS Directorate
Various DHCS program areas are responsible for maintaining and updating policies related to Medi-Cal approved services
File Maintenance
File 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 Delivery Process SDNs and system change requests.
Program Integrity (Performance) Management
Compliance Management
Determine Adverse Action Incident A&I Division A/R transactions; Suspect hold Providers;
TPL cases; Legal activities
Establish Compliance Incident A&IA&I coordinates with other DHCS Divisions and government agencies for referrals, data and investigative support
Identify Utilization Anomalies CAASDTARs; TAR denial appeals; Claims review for abnormalities in billing & cost containment ideas
Manage Compliance Incident Information
A&I A&I coordinates with other DHCS Divisions and government agencies for referrals, data and investigative support.
Concept of Operations 141
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Prepare Beneficiary Confirmation Letters
CA-MMIS Division, MDSD
For 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 preauthorized
Provider Eligibility and Enrollment Management
Provider Enrollment Determine Medi-Cal Provider Eligibility PED
PED determines eligibility for the majority of providers requesting enrollment into the Medi-Cal program.
Determine Provider Eligibility for Incentive Program OHIT
Applicant 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 Program
Determine CHDP Provider Eligibility SCD
Applicant 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 offices
Enroll Medi-Cal Provider
Provider Enrollment applications (out-of-state)
PED
Provider eligibility & enrollment applications;Approval/denial letter (out-of-state)
Enroll Drug Medi-Cal Provider PED (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.
Concept of Operations 142
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Enroll Mental Health Provider DMH
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 Provider MDSD Fiscal Intermediary for the CD-MMIS, Delta Dental, performs the majority of the steps.
Enroll CCS Provider SCD
Applicant 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 Provider SCD
Applicant 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 Provider PED
PED 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 Provider MDSD The 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.
Concept of Operations 143
CA-MMIS Business Area
CA-MMIS Business Category CA-MMIS Business Process Actors Types of Interaction
Inquire Medi-Cal Provider Information PED Inquiry transactions
Provider Management
Provider Information Management
Manage Medi-Cal Provider Information PED Provider information
Provider Support
Manage Medi-Cal Provider Grievance & Appeal
Provider Relations Organization Provider appeals & grievances
Manage Medi-Cal Provider Communication Provider O&E Program information;
Medi-Cal Provider education
Perform Medi-Cal Provider Outreach
Provider Communications
Provider O&E Communications to Medi-Cal Providers
Concept of Operations 144
D. Medi-Cal Enterprise
For 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 12: Medi-Cal Enterprise
Concept of Operations 145
E. Planned Releases Roadmap
Effective 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.
Figure 13: Roadmap for Releases 1 – 5
Concept of Operations 146
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