Part I – BUSINESS ARCHITECTURE
Chapter 4 – BUSINESS PROCESS MODEL
Part I – Business Architecture
Chapter 4 – Business Process Model
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Table of Contents
PART I – BUSINESS ARCHITECTURE ................................................................................................ 1
Chapter 4 – Business Process Model ..................................................................................... 1
Introduction ............................................................................................................................ 3
Purpose ............................................................................................................................... 3
Scope .................................................................................................................................. 3
Business Process Model ............................................................................................................ 3
MITA Business Process Model ................................................................................................... 4
The Business Process Hierarchy ............................................................................................. 4
Medicaid Enterprise ................................................................................................................. 5
Business Relationship Management ....................................................................................... 8
Care Management Business Area........................................................................................... 8
Contractor Management Business Area ................................................................................. 9
Eligibility and Enrollment Management .................................................................................10
Financial Management ........................................................................................................11
Member Management Business Area....................................................................................13
Operations Management Business Area ................................................................................14
Performance Management Business Area .............................................................................15
Plan Management Business Area ..........................................................................................16
Provider Management Business Area ....................................................................................17
MITA Business Process ............................................................................................................18
Transformation of Business Processes.......................................................................................21
List of Figures
Figure 4-1. MITA Business Process Model Hierarchy ........................................................................ 5
Figure 4-2. Medicaid Enterprise Business Process Model ................................................................. 5
Figure 4-3. MITA Framework 3.0 Business Process Model ................................................................ 7
Figure 4-4. Business Relationship Management Business Process Model .......................................... 8
Figure 4-5. Care Management Business Process Model ................................................................... 9
Figure 4-6. Contractor Management Business Process Model .........................................................10
Figure 4-7. Eligibility and Enrollment Management Business Process Model ....................................11
Figure 4-8. Financial Management Business Process Model ............................................................12
Figure 4-9. Member Management Business Process Model ............................................................13
Figure 4-10. Operations Management Business Process Model .......................................................14
Figure 4-11. Performance Management Business Process Model ....................................................15
Figure 4-12. Plan Management Business Process Model .................................................................16
Figure 4-13. Provider Management Business Process Model ...........................................................17
Figure 4-14. Description of Business Activity .................................................................................18
Figure 4-15. Business Processes and Business Capabilities ..............................................................21
List of Tables
Table 4-1. MITA Business Process Template ..................................................................................19
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Introduction
This chapter presents the Medicaid IT Architecture (MITA) Business Process Model (BPM)
and explains the role of the BPM in the MITA Framework. A business process model is a
visual diagram or narrative representation of the sequential flow and control logic of a set of
related activities or actions.
This topics covered in this chapter include:
Business Process Model
MITA Business Process Model
Medicaid Enterprise
MITA Business Process
Transformation of Business Processes
Purpose
This chapter focuses on communicating the structure of and rationale for the MITA BPM and
the role of the BPM in the MITA Framework. The BPM consists of ten (10) business areas
that accommodate desired operational activities of the Medicaid Enterprise. The BPM bases
business activities on key enterprise operations and standard business practices.
Scope
The MITA Framework delivers a baseline model with business area and descriptions of
business processes common to all State Medicaid Enterprises. (See Part I, Appendix C,
Business Process Model Details for more information.) In the MITA Framework, the
emphasis is on defining business processes for the State Medicaid Agency (SMA) as they
are today. The BPM model describes new business processes as the business matures
(e.g., at Maturity Level 3, where SMA coordinates with other state and local agencies to
create a “no wrong door” beneficiary intake process). Many business processes that States
engage in today will change and adapt in the future (e.g., at Maturity Level 4, claims
processing conducts message exchange directly between a provider’s electronic medical
record or other source of clinical information and a payer’s reimbursement process).
The MITA Business Architecture (BA) defines the common operations of all State Medicaid
Enterprises that are the foundation for creating the Information Architecture (IA) Conceptual
Data Model (CDM) and Logical Data Model (LDM). The BPM also provides critical
information (e.g., triggers, business rules, and shared data) that the Technical Architecture
(TA) needs to develop and provide services.
Business Process Model
A BPM describes what an organization or business does, including the events that initiate
those processes (i.e., the trigger event). A BPM also describes the results of those
processes. The MITA Team chose a process-oriented business model because it fits best in
a framework that supports over 51 State Medicaid Agencies, each with its own
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organizational structure, policies, and operational procedures. The MITA process-oriented
approach views the business cross-functionally and organizes the actions of the business as
a set of activities that respond to business events. Opportunities for real process
improvements and dramatic business changes are more likely to emerge from this
perspective because it dismantles existing organizational structures that do not share
information readily. The BPM does not care what the business organizational structure is,
who does the work, or where the organization performs the work. Its focus is on the activity
itself (i.e., what initiates the activity and what the activity produces). In this sense, the BPM
offers a one-size-fits-all solution because it focuses on the core business activity of the
Medicaid Enterprise and not the quality attributes, design and implementation constraints, or
external interfaces the system will have.
MITA Business Process Model
The MITA BPM is a model representing the operations of the Medicaid Enterprise for the
SMA. It describes the typical Medicaid business processes found in a state and organizes
them into various categories of common functionality or focus called Business Areas (e.g.,
Provider Management, Member Management, and Operations Management). The role of the
MITA BPM is to provide a common reference point for the SMA. The SMA and their vendors
can then map their current processes to the BPM, which lets them describe their business
processes in a standard way and use a common vocabulary. See Part I, Appendix C,
Business Process Model Details, for more information.
The Business Process Hierarchy
The MITA business process hierarchy is a structure that groups together business
processes that have a common purpose and share data. Provider Management, for
example, focuses on provider information management and support activities (distinct from
payment or auditing) and is responsible for a designated provider data store. Figure 4-1
illustrates the tiers, hierarchy, and groupings used by the MITA BPM. Tier 1 is the business
area grouping, Tier 2 is the business category grouping, and Tier 3 is the business process.
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Figure 4-1. MITA Business Process Model Hierarchy
The title of a business area or a Tier 1 grouping of business areas appears as a noun
(e.g., Operations Management, Provider Management). Tier 2 is a grouping of related
business categories and appears as a noun (e.g., Payment and Reporting, Claims
Adjudication). The business process appears in Tier 3 as a verb + object (e.g., Generate
Remittance Advice, Process Claim).
Medicaid Enterprise
The Medicaid Enterprise consists of ten (10) business areas that contain 80 individual
business processes. Figure 4-2 shows the first tier of hierarchy with each of the MITA
business areas that show the boundaries of the Medicaid Enterprise according to the MITA
Initiative.
Figure 4-2. Medicaid Enterprise Business Process Model
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Figure 4-3 provides an overview of the MITA Framework 3.0 Business Process Model with
business areas and business processes.
NOTE: The diagram exhibits Tiers 1 and 3 of the MITA BPM in order to present the BPM on
a single page.
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Figure 4-3. MITA Framework 3.0 Business Process Model
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Business Relationship Management
The Business Relationship Management business area is a collection of business processes
that facilitates the coordination of standards of interoperability. This business area defines
the exchange of information and Trading Partner Agreements (TPA) between the SMA and
its partners, including collaboration among intrastate agencies, interstate agencies, and
federal agencies. These agreements contain functionality for interoperability, establishment
of inter-agency Service Level Agreements (SLA), identification of the types of information
exchanged, and security and privacy requirements. The Business Relationship Management
business area has a common focus (e.g., data exchange standards and SLA) and is
responsible for the business relationship data store.
Figure 4-4 illustrates the Business Relationship Management BPM.
Figure 4-4. Business Relationship Management Business Process Model
Care Management Business Area
The Care Management business area illustrates the increasing shift away from the fee-for-
service model of care. Care Management collects information about the needs of the
individual member, plan of treatment, targeted outcomes, and the individual’s health status.
It also contains business processes that have a common purpose (e.g., identify members
with special needs, assess needs, develop treatment plan, monitor and manage the plan,
and report outcomes). This business area includes processes that support individual care
management and population management. Population management targets groups of
individuals with similar characteristics to promote health education and awareness. The
Electronic Health Record (EHR), Electronic Medical Record (EMR), and Personal Health
Record (PHR) are primary sources of individual health information from the Health
Information Exchange (HIE).
Care Management includes Disease Management, Catastrophic Case Management, Early
and Periodic Screening, Diagnosis, and Treatment (EPSDT), Population Management,
Patient Self-Directed Care Management, national health registries, and Waiver Program
Case Management. The Care Management business area is responsible for the case
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management, authorizations, referrals, and treatment plans data stores. Care Management
also contains business processes for authorization determination including authorizing
referrals, service and treatment plans.
Figure 4-5 illustrates the Care Management BPM.
Figure 4-5. Care Management Business Process Model
Contractor Management Business Area
The Contractor Management business area accommodates a SMA that has managed care
contracts or a variety of outsourced contracts. The Contractor Management business area
has a common focus on Medicaid contractors (e.g., managed care, at-risk mental health or
dental care, primary care physician), is responsible for contractor data store, and uses
business processes that have a common purpose (e.g., fiscal agent, enrollment broker,
Fraud Enforcement Agency, and third-party recovery).
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Figure 4-6 illustrates the Contractor Management BPM.
Figure 4-6. Contractor Management Business Process Model
Eligibility and Enrollment Management
The Eligibility and Enrollment Management business area is a collection of business processes
involved in the activity for determination of eligibility and enrollment for new applicants,
redetermination of existing members, enrolling new providers, and revalidation of existing
providers. The Provider Enrollment business category and related business processes focus on
patient safety and fraud prevention through functions such as determining screening level (i.e.,
limited, moderate or high) for provider verifications. These processes share a common set of
provider-related data for determination of eligibility, enrollment, and inquiry to provide services.
The Eligibility and Enrollment Management business area is responsible for the eligibility and
enrollment information of the member data store as well as the provider data store.
Figure 4-7 illustrates the Eligibility and Enrollment Management BPM.
NOTE: Due to the regulation rule-making efforts underway at Centers for Medicare & Medicaid
Services (CMS), the MITA Framework 3.0 does not include the Eligibility & Enrollment
(Member), the Member Management business processes or business capability matrices, and a
portion of the Concept of Operations (COO) outlining the “to-be” for eligibility, enrollment, and
insurance exchange information. CMS will update the MITA Framework 3.0 with appropriate
information from the final rules in 2012.
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Figure 4-7. Eligibility and Enrollment Management Business Process Model
Financial Management
The Financial Management business area is a collection of business processes to support
the payment of providers, managed care organizations, other agencies, insurers, Medicare
premiums, and supports the receipt of payments from other insurers, providers, and member
premiums and financial participation. These processes share a common set of payment-
and receivables-related data. The Financial Management business area is responsible for
the financial data store.
Figure 4-8 illustrates the Financial Management BPM.
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Figure 4-8. Financial Management Business Process Model
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Member Management Business Area
The Member Management business area is a collection of business processes involved in
communications between the SMA and the prospective or enrolled member and actions that
the agency takes on behalf of the member. This business area is responsible for managing
the member data store, coordinating communications with both prospective and current
members, outreach to current and potential members, and dealing with member grievance
and appeals issues.
Figure 4-9 illustrates the Member Management BPM.
NOTE: Due to the regulation rule-making efforts underway at CMS, the MITA Framework 3.0
does not include the Eligibility & Enrollment (Member), the Member Management business
processes or business capability matrices, and a portion of the Concept of Operations (COO)
outlining the “to-be” for eligibility, enrollment, and insurance exchange information. CMS will
update the MITA Framework 3.0 with appropriate information from the final rules in 2012.
Figure 4-9. Member Management Business Process Model
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Operations Management Business Area
The Operations Management business area is a collection of business processes that
manage claims and prepare premium payments. This business area uses a specific set of
claims-related data and includes processing (i.e., editing, auditing and pricing) a variety of
claim forms including professional, dental, institutional, drug and encounters, as well as
sending payment information to the provider. All claim processing activity incorporates
compatible methodologies of the National Correct Coding Initiative (NCCI). The Operations
Management business area is responsible for the claims data store.
Figure 4-10 illustrates the Operations Management BPM.
Figure 4-10. Operations Management Business Process Model
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Performance Management Business Area
The Performance Management business area is a collection of business processes involved in
the assessment of program compliance (e.g., auditing and tracking medical necessity and
appropriateness of care, quality of care, patient safety, fraud and abuse, erroneous payments,
and administrative anomalies). This business area uses information about an individual provider
or member (e.g., demographics, information about the case itself such as case manager ID,
dates, actions, and status, and information about parties associated with the case) and uses this
information to perform functions related to utilization and performance. The Performance
Management business area is responsible for the business activity and compliance data stores.
Figure 4-11 illustrates the Performance Management BPM.
Figure 4-11. Performance Management Business Process Model
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Plan Management Business Area
The Plan Management business area includes the strategic planning, policymaking,
monitoring, and oversight business processes of the agency. This business area is
responsible for the primary data stores (e.g., Medicaid State Plan, health plans and health
benefits) as well as performance measures, reference information, and rate setting data
stores. The business processes includes a wide range of planning, analysis, and decision-
making activities. These activities include service needs and goals, health care outcome
targets, quality assessment, performance and outcome analysis, and information
management.
As the Medicaid Enterprise matures, Plan Management benefits from immediate access to
information, addition of clinical records, use of nationally recognized standards, and
interoperability with other programs. The Medicaid Program is moving from a focus on daily
operations (e.g., number of claims paid) to a strategic focus on how to meet the needs of
the population within a prescribed budget.
Figure 4-12 illustrates the Plan Management BPM.
Figure 4-12. Plan Management Business Process Model
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Provider Management Business Area
The Provider Management business area is a collection of business processes involved in
communications between the SMA and the prospective or enrolled provider and actions that
the agency takes on behalf of the provider. Business processes focus on terminating
providers, communications with providers, dealing with provider grievances and appeals
issues, and performing outreach services to providers. The Provider Management business
area is responsible for the provider data store.
Figure 4-13 illustrates the Provider Management BPM.
Figure 4-13. Provider Management Business Process Model
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MITA Business Process
The MITA business process is Tier 3 in the BPM. A MITA business process defines a series
of activities that start with one or more events, manipulate a set of data, and end with one or
more results. The MITA BPM describes all of the business processes in a standard business
process template that captures the trigger, result, and business rules. The trigger is the
initiating event defined in terms of input data or a schedule that is due. The result is the
output of the process and describes the information produced by the business process. The
business rules define a sequence or series of steps (i.e., activity). A business rule is a
specific, actionable, testable directive that is under the control of the business and supports
a business policy. Business rules describe the operations, definitions, and constraints that
apply to an organization. Business rules can apply to people, processes, corporate behavior
and computing systems in an organization, and are in place to help the organization achieve
its goals.
Figure 4-14 illustrates the components of the business process.
Figure 4-14. Description of Business Activity
An example of a MITA business process is Determine Provider Eligibility. The trigger is the
receipt of enrollment application information. The result of the business process is the
provider’s eligibility determination. The business rules include validation of key data,
collection of the application fee, provider screening, a check for enrollment moratoriums,
verification of federal and state enrollment requirements, and notification of eligibility for
enrollment. One measurement of business process performance is the time elapsed
between the trigger and the result. Shared data includes the information from the SMA
Provider Network, external validation agencies, National Plan and Provider Enumeration
System (NPPES) database, and license/credential boards.
A trigger event starts a business process that carries out one or more steps, and produces
one or more results or outcomes. For example, the business process Determine Provider
Eligibility contains the following elements:
One or more triggers (e.g., receiving a provider enrollment application, revalidation due).
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A series of steps (e.g., maintain enrollment application information, collect application
fee, validate credentials based on category risk, check enrollment moratoriums, notify of
eligibility).
One or more results (e.g., authorize or deny enrollment, request more information, and
notify provider of result).
The MITA BPM contains the following items:
A statement describing the objective and purpose of the business process.
A listing of the input data that triggers the business process.
A listing of the output data (i.e., data in motion) contained in the results.
A sequence of steps (i.e., data at rest) describing the business rules.
A listing of failure points where a business process may stop before completion.
A description of constraints that may affect the performance of the business process.
A definition of performance standards that allows all stakeholders to measure the same
activity in the same manner.
In the BPM, the business processes represent the typical operations of the SMA. These
processes evolve over time. As the SMA matures, some processes transform, and the SMA
will replace others. Stakeholders develop new business processes for effectiveness and
efficiency.
Table 4-1 illustrates the Business Process Template (BPT) describing a MITA business
process. Part I, Appendix C, Business Process Model Details, contains the complete set of
business processes for the MITA Framework.
Table 4-1. MITA Business Process Template
Tier 1: Business Area Abbreviation - Tier 2: Business Category Title
Item
Details
Tier 3: Business Process Title
Description
A brief statement that describes active roles and the activity the role conducts
during the business process.
Trigger Event
One or more events that directly start a business process (e.g., Receive a
request, phone call, or a scheduled date).
The trigger is definable information.
Result
One or more outcomes from the execution of the business rules (results define
data in motion and are the immediate output from the business process, not
the ultimate, downstream result).
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Tier 1: Business Area Abbreviation - Tier 2: Business Category Title
Item
Details
Tier 3: Business Process Title
The result is definable information.
Business
Process Steps
A sequence of steps that execute the successful completion of the business
process (steps start with a verb).
Shared Data
Shared data is data at rest (i.e., data stores accessed to complete a step in the
business process).
Shared data is a defined data store with specific information.
Predecessor
The preceding business process to the activity conducted in this process. The
result of the previous business process is a trigger to this business process.
Successor
The succeeding business process to the activity conducted in this process. The
result of this business process is a trigger for the next business process.
Constraints
Conditions that CMS expects States to meet for this generalized process to
execute (e.g., enrolling institutional providers requires different information from
enrolling pharmacies).
Failures
An identification of the exit points throughout the business process where the
business rules specify that the process terminates because of failure of one or
more steps.
Performance
Measures
Key Performance Indicators (KPI) may include the following:
Quantitative indicators are usually numerical.
Practical indicators interface with existing processes.
Directional indicators specify whether an agency is getting better or not.
Actionable indicators are sufficiently in an agency's control to effect change.
Financial indicators CMS and the SMA use in performance measurement and
when looking at an operating index.
Measures that describe what to measure, but that are not specific measures in
themselves, such as the following examples:
Time to complete process (e.g. real-time response = within ___ seconds; batch
response = within ___ days)
Accuracy of decisions = ___%
Consistency of decisions and disposition = ___%
Error rate = ___% or less
The MITA business template specifies the type of measure, but not the actual
benchmark. See Part I, Appendix D, Business Capability Matrix Details, for specific
benchmarks for business capabilities.
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Transformation of Business Processes
The MITA BPM describes the common business activities and functions of the Medicaid
Enterprise. As the Medicaid Enterprise matures, business processes evolve to include
relevant business capabilities to satisfy the SMA needs. The Business Capability Matrix
(BCM) tracks the progression of this transformation. Figure 4-15 illustrates the relationship
between the business process and the different levels of capability. See Part I, Chapter 5,
Business Capability Matrix, for more information on business capabilities and Part I,
Appendix D, Business Capability Matrix Details, for a full list of capabilities associated with
each business process.
Figure 4-15. Business Processes and Business Capabilities
The MITA BPM will continue to evolve and change as MITA identifies and adds new
business processes. A change in the industry, such as adoption of EHR, PHR, Health
Insurance Exchange (HIX), or Health Information Exchange (HIE) may create a new
process. These innovations change the way the Medicaid Enterprise does business. (For
example, direct access to clinical data may alter the performance of service authorization
and claims adjudication). The new business processes replace or make an existing process
obsolete. For example, online coordination of benefits eliminates the need for cost recovery
(i.e., pay and chase).
