FM10 - Manage Member Financial Participation BPT 3.0

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Maturity Model Definition of Levels - General Timeline
Timeline Level 1 Level 2 Level 3 Level 4 Level 5
As-Is Near Future To Be
CMS expects majority of state agencies to be at appropriate Level based on federal initiative deadlines. Agencies may be at Level 1 for some business processes and Level 2 for others in the present time. MMM1.png

FM10 Manage Member Financial Participation

FM Accounts Payable Management
Manage Member Financial Participation
Item
Details
Description

The Manage Member Financial Participation business process is responsible for all operations aspects of preparing member premium payments. This includes premiums for Medicare, also known as Medicare Buy-in, and other health insurance. The business process begins with the alert to determine if the State Medicaid Agency (SMA) should pay a member’s premium.

The SMA will assist low-income Medicare beneficiaries in Medicare cost-sharing, defined as premiums, deductibles, and co-insurance in a process referred to as buy-in. Under the buy-in process the SMA, the Social Security Administration (SSA), and U.S. Department of Health & Human Services (HHS) enter into a contract where States pay the Medicare beneficiary share of premium costs, and, in some instances, deductibles, and co-insurance.

An exchange of eligibility information between Medicare and the SMA initiates Medicare premium payments. The service agreement between the SMA and business partner determines the intervals for this business process to execute. The business process receives eligibility information from Medicare, performs a matching process against the State Medicaid Enterprise member data store, generates buy-in files to Centers for Medicare & Medicaid Services (CMS) for verification, receives premium payment information from and generates payments to CMS.

The SMA will pay the private health insurance premiums for members who have private health insurance benefits, if it determines the insurance to be cost effective. In these circumstances, the SMA prepares and sends a premium to the member’s private health insurance company.

Health insurance premium payment initiates with an application for Medicaid where the applicant indicates they have third-party health coverage or by receiving eligibility information via referrals from Home and Community-Based Services (HCBS) Offices, schools, community services organizations, or phone calls directly from members. The business process checks for internal eligibility status as well as eligibility with other payers, producing a report identifying individuals where paying premiums would be cost effective, and notifying members via Manage Applicant and Member Communication business process.

NOTE: This business process does not include sending the premium payments as an Electronic Data Interchange (EDI) transaction.

Trigger Event

State transition Trigger Events:

  • Receive alert of Medicare eligibility from Health Insurance Marketplace (HIX).
  • Receive alert of Medicaid applicant with third-party insurance.

Environment-based Trigger Events:

  • Periodic timetable is due for receipt of Medicare eligibility information.
  • Periodic timetable (e.g., monthly) is due for insurance premium eligibility redetermination and payments.
  • Receive insurance information either by the member or through a referral.
Result
  • Modification to Medicare buy-in reporting.
  • Identification of individuals where paying insurance premiums is cost effective.
  • Alert to send notification of premium payment to member via Manage Applicant and Member Communication business process.
  • Alert to send notification of premium payment to Medicaid.
  • Alert to Manage Accounts Payable Information business process for conducting premium payment.
  • If applicable, alert send notification to business partner of member premium payment via Manage Business Relationship Communication business process.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business Process Steps

1. START: Alert to determine if the State Medicaid Agency (SMA) should pay a member’s premium.

2. Prepare Medicaid Premium Payment.

a. Receive State Data Exchange (SDX), Enrollment Data Base (EDB) file, and/or the SSA Beneficiary Data Exchange (BENDEX) eligibility files from the Receive Inbound Transaction.
b. Perform a matching process against the Member data store.
c. Generate buy-in file, containing both Medicare Part A and Medicare Part B members (includes all requests for action including discrepancies from previous month).
d. Send buy-in file to CMS.
e. Receive CMS responses to the buy-in file (i.e., the Billing File for both Part A and Part B) including eligibles, responses to errors, and Medicare buy-in file information.
f. Process CMS responses to the submitted buy-in file and assess the file for accuracy and completeness.
g. Post buy-in modifications to the Member data store.
h. Produce buy-in reports reflecting potential Medicare eligibles including any additions or deletions to existing Member data store as well as other discrepancies.
i. Staff researches unmatched and discrepancies to determine appropriate eligibility.
j. Send problem discrepancy form(s) reflecting potential Medicare eligibles, unmatched, and discrepancies to the Buy-in Administration, and update final Medicare buy-in file for internal use.

3. Prepare Health Insurance Premium Payment (HIPP):

a. Receive insurance information either from an applicant or through a referral.
b. Check internal and external eligibility information.
c. Edit eligibility information.
d. Determine cost effectiveness by collecting information such as policy coverage, past usage, and by making a determination of future need – the requirements for determining cost effectiveness will vary among States.
e. Produce a report of individuals where paying premiums is cost effective for the SMA.

4. Send alert to conduct premium payment to Manage Accounts Payable Information business process.

5. If applicable, send alert to notify member of premium payment via Manage Applicant and Member Communication business process.

6. If applicable, send alert to notify business partner of member premium payment via Manage Business Relationship Communication business process.

7. END: If applicable, send alert to notify Medicare of member premium payment.

Shared Data

Member data store including demographics, cost share, third-party insurance, and premium information

Health Insurance Marketplace (HIX) data store including applicant eligibility and member enrollment information (i.e., dual-eligibility)

Financial data store including accounts payable information

Predecessor

Receive Inbound Transaction

Determine Member Eligibility

Successor

Send Outbound Transaction

Manage Member Information

Manage Applicant and Member Communication

Manage Business Relationship Communication

Manage Accounts Payable Information

Manage Accounts Receivable Information

Constraints

The Manage Member Financial Participation business process will adhere to the federal policies and business rules.

Failures
  • State Medicaid dual eligibility information does not match Medicare dual eligibility information – errors in BENDEX, EDB, or SDX files.
Performance Measures
  • Time to complete the process: e.g., Real Time response = within ___seconds, Batch Response = within ___ hours
  • Accuracy with which rules are applied =___%
  • Consistency with which rules are applied=___%
  • Error rate =___% or less

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Scoring

Maturity Model Definition of Levels - General Timeline
Timeline Level 1 Level 2 Level 3 Level 4 Level 5
As-Is Near Future To Be
CMS expects majority of state agencies to be at appropriate Level based on federal initiative deadlines. Agencies may be at Level 1 for some business processes and Level 2 for others in the present time. MMM1.png


Detailed MITA Maturity Model Definitions - Business Architecture

MITA Maturity Model Detailed Qualities
Capability Question Level 1 Level 2 Level 3 Level 4 Level 5
Business Capability Descriptions: This section provides general background on the process to identify the differences between the levels of maturity.
Is the process primarily manual or automated? The process consists primarily of manual paper based activity to accomplish tasks. The SMA uses a mix of manual and automated processes to accomplish tasks. The SMA automates process to the fullest extent possible within the intrastate. The SMA automates process to the fullest extent possible within the interstate. The SMA automates process to the fullest extent possible across the nation.
Does the State Medicaid Agency use standards in the process? The SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards. The SMA applies a mix of HIPAA and state-specific standards. The SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information. The SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate exchange of information. The SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.
How does the SMA collaborate with other agencies or entities in performing the process? Very little collaboration occurs with other agencies to standardize information exchange or business tasks. The SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions. The SMA collaborates with other intrastate agencies and entities to adopt national standards, and develop and share reusable business services. The SMA collaborates with other interstate agencies and entities to adopt national standards, and develop and share reusable processes including clinical information. The SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.
Business Capability Quality: Timeliness of Process
How timely is the end-to-end process? Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation). Process timeliness improves through use of automation. Timeliness exceeds legal requirements. Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2. Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. The SMA has interstate interoperability, which further improves timeliness over Level 3. Information is available in real time. Processes improve further through connectivity with other States and federal agencies. Most processes execute at the point of service. Results are almost immediate.
Business Capability Quality: Data Access and Accuracy
How accurate is the information used in the process? Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making. HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1. Automation of information collection increases the reliability of SMA internal information. External sources of information use MITA Framework and industry standards for information exchange. SMA automates decision making based on intrastate standardized business rules definitions. Accuracy rating is at 99% or higher. Automation of information collection increases the reliability of the SMA internal and external sources of information. The SMA adopts MITA Framework and industry standards for information exchange with interstate agencies. The SMA automates decision making based on regionally standardized business rules definitions. Accuracy rating is at 99% or higher. The SMA adopts MITA Framework and industry standards for information exchange with national agencies. The SMA automates decision making based on nationally standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information used in the process? The SMA stores information in disparate systems including paper storage and obtains information manually. The SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1. The SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is greater than Level 2. The SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3. The SMA obtains information easily and exchanges with national agencies and entities. Accessibility is greater than Level 4.
Business Capability Quality: Cost-Effectiveness
What is the cost of the process compared to the benefits of its results? High relative cost due to low number of automated, standardized tasks. Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1. The SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2. The SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange. The SMA increases cost effectiveness ratio over Level 3. The SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. The SMA increases cost effectiveness ratio over level 4.
Business Capability Quality: Effort to Perform; Efficiency
How efficient is the process? Process is labor intensive. The SMA wastes effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low. Automation and state standards increase productivity. Efficiency is higher than Level 1. The SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher. The SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher. The SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.
Business Capability Quality: Accuracy of Process Results
How accurate are the results of the process? Manual processes produce a greater opportunity for human error. Accuracy is low. Automation and standardized business rules definitions reduce error and improve accuracy above Level 1. The SMA adopts MITA Framework, standardized business rules definitions, industry standards and information exchange with intrastate agencies and entities improving accuracy to 90% or higher. The SMA adopts MITA Framework, standardized business rules definitions, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher. The SMA adopts MITA Framework, standardized business rules definitions, industry standards and information exchange with national agencies and entities improving accuracy to 98% or higher.
Business Capability Quality: Utility or Value to Stakeholders
How satisfied are the stakeholders? Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process. Automation and standardized business rules definitions provides clear and useful information. Stakeholder satisfaction is greater than Level 1. The SMA adopts MITA Framework, standardized business rules definitions, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. The SMA uses survey or questionnaire for information collection. The SMA adopts MITA Framework, standardized business rules definitions, industry standards and information exchange with interstate agencies and entities improving stakeholder satisfaction to 95% or higher. The SMA adopts MITA Framework, standardized business rules definitions, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.

Detailed MITA Maturity Model Definitions - Technical Architecture

MITA Technical Capability Matrix
Level 1 Capabilities Level 2 Capabilities Level 3 Capabilities Level 4 Capabilities Level 5 Capabilities
Access and Delivery
Client Support (Business Results Condition)
Beneficiary and provider access to appropriate Medicaid business functions via manual or alphanumeric devices. Beneficiary and provider access to appropriate Medicaid business functions via portal with single online access point. The SMA provides single browsers (i.e., Microsoft Internet Explorer) support for portal. Viewer is unable to customize or make adjustments (e.g., font size, language support) to portal presentation. Beneficiary and provider access to appropriate Medicaid business functions via portal with single online access point. The SMA supports three (3) most popular browser versions (i.e., Microsoft Internet Explorer), Google Chrome, and Mozilla Firefox). Beneficiary, provider, and other staff access beneficiary electronic health information online including clinical information. The SMA exchanges health information with Health Information Exchange (HIE). Beneficiary has access to Health Insurance Exchange (HIX). The SMA supports most major browsers for devices that include the most popular operating system brands (i.e., Android, Macintosh, and Windows). The SMA adopts nationally exchange of beneficiary, provider, and other appropriate information. The SMA adopts information exchange with national agencies and Health Information Exchange (HIE). The SMA provides cross-regional Beneficiary access to Health Insurance Exchange (HIX). SMA provides linguistically, culturally, and competency appropriate information for all services. The SMA fully complies with Section 508 Accessibility on various end-user devices (i.e., computers, mobile devices, etc.).
Business Intelligence (Business Results Condition and Reporting Condition)
Business intelligence information available by custom-coded programming. Business intelligence information is inconsistent and unreliable with very little automation. Business intelligence information is available for specific business functions. The SMA limits access to a small group of stakeholders. The SMA adopts strategic business intelligence environment with defined governance policies and enforcement. Business objectives drive business analysis and performance management strategies. The SMA adopts enterprise-wide performance standards and metrics for business analysis. The SMA adopts business process specific performance standards and metrics for business analysis. The SMA performs behavior simulation and prediction modeling on large populations. The SMA shares business analysis with providers, beneficiaries, and trading partners.
Forms and Reporting (Business Results Condition and Reporting Condition)
The SMA conducts direct data entry from paper forms. The SMA and stakeholders conducts data entry using electronic forms. The SMA produces reports with manual data entry and processing. Online electronic forms accept limited file type (e.g., txt, xls, or pdf) attachments. The SMA adopts periodic submission of electronic reports. The SMA adopts real-time submission of claims, clinical, and other reporting information. The SMA adopts real-time national database accessible with regional, state, and local reporting information.
Performance Measurement (Reporting Condition)
The SMA calculates performance measures and metrics in spreadsheets. The SMA defines enterprise performance standards. The SMA collects information in predefined formats. The SMA generates performance measures and metrics using predefined and ad hoc reporting methods. The SMA adopts CMS-defined performance standards and metrics. The SMA defines performance measures and metrics for specific business processes for collection and reporting of performance standards. The SMA produces automatic system alerts and alarms when performance metric is not within defined performance standard boundaries. The SMA adopts national performance standards with system alerts when performance metric is not within defined performance standard boundaries.
Security and Privacy (Industry Standards Condition)
Beneficiary and provider access to services via manual submission, alphanumeric devices (i.e., paging), or Electronic Data Interchange (EDI). The SMA uses policy and procedures controls to ensure privacy of information. The SMA provides member and provider access to services via browser, kiosk, voice response system, or mobile phone. The SMA provides member and provider access to services online via mobile device. The SMA supports automatic user authentication. The SMA provides staff with Single Sign-On (SSO) functionality to a majority of the applications in the State Medicaid Enterprise. The SMA restricts access to data elements based on defined access roles. The SMA provides user authentication via SecureID tokens and delivery of results to authentication and authorization functions. The SMA provides user authentication via biometric identification and delivery of results to authentication and authorization functions.
Intermediary and Interface
Business Process Management (MITA Condition)
Business processes consists primarily of manual paper-based activity to accomplish tasks. The SMA is not using MITA initiative for business, architecture and data. The SMA uses a mix of manual and automatic business processes. The SMA aligns business workflows with any provided by CMS in support of the Medicaid and Exchange business operation’s and requirements (i.e., MITA Framework). The SMA adopts specification and management of business processes in conformance with nationally recognized BPM standards (e.g., Business Process Execution Language (BPEL)). The SMA has full integration of the MITA initiative with business, architecture and data within the intrastate. The SMA aligns to and advances increasingly in MITA maturity for business, architecture, and data. The SMA develops MITA Maturity Model Roadmap to monitor progress in MITA maturity. The SMA has full integration of the MITA initiative with business, architecture, and data within the interstate. The SMA reaches targeted MITA maturity for business, architecture, and data. The SMA has full integration of the MITA initiative with business, architecture, and data within the nation.
Relationship Management (Modularity Standard and Industry Standards Condition)
The business relationship processes consists primarily of manual activity to accomplish tasks. The SMA uses non-standardized definition and invocation of services. The SMA applies a mix of HIPAA and state-specific standards for service support. The SMA adopts intrastate Basic Business Relationship Management (BRM), including tracking relationships between Medicaid system users (e.g., beneficiaries and providers) and the services requested and received. The SMA provides services support using architecture that complies with MITA Framework, industry standards, and other nationally recognized interface standards. The SMA adopts business analytics for its BRM. The SMA provides offers personalization capabilities to beneficiaries, providers, and business partners. The SMA provides services support using a cross-enterprise services registry. The SMA adopts business analytics for its interstate BRM. The SMA provides offers personalization capabilities to beneficiaries, providers. The SMA provides services support using a cross-enterprise services registry.
Data Connectivity (Leverage Condition)
Manual information exchange between multiple organizations, sending information requests via telephone or e-mail to data processing organizations and receiving requested information in nonstandard formats and in various media (e.g., paper, facsimile, EDI). The SMA conducts electronic information exchange within the agency via an information hub using secure information. The location and format are transparent to the stakeholder and the results delivered in a defined style that meets the stakeholder’s needs. The SMA conducts electronic information exchange with multiple intrastate agencies via an information hub. The SMA performs advanced information monitoring and route system alerts and alarms to communities of interest if the system detects unusual conditions. The SMA uses canonical data models to communicate between different data formats. The SMA adopts enterprise integration strategy. The SMA is migrating from a point-to-point to message based exchange.

The SMA obtains information easily and exchanges with intrastate agencies and entities.

The SMA uses canonical data model to communicate between interstate agencies, federal entities, and health care stakeholders.
Service Oriented Architecture (SOA) (Modularity Standard and Interoperability Condition)
The SMA uses non-standardized approaches to orchestration and composition of functions. The SMA conducts reliable messaging, including guaranteed message delivery (without duplicates) and support for non-deliverable messages. The SMA adopts MITA recommended ESB, automated arrangement, coordination, and management of system. SMS conducts system coordination between intrastate agencies and some external entities. The SMA adopts MITA recommended ESB. The SMA uses SOA and System Development Life Cycle (SDLC) methodologies and ensures seamless coordination and integration with intrastate agencies and entities, Health Information Exchange (HIE), and Health Insurance Exchange (HIX). Systems ensure seamless coordination and integration with federal agencies and entities, Health Information Exchange (HIE), and Health Insurance Exchange (HIX)
System Extensibility (Business Results Condition and Interoperability Condition)
The SMA does not use web services. The SMA conducts extensive code changes for additional system functionality. The SMA uses a mix of manual and electronic transactions to conduct business activity. The SMA uses some isolated web services. The SMA uses RESTful and/or SOAP-based web services for seamless coordination and integration with other U.S. Department of Health & Human Services (HHS) applications and intrastate agencies including the Health Insurance Exchange (HIX). The SMA coordinates RESTful and SOAP-based web services with interstate agencies including Health Information Organizations (HIO) and the Health Information Exchanges (HIE). The SMA adopts web services of Nationwide Health Information Network (NwHIN) priority areas. The SMA coordinates RESTful and SOAP-based web services with all available federal agencies (i.e., Internal Revenue Service). The SMA increases federation and intrinsic interoperability with minimal impact for new service capability. The SMA adopts full usage of NwHIN with exposed services to all appropriate parties.
Integration and Utility
Configuration Management (Modularity Standard and Leverage Condition)
The SMA uses technology-dependent interfaces to applications. Introduction of new technology significantly affects interfaces to applications. The SMA does not use Configuration Management methodology. The SMA uses technology-neutral interfaces that localize and minimize the impact of the introduction of new technology (e.g., information abstraction in data management services to provide product-neutral access to information based on metadata definitions). The SMA uses a mixture of manual and automated Configuration Management methodology. The SMA uses Software Configuration Management to reproduce solutions in a controlled, incremental fashion, rather than focusing on controlling solution products. The SMA identifies intrastate configuration items and baselines. The SMA adopts Build Management, Process Management, and Environment Management through the SDLC. The SMA adopts system development process between interstate agencies and external entities. The SMA fully utilizes Build Management, Process Management, and Environment Management through the SDLC. The SMA adopts system development process between intrastate and interstate agencies, federal entities, and external health care stakeholders.
Data Access and Management (Interoperability Condition)
The SMA uses ad hoc formats for information exchange. The SMA uses ad hoc, point-to-point approaches to systems integration. The SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards. The SMA has information residing in one schema with tight coupling approach. The SMA applies single source of information methodologies. The SMA develops data models and maps information exchanged with external organizations to the model. The SMA has information residing in multiple locations. The SMA conducts information exchange (internally and externally) using MITA Framework, industry standards, and other nationally recognized standards. The SMA uses service-enabling legacy systems using MITA Framework, industry standards, and other nationally recognized standards. The SMA performs data management storage optimization and consolidation techniques. The SMA has information residing in multiple locations, but accessible to stakeholders providing uniform access in an intrastate mediated schema. The SMA conducts information exchange (internally and externally) using MITA Framework, industry standards, and other nationally recognized semantic data standards (ontology-based) for clinical information and electronic health records. The SMA adopts information archiving solutions to meet data-retention policies and compliance guidelines. The SMA develops data model using MITA Framework, industry standards, and other nationally recognized standards and has access to technical services in a national repository.
Decision Management (Leverage Condition)
The SMA uses manual application of business rules that which results in unreliable and inconsistent decision-making. The SMA does not document business rules. The SMA does not apply business rules consistently. The SMA imbeds business rules in the core application code. Business rules execute in a batch-operating environment. The SMA documents business rules as narrative description from which a developer creates programming code. The SMA uses standardized business rules definitions that reside in a separate application or Rules Engine. Business rules execute in a runtime environment. The SMA uses production or inference rules to represent behaviors (e.g., IF Then conditional logic). A rules editor maintains the current version of standardized business rules definitions in a language that business people can interpret and transforms them into machine language to automate them. The SMA uses rules engine that utilizes technical call-level interface using Application Programming Interface (API) standard. The SMA uses Event Condition Action rules. The reactive rules engine detects and reacts to incoming events and process event patterns. The rules editor provides traceability, impact analysis, and capabilities so The SMA can evaluate changes across multiple areas. The SMA establishes an integrated environment for development, authoring, and testing. The SMA uses multiple methods for rule creation and management, including decision trees, scorecards, decision tables, formula builder, graphical decision flows, and customized templates. The SMA uses deterministic rules engine that utilizes domain-specific language involving multiple environments (e.g., Cloud Computing services). The rules engine tool generates automated testing scenarios and enables analysts and developers to trace through execution paths for implementation verification. The SMA uses an open system for ease of integration with any computing environment. Rules engine accepts inputs from multiple databases, XML documents, Java objects, .NET/COM objects, and COBOL copybooks and integrates with various environments (e.g., HIX).
Logging (Business Results Condition and Reporting Condition)
Stakeholders use log-on identification and password for access to system capabilities. The SMA manually conducts logging and analysis. The SMA has access to the user’s activity history and other management functions, including log-on approvals/disapprovals and log search and playback. The SMA conducts user authentication using public key infrastructure in conformance with MITA Framework, industry standards, and other nationally recognized standards. The SMA uses role-based authorization to system resources using log-on credentials. The SMA uses contemporary enterprise-based auditing tools such as, TrustedBSD, or OpenBSM to generate and process audit records. The SMA uses open source components, such as, OpenXDAS.
Utility (Industry Standards Condition and Leverage Condition)
Business processes consists primarily of manual activity to accomplish unique tasks. The SMA conducts Research and Development experimentation where pilot project(s) are taking place using state-specific standards. The SMA uses minimal web service utility type services in isolated areas. The SMA uses simple architected software services involving database integration and reliable messaging. The SMA introduces versioning, mediation, and distributed systems. The SMA integrates multiple applications. The SMA incorporates industry standards in requirements, development, and testing phases of projects including security measures. The SMA conducts initial performance management activities. The SMA uses a set of computer programs to perform unique business and technical tasks. The SMA adopts business processes orchestration in an event-driven environment. The SMA does have transactions that take long time to execute. The SMA uses composite applications including initial external service enablement. The SMA uses SDLC governance activities. The SMA adopts all industry standards set by the HHS Secretary for requirements, development, and testing phases of projects. The SMA uses measured business services involving business activity monitoring along with event-driven dashboard information. The SMA has multiple enterprises involving shared Business-to-Business services. The SMA provides services to the stakeholder community to perform business functions without human intervention. The SMA implements self-correcting business processes. The SMA conducts real-time event stream processing to optimize service offering.

Detailed MITA Maturity Model Definitions - Information Architecture

Business Area Title
Establish Business Relationship
Level 1 Level 2 Level 3 Level 4 Level 5
Data Management Strategy (DMS)
Does business area have governance of data management? No data governance implemented. Implementation of internal policy and procedures to promote data governance, data stewards, data owners, and data policy. Adoption of governance process and structure to promote trusted data governance, data stewards, data owners, data policy, and controls redundancy within intrastate. Participation in governance, stewardship, and management process with regional agencies to promote sharing of Medicaid resources. Participation in governance, stewardship, and management process with Centers for Medicare & Medicaid Services (CMS) and other national agencies and groups to promote sharing of Medicaid resources.
Does business area have common data architecture? No standards for data architecture development. Implementation of internal policy and procedures to promote data documentation, development, and management where the SMA defines data entities, attributes, data models, and relationships sufficiently to convey the overall meaning and use of Medicaid data and information. Adoption of intrastate metadata repository where the SMA defines the data entities, attributes, data models, and relationships sufficiently to convey the overall meaning and use of Medicaid data and information. Adoption of a regional metadata repository where the SMA defines the data entities, attributes, data models, and relationships sufficiently to convey the overall meaning and use of Medicaid data and information. Adoption of a national centralized metadata repository where the SMA defines the data entities, attributes, data models, and relationships sufficiently to convey the overall meaning and use of Medicaid data and information.
Does each business area use Enterprise Modeling? No enterprise modeling exists. Implementation of Medicaid internal policy and procedures to promote enterprise modeling. Adoption of intrastate enterprise modeling to promote standardized data across data source systems and third-party resources to decrease resource expenditure and increase enterprise knowledge. Adoption of regional enterprise modeling to promote standardized data across data source systems and third-party resources to decrease resource expenditure and increase enterprise knowledge. Adoption of national enterprise modeling to promote standardized data across data source systems and third-party resources to decrease resource expenditure and increase enterprise knowledge.
Does business area utilize data sharing architectures? No sharing of data. Development of Medicaid centralized data- and information-exchange formats. Adoption of statewide standard data definitions, data semantics, and harmonization strategies. Adoption of regional mechanisms used for data sharing (i.e., data hubs, repositories, and registries). Adoption of national mechanisms used for data sharing (i.e., data hubs, repositories, and registries).
Conceptual Data Model (CDM)
Does business area have CDMs? No CDM developed. Adoption of diagrams or spreadsheets that depict the business area high-level data and general relationships within the agency. Adoption of a CDM that depicts the business area high-level data and general relationships for intrastate exchange. Adoption of a CDM that depicts the business area high-level data and general relationships with regional exchange including clinical information. Adoption of a CDM that depicts the business area high-level data and general relationships with national exchanges.
Logical Data Model (LDM)
Does business area have LDMs? No LDM developed. Identification of data classes and attributes relationships, data standards, and code sets within the agency. LDM identifies the data classes, attributes, relationships, standards, and code sets for intrastate exchange. LDM identifies data classes, attributes, relationships, standards, and code sets for regional exchange including clinical information. LDM identifies data classes, attributes, relationships, standards, and code sets for national exchange.
Data Standards
Does business area use structure and vocabulary data standards to support current and emerging health data standards? The agency uses non-standard structure and vocabulary data standards. SMA implements internal structure and vocabulary data standards used for performance monitoring, management reporting, and analysis. SMA implements state-specific and Health Insurance Portability and Accountability Act of 1996 (HIPAA) data standards. SMA standardizes structure and vocabulary data for automated electronic intrastate interchanges and interoperability. SMA implements MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information. SMA standardizes data for automated electronic regional interchanges and interoperability. SMA implements the MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate exchange of information. SMA standardizes data for automated electronic national interchanges and interoperability. SMA implements the MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.

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