APPENDIX A: L.A. COUNTY LEADER ELIGIBILITY DATA FLOW

Transcription

1 APPENDIX A: L.A. COUNTY LEADER ELIGIBILITY DATA FLOW

2 APPENDIX A TITLE: L.A. COUNTY LEADER ELIGIBILITY DATA FLOW 7.0 R E AM SCI MEDS R E AM Recipient presents to establish benefits Locations:! DSS! Prenatal Clinic s! CBOs! WIC sited! Main-in Recipient received applic ation and pre-interview sheet to complete Recipients complete application Recipients presents to Case Opening Clerk (COC) 4.0 COC reviews paperwork, determines potential eligibility and assigns case number LEADER COC determines CIN for recipient COC generates referral for Maximus Referral Recipient presents to Intake Worker Immediate need case? Intake Worker processes interview online using LEADER LEADER Intake Worker completes processing of case Case approved? LEADER updated with case denial information Transaction sent to MEDS 18.0 MEDS Worker Alert generated and sent to LEADER OUTLOOK ASSOCIATES, INC. PAGE 1OF 4

3 APPENDIX A TITLE: L.A. COUNTY LEADER ELIGIBILITY DATA FLOW. Finding Process or Finding Description 1.0 Medi-Cal eligibility is processed in multiple sites within County, including prenatal clinics, CBOs, WIC sites, via mail in (Healthy Families) and DSS location. 2.0 A person presents at the County office and fills out an application for enrollment into Medi-Cal. A County worker determines Medi-Cal eligibility. County determines eligibility status and assigns the appropriate AID code. The AID code determination is based on existing conditions, review of documentation supplied by the recipient, etc. Recipients are approved effective date first of the following month. 3.0 The Case Opening Clerk (COC) reviews the application for completeness, explains the process to the recipient and answers any questions. The recipient may be asked to provide the following:! Verification of SSN! Birth certificate! Verification of address! Statement of property! Statement of income! Utility/Rent receipts! Immunization records (for children)! Verification of school attendance (for children) Information about the case is entered into LEADER. 4.0 Only a few County districts are using LEADER. LEADER went live at their location in 10/99. LEADER is supported and maintained through UNISYS. 5.0 Functions within LEADER are still not functioning properly. For example, LEADER cannot generate/issue Medi-Cal cards, and thus, cards are still requested through MEDS. At times, adds, changes and terms do not pass through the interface to MEDS accurately. Additionally, when LEADER was installed, the district office went from an old legacy system, which was updated by clerks on the backend, to PC level functionality on most desks. Users have little or no knowledge of PC level functionality and training was insufficient. As a result of the existing issues, the rollout of LEADER across other districts within the County has been delayed. 6.0 With the LEADER system, the minimum time required to process and approve a case has dropped from 10 days to 2-3 hours. Cases can still be Pending in LEADER for up to days, depending on the specifics of the case. 7.0 The Statewide Client Index Database (SCI) maintains the CIN for all State programs using CIN. Counties access SCI directly to look for existing CINs or generate new CINs numbers. SCI was implemented in August SCI is used by Welfare, MEDS, Healthy Families, other public programs and fingerprinting programs. SCI was developed partially to replace the CIN functionality on MEDS. SCI has been developed to store potentially static fields only about the client, such as name, SSN, birthdate, gender, County code and other data such as mother s name and place of birth. With those Counties utilizing ISAWS, multiple checks are in place during CIN processing, to prevent duplication of the CIN. At this 8.0 point, the number of forced adds (when the County asks for a new CIN rather than accept an existing client) is between %. R E AM During the LEADER development, the business process for researching and potentially generating CIN numbers was streamlined. As a result, the number of forced adds is extremely high for those L.A. County districts using LEADER. While recently at 70%, it is now 45 53%. OUTLOOK ASSOCIATES, INC. PAGE 2 OF 4

4 APPENDIX A TITLE: L.A. COUNTY LEADER ELIGIBILITY DATA FLOW. Finding Process or Finding Description 9.0 R E AM 10.0 With the implementation of LEADER, CIN is now the primary ID for the recipient. With the previous legacy system, CIN was not used as the primary ID for the recipient. This has been a significant change in operations, causing significant issues and errors related to CIN assignment. With LEADER, the front line worker, the COC, is responsible for assigning the CIN to all recipients. They must first attempt to find an existing CIN for the recipient. When the worker uses SCI, they could get several matches (for example, 25). The name at the top of the screen would be highlighted (part of the screen appearance) and the COC automatically assumes that it was the correct recipient and therefore the correct CIN. This resulted in identical CIN assignments to multiple parties. Additionally, if the COC did not enter enough data, or did not perform enough research, no matches may be found. In that case, a new CIN might be created for a recipient with an existing CIN. DSS has had to create very strict guidelines for this process. This includes checking MEDS for CIN matches and generating a MEDS printout once the CIN has been determined. MEDS has zip code software to identify bad address. This software checks the address information during a batch process and flags the bad address. However, it does not work during the initial entry of the address data. For the County districts with LEADER, the connection with SCI is on-line and CIN is used as the primary key. When CINs are created in SCI via file clearance, MEDS is also updated. Additionally in the County, the legacy system does not connect with SCI, so an index of 11.0 all County clients with CIN is also maintained on LEADER. All other Counties send batch transactions to SCI for processing and do not utilize CIN in their systems The COC generates the Maximus referral and places in a basket for Maximus workers to retrieve and process. All Counties can send immediate need transactions. This screen exists on the LEADER system. These are for claims that must be paid immediately or to allow a recipient to see a provider on the same day. These transactions to a daily file which is accessed by EDS 13.0 during the inquiry processing (POS network, AEVS, Website, CERTS) so changes to a member s eligibility can be reflected in the inquiry processing on the same day. Additionally, these transactions are fed back through the MEDS nightly batch process. The Counties are 14.0 R E AM also required to send confirmation transactions via the regular method. With Title 1391B, the Medicaid Expansion Project, additional calculation is required to determine if the recipient is eligible. This functionality does not currently exist in LEADER. As a result, case workers must remember to manually determine and update the system for recipients eligible for 1391B. Additionally the manual override must be performed each time the case is updated (LEADER shows that a manual override is required, as a reminder). Continuing recipients must submit proof of ongoing eligibility for the Medi-Cal program. Some AID codes require monthly verification; other AID codes require Quarterly review (called Re-Determination). The beneficiary is allowed 10 days to return the paperwork. Officially, if the beneficiary does not return their paperwork by the 20th of the month, their eligibility is terminated in LEADER until the paperwork is received. If the recipient actually returns their paperwork by the first day of the next month, the County will reinstate. There is a bad address flag in MEDS. The authorization to update demographic data lies with the recipient. Recipients can call into their case worker to verify and/or update phone and address information. If the data is phoned in, DSS will follow-up with a letter requesting verification. Additionally, County offices may receive address updates, however, there is concern that these updates are never entered into MEDS. This may be due to understaffing at the County offices. There is discussion in progress to potentially change this process. Once a member is determined to be eligible for Medi-Cal, updates are made in LEADER and transactions are sent to MEDS. MEDS contains data about eligibility for several programs, including, food stamps, AFDC and Medi-Cal. The MEDS system uses AID codes to define a person s eligibility requirements in a certain program. The MEDS system is supported by ITSD at DHS. The Counties own the OUTLOOK ASSOCIATES, INC. PAGE 3 OF 4

5 APPENDIX A TITLE: L.A. COUNTY LEADER ELIGIBILITY DATA FLOW. Finding Process or Finding Description data and are responsible for the input and validity of the data For every transaction sent to MEDS that does not pass cleanly through the edit process, a Worker Alert is generated. In some cases the transaction will be rejected by MEDS. The Worker Alerts can be generated both on-line and as a report. Counties are responsible for researching and correcting these Worker Alerts. There appears to be a training issue as the Counties may generate another transaction (causing a duplicate) rather than submitting a record to clean up the original transaction. Because of its size, the County has a very large number of Worker Alerts. The County requires the Worker Alerts to have the district number and eligibility worker code. If this is missing, it is difficult to track down who should correct the Worker Alerts. With severe staffing issues in the County (600 cases per EW), Worker Alerts are not considered the highest priority. Per DHS, LEADER can accept an electronic file from the nightly process and actually perform updates without manual intervention. DHS was not sure if this process was in production. DATA DICTIONARY LEGEND Icon Name Definition Best Practice Represents an efficient, well-designed process that should be examined for potential use at other organizations. Communication Breakdown Represents area of poor communication between parties. ABC... ABC... Duplicate Records Represents a process with the potential for duplicate record submission. R E AM Major Error/Data Scramble Manual Process Represents problem with a process which has a strong potential to mis-translate or corrupt data. Represents a process involving one or more manual steps that could potentially be automated. Poor Process Represents poor process compared to industry standards. Process with Major Data Loss Potential Indicates a process with the potential for major data loss Time Delay Under-utilized Technology Indicates a process with significant delays that impact the timelines of the data submission. Represents a process that does not take advantage of existing technology (e.g., calling the plan when the provider could use the plan's AEVS which has identical data). OUTLOOK ASSOCIATES, INC. PAGE 4 OF 4

6 APPENDIX B: MAXIMUS ELIGIBILITY DATA FLOW

7 APPENDIX B TITLE: MAXIMUS ELIGIBILITY DATA FLOW A. PLAN AND PCP SELECTION A Recipient presents to County office or designated site to apply for benefits County worker(s) begin to process case HCO referral scheduled? Maximus worker picks up paper referral and attempts to schedule presenta tion with recipient Is a presentation scheduled? Ma ximus performs presentation and distributes packet Choice form completed? Choice form sent to Maximus in Sacramento B action taken until Maximus received notifica tion via MEDS Recipient instructed to complete forms and mail in Are forms mailed in by recipient? OUTLOOK ASSOCIATES, INC. PAGE 1 OF 6

8 APPENDIX B TITLE: MAXIMUS ELIGIBILITY DATA FLOW A. PLAN AND PCP SELECTION (CONT.) 12.0 MaxStar Maximus generates weekly sub-plan/ PCP file by plan File sent weekly via to plans R E AM D 8.0 MEDS updated with selection Recipient sent confirmation letter B Choice form(s) processed in Maximus system (MaxStar) MaxStar transaction created Nightly cycle processing Is Maximus transaction approved? 10.0 C Has it been 60 days? Transaction in MaxStar removed END 9.0 Error correctable by Maximus? Error corrected by Maximus OUTLOOK ASSOCIATES, INC. PAGE 2 OF 6

9 APPENDIX B TITLE: MAXIMUS ELIGIBILITY DATA FLOW 47 days B. PROCESSING APPROVED CASES 10.0 County completes case processing Case approved? County sends transaction to MEDS MEDS MEDS downloads newly eligibles file to MaxStar nightly Choice form already processed in MaxStar? D See page A END IA transaction generated in MaxStar and sent to mailroom Recipient mailed packet, IA letter and asked to respond in 30 days Recipient respond? Form complete, ready to process? C E 16.0 Form sent back to recipient E ID transaction generated in MaxStar and sent to mailroom Recipient mailed ID letter and reminded to respond in 30 days Recipient respond? Form complete, ready to process? C F Form sent back to recipient F Default transaction created and sent to MEDS MEDS processes default Maximus retrieved accepted default and a Confirmation Letter is sent OUTLOOK ASSOCIATES, INC. PAGE 3 OF 6

10 APPENDIX B TITLE: MAXIMUS ELIGIBILITY DATA FLOW. Finding Process or Finding Description 1.0 Maximus currently has a contract to support the enrollment process in thirteen counties. In L.A. County, Maximus is present in 24 DSS offices and 13 WIC sites. The Maximus process assists recipients in selecting a plan, sub-plan and PCP and via presentation or an enrollment packet sent to new beneficiaries. The enrollment packet contains all materials for enrolling into a health plan, including a Choice form (enrollment), exception form (FFS), provider directory, comparison chart, etc. te: In San Diego County, Maximus processes the forms but does not interact with the recipient. Additionally, Maximus operates a State-wide Call Center to answer recipient questions and help guide them through the process. 2.0 Maximus follows a predetermined script in an unbiased format. They explain managed care, including the recipients rights as health plan members, and offer assistance in filling out the forms. Maximus instructs the recipient to contact their Intake Worker to submit any demographic changes (e.g., address, phone). 3.0 Enrollment forms completed at the time of the presentation are sent to the Maximus office in Sacramento that day. Maximus is required to process the enrollment forms within 72 hours of receipt from the recipient. For those enrollment forms submitted by the 20 th 25 th of the month, the recipient will be eligible the first of following month. Otherwise the recipient is not eligible until the first of the second month following the current month (up to 45 days). Recipients are eligible for services under FFS until they become select or default to a health plan. 4.0 When Maximus receives a completed enrollment form from the recipient, it is entered into MaxStar. Recipient may choose just the health plan or health plan and PCP. 5.0 Maximus maintains their own system, MaxStar, a proprietary system, UNIX based, written in C or C++. If Maxstar was available in all County locations, the local Maximus workers could resolve any issues related to the application on the spot with the recipient present. This could possibly include other information such as address and phone number. Maximus receives PCP data related to provider participation and panel capacity for accepting new members on a quarterly basis from the health plans. Because of the amount of ongoing change with physicians and their practices, this data is often outdated and new members R E AM may select a physician that is no longer with a particular health plan or is currently not receiving any new members into her/his panel. Once the selection is sent to the health plans, the plans must contact the recipient and make the change. This can be extremely confusing and frustrating to members who are new to this process and new to managed care, in particular. When bad addresses are identified (e.g., bad matches, packet comes back with bad address notice), Maximus updates a flag on MaxStar. Maximus sends a transaction to MEDS noting a bad address. According to Maximus, this notification is not stored on MEDS. While MaxStar currently shows approximately 12,600 bad addresses, MEDS shows approximately 3,200 bad addresses. This slows down the selection process for the recipient. 6.0 Maximus receives updated PCP data from the plans on a quarterly basis. 7.0 Each night all MaxStar transactions still requiring case approval are sent to MEDS to determine if the case has been approved and updated in MEDS. 8.0 If the MaxStar transaction is rejected, Maximus will determine the reason and try and correct, if possible. 9.0 Example of an error is bad address If no case approval appears in MEDS within sixty days, the transaction is removed from MaxStar. If the recipient s case eventually becomes approved in MEDS, the recipient will receive a packet via MaxStar and have to choose a plan and PCP again Maximus users may view data on MEDS. Transactions sent back via MaxStar update MEDS regarding plan selection Maximus sends a weekly file via disk or bulletin board containing the prospective members Plan Partner and PCP (if selected). Maximus OUTLOOK ASSOCIATES, INC. PAGE 4 OF 6

11 APPENDIX B TITLE: MAXIMUS ELIGIBILITY DATA FLOW. Finding Process or Finding Description has also been sending the forms to the plans. It was perceived by the plans that they were not receiving all enrollments Recipients wishing to change plans go back through Maximus and submit a completed Choice From. The change will occur within 60 days. Recipients may also submit a Medical Exemption Request to Maximus in order to involve FFS Medi-Cal The current Intent to Assign (IA) process provides recipient 30 days to make a selection. The only exception is if recipients submit incomplete forms. In that case, they are given 10 additional days The IA transaction generates the packet and IA letter indicating the recipient has 30 days to respond with a selection (includes specific date). If the recipient never responds and is defaulted into a health plan, the entire process is about 47 days. This includes time for internal processing The Intent to Default (ID) transaction generates the ID letter reminding the recipients of the due date for plan selection The Confirmation Letter is sent explaining what plan the recipient was defaulted to. In defaulting plans, Maximus utilizes a continuity of care model. If the recipient has been in a plan prior or a family member is in a plan, they will assign the recipient to that plan. The recipient will be defaulted if no plan is selected within 30 days. Recipient is defaulted to a plan and the PCP selection process is handled by the plan The default rate for recipients not completing the entire process runs from 20 25%. Maximus believes part of the default percentage is due to the fact they are not on-site in all locations in which Medi-Cal benefits are assigned. As a result, a percentage of the recipients receive the packets in the mail only and this results in less compliance. DATA DICTIONARY LEGEND Icon Name Definition Best Practice Represents an efficient, well-designed process that should be examined for potential use at other organizations. Communication Breakdown Represents area of poor communication between parties. ABC... ABC... Duplicate Records Represents a process with the potential for duplicate record submission. R E AM Major Error/Data Scramble Manual Process Represents problem with a process which has a strong potential to mis-translate or corrupt data. Represents a process involving one or more manual steps that could potentially be automated. Poor Process Represents poor process compared to industry standards. Process with Major Data Loss Potential Indicates a process with the potential for major data loss Time Delay Indicates a process with significant delays that impact the timelines of the data submission. OUTLOOK ASSOCIATES, INC. PAGE 5 OF 6

12 APPENDIX B TITLE: MAXIMUS ELIGIBILITY DATA FLOW DATA DICTIONARY LEGEND Icon Name Definition Under-utilized Technology Represents a process that does not take advantage of existing technology (e.g., calling the plan when the provider could use the plan's AEVS which has identical data). OUTLOOK ASSOCIATES, INC. PAGE 6 OF 6

13 APPENDIX C: DHS ELIGIBILITY DATA FLOW

14 APPENDIX C TITLE: DHS ELIGIBILITY DATA FLOW 18.0 SSA Federal Medi-Cal eligibles SDX Input change by MEB 12.0 Change file daily 14.0 FAME extract distributed to COHS COHS pick-up eligibility SCI MEDS Nightly batch processing (midnight - 2 a.m.) FAME file EDS manages inquiry system! POS Network! AEVS! Web site! CERTS Eligibility processed at the counties County systems 9.0 MaxStar Maximus eligibility processing FAME extract distributed to EDS weekly EDS processes encounters! ISAWS! CDS! Custom (e.g., LEADER, etc.) Monthly batch processing FAME extract by plan EDS distributes eligibility to non-cohs plans via MESH Worker Alert generated R A E M Worker Alert mailed to plans Health plans update internal systems Worker Alert OUTLOOK ASSOCIATES, INC. PAGE 1 OF 5

15 APPENDIX C TITLE: DHS ELIGIBILITY DATA FLOW. Finding Process or Finding Description 1.0 SSA submits eligibility data on a SDX tape to ITSD twice a month, the 10 th and 15 th. The SDX tape received on the 15 th is a cleaner version of the tape received on the 10 th, and is the only version of the SDX tape which ITSD processes. DHS states there is no overlap in the eligible members submitted to ITSD from the Counties and the SSA. If a member receives Social Security funding, they are reported to DHS directly by the SSA. 2.0 Counties are responsible for researching and correcting these Worker Alerts. There appears to be a training issue as the Counties may generate another transaction (causing a duplicate) rather than submitting a record to clean up the original transaction. Because of their size, County has a very large number of Worker Alerts. One County requires the Worker Alerts to have the district number and eligibility worker code. If this is missing, it is very difficult to track down who should correct the Worker Alerts. With the severe staffing issues in this County (600 cases per EW), Worker Alerts are not considered the highest priority. 3.0 Per the State legislature, no more than four systems can be developed and maintained as Statewide Automated Welfare Systems (SAWS). The current systems are ISAWS, CDS (which is now referred to as CalWIN), LEADER and C4. Approximately 18 Counties use CDS, and approximately 35 other Counties have installed ISAWS. Counties have been moving to ISAWS since CalWIN is the new development effort underway to replace CDS. LEADER has been implemented in several County districts. Other Counties may look to move to LEADER in the future. The remaining Counties are on C4 (previously referred to as Magic ). All these internal systems must match the parameters defined by the Medi-Cal Eligibility Data Systems (MEDS) so they can transfer/upload data to MEDS. 4.0 For ISAWs and County districts with LEADER, the connection with the Statewide Client Index Database (SCI) is on-line. Both systems utilize CIN. When CINs are created in SCI via file clearance, MEDS is also updated. Additionally in Leader County districts, the legacy system does not connect with SCI, so an index of all County clients with CIN is also maintained on LEADER. All other Counties send batch transactions to SCI for processing and do not utilize CIN in their systems. 5.0 All County systems send in batch transactions to MEDS. ISAWs and LEADER systems send on-line transactions that are accepted via batch. All Counties have inquiry and some update capabilities within MEDS. The file clearance function generates a new CIN. While this happens in SCI, SCI updates MEDS Current policies and practices require a Medi-Cal member to notify DSS offices to correct or change address and telephone number information. If the member calls the change into a DSS worker, DSS offices must follow-up with a letter requesting verification. Facilitating a member through this process results in long delays in updates to MEDS address data. Prior to the change by DHS in the early 1990 s from the monthly ID cards/stickers for the Medi-Cal population, members were required to keep address information current in order to receive benefits. Since this change, address information within MEDS is extremely inaccurate, yet it remains the source of information for health plan eligibility and demographic updates. SCI maintains the CIN numbers for all State programs using CIN. Counties access SCI directly to look for existing CIN numbers or generate new CIN numbers. SCI was implemented in August SCI is used by Welfare, MEDS, Healthy Families, other public 6.0 programs and fingerprinting programs. SCI was developed partially to replace the CIN functionality on MEDS. SCI has been developed to store potentially static fields only about the client, such as name, SSN, birthdate, gender, County code and other data such as mother s name and place of birth. OUTLOOK ASSOCIATES, INC. PAGE 2 OF 5

16 APPENDIX C TITLE: DHS ELIGIBILITY DATA FLOW. Finding Process or Finding Description 7.0 With those Counties utilizing ISAWS, multiple checks are in place during CIN processing, to prevent duplication of CIN numbers. At this point, the number of forced adds (when the County asks for a new CIN number rather than accept an existing client) is between %. During the LEADER development, the business process for researching and potentially generating CIN numbers was streamlined. As a result, the number of forced adds is extremely high for those County districts using LEADER. While recently at 70%, it is now around 45 53%. 8.0 MEDS holds all data about Medi-Cal eligibility for recipients. The MEDS system is supported by ITSD at DHS. The MEDS system contains data about the eligibility for several programs, including, food stamps, AFDC, Medi-Cal. The MEDS system uses AID codes to define a person s eligibility requirements in a certain program. 9.0 The MEDS renewal process occurs around the 23 rd of each month. A new membership file is created with all changes occurring during the previous month. Additionally the calendar rolls on the MEDS file so that the next month becomes the current month. For example, after the process runs on the 23 rd of April, the current month then becomes May. History on MEDS goes back 15 months. A new FAME extract is created. Finally a FAME extract is created for every health plan. This FAME extract is distributed to the plans monthly. The health plans believe the early cutoff date (23 rd each month) for subsequent month eligibility contributes to the high volume of health plan Worker Alerts. If eligibility determination and paperwork within DSS is not complete by this deadline, the member appears on hold, ineligible for services until the hold is released via a Worker Alert. Health plans believe that if deadlines could be moved forward by several days, hold rates, errors and manual effort would decrease significantly DHS has plans to change the MEDS renewal process to become a daily function. Daily files will be then available to the health plan. timeframe was provided Each quarter, a reconciliation process occurs and MEDS is updated with all the data received from the Counties. Additional Worker Alerts are generated out of this process and the Counties are asked to research and correct. DHS identifies Burman holds which are those eligibility conflicts between the County systems and MEDS All Counties can send immediate need transactions for claims that must be paid immediately or to allow a recipient to see a provider on the same day. These are transactions to a daily file, which is accessed by EDS during the inquiry processing (POS network, AEVS, Website, CERTS) so changes to a member s eligibility can be reflected in the inquiry processing on the same day. Additionally, these transactions are fed back through the MEDS nightly batch process. The Counties are also required to send confirmation transactions via the regular method Each night, MEDS is down from 12 midnight to 2 am for batch processing. All transactions received during the day from the Counties are processed through MEDS. MEDS validates the transactions and generates Worker Alerts for any errors in editing. The Worker Alerts are available the following day to the Counties via report printout or MEDS. LEADER can accept an electronic file from the nightly process and actually perform updates without manual intervention. DHS was not sure if this processing was yet in production. A file of newly eligible clients is sent to Maximus for plan/pcp selection. The FAME extract is updated with any changes received during the previous 22 hours and the daily file is cleaned out of any changes received. Each changed record is replaced on FAME. All Statewide inquiry functions (POS, AEVS, Website, CERTS) are unavailable during nightly processing COHS have a direct lease line to ITSD to pickup eligibility. COHS pickup FAME extract each day. Extract contains all membership. OUTLOOK ASSOCIATES, INC. PAGE 3 OF 5

17 APPENDIX C TITLE: DHS ELIGIBILITY DATA FLOW. Finding Process or Finding Description 15.0 FAME is a subset of the MEDS data, containing the data specific to Medi-Cal eligibility. CIN is the key on the FAME extract. te: If a Medi-Cal member has no SSN when their Benefits Identification Card (BIC) is generated, the CIN will appear on front side. Otherwise just the SSN will appear on the front side of the BIC. Both CIN and SSN are embedded in the magnetic stripe on the backside of the BIC. All plans are using the FAME format. The prior format/process was not Y2K-compliant so all plans converted to FAME in FAME contains the eligibility status of every Medi-Cal managed care member for the current month plus 12 months back We were unable to verify through DHS where within DHS the health plan Worker Alerts were generated and mailed. Per DHS, this process was stopped, as daily electronic files were now available via MESH with this data. One plan reported receiving S1 transactions with their monthly FAME file, but was unaware of a new daily file. All of the other health plans surveyed were still receiving and processing paper Worker Alerts and were not aware of a new electronic file format Health Plan Worker Alerts (paper reports) are generated and mailed to the plans on a daily basis. This includes enrollment, disenrollment and demographic changes that must be keyed into the health plan systems. The current process incorporates about a 3-5 day delay before the data reaches the health plans. One health plan has reported receiving 20,000 per month. However, this jumped to 70,000 in February R E and March with the 1931B Medicaid Expansion project. The health plans believe the early cutoff date (23 AM each month) contributes to the high volume of health plan Worker Alerts. On-line changes can be made to demographics in the MEDS system by DHS staff. However, changes made to data for federally eligible 18.0 members are overwritten by subsequent Federal eligibility (SDX) file submissions. DHS does not have the ability to save their input changes. As a result, more current information obtained by DHS will be overridden by the monthly SDX submission. DATA DICTIONARY LEGEND Icon Name Definition Best Practice Represents an efficient, well-designed process that should be examined for potential use at other organizations. Communication Breakdown Represents area of poor communication between parties. ABC... ABC... Duplicate Records Represents a process with the potential for duplicate record submission. R E AM Major Error/Data Scramble Manual Process Represents problem with a process which has a strong potential to mis-translate or corrupt data. Represents a process involving one or more manual steps that could potentially be automated. Poor Process Represents poor process compared to industry standards. Process with Major Data Loss Potential Indicates a process with the potential for major data loss. OUTLOOK ASSOCIATES, INC. PAGE 4 OF 5

18 APPENDIX C TITLE: DHS ELIGIBILITY DATA FLOW DATA DICTIONARY LEGEND Icon Name Definition Time Delay Indicates a process with significant delays that impact the timelines of the data submission. Under-utilized Technology Represents a process that does not take advantage of existing technology (e.g., calling the plan when the provider could use the plan's AEVS which has identical data). OUTLOOK ASSOCIATES, INC. PAGE 5 OF 5

19 APPENDIX D: EDS ELIGIBILITY DATA FLOW

20 APPENDIX D TITLE: EDS ELIGIBILITY DATA FLOW COUNTY 5.0 DHS 7.0 EDS PLANS/PROVIDERS Change file daily FAME extract distributed to COHS 13.0 COHS pick-up eligibility POS Network - card swipe device 14.0 Enrollment/ eligib ility data processed at County office MEDS Nightly batch processing (midnight - 2 a.m.) FAME extract Inquiry processing handled by EDS 15.0 Web site AEVS - automated phone CERTS - direct dial from provider, software distributed by EDS Provider Master Partner file Sub-plan PCP database Daily sub -plan PCP update file (3 Health Plans) FAME extract distributed to EDS weekly EDS picks up eligibility 12.0 EDS processes encounters Monthly batch processing FAME extract by plan Sent to EDS EDS distrib utes into MESH Plans pick-up eligibility Plans process eligibility OUTLOOK ASSOCIATES, INC. PAGE 1OF 4

21 APPENDIX D TITLE: EDS ELIGIBILITY DATA FLOW. Finding Process or Finding Description 1.0 A person presents at the County office and fills out an application for enrollment into Medi-Cal. A County worker determines Medi-Cal eligibility. Once a member is determined to be eligible for Medi-Cal and the manual processing is complete, the MEDS system is updated via the County system. Per EDS, Maximus supports the enrollment process in the County office (help with enrollment into plans and PCPs). 2.0 The MEDS system is supported by ITSD at DHS. The MEDS system contains data about the eligibility for several programs, including, food stamps, AFDC, Medi-Cal. The MEDS system uses AID codes to define a person s eligibility requirements in a certain program. The CIN is created when a person is entered into MEDS as a new Medi-Cal recipient. 3.0 DHS has plans to change the MEDS renewal process to become a daily function. Daily files will be then available to the health plans. 4.0 The MEDS Renewal process occurs each month. During the monthly batch process, a new membership file is created with all changes occurring during the previous month. This includes all potential beneficiaries that show a n Eligible status. A new FAME extract is created. Finally a FAME extract is created for every health plan. This FAME extract is distributed to the plans monthly. 5.0 Some updates made by the County are also sent simultaneously to a daily file. This file is accessed by EDS during the inquiry processing (POS network, AEVS, Web site, CERTS) so changes to a member s eligibility can be reflected in the inquiry processing on the same day. This file contains updates to Medi-Cal only. 6.0 Each night, MEDS is down from 12 midnight to 2 am for batch processing. The FAME extract is updated with any changes received during the previous 22 hours and the daily file is cleaned out of any changes received. All Statewide inquiry functions (POS, AEVS, Web site, CERTS) are unavailable during nightly processing. 7.0 COHS have a direct lease line to ITSD to pickup eligibility. COHS pickup FAME extracts each day. Extract contains all membership. 8.0 FAME is a subset of the MEDS data, containing the data specific to Medi-Cal eligibility. CIN is the key on the FAME extract. te: If a Medi-Cal member has no SSN when their BIC is generated, the CIN will appear on front side. Otherwise just the SSN will appear on the front side of the BIC. Both CIN and SSN are embedded in the magnetic stripe on the backside of the BIC. All plans are using the FAME format. The prior format/process was not Y2K-compliant so all plans converted to FAME in FAME contains the eligibility status of every Medi-Cal managed care member for the current month plus 15 months back. (16 months). 9.0 Several files are maintained at EDS to support the inquiry process. Provider ID, PIN and Provider Status is maintained in the Provider Master file. Valid Access Method by provider is maintained in the Partner file Three health plans submit daily replacement files with sub-plan and PCP assignment data by member to EDS. The files are merged into a separate database and maintained by EDS. This data is then accessed during the inquiry functions (POS, AEVS, Web site, CERTS) for the three health plans. EDS accesses the information and appends the Sub-plan and PCP name and phone number to the inquiry message. EDS has contracted with the three health plans individually (separate from the DHS contract) to support and maintain this function EDS picks up a weekly FAME extract from DHS for verifying eligibility during the encounter process MESH is a private, secure network created by EDS and DHS to transmit/receive eligibility and encounter data from/to the health plans. MESH is managed by EDS. OUTLOOK ASSOCIATES, INC. PAGE 2 OF 4

22 APPENDIX D TITLE: EDS ELIGIBILITY DATA FLOW. Finding Process or Finding Description 13.0 POS Network processing. All phone lines (leased and dial-up) terminate at ITSD for POS network inquiries. Therefore, any inquiry requests received via the POS Network originate at ITSD. The inquiry request is sent to EDS. EDS checks to ensure the provider ID is valid, the PIN (password) is valid and that the access method is a valid method for the submitter. The inquiry request is sent back to ITSD to access FAME and pull out the appropriate record. This inquiry request and FAME data is sent back to EDS. EDS receives the inquiry request, reads the FAME record, interprets the data and formats a response. If the member belongs to one of the 3 separately contracted health plans, EDS will also check the Sub-Plan/PCP database to pull out the name and phone number of the Sub-Plan and PCP. This data will also be interpreted and formatted into the response. The response is sent back to ITSD. ITSD sends the response back to the submitter Automated Eligibility Verification System (AEVS) processing. All phone lines terminate at EDS for AEVS inquiries. EDS receives the inquiry and checks to ensure the provider ID and PIN (password) is valid. The inquiry request is sent back to ITSD to access FAME and pull out the appropriate record. The inquiry request and FAME data is sent back to EDS. EDS receives the inquiry request, reads the FAME record, interprets the data and formats a voice response. If the member belongs to one of the 3 separately contracted health plans, EDS will also check the Sub-Plan/PCP database to pull out the name and phone number of the Sub-Plan and PCP. Data from this database will also be interpreted and formatted into a voice response, except for the PCP name. EDS sends the response back to the submitter Web site processing. All phone lines terminate at EDS for Web site inquiries. EDS receives the inquiry and checks to ensure the provider ID is valid, the PIN (password) is valid and that the access method is a valid method for the submitter. The inquiry request is sent back to ITSD to access FAME and pull out the appropriate record. This inquiry request and FAME data is sent back to EDS. EDS receives the inquiry request, reads the FAME record, interprets the data and formats a response. If the member belongs to one of the 3 separately contracted health plans, EDS will also check the Sub-Plan/PCP database to pull out the name and phone number of the Sub-Plan and PCP. This data will also be interpreted and formatted into the response.. EDS sends the response back to the submitter CERTS processing. CERTS inquiries are managed through the POS network. All phone lines terminate at ITSD for POS network inquiries. Therefore, any inquiry requests received via CERTS originate at ITSD. The inquiry request is sent to EDS. EDS checks to ensure the provider ID is valid, the PIN (password) is valid and that the access method is a valid method for the submitter. The inquiry request is sent back to ITSD to access FAME and pull out the appropriate record. The inquiry request and FAME data is sent back to EDS. EDS receives the inquiry request, reads the FAME record, interprets the data and formats a response. If the member belongs to one of the 3 separately contracted health plans, EDS will also check the Sub-Plan/PCP database to pull out the name and phone number of the Sub-Plan and PCP. This data will also be interpreted and formatted into the response. The response is sent back to ITSD. ITSD sends the response back to the submitter CERTS is a DOS-based software available to providers through DHS. Developed several years ago, CERTS provides a method to submit claims and confirm eligibility (single and batch functions). DHS would like to enhance the existing Web site to incorporate and replace the existing CERTS software. Certain providers (long-term care) continue to use the batch eligibility functions (up to 250 verifications can be entered on one screen). OUTLOOK ASSOCIATES, INC. PAGE 3 OF 4

23 APPENDIX D TITLE: EDS ELIGIBILITY DATA FLOW DATA DICTIONARY LEGEND Icon Name Definition Best Practice Represents an efficient, well-designed process that should be examined for potential use at other organizations. Communication Breakdown Represents area of poor communication between parties. ABC... ABC... Duplicate Records Represents a process with the potential for duplicate record submission. R E AM Major Error/Data Scramble Manual Process Represents problem with a process which has a strong potential to mis-translate or corrupt data. Represents a process involving one or more manual steps that could potentially be automated. Poor Process Represents poor process compared to industry standards. Process with Major Data Loss Potential Indicates a process with the potential for major data loss Time Delay Indicates a process with significant delays that impact the timelines of the data submission. Under-utilized Technology Represents a process that does not take advantage of existing technology (e.g., calling the plan when the provider could use the plan's AEVS which has identical data). OUTLOOK ASSOCIATES, INC. PAGE 4 OF 4

24 APPENDIX E: HEALTH PLAN GENERIC ELIGIBILITY DATA FLOW

25 APPENDIX E TITLE: HEALTH PLAN GENERIC ELIGIBILITY DATA FLOW NON-COHS Plan partner or network PCP assignments/ changes 10.0 Pa per submission Disk submission Member Services manual entry 11.0 PCP assignment load routines Temporary file hold Monthly Maximus PCP Assignments 1.0 Pa per submission COHS Monthly 24-26th of month State FAME file direct Ta pe submission Plan data extraction programs OTHER MODELS R E AM 9.0 State FAME file via EDS Download file Load routines Record count verification routines Processing and error routines Data errors? Error reports Member Services manual review Correction by health plan? Manual correction A A A tify State or EDS for new submission OUTLOOK ASSOCIATES, INC. PAGE 1 OF 4

26 APPENDIX E TITLE: HEALTHPLAN GENERIC ELIGIBILITY DATA FLOW 14.0 A PCP member matching routines PC assigned (partners and/or PC)? Auto assignment routines (manual or automated) R E AM 19.0 Health plan system Data warehouse reporting Errors or panel problems? Member Services manual processing 17.0 Corrected? Merge or overlay with prior eligibility data Health plan system updated 21.0 Pa per submission DSS manual eligibility and demographic corrections 24.0 State systems 'Worker Alerts' Request to DSS Mailed to healthplans Letter 27.0 Member Services manual entry Produce PCP eligibility files 22.0 Ta pe submission Electronic file submission?? END Member PCP change requests Telephone Load to customer Web site OUTLOOK ASSOCIATES, INC. PAGE 2 OF 4

27 APPENDIX E TITLE: HEALTH PLAN GENERIC ELIGIBILITY DATA FLOW. Finding Process or Finding Description 1.0 COHS receive a unique FAME format directly from the State. FAME data is submitted to COHS via tape COHS 6 5 receive full State files and must extract their data via County code from all data submitted. 3.0 n-cohs receives a different FAME format from EDS. Most receive data via electronic MESH transmissions. 4.0 Health plans run load routines to count records and load them into temporary files for processing. 5.0 Record counts are verified and data is reformatted from the State format to health plan formats. 6.0 Pre-processing and error routines are run to assume correct data (e.g., County, AID codes, time frames) is received. 7.0 R E AM Error reports are produced and reviewed by Member Service functions within the health plan If the data contains errors that cannot be corrected by the health plans, the State or EDS is not notified of the problem and a new file is requested by the health plan. 9.0 If manual corrections can be made to the data, Member Services corrects it for further processing PCP assignment data is collected, when possible, by Maximus for non-cohs members Data from Maximus is processed by the health plans and loaded to temporary files for merging with monthly FAME processing For health plans having Partner or Network delivery systems, PCP assignment/change data is received from Partners/Networks Paper PCP submissions are processed by health plan Member Services staff. Disk data is automatically loaded (see step 11) FAME tape is compared to Maximus data to determine PCP assignment for new health plan members If PCP (and/or Partner/Network is not indicated for the member on the Maximus data, manual and auto-assignment processes are used Member Services review and address all PCP assignment errors and work directly with members to correct assignments For R E AM errors resulting from demographic errors (e.g., birth date error prevents pediatric assignment, zip code/address error prevents local physician assignment) Member Services works with the member and DSS to have the demographic error corrected. Processed FAME data is either overlaid in total over existing health plan data or is pre-processed to extract new and changed data only and the new/changed data is merged into existing health plan eligibility files. Most plans, because of systems constraints, overlay and must then re-apply manual updates added in prior months to new processing data Health plan updates are finalized Some health plans have developed reporting data warehouses that must also be updated with eligibility data (either overlay or merge). Health plans then produce eligibility files and reports for their contracted providers from the updated eligibility files/databases. Some 21.0 health plans and/or providers use paper eligibility reports. Some use disk eligibility submissions that providers (or Partners or Network) can load to their own systems. Still fewer use electronic eligibility submissions A few health plans have created custom Web sites for providers eligibility data DSS workers and State processing generates daily eligibility/demographic changes of which health plans must be notified Daily and emergency updates are made to the State MEDS file and paper Worker Alerts are generated. OUTLOOK ASSOCIATES, INC. PAGE 3 OF 4

28 APPENDIX E TITLE: HEALTH PLAN GENERIC ELIGIBILITY DATA FLOW. Finding Process or Finding Description 25.0 Paper Worker Alerts are mailed to the health plans. These Worker Alerts are processed manually by the health plans Members make PCP change requests to health plans throughout the month into health plan eligibility databases These Worker Alerts are processed manually. DATA DICTIONARY LEGEND Icon Name Definition Best Practice Represents an efficient, well-designed process that should be examined for potential use at other organizations. Communication Breakdown Represents area of poor communication between parties. ABC... ABC... Duplicate Records Represents a process with the potential for duplicate record submission. R E AM Major Error/Data Scramble Manual Process Represents problem with a process which has a strong potential to mis-translate or corrupt data. Represents a process involving one or more manual steps that could potentially be automated. Poor Process Represents poor process compared to industry standards. Process with Major Data Loss Potential Indicates a process with the potential for major data loss Time Delay Indicates a process with significant delays that impact the timelines of the data submission. Under-utilized Technology Represents a process that does not take advantage of existing technology (e.g., calling the plan when the provider could use the plan's AEVS which has identical data). OUTLOOK ASSOCIATES, INC. PAGE 4 OF 4