CM: Screening and Assessment Process s1

Operations Management (OM) Manage TPL Recovery Item Details Description The Manage Third Party Liability (TPL) Recovery business process receives third party liability data from various sources such as external and internal data matches, referrals, Attorneys, Fraud and Abuse units, providers/contractors and insurers, identifies the provider/contractor or TPL carrier, locates recoverable claims from payment history, creates post-payment recovery files, sends notification to other payers or providers/contractors, receives payment, sends receivable data, and updates payment history. MITA Source Process Name: Manage TPL Recovery Reference Source Process Business Area: Operations Management References: Part 1 Appendix C, Business Process Model Details Part 1 Appendix D, Business Process Capability Matrix Details http://www.cms.hhs.gov/MedicaidInfoTechArch/04_MITAFramework.asp Sample Data Client data Provider/contractor data Insurer data Indian Health Service Other Agency Data – DMV, Veterans INS Administration Fraud case file

Level 1 Level 2 Level 3 Level 4 Level 5 The process is a The process is The process is fully COB is Data exchange for mix of paper, phone, increasingly automated, and automatically COB occurs on a fax and proprietary automated, data and formats coordinated through national scale. EDI. Nonstandardized incorporating direct are standardized. regional HIEs. Client Client and data connectivity to The process uses and provider/contractor and format from provider/contractor; BH-MITA standard provider/contractor information is multiple sources Web interfaces for interfaces for the information is federated with HIEs requires manual inquiries; basic payer to payer COB accessible through nationally and can effort; processes are business rules; and process reducing HIEs statewide and be accessed to the siloed across state agency the burden to can be accessed to extent authorized programs. The specific standards. providers/ the extent anywhere in the process is Formats and data contractors and authorized. country. This accomplished are aligned with optimizing Response and process is primarily via payerto- HIPAA and timeliness. Cross payment outcomes minimized with provider/ standardized within agency are immediate. access to real time contractor COB. the state. collaboration results clinical and The process is in a one-stop shop This Level adds administrative data. inconsistent in rule This Level includes with shared clinical data. application rules, additional data and processes. This Level adds data reporting, and quality edits. nationwide technical response timing. At this Level data is interoperability. Data access is standardized limited; reports and against HL7 RIM. analyses are costly, untimely and may be inaccurate.

This Level complies with agency requirements. VA As Is VA To Be Automation Level 1 Level 2 Level 3 Level 4 Level 5 All/mostly paper Internal processes Internal agency External agency Non-state entity mostly automated processes/interfaces processes/interfaces processes/interfaces mostly automated mostly automated mostly automated VA As Is VA To Be Standards Level 1 Level 2 Level 3 Level 4 Level 5 Use few or no Internal processes Internal agency External agency Non-state entity national standards use national processes/interfaces processes/interfaces processes/interfaces standards mostly use national mostly use national mostly use national standards standards standards VA As Is VA To Be Cross Coordination Level 1 Level 2 Level 3 Level 4 Level 5 Little/no Internal agency Internal agency External agency Non-state entity coordination across operational program processes program and program and processes or with processes coordinated operational operational other programs coordinated processes processes coordinated coordinated VA As Is VA To Be Client Data Level 1 Level 2 Level 3 Level 4 Level 5 Little/no access to Internal processes Internal agency External agency Non-state entity client specific data have access to processes have processes have processes have client access to client access to client access to client specific data specific data specific data specific data VA As Is VA To Be Interoperability Level 1 Level 2 Level 3 Level 4 Level 5 None Limited Interoperability with Interoperability with Interoperability with interoperability internal agency external agency non-state entity internally or limited systems other than systems other than systems to claims processing claims processing claims processing systems VA As Is VA To Be