Initiate Case Business Capability Matrix (BCM)
Initiate Case Business Capability Matrix (BCM)
Initiate Case Business Capability Matrix (BCM)
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Item<br />
Description<br />
MITA<br />
Reference<br />
Sample Data<br />
This business<br />
process is primarily<br />
manual, using<br />
nonstandard<br />
formats<br />
and data.<br />
Requirements may<br />
be variable across<br />
agencies. The<br />
process is often<br />
lengthy and<br />
inconsistent in the<br />
application of the<br />
rules.<br />
This Level complies<br />
with agency<br />
requirements.<br />
VA As Is<br />
VA To Be<br />
Accountability Management (AM)<br />
AM: <strong>Initiate</strong> <strong>Case</strong> Process<br />
Details<br />
The <strong>Initiate</strong> <strong>Case</strong> business process uses criteria and rules to identify patterns or<br />
parameters of acceptable/unacceptable behavior, determine when action is<br />
needed, and open a case for further investigation. Each type of case is driven by<br />
different criteria and rules, different relationships, and different data.<br />
Source Process Name: Identify Candidate <strong>Case</strong><br />
Source Process <strong>Business</strong> Area: Program Integrity Management<br />
References: Part 1 Appendix C, <strong>Business</strong> Process Model Details<br />
Part 1 Appendix D, <strong>Business</strong> Process <strong>Capability</strong> <strong>Matrix</strong> Details<br />
http://www.cms.hhs.gov/MedicaidInfoTechArch/04_MITAFramework.asp<br />
Member Information<br />
Benefits/Reference<br />
Provider Information<br />
Program Information<br />
Payment History Information<br />
<strong>Case</strong> Selection Parameters<br />
AM: <strong>Initiate</strong> <strong>Case</strong>: Maturity Levels<br />
Level 1 Level 2 Level 3 Level 4 Level 5<br />
The process<br />
The process has Formats, data and Formats, data and<br />
incorporates direct virtual access to processes are<br />
processes are<br />
connectivity across administrative<br />
standardized and standardized and<br />
agencies; Web records and self automated using automated using<br />
interfaces; basic adjusting business HIEs across all HIEs across all<br />
business rules; and rules. Formats and government<br />
government<br />
enhanced<br />
data are<br />
agencies at all<br />
agencies at all<br />
consistency of<br />
standardized and levels in the state. levels nationwide.<br />
process and timing. automated within all The process uses The process has<br />
Formats and data state health<br />
virtual administrative point-to-point<br />
are standardized agencies, and<br />
records and<br />
collaboration and<br />
within state health processes are<br />
integrated systems full interoperability<br />
agencies, and<br />
shared and<br />
to immediately set with other local,<br />
information can be coordinated. <strong>Case</strong>s up cases for further state, and federal<br />
shared online.<br />
can be initiated from investigation.<br />
programs with<br />
Increased<br />
automated review of Standards and complete virtual<br />
availability of data the data, and rules cross agency<br />
access to<br />
electronically aids are consistently communication administrative and<br />
case identification. applied. Interfaces reduce time needed clinical data.<br />
<strong>Case</strong> investigation use BH-MITA<br />
to set the case in<br />
is more automated, standardized data motion.<br />
This Level adds<br />
so consistency and and are compatible<br />
nationwide technical<br />
set up time is<br />
with Medicaid MITA. This Level adds interoperability.<br />
improved.<br />
clinical data.<br />
This Level includes<br />
additional data and<br />
quality edits.<br />
At this Level data is<br />
standardized<br />
against HL7 RIM.<br />
Automation<br />
Level 1 Level 2 Level 3 Level 4 Level 5<br />
All/mostly paper Internal processes<br />
mostly automated<br />
VA As Is<br />
VA To Be<br />
Use few or no<br />
national standards<br />
Internal agency<br />
processes/interfaces<br />
mostly automated<br />
External agency<br />
processes/interfaces<br />
mostly automated<br />
Non-state entity<br />
processes/interfaces<br />
mostly automated<br />
Standards<br />
Level 1 Level 2 Level 3 Level 4 Level 5<br />
Internal processes Internal agency External agency<br />
use national processes/interfaces processes/interfaces<br />
Non-state entity<br />
processes/interfaces
VA As Is<br />
VA To Be<br />
Little/no<br />
coordination across<br />
processes or with<br />
other programs<br />
VA As Is<br />
VA To Be<br />
standards<br />
mostly use national<br />
standards<br />
mostly use national<br />
standards<br />
mostly use national<br />
standards<br />
Cross Coordination<br />
Level 1 Level 2 Level 3 Level 4 Level 5<br />
Internal agency Internal agency External agency Non-state entity<br />
operational<br />
program processes program and program and<br />
processes<br />
coordinated<br />
operational<br />
operational<br />
coordinated<br />
processes<br />
processes<br />
coordinated<br />
coordinated<br />
Client Data<br />
Level 1 Level 2 Level 3 Level 4 Level 5<br />
Internal processes Internal agency External agency Non-state entity<br />
have access to processes have processes have processes have<br />
client<br />
access to client access to client access to client<br />
specific data specific data specific data specific data<br />
Little/no access to<br />
client specific data<br />
VA As Is<br />
VA To Be<br />
Interoperability<br />
Level 1 Level 2 Level 3 Level 4 Level 5<br />
None<br />
Limited<br />
interoperability<br />
internally or limited<br />
to<br />
claims processing<br />
systems<br />
Interoperability with<br />
internal agency<br />
systems other than<br />
claims processing<br />
Interoperability with<br />
external agency<br />
systems other than<br />
claims processing<br />
Interoperability with<br />
non-state entity<br />
systems<br />
VA As Is<br />
VA To Be
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