Part 4 - Iowa Medicaid Enterprise

RFP MED-12-001 | Technical ProposalIowa Medicaid Enterprise System Service Procurement | MMIS and Core MMIS OperationsLogical Data Model (LDM). The new MMIS has a robust data model that addresses the process and dataneeds of enterprise-wide Medicaid operations. It has evolved over multiple versions, and represents aharmonization of data needs across multiple states. The new MMIS has taken a layered approach to addressingthe process and data needs of Medicaid operations. The data model approach balances the normalization needsof a data model with the performance needs of large-volume transaction processing system.The data model is layered into the Medicaid foundation entities and transactional entities. This approachallows for more coherent data management and provides better data integrity handling at the databaselayer. The data model is very flexible and provides the business agility to accommodate state policychanges, such as supporting different health care programs like the State Children’s Health InsuranceProgram (SCHIP). The reference and benefits administration data structures allow the business user tocreate different programs (like a specific program for breast and cervical health) or alter benefits duringtransition from traditional FFS to CCN, and associate the relevant data sets, such as covered services andspecific pricing decision matrices. A unique and innovative data structure associated with the new MMISmodel is referred to as the “group model.” This group structure uses a flexible approach to associatedifferent code sets into a powerful decision-evaluation framework. The group structure allows the systemto link and dynamically define relationships among the following dimensions:• Service code set (i.e., procedure, diagnosis, and revenue)• Taxonomy• Place of service and facility type• Claim type• Eligibility code category• Provider typeThese different dimensions give a range of flexibility to customize the business behavior of the solution.For example, to accommodate a new program, the system can set up a group structure that defines theassociated service code, applicable taxonomy codes, and allowed place of services for specific eligibilitycode categories. This framework has been used in production operations to implement changes in statehealth care programs without a single line of code change. Furthermore, the object-oriented approachtaken within the new MMIS design allows for evaluating this flexible criteria tool using a simple API set,which ensures adequate performance and throughput.In addition, the new MMIS solution strategy for incorporating future modifications is to accommodateadditional data elements (specific to state needs) as additional columns, referred to as “opt fields”(optional fields). This reduces the amount of rework on the user interface and avoids additionalbackground processes when changes are initiated, while still allowing for backward compatibility.Data Standards and Dictionary. The data model of the new MMIS follows industry standards for dataelements definition. The system documents the data dictionary by cataloguing the different aspects ofattributes, including size and other constraints. The system publishes a standard business data dictionary thatshows the definition, the semantics, and element usage across different systems and uses the concept ofcreating crosswalks between the different definitions of industry standards. The alignment and adoption ofindustry standards ensure easier reporting from the new MMIS. This standards-based approach allows theproposed solution to leverage industry benchmarks to improve the overall program delivery.Data Management Strategy. The data management strategy establishes the basic governance processesto handle the complex set of systems and applications interfacing and interoperating with the Medicaidprogram. This aspect also becomes even more relevant as Iowa shifts from largely traditional fee-forservicemodel to a more coordinated care model. This is primarily because the inculcation of additionaldata elements and reuse of existing elements for different purposes is a typical aspect of shifting businessmodels. As part of a successful approach for data management in previous implementations, TeamNoridian proposes the following approach for data governance:9 | 10