File maintenance makes change and verifies change on the file. Claims Submitted and goes through edits. Procedure/drug formulary, usual and customary fee, prevailing fee, payment policy maintenance (Claims processing continues)Prepare Remittance Advice Encounter Report Successor – Federal and State Rules and Regulations Constraints Claim is rejected Failures Performance Measures None Price Claim Value Encounter Business Capability Matrix – “To-Be” Business Capability Descriptions Level 2 More services are automatically priced and there are fewer manual pricing exceptions. Most single claim “by-report” adjustments are automated. Louisiana Medicaid can support payment of waiver program and a-typical providers. Pricing formulas are changeable Timeliness of Process Level 2 Automation of Retroactive reimbursement saves time of manual pricing. Data Access and Accuracy Level 2 Automation of Retroactive reimbursement improves accuracy. Effort to Perform; Efficiency Level 2 Automation of Retroactive reimbursement saves time of manual pricing. Cost Effective 2 Automation of Retroactive reimbursement saves operating cost associated with manual pricing. Accuracy of Process Results Level 2 Automation of Retroactive reimbursement improves accuracy and benefits the entire process. Utility of Value to Stakeholders Level N/A
File maintenance makes change and verifies change on the file. Claims Submitted and goes through edits. Procedure/drug formulary, usual and customary fee, prevailing fee, payment policy maintenance Successor (Claims processing continues)Prepare Remittance Advice – Encounter Report Constraints Federal and State Rules and Regulations Failures Claim is rejected Performance Measures None Price Claim – Value Encounter “To-Be” Business Capability Matrix Business Capability Descriptions Level 2 More services are automatically priced and there are fewer “by-report” manual pricing exceptions. Most single claim adjustments are automated. Louisiana Medicaid can support payment of waiver program and a-typical providers. Pricing formulas are changeable Timeliness of Process Level 2 Automation of Retroactive reimbursement saves time of manual pricing. Data Access and Accuracy Level 2 Automation of Retroactive reimbursement improves accuracy. Effort to Perform; Efficiency Level 2 Automation of Retroactive reimbursement saves time of manual pricing. Cost Effective 2 Automation of Retroactive reimbursement saves operating cost associated with manual pricing. Accuracy of Process Results Level 2 Automation of Retroactive reimbursement improves accuracy and benefits the entire process. Utility of Value to Stakeholders Level N/A