OM04 Apply 1 Attachments must be submitted with a paper claim. Attachment The attachment and the claim are imaged and stored in electronic format. There is no way currently to receive an electronic attachment at the present time. Validation of the attachment is a manual process. The satisfaction of the stakeholder is fairly high but it still rated at a level 1. 1 OM05 Apply Mass The paper form or list of transactions is entered for adjustment Adjustment processing which can take several working days to complete. This process is inaccurate and inefficient. satisfaction is low due to delays and Stakeholders’ inconsistencies that are produced in the Mass Adjustment process. 1 OM06 Edit Claim/ No sister agency uses the MMIS edit claim process. Encounter There is some integration of Claims editing process across the whole Medicaid Enterprise. There are some instances where suspended claims may take days to resolve. The cost effectiveness of the process is low due to high effort needed to change some business rules. Many changes to the edit program may be made via table configuration but some may require coding changes. Stakeholder satisfaction is still at a level 1 but continued effort toward improvement should move this to the next level. OM07 Audit 1 Some validations are automated while others require manual Claim/Encounter review. Any change in business rule requires maintenance that is time consuming and costly. Suspended transactions require many days to resolve. Stakeholder satisfaction appears not to be measured and therefore is considered low. 2 OM08 Price The majority of Medicaid services are priced automatically. Claim/Value DMS and its vendors use reference data or commercial sources Encounter to assign a price to a claim or value an encounter. Pricing changes are made easily to the systems. MMIS is able to support multiple waiver and a-typical programs. The satisfaction of stakeholders and agency staff is greater than a level 1.
OM04 Apply Attachment 1 Attachments must be submitted with a paper claim. The attachment and the claim are imaged and stored in electronic format. There is no way currently to receive an electronic attachment at the present time. Validation of the attachment is a manual process. The satisfaction of the stakeholder is fairly high but it still rated at a level 1. OM05 Apply Mass Adjustment 1 The paper form or list of transactions is entered for adjustment processing which can take several working days to complete. This process is inaccurate and inefficient. Stakeholders’ satisfaction is low due to delays and inconsistencies that are produced in the Mass Adjustment process. OM06 Edit Claim/ Encounter 1 No sister agency uses the MMIS edit claim process. There is some integration of Claims editing process across the whole Medicaid Enterprise. There are some instances where suspended claims may take days to resolve. The cost effectiveness of the process is low due to high effort needed to change some business rules. Many changes to the edit program may be made via table configuration but some may require coding changes. Stakeholder satisfaction is still at a level 1 but continued effort toward improvement should move this to the next level. OM07 Audit Claim/Encounter 1 Some validations are automated while others require manual review. Any change in business rule requires maintenance that is time consuming and costly. Suspended transactions require many days to resolve. Stakeholder satisfaction appears not to be measured and therefore is considered low. OM08 Price Claim/Value Encounter 2 The majority of Medicaid services are priced automatically. DMS and its vendors use reference data or commercial sources to assign a price to a claim or value an encounter. Pricing changes are made easily to the systems. MMIS is able to support multiple waiver and a-typical programs. The satisfaction of stakeholders and agency staff is greater than a level 1.