and Efficiency has been improved. Satisfaction with this process is improved for all stakeholders. AS-IS TO-BE Note(s) Manage Provider Recoupment Assessment Assessment Capability Question Is the process primarily manual or automatic? 2 3 What is the mode of communication? 2 3 Constraint: No How does the State Medicaid Agency requests 3 3 planned recoupment of monies in third party liability enhancements. situations requested? Medicaid B TPL rarely has provider recoupment. How integrated is the process? 2 2 Constraint: Technical limitation of system outside SMA. Constraint: Does State Medicaid Agency use standards in the 3 3 Technical process? limitation of system outside SMA. How timely is this end-to-end process? 1 2 How accurate is the information in the process? 2 3 Constraint: How accessible is the information in the process? 3 3 Technical limitations of system outside SMA. Regional exchange does not currently exist. Constraint: No What is the cost to perform the process compared 3 3 further to the benefits of the results? enhancements planned. How efficient is the process? 2 3 How accurate are the results of the process? 2 3 Does the business process satisfy stakeholders? 2 3 Business Process Assessment 1 2 Table 42: Manage Provider Recoupment Business Process 2.2.5.2 Manage TPL Recovery The Manage TPL Recovery business process begins by receiving TPL information from various sources such as external and internal information matches, tips, referrals, attorneys, compliance management incident, Medicaid Fraud Control Unit (MFCU), providers, and insurance companies. The business process: Identifies the provider or TPL carrier, locates recoverable claims. Creates the coordination of benefits file. Creates post-payment recovery files.
and Efficiency has been improved. Satisfaction with this process is improved for all stakeholders. Manage Provider Recoupment AS-IS Assessment TO-BE Assessment Note(s) Capability Question Is the process primarily manual or automatic? 2 3 What is the mode of communication? 2 3 How does the State Medicaid Agency requests recoupment of monies in third party liability situations requested? 3 3 Constraint: No planned enhancements. Medicaid B TPL rarely has provider recoupment. How integrated is the process? 2 2 Constraint: Technical limitation of system outside SMA. Does State Medicaid Agency use standards in the process? 3 3 Constraint: Technical limitation of system outside SMA. How timely is this end-to-end process? 1 2 How accurate is the information in the process? 2 3 How accessible is the information in the process? 3 3 Constraint: Technical limitations of system outside SMA. Regional exchange does not currently exist. What is the cost to perform the process compared to the benefits of the results? 3 3 Constraint: No further enhancements planned. How efficient is the process? 2 3 How accurate are the results of the process? 2 3 Does the business process satisfy stakeholders? 2 3 Business Process Assessment 1 2 Table 42: Manage Provider Recoupment Business Process 2.2.5.2 Manage TPL Recovery The Manage TPL Recovery business process begins by receiving TPL information from various sources such as external and internal information matches, tips, referrals, attorneys, compliance management incident, Medicaid Fraud Control Unit (MFCU), providers, and insurance companies. The business process: Identifies the provider or TPL carrier, locates recoverable claims. Creates the coordination of benefits file. Creates post-payment recovery files.