Prescription Medical Documentation Predecessor Member has medical need that requires the service to be authorized Prescription Denied Claim Successor Audit Claim/Encounter process Member Grievance and Appeal Process PA requests have a contracted turn-around limit by the PA contractor or FI Constraints Failures None Performance Measures Number of post authorizations per member; per PCP Authorize Service Business Capability Matrix “To-Be” Business Capability Descriptions 3 The Agency receives EDI transactions via electronic means that support even small, rural, and waiver providers. Web portals support error free submissions with data field masks, client-side edits, and pre-populated fields, thereby eliminating the need for these submissions to go through manual validation. The Authorize Service process is completely automated and only rare exceptions must be manually reviewed. Optimizing automation improves error rates and timeliness, thereby enabling support of real-time processing. Authorize Service processing is highly flexible so that rule changes can be made quickly and inexpensively in response to need for new or different rules. . Timeliness of Process Level 3 Time is greatly improved due to electronic PA approvals on a portal and reviews verses the mail. The approval process is automated and decisions are made systematically and with consistency. Data Access and Accuracy Level 3 Access and accuracy is improved through the ease of access to data through the portals. The approval process is automated and decisions are made systematically and with consistency. Effort to Perform; Efficiency Level 3 Effort is decreased due to the elimination of mailing information. Cost Effective Level 3 Postage is saved due to electronic communication. Staff is not needed for mailing and processing of postage. Accuracy of Process Results Level 3 Benefits of results are shown through the accuracy of information and the speed of PA approval. Member will be satisfied due to accurate information between the specialty provider or Hospital and the PCP. Utility of Value to Stakeholders Level 3 Provider will be able to diagnose and manage health better due to accuracy and efficiency of health information. Speed of information between providers will increase, which will create tighter and more efficient networks.
Prescription Medical Documentation Predecessor Member has medical need that requires the service to be authorized Prescription Denied Claim Successor Audit Claim/Encounter process Member Grievance and Appeal Process Constraints PA requests have a contracted turn-around limit by the PA contractor or FI Failures None Performance Measures Number of post authorizations per member; per PCP Authorize Service “To-Be” Business Capability Matrix Business Capability Descriptions 3 The Agency receives EDI transactions via electronic means that support even small, rural, and waiver providers. Web portals support error free submissions with data field masks, client-side edits, and pre-populated fields, thereby eliminating the need for these submissions to go through manual validation. The Authorize Service process is completely automated and only rare exceptions must be manually reviewed. Optimizing automation improves error rates and timeliness, thereby enabling support of real-time processing. Authorize Service processing is highly flexible so that rule changes can be made quickly and inexpensively in response to need for new or different rules. . Timeliness of Process Level 3 Time is greatly improved due to electronic PA approvals on a portal and reviews verses the mail. The approval process is automated and decisions are made systematically and with consistency. Data Access and Accuracy Level 3 Access and accuracy is improved through the ease of access to data through the portals. The approval process is automated and decisions are made systematically and with consistency. Effort to Perform; Efficiency Level 3 Effort is decreased due to the elimination of mailing information. Cost Effective Level 3 Postage is saved due to electronic communication. Staff is not needed for mailing and processing of postage. Accuracy of Process Results Level 3 Benefits of results are shown through the accuracy of information and the speed of PA approval. Member will be satisfied due to accurate information between the specialty provider or Hospital and the PCP. Utility of Value to Stakeholders Level 3 Provider will be able to diagnose and manage health better due to accuracy and efficiency of health information. Speed of information between providers will increase, which will create tighter and more efficient networks.
To-Befinal81009.docx