Determine Member Eligibility Workflow Enroll Member Enroll Member Process Model Item Details Description The Enroll Member business process receives eligibility data from the Determine Eligibility process or sources, determines additional qualifications for enrollment in programs for which the member may be eligible, loads the enrollment outcome data into the Member and Contractor (TPA) Registries, and produces notifications to the member and the contractor Receive member eligibility data and enrollment application from the Determine Eligibility Trigger Event process or other sources Member is enrolled in specific programs Result Receive referral via internal/external sources in either paper or electronic: Business Process Steps LaHIPP internal and external referrals – Hospice external referrals – OGB Office of Group Benefits referrals – FOA Family Opportunity Act referrals – LAP LA Affordable plan referrals – CommunityCare system generates run in MMIS on individual record Send application to individual or policy holder Verify program requirements are met If Yes, continue to Step 4 If No, go to Step 6 Make enrollment decision Enter decision into TPA registries Generate and send notices Shared Data Verify: INS, Medical Reports, Employers Determine Eligibility process approves applicant as eligible for one or more program Predecessor and benefit packages. Outreach MA eligible Manage Applicant and Member Communication Successor Manage Contractor Communication Phone Call, Fax, Mail and/or Internet Manage Member Information Manage Provider Communication Recipient receiving hospice care. Manage Employer Sponsored Insurance Phone Call, Fax, Mail and/or Internet Provider/MEDS and records updated State and Federal Rules and Regulations Constraints None Failures None Performance Measures
Determine Member Eligibility Workflow Enroll Member Enroll Member Process Model Item Details Description The Enroll Member business process receives eligibility data from the Determine Eligibility process or sources, determines additional qualifications for enrollment in programs for which the member may be eligible, loads the enrollment outcome data into the Member and Contractor (TPA) Registries, and produces notifications to the member and the contractor Trigger Event Receive member eligibility data and enrollment application from the Determine Eligibility process or other sources Result Member is enrolled in specific programs Business Process Steps Receive referral via internal/external sources in either paper or electronic: LaHIPP – internal and external referrals Hospice – external referrals OGB – Office of Group Benefits referrals FOA – Family Opportunity Act referrals LAP – LA Affordable plan referrals CommunityCare system generates run in MMIS on individual record Send application to individual or policy holder Verify program requirements are met If Yes, continue to Step 4 If No, go to Step 6 Make enrollment decision Enter decision into TPA registries Generate and send notices Shared Data Verify: INS, Medical Reports, Employers Predecessor Determine Eligibility process approves applicant as eligible for one or more program and benefit packages. Outreach MA eligible Successor Manage Applicant and Member Communication Manage Contractor Communication Phone Call, Fax, Mail and/or Internet Manage Member Information Manage Provider Communication Recipient receiving hospice care. Manage Employer Sponsored Insurance Phone Call, Fax, Mail and/or Internet Provider/MEDS and records updated Constraints State and Federal Rules and Regulations Failures None Performance Measures None
AS-ISBusinessProcessValidation-FinalUpdatedv6February19,2009.docx