ATTACHMENT 3
/ Project Assessment Quotation /PAQ INFORMATION
Contract No.: MME HIT Services RFP / PAQ No: 3
PAQ Title: MMIS & Fiscal Agent Procurement Services / Total PAQ Amount:
State Agency: ITSD-DSS / State Agency Address:
Department of Social Services
MO HealthNet Division
615 Howerton Court
Jefferson City, MO 65102
ITSD Project Manager: / Phone:
Email:
State Agency Project Manager: / Phone:
Email:
MHD Director of Information Systems: / Phone:
Email:
Contractor Point of Contact: / Phone: ( 573 ) 751- 0000 / Email: First.Last@
Contractor Company Name: / Phone: (000 ) 000- 0000 / FAX: (000 ) 000- 0000
Contractor Address: / List / Description of Attachments:
This Project Assessment Quotation (PAQ) is pursuant to HIT Consulting Services – Qualified Provider List Statewide Contract. The Contractor agrees and understands that the terms and conditions specified in the HIT Consulting Services Contract apply to this PAQ, except where a term or condition in this PAQ is more restrictive than that in the HIT Consulting Services Contract, in which case the PAQ term will govern.
If under this contract you committed to use a MBE and/or WBE, please state if you intend to use a MBE and/or WBE for this PAQ. [Yes, No or N/A] If your response was “Yes,” please complete the information below for each MBE and/or WBE you propose for this PAQ (add lines as necessary):
MBE/WBE Name: / Type: [MBE, WBE or Both] / Percentage or Dollar Amount of work that MBE/WBE will perform for this PAQ:
MBE/WBE Address: / Specific work that MBE/WBE will perform, noting the PAQ provisions related to such work:
APPROVALS REQUIRED TO PROCEED / DATE
Contractor:
Agency/Program Approval:
CIO Office:
PROJECT REQUIREMENTS
PROJECT GOALS AND OBJECTIVES:
Background
Missouri Medicaid Enterprise:
The purpose of the Missouri Medicaid Enterprise (MME) is to purchase and monitor health care services for low income individuals who are elderly, disabled, blind, members of families with dependent children, children and pregnant women in poverty, refugees and children in state custody. The MME is operated by the Missouri Department of Social Services ("Department") as the designated State Medicaid Agency (SMA). The Department provides services that help vulnerable Missourians of all ages maintain or enhance their quality of life, which may be threatened by lack of financial resources, emotional crises, disabling conditions, or an inability to protect themselves. The MO HealthNet Division (the MHD) of the Department is responsible for administering the Missouri Medicaid Program. The MME also includes the following State Agencies:
a. The Family Services and Children’s Divisions of the Department are responsible for the Medicaid eligibility and enrollment functions.
b. The Missouri Medicaid Audit and Compliance (MMAC) Division of the Department of Social Services is responsible for the Medicaid program integrity functions.
c. The Division of Finance and Administrative Services (DFAS) of the Department is responsible for providing administrative support for MHD including Medicaid payment processing and financial reporting.
d. The Division of Legal Services of the Department is responsible for all legal services related to the Medicaid program.
e. The Information Technology Services Division (ITSD) of the Office of Administration is responsible for development and operation of systems related to the Medicaid program.
f. The Missouri Department of Mental Health (DMH) is responsible for administering Medicaid waiver programs.
g. The Missouri Department of Health and Senior Services is responsible for administering Medicaid waiver programs.
The MHD is divided into four primary operational units: Program Operations, Information Systems, Finance, and Medical Services. The Program Operations unit includes Pharmacy Services, Clinical Services, Program Relations, Managed Care, and Waiver Programs. The Information Systems unit includes the Medicaid Management Information System (MMIS) and the Clinical Management Services and System for Pharmacy Claims and Prior Authorizations (CMSP). The Finance unit includes Financial Services and Reporting, Institutional Reimbursement, Waiver Financing, Rate Setting, Budget, Cost Recovery, Audit Services, Pharmacy Fiscal, and CMS Financial Reporting. The Medical Services unit includes Program Quality, Psychology, and Medical Services. All four units report to a Division Director and Deputy Division Director. MHD employs over 200 staff.
Key information regarding the Missouri Medicaid Program can be found at http://dss.mo.gov/mhd/general/pages/about.htm.
Medicaid Management Information System (MMIS):
MHD receives claims for medical services performed by fee-for-service providers and encounter data submitted by managed care health plans. The primary MMIS is a computerized claims processing system that assists the MHD staff with the claims and encounter processing, provider payment, and reporting business functions including recording, sorting, classifying and adjudicating claims; issuing checks or notices of denial of claims; issuing monthly invoices for spenddown and premium collections; and reporting (weekly, monthly, quarterly, annually and ad-hoc). Guidance for the development and maintenance of the MMIS is provided by the Federal government's Centers for Medicare and Medicaid Services (CMS) – see https://www.cms.gov/MMIS/ and http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/MMIS.html .
The current primary MMIS solution was implemented in 1979 and has gone through many modifications over the past 32 years. The MMIS core is a mainframe system. Web portals have been created to facilitate system interactions for State staff and providers. Providers submit either electronic HIPAA-compliant Electronic Data Interchange transactions or direct data entry through a web portal or paper claims. Approximately 99% of all claims are submitted electronically. Paper claims are scanned or manually entered into the MMIS. Once claims are in the MMIS, various batch processes and jobs are used to complete the claims adjudication, payment, and other processes. On an annual basis, the current MMIS processes over 95 million claims received from over 800 claims transactions submitters representing an average of over 8,000 providers in each payment cycle.
The MMIS has been modified and enhanced numerous times to add new components and functionality. Most recently, the current MMIS contract included 19 separate enhancements to the MMIS including migration to a relational database and implementation of a rules engine. These enhancements have lengthened the useful life of the existing system but additional enhancements are needed to create a system capable of meeting conditions and requirements established by the CMS.
The current Missouri Fiscal Agent is Wipro Infocrossing, Inc., who is responsible for the maintenance, operation, and development of the primary MMIS. The current MMIS and Fiscal Agent contract commenced in 2007 and can be extended through June 30, 2017. A copy of the current Missouri MMIS contract will be made available upon request by a vendor. The primary services provided by Wipro Infocrossing, Inc under the Fiscal Agent contract are as follows:
· Development, operation, and maintenance of the MMIS including the provider and MHD portals, claims processing, financial subsystem, and provider enrollment
· Hosting of all system hardware
· Development, operation, and maintenance of the Decision Support Systems including Ad Hoc Reporting, Surveillance & Utilization Review, and Management and Administrative Reporting
· Prior-Authorization and Pre-Certification of Participant Services
· Operation of the Participant Services, Provider Relations, and Clinical Authorizations (Pharmacy, Medical, Psychology) Call Centers and the MMIS Help Desk
· Managed Care Enrollment Broker
· Third Party Liability Cost Avoidance
· Issuance of Medicaid Participant Identification Cards
· Distribution of provider manuals
· Mailroom and Data Entry
· Imaging of all paper documentation
· Project Management services
In 2001, the MHD committed to the development of a supplemental MMIS solution referred to as the Clinical Management Services and System for Pharmacy Claims and Prior Authorization (CMSP) to automate clinical editing and prior authorizations of services provided to Medicaid participants. Subsequently, the CMSP solution was expanded to provide a web portal allowing providers to view Medicaid claims and support coordination of care within the Missouri Medicaid Program. The CMSP solution has also been expanded to provide a solution for managing the Missouri Medicaid Electronic Health Record Incentive Program.
The MHD currently contracts with Xerox Heritage, LLC for the maintenance, operation, and development of the CMSP. The contract with Xerox Heritage, LLC can be extended through June 30, 2017. A copy of the current Missouri CMSP contract will be available upon request by a vendor. The primary services provided by Xerox Heritage, Inc under the CMSP contract are as follows:
· Adjudication of claims using clinical and pharmacy edits
· Generation of clinical letters
· Automated and manual pre-certification of Optical, DME, Radiology, Psychology services
· Automated and manual pre-certification of inpatient services and determination of length of stay
· Support for internal case management and coordination of care services
· Automated and manual pre-certification of outpatient Radiology services performed on advanced imaging technologies
· Portal allowing providers access to Medicaid claims history and tools including e-prescription and medication possession ratio
· Personal Health Record portal for Medicaid participants
· Medication Therapy Management and Immunization Billing
· Home and Community Based Services portal and management tools
· Decision Support Systems
Project Governance Structure
The Project Governance Structure (PGS) is the management and decision-making framework to support the execution of a Project. A well-defined PGS is critical to the success of any project by establishing the following:
1. Direction and oversight to ensure that decisions are made effectively and efficiently;
2. Standards of the organization that the project must adhere to;
3. Alignment of the project execution with the organization’s mission and the project’s goals and objectives;
4. Visibility into the project execution by defining a project reporting system and communications plan;
5. Accountability for the project execution;
6. Definition of the specific roles and responsibilities for the Project leadership and team; and
7. Sufficient resources to ensure project success.
The State’s PGS for the MMIS and Fiscal Agent Procurement project will consist of the MMIS Executive Steering Committee, the MHD Project Manager, and the ITSD Project Manager. The Executive Steering Committee will include the Department Directors from the organizations comprising the MME, Division Directors within the Department of Social Services, representatives from the Office of Administration, and the State Chief Information Officer. The Contractor may designate a representative to serve as a resource to the Executive Steering Committee who may participate at the State’s discretion.
The MHD and ITSD Project Managers will have the authority of the Executive Steering Committee to manage project execution and will represent the interests of the business owners and key stakeholders. The MHD and ITSD Project Managers will establish the Project Management standards and processes to be applied by the State during Project execution, ensure the program and projects are conducted in a disciplined, well-managed, and consistent manner, and coordinate with the project management approaches proposed by the Contractor. The MHD and ITSD Project Managers will establish the change management process for the Projects. The MHD and ITSD Project Managers will have responsibility for the success of the MMIS and Fiscal Agent Procurement project.
A major contributing factor in the success of this project will be the degree of collaboration between the Contractor, the MHD and ITSD Project Managers, and the MMIS and Fiscal Agent vendors. The MHD and ITSD Project Managers shall establish the processes for communications with State staff including the frequency, techniques, and tools and will coordinate interactions between the Contractor and the State staff. The MHD and ITSD Project Managers will participate directly in all phases of the project.
The MHD and ITSD Project Managers will manage State project staff that include Business Analysts and Subject Matter Experts. A Project Committee consisting of representatives from the business units will assist with coordinating the efforts of the business unit SMEs, communicating project status and decisions to the business units, and scheduling project tasks. The MHD and ITSD Project Managers will also manage the collaboration between OA-ITSD and all MMIS and Fiscal Agent vendors involved in the project.
Centers for Medicare and Medicaid Services (CMS) Guidance Provided in the Medicaid Information Technology Architecture (MITA) and the Seven Conditions and Standards for Enhanced Federal Funding
The CMS has launched an initiative referred to as the MITA Maturity Model – see http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/Medicaid-Information-Technology-Architecture-MITA.html - to foster integrated business and IT transformation across the Medicaid Enterprise to improve the administration of the Medicaid program and to serve as a national framework to support improved systems development and health care management for the Medicaid Enterprise and to establish federal-state partnerships promoting technologies and processes that support flexibility and adaptability and can rapidly respond to changes in the Medicaid program. The CMS released MITA Version 3.0 for public comment in November 2011.
The CMS has also issued guidance in the form of the Medicaid IT Supplement (MITS-11-01-V1.0) Enhanced Funding Requirements: Seven Conditions and Standards (hereinafter referred to as the Seven Conditions and Standards) defining the following requirements for Medicaid technology investments to qualify for enhanced match:
1. Modularity standard requires the use of a modular, flexible approach to system development;
2. Alignment with and advancement in the MITA Maturity Model for business, architecture, and data;3. Alignment with industry standards;
4. Promotion of sharing, leverage, and reuse of Medicaid technologies and systems within and among States;
5. Support of accurate and timely processing of claims, adjudications, and effective communications with providers, beneficiaries, and the public;
6. Support of transaction data, reports, and performance information that would contribute to program evaluation, continuous improvement in business operations, and transparency and accountability; and
7. Seamless integration and coordination with other systems and interoperability with health information exchanges.
The Missouri Medicaid Enterprise has completed a MITA State Self-Assessment (SS-A) to assess its maturity using the MITA 3.0 Framework. Results from the MITA SS-A sessions have been synthesized and summarized into a SS-A Report which includes a 5-year enterprise-wide strategic roadmap of improvement initiatives for the Missouri Medicaid Enterprise. The Missouri Medicaid Enterprise has also developed an MMIS strategy.