Transmittal Letter (rfp 1)
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Key Activity: Identify and Review MMIS Interfaces for Impacts of NPI Compliance (RFP 3.2.2.2.1)Key Activity: Identify and review MMIS interfaces for impacts of NPI compliance. MMIS interfaces include but may not be limited to:
Contractor Responsibilities:
Deliverables:
Performance Measures:
Key ActivityThe systems and applications surveys will determine the existence of and the extent of interfaces for IME. Specifically, the interfaces related to the MMIS including the Pharmacy POS, E-Cares, Socrates, Department of Public Health, University of Iowa, M2 Clearinghouse, Iowa Plan, Coventry, Department of Administrative Services Information Technology Enterprise, and the Medicaid Claims Payment Check Write will be examined. These interfaces follow the path of provider identifier logic to complete some level of processing or reporting that is essential to IME business operations. Replacement of these provider identifiers with a single NPI must include additional data or processing logic to assure that data flows through the systems, their related interfaces, and back again seamlessly. For instance, the Medicaid Quality Utilization Improvement Data System (MQUIDS) imports claims and provider details from the Data Warehouse (DW). The Iowa Automated Benefit Calculation (IABC) System interfaces with approximately 30 other systems, and will need each interface checked for NPI impacts. Contractor ResponsibilitiesFOX understands that the responsibilities included in this phase of the project include a review of interfaces for all medical or medical-related systems, a complete list of interfaces as needed, an identification of specific impacts of NPI to all interfaces, and identification of gaps in interfaces relative to NPI. FOX’s methodology searches through systems, applications and interfaces. Software and interface modification projects often follow an undisciplined, unstructured course leading to a haphazard and even chaotic development environment. Projects on this path run the risk of producing a poorly designed and developed system that will not meet the client’s needs or expectations. While IME has made great efforts in its restructuring to not run this risk, it is important to examine each systems interface to ensure that remediation for subsystems that are impacted by NPI include their interface structures as well. For instance, the TXIX receives eligibility data from the IABC, and adds data elements for the MSIS, and then passes the information to the MMIS recipient sub-system used for claims processing. In addition to internal interfaces within the IME, the external interfaces must also be examined for NPI impacts. For instance, Medicare crossover claims processing will be impacted by Medicare use of NPI in all crossover claims, thus impacting claims processing and the provider file which maintains the current Medicare and Medicaid provider number cross reference. Our approach lays the groundwork for assessing modifications and the associated development efforts of interfaces in order to feature greater functionality and reliability. Upon completion IME can expect system interfaces that not only comply with the NPI and IME requirements, but which enhance the productivity and efficiency of their operations. DeliverablesFOX will create a matrix listing each Medicaid interface and the NPI impacts to that interface, as well as a report identifying any gaps in the MMIS interfaces relative to NPI. Performance MeasuresThese deliverables will be developed and submitted according to the Department approved work plan. Key Activity: Identify and Review Medicaid Business Processes for Impacts of NPI Compliance (RFP 3.2.2.3)Key Activity: Identify and review Medicaid Business processes for impacts of NPI compliance. Contractor Responsibilities:
Deliverables:
Performance Measures:
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Num |
Do you use any part of this number to identify any of the following: |
Data Warehouse |
Managed Care |
Long- Term Care |
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1 |
Provider type (i.e., MD, DO, Psychologist, etc.) |
Yes |
Yes |
Yes |
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2 |
Provider specialty (i.e., pediatrician, neurologist, etc.) |
Yes |
Yes |
Yes |
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3 |
Type of service |
Yes |
Yes |
Yes |
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4 |
Location of the provider’s service (rural or underserved area) |
No |
Yes |
Yes |
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5 |
Specific contract terms |
No |
No |
Yes |
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6 |
Specific benefit plans for a specific recipient |
No |
Yes |
Yes |
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7 |
Reporting requirements |
Yes |
Yes |
Yes |
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8 |
Legal requirements |
Yes |
Yes |
Yes |
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9 |
Specific services for specific recipients (i.e., waiver providers) |
Yes |
No |
Yes |
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10 |
To identify the provider as a member of a specific provider network (i.e., PPO) |
Yes |
Yes |
Yes |
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11 |
Accounting purposes |
No |
No |
No |
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12 |
Budgeting purposes |
No |
No |
Yes |
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13 |
Detecting fraud and abuse |
No |
No |
Yes |
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14 |
Forecasting program requirements based on historical data |
No |
Yes |
Yes |
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15 |
Certification requirements (i.e., JCAHO, MMIS, etc.) |
No |
No |
Yes |
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16 |
Others, please specify: |
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1a. Are any provider numbers hard coded into your system(s) so that they bypass the original entry logic? Data Warehouse – No Managed Care – No LTC - No
2. Identify when you use a ‘provider type’ (i.e., MD, DO, Psychologist, etc.) or provider specialty (i.e., pediatrics, neurology) in your day to day business processes.
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Purpose |
Used in electronic transactions |
Found in what system |
Type, Specialty, or Both |
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Forecasting |
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Accounting |
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Proper payment |
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Fraud and abuse |
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Decision support |
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Reporting requirements |
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Contract provisions |
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Other: |
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The institution of the National Provider Identifier (NPI) is intended to simplify the way that providers bill for the services they supply. Until this point, providers have had numbers for Medicare, numbers for Medicaid, and separate numbers for the multitude of health plans in which they participate. There are currently 13 provider identifiers in the 837P standard Transaction. The 834 also contains a place for provider number and the 276/277 requires the identifier of the provider originally submitting the claim of inquiry. The NPI Rule selected a number that bore no resemblance to any numbers currently in use.
Implementation of this new Rule may pose some problems because health plans have used multiple provider numbers with innate intelligence to represent the various providers in different business roles. Provider numbers may define the type of provider (MD, psychologist, and nurse), the specialty of the provider (pediatrician, neurologist, family practice) or the specialty certification of the provider (board certified, intern, resident). In other cases, the provider number defined the contract rate negotiated with that health plan versus the fee for service rate, or it identified a particular type of service that might be paid differently or excluded from the benefit plan (such as mental health or orthodontia). In still other cases, the provider number has been used to determine services provided in underserved or rural locations, perhaps to augment payment for providers who willingly serve these areas. It has been very simple for health plans to budget, monitor, audit, forecast, assure quality, or negotiate benefit plans by liberally assigning provider numbers that could easily be tracked, aggregated and reported. All of these provider numbers, and their respective payment logic, will be converted to a single NPI. Provider organizations and corresponding subparts will have to determine how this single NPI can proceed through the system to seamlessly continue the same business and payment processes. The following table demonstrates at a high level how intelligence may be built into the provider ID.
Table 4: Example of Embedded Intelligence to Provider ID
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Provider Number |
Program requirements |
Payment structure |
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12345 |
Fee for Service (FFS) |
Pays 80% of Billed Charges up to $5000 then 100% thereafter |
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23456 |
Primary Care Provider (PCP) |
Pays $10 per patient per month |
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34567 |
Contract Rate for Managed Care |
Pays fixed rate per procedure for each of X procedures |
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45678 |
Contract Rate for Managed Care for Nowhere County |
Pays fixed rate per procedure for each of X procedures in that county only |
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56789 |
FFS Underserved Area |
Pays 80% of billed charges plus 10% bonus for work in underserved location |
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67891 |
Long Term Care (LTC) Waiver Provider |
Pays 80% of billed charges payable from the LTC waiver program budget |
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78912 |
Disabled Children’s Waiver (DCW) Provider |
Pays 90% of billed charges payable from the DCW waiver program budget |
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89123 |
Referral Provider |
Pays $20 per referral review |
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91234 |
Dialysis Provider |
Pays fixed rate per dialysis procedure for End Stage Renal Disease (ESRD) program patients |
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10234 |
Medical Director for Nursing Home |
Pays $30 per month per resident on Medicaid billed on an institutional claim |
Data for the NPI Impact Analysis Report is triangulated to include the data from the surveys, program questionnaire, as well as the review of system documentation and of the IME’s systems regarding transactions and provider identifiers. The NPI Impact Analysis Report is used to help executive management make decisions in developing Planning and Remediation Strategies.
Deliverables
The FOX Team will create an NPI Impact Analysis report as a result of the program questionnaire, system searches, and surveys. From these reports, FOX will create two documents for this Key Activity: one matrix that lists each Medicaid business process and the NPI impacts on that process, and one Gap Analysis Report that identifies any gaps in the Medicaid Business Processes relative to NPI.
Performance measures
These deliverables will be submitted on the dates in the Department approved work plan.