MITA Business Processes, Technical Functions & Services

Monday Quarter 2 Presentation

May 18, 2009

2

Technical / Business Services: Where does one start and/or stop

and the other take over?

3

Foundation Concepts

4

International Standards Organization (ISO) defined communications model, Open Systems Interconnection (OSI)

reference model

7

6

5

4

3

2

1

LevelsHL7 corresponds to the

conceptual definition of an application-to-application

interface placed in the seventh layer of the OSI model.

5

6

International Standards Organization (ISO) defined communications model, Open Systems Interconnection (OSI)

reference model

7

6

5

4

3

2

1

Levels

MITA Business Process.

MITA Technical Functions

7

NHIN Services Interface Standard Description

Subject Discovery PIXv3 Service for locating patients based on demographic information

Query for Documents XCA Locate health documents associated with a specific patient that conforms to a set of criteria

Retrieve Documents XCA Retrieve specific requested documents associated with a patient

Query Audit Log IHE ATNA Log requests for patient health information and make this log available to patients.

Authorization Framework SAML Articulate the justification for requesting patient medical information

Consumer preference XACML Enable consumers to specify with whom they wish to share their electronic health information

Messaging SOAP/WSDL/WS-addressing/ws-security

Provide secure messaging services for all communication between nhin ENABLED HEALTH ORGANIZATIONS

Authorize Case follow up

PIXv3 Provide an ability to re-identify pseudonymized patient record when legally permitted for public health case investigation

Health Information Event messaging

WS-Base Notification Provides a publish/subscribe capability for ongoing feeds of data between NHIN enabled health organizations

NHIE Service registry UDDI Registry that enables NHIN enabled health organizations to discover the existence and connection information for other NHIN enabled health organizations

8

MITA Basics

9

– MITA guidelines apply; FFP available

– Entity is encouraged to follow MITA guidelines

– May exchange information; may influence MITA or vice versa

SURSor Fraud

Contractor

BenefitManager

Provider

OtherPayer

OtherAgency

CMS

LicenseBoard

RHIO

FEAFHA

CDCDepartmentof Homeland

Security

ONC

StandardsOrganization

MITABusinessProcess

#3

MITABusinessProcess

#2

MITABusinessProcess

#1

StateUnemploy-

mentAgency

MS

IS D

ata;

D

ual

Elig

ibili

ty

InterfaceInterface

Inte

rface

Interface

Interface

Inte

rface

Interface

Interface

Standards of Interoperability

;

EHR

Interface

Use Standards;

Develop New Ones

Info

rmat

ion

Exc

han

ge

Guidelines;Directives

No

tifi

cati

on

san

d A

lert

sN

otificatio

ns

and

Alerts

MITA Medicaid Enterprise

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ProviderManagement

ContractorManagement

Operations Management

ProgramManagement

BusinessRelationshipManagement

ProgramIntegrity

Management

CareManagement

Authorize Referral

Authorize Service

Authorize Treatment Plan

Apply Attachment

Apply Mass Adjustment

Audit Claim-Encounter

Edit Claim-Encounter

Price Claim – Value Encounter

Prepare COB

Prepare EOB

Prepare Premium EFT-check

Prepare Provider EFT-check

Prepare Medicare Premium Payment

Inquire Payment Status

Manage Payment Information

Prepare Remittance Advice-Encounter Report

Calculate Spend-Down Amount

Prepare Member Premium Invoice

Manage Drug Rebate

Manage Estate Recovery

Manage Recoupment

Manage Cost Settlement

Manage TPL Recovery

Prepare Capitation Premium Payment

Prepare Home & Community Based Services Payment

Prepare Health Insurance Premium Payment

Manage Contractor Information

Manage Contractor Communication

Perform Contractor Outreach

Support Contractor Grievance and Appeal

Inquire Contractor Information

Award Administrative or Health Services Contract

Close out Administrative or Health Services Contract

Manage Administrative or Health Services Contract

Produce Administrative or Health Services RFP

Member Management

Determine Eligibility

Enroll Member

Disenroll Member

Manage Member Information

Inquire Member Eligibility

Perform Population & Member Outreach

Manage Applicant & Member Communication

Manage Member Grievance & Appeal

Manage FFP for Services

Manage F-MAP

Manage State Funds

Manage 1099s

Perform Accounting Functions

Monitor Performance & Business Activity

Maintain Benefits-Reference Information

Manage Program Information

Develop & Maintain Benefit Package

Manage Rate Setting

Develop Agency Goals & Objectives

Develop & Maintain Program Policy

Maintain State Plan

Formulate Budget

Manage FFP for MMIS

Draw and Report FFP

Designate Approved Services & Drug Formulary

Establish Case

Manage Case

Manage Medicaid Population Health

Manage Registry

Identify Candidate Case Manage CaseEstablish

Business Relationship

Manage Business Relationship Comm.

Manage Business Relationship

Terminate Business Relationship

Enroll Provider

Disenroll Provider

Manage Provider Information

Inquire Provider Information

Manage Provider Communication

Manage Provider Grievance & Appeal

Perform Provider Outreach

Dev. & Manage Perform. Measures & Reporting

Monitor Performance & Business Activity

26 19 9 8

7442

Business Process Model v2.01

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Technical Functions

Inconsistent use of the word “capabilities” in TA

Not consistent with taxonomy of the business architecture

BA -> BP -> ML -> BS -> SS TCM -> ML -> TS -> SS

Achieves consistency Business process equivalent to

technical function BP -> ML -> BS -> SS TF -> ML -> TS -> SS

Framework 2.0

TechnologyStandards

Application Architecture

Technical Services

Technical Capability

Matrix

Business Services

Solution Sets

Framework 2.0 Plus

TechnologyStandards

Application Architecture

Technical Services

Technical Functions

Business Services

Solution Sets

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Technical Functions

Examples of technical functions are Authentication and Authorization.

Interfaces to technical functions modeled as triggers and results.

Technical function only exists to enable the business processes.

Initially, technical functions will be defined using a template but like the business processes will ultimately be based on UML models.

Technical function maturity level pairs (function + capability) will result in a technical service.

The technical functions are being defined by the Private Sector Technology Group’s Technical Architecture Committee (TAC).

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Technical Maturity LevelsAre Based on Industry Standards

Artificially linked technology to MITA Business maturity

Did not allow flexibility for industry standards

Did not provide flexibility in designing technical services/solution sets

One to many maturity levels for each technical functions

Maturity levels are specified by letter (A, B, C)

Maturity levels only have meaning within the scope of that particular technical function

Provides flexibility

Framework 2.0

Technical Services

Technical Function

Maturity Levels

54321

Framework 2.0 Plus

Maturity Levels

Z…..BA

Technical Services

Technical Function

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Benefits of New Maturity Level Approach

Technical maturity no longer maps technology to the five levels of business maturity. Instead each technical function is defined with its own independent maturity levels.

The technical function may have one or many levels of maturity based on the industry standards for that particular technical function.

This allows a technical service to be based on the industry derived capabilities/maturity levels.

Solution sets for business services can make use of a heterogeneous mix of technical maturity levels based on the value that they bring to the business process.

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Technical Services Update

There have been no structural changes to the concept of Technical Services.

A service can be defined for each technical function—maturity level pair.

The methodology used to define the technical service is the same as for business services, i.e., HL7.

The HL7 Reference Information Model will be used in the development of the technical service interfaces whenever possible.

16

Application Architecture

Application Architecture Updates The application architecture captures technical infrastructure needs that

can not be defined as a technical function/technical service. An example of this is an enterprise service bus.

Each element of the application architecture will have technical maturity levels and technical solution sets.

BusinessServiceEnd User

TechnicalService

TechnicalService

TechnicalService

TechnicalService

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Technical Solution Sets

The role of technical solution sets remains unchanged. There may be one or many technical solution sets for each

technical function—maturity level or application element-maturity level pair.

A solution set has the metadata describing a specific implementation approach.

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Technical Maturity Levels

Framework 2.0 Framework 2.0 Plus

Business Service

BusinessProcess

Maturity Levels

54321

Business Solution

Set

Technical Service

Technical Function

A

Maturity Levels

54321

Technical Solution

SetTechnical Service

Technical Function

B

Maturity Levels

54321

Technical Solution

Set

Business Service

BusinessProcess

Maturity Levels

54321

Business Solution

Set

Maturity Levels

DBA

Technical Services

Technical Function

Maturity Levels

BA

Technical Services

Technical Function

C

Technical Solution

Set

Technical Solution

Set

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Relation to Business Service Solution Sets

Business services solution sets contain pointers to all technical function—maturity level pairs that are used by the particular implementation of the business service.

Allows maximum flexibility for the implementer to use the mix of technology while maintaining a loose inventory of technology available for use.

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Technical Assessment

Framework 2.0 Sporadically mentioned

Process same as Business process self assessment

Resulted in an assessment of the technical maturity in terms of the five levels of MITA Business Maturity

Assessed technology for technology sake

Framework 2.0 Plus Refocuses assessment process on

business Process is now an inventory of the technical

services and applications available Technical assessment is performed to

determine what technical assets are currently available in a State’s infrastructure that can support future business needs

Used in conjunction with Business service solution sets and the “to-be” business service assessment to determine technical needs to meet the business “to-be” configuration.

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MITA Technical Services

Goal is to support semantic interoperability of the MITA business processes and technical functions

Interface standardization begins at Maturity level 3

Provides enabling functionality to business services

Examples Gateways/adapters

CAQH Content X12

Communications CAQH connectivity NHIN EDI

Authorization & Authentication

Audit logging Encryption

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MITA Business Process, Business Capability Matrix, and Business Services

ResultTrigger Business Logic

Business Process

•Definition•Description of business logic•Performance measures

Level 1Capability

Level 2Capability

Level 3Capability

Level 5Capability

Level 4Capability

Business Capability Maturity

Level 2Business

Service

Level 3Business

Service

Level 4Business

Service

Level 5Business

Service

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Purpose of a MITA Business Service

The MITA Business service is a logical implementation of a Medicaid Enterprise business process (e.g., Enroll Provider)

The MITA business service supports Interoperability and plug-and-play States adapting and extending the

service to meet their individual requirements

A MITA business service is implementation neutral

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Black Box Concept of a Service

ServiceLegacy Application

ServiceCustom Code

COTSCustom Code

ServiceCOTS

ServiceCustom Code

ServiceService Service Service

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Parts of a MITA Service

Service nameFormally defined interfaceBehavior characteristics

Business logic Service Contract (Processing pattern,

etc.)Business Service Definition Package

(BSDP)

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MITA Service Flow

Services are loosely coupledNO predefined predecessor or successor

services to an individual serviceServices configured through use of a service

contract and an orchestration languageChanges to the flow of services through changes

to this orchestration; NOT by changes to the service

Interfaces between the services must be compatible

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Interoperability - Replacement

ServiceB

ServiceA

ServiceC

ServiceB1

ServiceA

ServiceC

StartingConfiguration

FinalConfiguration

e.g., replacement of legacy service with

COTS

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Interoperability – Addition

ServiceB

ServiceA

ServiceC

ServiceB

ServiceA

ServiceC

ServiceD

StartingConfiguration

FinalConfiguration

e.g., HIPAA translator

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Interoperability – New

ServiceB

ServiceA

ServiceC

ServiceB

ServiceA

ServiceC

StartingConfiguration

FinalConfiguration

ServiceE

e.g., new utilization review

process

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Interoperability – New Business Process

ServiceB

ServiceA

ServiceC

ServiceB3

ServiceA

ServiceC

ServiceF

StartingConfiguration

FinalConfiguration

e.g. , utilization review service with new potential fraud

report e.g., automated fraud detection processing

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Business Process and Business Service Relationship

Trigger Business Logic

Business Process

Result

Business Service

Service Contract

Business Logic Data

WSDL defined WSDL defined

Shared between or with other services

Example Eligibility Inquiry Response•HIPAA 271 XML schema

Example Eligibility Inquiry•HIPAA 270 XML schema

Performed by legacy subsystem, new code or services, COTS or combination

DefinitionDescription of business logicPerformance measures

What does the service do and what is needed to engage the service

Business capability

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MITA Service Definition Methods

Interfaces are defined in Web Service Definition Language (WSDL)

Messages are defined in XML schemas Business Logic – currently free form text, will become

business rules in the future Business Service Management (orchestration) is defined in

Web Service – Business Process Execution Language (WS-BPEL)

Data is defined in MITA logical data model

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State Personalization of Services

Change Message Structure - Schema changeChange data being used – Change data set name

(e.g., instead of mapping to “state-A-MVA” map to “state-B-MVA)

Replace capability – Replace service with state unique service preserving input and output

Re-Orchestrate business services – Add new services to flow

Change business rules – Replace the set of business rules used by a service with a new set of business rules

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Service Interface Specification Development Process

Develop BS Interface Specification adoption

recommendation(WSDL, XML Schema and models)

Applicable Standard Report

Coordinatewith TAC andidentify Technical Service gaps

StandardAnalysis

MITA Business Process

Specification(template & BCM)

ModelBusinessProcess

TAC

MITAGovernance

Boards

(Adoption packages)

(Adoption packages)

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Putting it all together

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Service Orchestration

Business Service Invocation

TrueFalse

Business Service- D

Technical Service- 3

Business Service - B

Business Service - A

Business Service- C

Technical Service - 2

Technical Service - 1

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Service Contract

Service “XYZ”

Service

Request

Interaction

Specification

Interface Response

Interface Request

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MIT

A D

eter

min

e E

ligib

ility

R

equ

est

Sample Service #2 – Member Eligibility and Enrollment

Enterprise Service Bus

Service Management Engine

Member Service Portal

Determine Eligibility Request

AccessChannel

AccessChannel

Step 1: Member Invokes

“Determine Eligibility” Service

Security & Privacy Services

Data Format Services

Logging Services

Determine EligibilityService

Contract

Step 2: Receive/ Route/

Manage

Step 4: Return Response

Step 3: Execute Determine Eligibility Business Process

Eligibility Response

MIT

A D

eter

min

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ligib

ility

Res

po

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MIT

A D

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ligib

ility

Req

ues

t

MIT

A D

eter

min

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ligib

ility

R

esp

on

se

Determine Eligibility Service

Step 5: Receive/ Route/

Manage

Step 6: Provider Receives

“Determine Eligibility” Response

MIT

A E

nro

ll M

emb

er R

equ

est

Enroll Member Service

MIT

A E

nro

llmen

t In

fo R

equ

est

MIT

A E

nro

llmen

t In

fo R

equ

est

Enrollment Info Request

Enrollment Info Response

MIT

A E

nro

llmen

t In

fo R

esp

on

se

MIT

A E

nro

llmen

t In

fo R

esp

on

se

MIT

A E

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t R

esp

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se

MIT

A E

nro

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esp

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se

Enrollment Response

Enroll MemberService

Contract

Step 7: Service contract – “activate”

enroll member service

Step 8: Request

Information for enrollment

Step 9: Route request for

more information to Service Portal

Step 10: Send request for more info

Step 11: Member completes

enrollment form

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MIT

A E

nro

llmen

t R

equ

est

Sample Service #1 – Provider Enrollment

Enterprise Service Bus

Service Management Engine

Provider Service Portal

Enrollment Request

AccessChannel

AccessChannel

Step 1: Provider Invokes

“Enroll Provider” Service

Security & Privacy Services

Data Format Services

Logging Services

Provider Enrollment

Service

Contract

Step 2: Receive/ Route/

Manage

Step 4: Return Response

Step 3: Execute Provider Enrollment Business Process

Enrollment Response

MIT

A E

nro

llmen

t R

esp

on

se

MIT

A E

nro

llmen

t R

equ

est

MIT

A E

nro

llmen

t R

esp

on

se

EnrollProvider Service

Step 5: Receive/ Route/

Manage

Step 6: Provider Receives

“Enroll Provider” Response

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– MITA guidelines apply; FFP available

– Entity is encouraged to follow MITA guidelines

– May exchange information; may influence MITA or vice versa

SURSor Fraud

Contractor

BenefitManager

Provider

OtherPayer

OtherAgency

CMS

LicenseBoard

RHIO

FEAFHA

CDCDepartmentof Homeland

Security

ONC

StandardsOrganization

MITABusinessProcess

#3

MITABusinessProcess

#2

MITABusinessProcess

#1

StateUnemploy-

mentAgency

MS

IS D

ata;

D

ual

Elig

ibili

ty

InterfaceInterface

Inte

rface

Interface

Interface

Inte

rface

Interface

Interface

Standards of Interoperability

;

EHR

Interface

Use Standards;

Develop New Ones

Info

rmat

ion

Exc

han

ge

Guidelines;Directives

No

tifi

cati

on

san

d A

lert

sN

otificatio

ns

and

Alerts

MITA Medicaid Enterprise

Business Service

Technical ServiceConnection

41

The TAC’s 5010 Gateway Project

InquireMember

Eligibility 1

GUI

Legend

Business Service

Technical Service

GUI

TS-B1 TS-C1GUI

TS-A TS-B1 TS-C1 TS-DGUI

IME

IME

Phase 1

Phase 2

Phase 3

PotentialPost

Phase 3

TS-B TS-COtherBusinessServices

TSTS

TSTS

42

IME Test Suite

CAQH Core InConnectivity TS

X12/MITA XMLadapter TS

MITA XML/X12adapter TS

CAQH Core OutConnectivity TS

Inquire MemberEligibility BS

Dash-Board

43

The Big Picture

NMEH

HL7-MITAProject

TAC

BARB

IARB

TARB

ARB

MITA Users

STAG

New Bus Proc

Other DSMOs

HL7 HL7Healtth DataCommunity

Technical Implementer

IndependentInformation Spec.

State BusinessSMEs

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MITA Architecture Governance Structure

MITA Architecture Review Board

MITA Business Architecture

Review Board

MITA Information Architecture

Review Board

MITA Technical Architecture

Review Board

•Business Process

•Business Capability

•S-SA process

•Conformance Criteria

•Data Models

•Vocabulary

•Mapping to Standards

•Data Management Strategy

•Service definitions

•Infrastructure definitions

•Technical processes

•Technical capabilities

•Mapping to Standards

•MITA Standards

•Framework updates

45

MITA Architecture Governance Artifacts

MITA Architecture Review Board

MITA Business Architecture

Review Board

MITA Information Architecture

Review Board

MITA Technical Architecture

Review Board

•Business Process

•Templates

•Activity diagrams

•Business Capability

•Business Information Vocabulary and glossary

•Conformance Criteria

•Data Models and associated views

•WSDL and associated XSD

•Information Vocabulary and glossary

•Mapping to Standards

•Service definitions

•Technical Functions

•Templates

•Activity diagrams

•Technical Information Vocabulary and glossary

•Tec Function capabilities

•Mapping to Standards

•Infrastructure definitions

•MITA Standards

•Framework updates