MITA Business Processes, Technical Functions & Services

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Oct 23, 2013 (4 years and 15 days ago)

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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

Levels

HL7 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

SURS

or Fraud

Contractor

Benefit

Manager

Provider

Other

Payer

Other

Agency

CMS

License

Board

RHIO

FEA

FHA

CDC

Department

of Homeland

Security

ONC

Standards

Organization

MITA

Business

Process

#3

MITA

Business

Process

#2

MITA

Business

Process

#1

State

Unemploy
-

ment

Agency

MSIS Data;
Dual
Eligibility

Interface

Interface

Interface

MITA Medicaid Enterprise

10

Provider

Management

Contractor

Management

Operations

Management

Program

Management

Business

Relationship

Management

Program

Integrity

Management

Care

Management

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 Case

Establish

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

7

4

4

2

Business Process Model
v2.01

11

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

Technology

Standards

Application
Architecture

Technical
Services

Technical
Capability
Matrix

Business
Services

Solution
Sets

Framework 2.0 Plus

Technology

Standards

Application
Architecture

Technical
Services

Technical
Functions

Business
Services

Solution
Sets

12

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).


13

Technical Maturity Levels

Are 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

5

4

3

2

1

Framework 2.0 Plus

Maturity Levels

Z

…..

B

A

Technical
Services

Technical
Function

14

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.

15

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.

Business

Service

End User

Technical

Service

Technical

Service

Technical

Service

Technical

Service

17

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.

18

Technical Maturity Levels

Framework 2.0

Framework 2.0 Plus

Business
Service

Business

Process

Maturity Levels

5

4

3

2

1

Business
Solution

Set

Technical
Service

Technical
Function
A

Maturity Levels

5

4

3

2

1

Technical
Solution

Set

Technical
Service

Technical
Function
B

Maturity Levels

5

4

3

2

1

Technical
Solution

Set

Business
Service

Business

Process

Maturity Levels

5

4

3

2

1

Business
Solution

Set

Maturity
Levels

D

B

A

Technical
Services

Technical
Function

Maturity Levels

B

A

Technical
Services

Technical
Function

C

Technical
Solution

Set

Technical
Solution

Set

19

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.

20

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.


21

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



22

MITA Business Process, Business Capability Matrix, and
Business Services

Result

Trigger

Business Logic

Business Process


Definition


Description of business logic


Performance measures

Level 1

Capability

Level 2

Capability

Level 3

Capability

Level 5

Capability

Level 4

Capability

Business Capability Maturity

Level 2

Business

Service

Level 3

Business

Service

Level 4

Business

Service

Level 5

Business

Service

23

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

24

Black Box Concept of a Service

Service

Legacy


Application

Service

Custom


Code

COTS

Custom


Code

Service

COTS

Service

Custom


Code

Service

Service

Service

Service

25

Parts of a MITA Service


Service name


Formally defined interface


Behavior characteristics


Business logic


Service Contract (Processing pattern,
etc.)


Business Service Definition Package
(BSDP)


26

MITA Service Flow


Services are loosely coupled


NO

predefined predecessor or successor
services to an individual service


Services configured through use of a service
contract and an orchestration language


Changes to the flow of services through changes
to this orchestration;
NOT

by changes to the
service


Interfaces between the services must be
compatible

27

Interoperability
-

Replacement

Service

B

Service

A

Service

C

Service

B1

Service

A

Service

C

Starting

Configuration

Final

Configuration

e.g., replacement of
legacy service with
COTS

28

Interoperability


Addition

Service

B

Service

A

Service

C

Service

B

Service

A

Service

C

Service

D

Starting

Configuration

Final

Configuration

e.g., HIPAA
translator

29

Interoperability


New

Service

B

Service

A

Service

C

Service

B

Service

A

Service

C

Starting

Configuration

Final

Configuration

Service

E

e.g., new
utilization review
process

30

Interoperability


New Business Process

Service

B

Service

A

Service

C

Service

B3

Service

A

Service

C

Service

F

Starting

Configuration

Final

Configuration

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

e.g., automated fraud
detection processing

31

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

Definition

Description of business logic

Performance measures


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


Business capability

32

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

33

State Personalization of Services


Change Message Structure
-

Schema change


Change 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

34

Service Interface Specification Development
Process

Develop BS Interface

Specification adoption

recommendation

(WSDL, XML Schema and models)

Applicable

Standard


Report

Coordinate

with TAC and

identify Technical


Service gaps

Standard

Analysis

MITA Business

Process

Specification

(template & BCM)

Model

Business

Process

TAC

MITA

Governance

Boards

35

Putting it all together

36

Service Orchestration

Business


Service Invocation

Business


Service
-

D

Technical


Service
-

3

Business


Service
-

B

Business


Service
-

A

Business


Service
-

C

Technical


Service
-

2

Technical


Service
-

1

37

Service Contract

Service “XYZ”



Service

Request

Interaction

Specification

Interface Response

Interface Request

38

MITA Determine

Eligibility

Request

Sample Service #2


Member Eligibility and Enrollment

Enterprise Service Bus

Service Management Engine

Member

Service Portal

Determine Eligibility

Request

Access

Channel

Step 1: Member
Invokes

“Determine
Eligibility” Service

Security

& Privacy


Services

Data Format


Services

Logging


Services

Determine Eligibility

Service

Contract


Step 2:
Receive/
Route/
Manage

Step 4: Return
Response

Step 3: Execute
Determine Eligibility
Business Process

Eligibility

Response

MITA Determine

Eligibility Response

MITA Determine


Eligibility Request

MITA Determine

Eligibility

Response

Determine Eligibility

Service

Step 5:
Receive/
Route/
Manage

Step 6: Provider
Receives

“Determine
Eligibility”
Response

MITA Enroll

Member Request

Enroll Member

Service

MITA Enrollment

Info Request

MITA Enrollment

Info Request

Enrollment

Info Request

Enrollment Info Response

MITA Enrollment

Info Response

MITA Enrollment

Info Response

MITA Enrollment

Response

MITA Enrollment

Response

Enrollment

Response

Enroll Member

Service

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

39

MITA Enrollment

Request

Sample Service #1


Provider Enrollment

Enterprise Service Bus

Service Management Engine

Provider

Service Portal

Enrollment

Request

Access

Channel

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

MITA Enrollment

Response

MITA Enrollment

Request

MITA Enrollment

Response

Enroll

Provider

Service

Step 5:
Receive/
Route/
Manage

Step 6: Provider
Receives

“Enroll Provider”
Response

40



MITA guidelines apply; FFP available



Entity is encouraged to follow MITA guidelines



May exchange information; may influence MITA or vice versa

SURS

or Fraud

Contractor

Benefit

Manager

Provider

Other

Payer

Other

Agency

CMS

License

Board

RHIO

FEA

FHA

CDC

Department

of Homeland

Security

ONC

Standards

Organization

MITA

Business

Process

#3

MITA

Business

Process

#2

MITA

Business

Process

#1

State

Unemploy
-

ment

Agency

MSIS Data;
Dual
Eligibility

Interface

Interface

Interface

MITA Medicaid Enterprise

Business Service

Technical Service

Connection

41

The TAC’s 5010 Gateway Project

Inquire

Member

Eligibility 1

GUI

Legend


Business Service



Technical Service


GUI

TS
-
B1

TS
-
C1

GUI

TS
-
A

TS
-
B1

TS
-
C1

TS
-
D

GUI

IME

IME

Phase 1

Phase 2

Phase 3

Potential

Post

Phase 3

TS
-
B

TS
-
C

Other

Business

Services

TS

TS

TS

TS

42

IME Test Suite

CAQH Core In

Connectivity TS

X12/MITA XML

adapter TS

MITA XML/X12

adapter TS

CAQH Core Out

Connectivity TS

Inquire Member

Eligibility BS

Dash
-

Board

43

The Big Picture

NMEH

HL7
-
MITA

Project

TAC

BARB

IARB

TARB

ARB

MITA Users

STAG

New Bus Proc

Other DSMOs

HL7

HL7Healtth Data

Community

Technical Implementer

Independent

Information Spec.

State Business

SMEs

44

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