Medicaid Management Information System (MMIS) Replacement Design, Development and Implementation Phase

System Requirements Federally Certified MMIS by CMS Fully HIPAA compliant National Provider Identification Claims Attachment Transaction Modifications On-line, real-time adjudication and inquiry capabilities MMIS must be a modular and flexible system Web based services On-line provider enrollment, eligibility verification and enrollment, member services, benefits administration, service authorization, provider enrollment, claims submission and processing and utilization management

Design Phase Subject Matter Experts will meet with contractor staff to refine and finalize all system and business process requirements. Each subsystem will contain staff from both the IT and business side to ensure system requirements are met and business processes are evaluated and improved with each program area. Verify that system business rules are synchronized with business policy Review of system test plan, system test results

Business Needs for Replacing MMIS Old Technology, implemented in 1978 Current MMIS does not provide sufficient technology and innovation to further automate and support DHS’s business processes Problems with data integrity Changes in legislative enactments, new technology, new programs, new methodologies all require a timely enhancements or changes of the MMIS

Business Needs for Replacing MMIS Difficult to staff and maintain legacy technology Difficult to perform user ad-hoc reporting Lack of flexibility - business rules embedded in code, scattered throughout the code MMIS must support a variety of benefit programs The need to adapt and implement future compliancy issues that are required under the federal Health Insurance Portability and Accountability Act (HIPAA).

Business Process Improvements On-line submission, adjudication, and inquiry of claims, prior authorizations, and provider enrollment information Improved accuracy and timeliness of claims processing Flexible, modularly designed system that is user-friendly, easy to maintain, and easy to enhance Handle specialized program components within Medicaid and State CHIP programs, as well as other State health care programs

Business Process Improvements Workflow systems streamline the claims processing functions and improve the efficiency of claims operations Internet access and portals will greatly enhance selective access of external stakeholders Automated review of claims and codes, rather than current manual processes Faster, more accessible, and accurate reports through the DSS system Support

Business Process Improvements Integrated telephone answering with claims system Document Management component to facilitate the consistency of forms submitted and scanned. Improved Internal Controls (dupe payments, etc) Support new and changing claims payment methodologies Ability to communicate rule changes and current rules with stakeholders Reduction in development costs

Replacement Options We are considering several options, which Fox Systems, Inc. will be detailing in their final Cost/Benefit Analysis The options range from “turn-key” operations to outsourcing various business functions. The RFP will likely contain several options for the vendors to consider, with a preference issued by the state.