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SD/MC Phase II

SD/MC Phase II. Short-Doyle Medi-Cal is a computer system that adjudicates behavioral health claims for Federal funding. Current System – Phase I. How it works Limitations Cost model Brought DHCS closer to HIPAA Compliance, but…not fully compliant with HIPAA. Business Process.

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SD/MC Phase II

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  1. SD/MC Phase II Short-Doyle Medi-Cal is a computer system that adjudicates behavioral health claims for Federal funding

  2. Current System – Phase I • How it works • Limitations • Cost model • Brought DHCS closer to HIPAA Compliance, but…not fully compliant with HIPAA

  3. Business Process • State Controllers Office cuts check • DMH and ADP manage the payment to the Counties • DMH and ADP Invoice DHCS for Claims • Claims are submitted • Counties • Direct Providers • Claims are received by DMH • Both DMH and ADP Claims • 15m annually (worth ≈ $2B) • This business process is maintained by DMH • Claims are sent to DHCS • Data processing occurs • Claims are adjudicated

  4. Systems and Interfaces Current System

  5. Systems and Interfaces SD/MC Phase II

  6. Problems with current SD/MC • Its not fully HIPAA compliant • Translator near its end of life • Biz rules are embedded in code • Full Financial information is not captured • COBOL programmers are endangered species • Legacy design – difficult to modify, • maintain, and interoperate

  7. Cost of current system • DMH pays for the Web Application • DMH/ADP pay for the translator software • configuration maintenance (two contracts) $500K • DHCS pays • Translator hardware (DTS charges) $360K annualized • Translator 3rd party license • Mainframe hardware (DTS charges) $700K annualized • Support staff to maintain COBOL Annual cost of Current System $1.5M annualized Estimated Annual Cost of New System $800K

  8. SD/MC Phase II • EDIFECS HIPAA Engine • DHCS Standard - .NET • Only HIPAA formats • Biz rules maintained • by MS BizTalk (Table Driven) • SOA, MITA ready • Translator goes away • No COBOL • No Mainframe • No legacy formatted data

  9. SD/MC Phase II Claim Convoy SD/MC Phase II Processing Claims received from web App Sent to SD/MC Phase II Format is Validated HIPAA Standard Biz Rules are applied DMH and ADP Accounting Systems are updated SCO prepares warrant DMH and ADP Accounting Systems are updated Web app is updated with Results for Counties ‘In Scope’ for SD/MC Phase II ‘In Scope’ for SD/MC Phase II Claims are processed as they are received – No more batch!

  10. Trading Partner Impacts • HIPAA Transactions only • HIPAA Transaction rule enforced • Potential other impacts • Testing environment will be available

  11. SD/MC Phase II Cost • Design, Development, and Implementation – $3.6M • Hardware and Support from DTS – (est. $500K annual) • Application support 3 PY’s (Includes one existing and two new positions – effective 7/1/2008) - $300K annual Estimated Annual Cost of New System $800K

  12. SD/MC Phase II Questions?

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