ACS System and Operational Changes DCH Board Meeting Georgia Healthy Families September 8, 2005

1. ACS System and Operational Changes DCH Board MeetingGeorgia Healthy FamiliesSeptember 8, 2005

2. New and Significantly Changed Activities • Establishment of CMOs as “Providers” • Enrollment processing • Eligibility determination • Data interfaces among ACS, Enrollment Broker, and CMOs

3. New and Significantly Changed Activities (cont’d) • Capitation payment and adjustments • Web—IVR—MEVS modifications • Reporting—Federal and State • Health Services • Authorization/Pre-Cert coordination • CMO Encounter Processing • Health Check (EPSDT) coordination

4. Current vs. CMO Systems and Operations Support

5. New Web Portal Functionality View  

6. Sample Detailed System & OperationalChanges

7. CMO Provider Management • Store information about CMOs and their proposed network of providers • Assign Georgia Counties to one (1) of the six (6) Service regions as defined in the CMO RFP • Maintain capitation rate cells for the various delineation of members that are included in the GHF program based on age, gender or other variables as documented in the CMO RFP • Prevent enrollment (this applies to auto assignment only) into a CMO from exceeding threshold percentage based on total population assigned in the Service Region

8. CMO Provider Management (cont’d) • Provide the ability to affiliate CMO providers with the CMO Plan • Maintain ability to track providers participating in multiple CMOs • Modify current provider file suspense processing for situations where the provider in the CMO network has not filed a FFS claim with Medicaid • For each region maintain and track maximum percentage of members eligible for each CMO, actual percentage of members assigned to each CMO, display the total number of members assigned to the CMO

9. Member Management • Using an automated program, determine nightly whichmembersshould be enrolled in the GHF program • Transmit GHF eligible members to the Enrollment Broker for further member education and outreach • Accept a daily file from the Enrollment broker that contains CMO choices made by the members, editing the validity of each transaction to validate that the member is still “eligible” for the CMO program prior to accepting and applying the enrollment transaction

10. Member Management (cont’d) • Provide the ability to Auto Assign members who have not selected a CMO within a 30 day choice period using a similar algorithm used today under the GBHC program • Provide each CMO with the Prior Authorizations, existing GBHC Referrals (during initial transition only) or Pre-certifications on file for each member being assigned to them to allow for continuity of care • Update systems including MEVS, GHP Portal, and the IVR to display/speak the member’s CMO plan ID, name and telephone number • Perform Mass Changes of members at the direction of DCH

11. Payment Management • Monthly capitation payments and adjustments • Provide the ability to make manual payments or create manual financial transactions • Allow for the recoupment of capitation from the CMO on a per member basis • Provide ability to make retroactive capitation payments for newborns back to the date of birth

12. Payment Management (cont’d) • Create Newborn incremental payment to cover costs of pregnancy care and delivery • Pay claims, in limited situations, where the member is a CMO member • Ensure that claims, excluding those few exceptions identified by DCH submitted for CMO members are not paid on a FFS basis • Have the capability to suspend all capitation and delivery payments to a particular CMO or a specified time period

13. Encounter Management • Accept, via an interface with each CMO, encounter data on a monthly basis • Provide DCH with the capability to perform “Shadow” Processing on encounters wherein DCH can estimate or validate how much they would have paid for the same service if it had been provided in a FFS setting as opposed to the CMO program • Incorporate Encounter Data as needed and modify existing MAR, SUR and MSIS data layouts and reports to accommodate the co-existing FFS and managed care delivery systems • Perform data validation on the encounter data received from the CMO and update the member’s claims/encounter history records

14. Encounter Management (cont’d) • Update the Data Repository with Encounter data on a monthly basis • Transmit Encounter data to the DSS vendor on a monthly basis • Accept and process encounter “adjustments” from the CMOs on a monthly basis • Update Health Check data in the MMIS based on Encounter data received from the CMOs • Provide ability to process Encounters on a monthly or quarterly basis as if they were FFS claims for comparative purposes, without generating any payments to providers. The Encounter processing will contain edits similar to the edits utilized in the FFS program at a minimum.

15. Monitoring and Reporting • Produce other ad hoc or DCH defined management level reports to assist DCH in monitoring the program • Provide a monthly update to each CMO reporting any providers that are affiliated with the CMO who have been suspended or terminated for the FFS Medicaid program due to licensing issues, sanctioning/adverse action or are included on the Federal Exclusion Data base

16. Monitoring and Reporting (cont’d) • Produce and send capitation rosters to the CMOs on a monthly basis • Produce and send an Enrollment Roster to each CMO (and send all CMO rosters to the Enrollment Broker) which lists all members and their related information for those who have been enrolled, disenrolled, are ongoing enrollees, or had information changed that the plan needs notification

17. CMO Web Portal Functions • Verify Member Eligibility • Verify Member Enrollment within the Eligibility Verification to include: • CMO enrollment begin date, end date, historical • CMO name and telephone number • View Member’s previous PCP within the Eligibility Verification Window • View member Enrollment/ Disenrollment reason codes • View Payment Amounts

18. CMO Web Portal Functions (cont’d) • Find a HealthCare Resource • Message Center • View Prior Authorizations/Pre-certification information for members enrolled in the CMO

19. CMO Web Portal Functions (cont’d) • View Health Check Appointment Tracking System • Newborn Notification • Add links to the Enrollment Broker to the Member Information public pages