attachment c.6.a unitedhealthcare management information system · 2020-06-19 · attachment c.6.a...

Helping People Live Healthier Lives

Medicaid Managed Care Organization (MCO) – All Regions Attachments

RFP 758 2000000202 of 31

ATTACHMENT C.6.A UNITEDHEALTHCARE MANAGEMENT INFORMATION SYSTEM

A detailed description of the UnitedHealthcare Management Information System (MIS), including diagrams and flowcharts, is provided herein. The diagram on the next page provides an overview of the major capabilities and systems planned to support the Commonwealth. Following this overview diagram, we provide flowcharts or diagrams corresponding to RFP Section C.6.a.i-viii along with summary tables containing descriptions of how the subsystems are used in managing a particular operational area, dataset and transactional function.

Our Reporting subsystems are presented and described herein in subsection C.6.a.ix. Our Testing subsystems are described in subsection C.6.a.x. Descriptions of our Information Systems Management subsystems are provided in subsection C.6.a.xi. These subsystems enable user-friendly means for enrollees to access services, get information, and to be empowered to improve their health and well-being.


Medicaid Managed Care Organization (MCO) – All Regions Attachments

RFP 758 2000000202 of 31

FIGURE 1: C.6.A MANAGEMENT INFORMATION SYSTEM OVERVIEW

Provider ManagementClaims Processing Engine (CPE) - Optum Transaction Validation

Manager (OTVM) EDI Claims Intake, HIPAA Compliance, Quality, and Routing Enhanced Claim Edits

Interactive Voice Response (IVR) System Call Routing, Claims and Eligibility / Enrollment Status

Encounters Management

National Encounter Management Information System (NEMIS)

Encounters Processing for Medicaid

Member Management

myuhc.com & UnitedHealthcare Mobile App Profile, Claims Status, Prior Auth Status, Member Status, EOB, Electronic Communications

Advocate4Me & Task Tracker Intelligent Call Routing, Claims and Eligibility / Enrollment Status, and Welcome and Reminder Campaign Management

External UnitedHealthcare Community Plan

ConsumerDatabase

(CDB)

Claims Management

enrollee

Analytics

Online Provider Search Provider Directory Search from a web

care coordinator

Care Management

Impact Pro Identification & Risk Stratification

CSP Facets Member Enrollment Provider Network Data Claims Processing Provider Agreements Pricing and Adjudication

Claims Payment EOB and Remittance

Capitation Payments Member Benefits

Third Party Liability

MACESS Claims Paper Claims Imaging and Claims Routing

NetworX Provider Contracts and Pricing

Prospective 2.0 Pre-Payment Fraud and Abuse

Smart Audit Master (SAM) Post Payment Claim Review

iCES Facility and Professional Claims Editing

Strategic Management Analytical Reporting Tool (SMART) & Crystal Reports Integrated Analytical Data Reporting Ad Hoc Reporting Big Data Platforms

ICUE

Utilization Management

Service Authorization

ClaimSphere Predictive NCQA HEDIS Compliance & Provider Profiling Clinical Data Quality Management

UnitedHealthcare –�Kentucky Architecture

HIPAA Gateway HIPAA Transaction Mapping & Compliance

Financial Management

FTS Financial Tagging Service

FSDB Consolidated Financial Systems Database

Escalation Tracking System (ETS) Grievances and Appeals

Information Technology Management

ServiceNow Issue Tracking, Change Management, System Monitoring, & Reporting Critical Incident Data

PeopleSoft Accounting and HR Management

Ver.1.1 - Updated 01/25/20

UHCCommunityPlan.com Community Plan Informational site

CSP Call Center, Avaya Qfinity Call Center Inquiries, Statistics

call center

WebStrat Claims Reimbursement using DRG and Ambulatory Groupers

MedReview DRG Validation on Claims

B2B External Customer Gateway

Transaction Routing, EDI, HIPAA 5010, XML, State Interfaces

medical & behavioral

healthproviders

NDB and Contract Management Provider Network Management Provider Agreements

Network Database

CommunityCareTM

Community-Based Case Management

Person Centered Care

Care Management

Complex Case management

Care Plan & Service Plan Development

Automated Care Transitions

Clinical Information

Medication Management

Electronic Case Management

Clinical Records

SMART

CSP Facets

Provider Recommendation Engine (PRE) Member PCP assignment

Doc360 Scanned Paper Document Storage

UHCprovider.com and LINK Dashboard Application dashboard and messaging portal Provider Portal, Profile Management Claims and Member Status, Prior Authorizations

CommunityCareTM Care Collaboration, Patient Registry, and

Automated Care Transitions


Medicaid Managed Care Organization (MCO) – All Regions

Attachment C.6.a UnitedHealthcare Management

Information System

RFP 758 2000000202 of 31

C.6.a.i Enrollee Subsystems The flowchart following the table depicts how our enrollee systems supporting eligibility and enrollment receive eligibility files, then route the data contained from the files to various operational areas for day-to-day enrollment and eligibility activities such as care coordination, PCP assignment, eligibility verification, claims and related services. The summary table below provides the name of the subsystem and a description of the system’s support functionality.

Table C.6.a.i Enrollee Subsystem Descriptions

Management Information System General Description/Functions Supported by System

Subsystem: Enrollee

Alvar Monitors and tracks important business operations, transactions and processes to provide dashboards across end-to-end process flows.

B2B/Electronic Communication Gateway (ECG)

Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties.

Business Process Management System (BPM)

Manages the enrollment error queues including corrections and resubmission of records to CSP Facets.

Consumer Database (CDB) Consolidated database of all UnitedHealthcare Enrollees that serves as a “master index” of Enrollees across all UnitedHealthcare systems.

CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:

Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment

Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information

Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission

Claim status data including incurred claims, processing status and payment timeliness data

Documents distribution of capitation payments

Generates explanation of benefits, remittance advice, and statements

Data for provider payment issuance purposes

Eligibility Enrollment Management System (EEMS)

Enhanced enrollment module for CSP Facets that increases efficiency and accuracy of the enrollment process, improved speed to market for format changes, reduced maintenance costs and improved end-to-end cycle time for loading eligibility.

Interactive Voice Response (IVR) System and Avaya Dialer

Handles basic Enrollee inquiries and directs incoming calls to the most appropriate Enrollee services center professional.




Information System

RFP 758 2000000202 of 31


MACESS Workflow application that facilitates claim processing, including viewing of paper claims and supporting documentation in EDMS and Doc360, and routing of claims to our claim processors.

Provider Recommendation Engine (PRE)

Intelligent rules engine that systematically matches Enrollees with “preferred” PCPs who have the highest quality scores and best outcomes, costs and location.

Public Enrollee Portal (uhccommunityplan.com)

UnitedHealthcare public web presence used for posting general information, handbooks and bulletins — common entry point for Enrollees. Provides flexible search capability by type of provider, specialty, location and other criteria.

Strategic Management Analytic Reporting Tool (SMART)

Comprehensive, integrated analytical data warehouse, using the latest Oracle Exadata Database platform that holds all Medicaid relevant information — including claims data (e.g., medical, pharmacy, vision and lab), Enrollee data, provider data, authorizations, external subcontractor data and predictive modeling information. SMART:

Supports quality management, performance management and compliance reporting, and ad hoc reporting as needed with turnaround times averaging less than five business days

Stores service-specific data that includes behavioral health, LTSS, pharmacy, inpatient and outpatient services

Includes consolidated patient census (common store of all patients receiving care)

Consolidates data for Impact Pro health-risk modeling and stratification

Consolidates relevant data for ClaimSphere EPSDT and HEDIS reporting and related analysis and monitoring

Secure Enrollee Mobile App (UnitedHealthcare)

The free Enrollee mobile app provides personalized care notifications, medication management capabilities, administrative transactions, and can connect users directly with a member service advocate (MSA).

Secure Enrollee Portal (myuhc.com) Secure health and wellness information is available 24 hours a day, seven days a week through our Enrollee portal. Enrollees register for online access by setting up a secure HealthSafe ID™ and password. The personalized and easy-to-navigate digital experience allows Enrollees to search for covered benefits (medical, dental, vision, pharmacy and mental health), manage personal preferences, update contact information (including email addresses for facilitating contacts and information exchange), view/print and request we mail an ID card, change their PCP and locate providers through a searchable provider directory. The portal also offers personalized health and wellness content such as seasonal reminders (i.e., flu shots), personalized care recommendations, links to plan programs, and links to online resources and tools.




Information System

RFP 758 2000000202 of 31

Eligibility Files

(KY)

1

Enrollee Subsystems: Eligibility and Enrollment

EDI

(Clearinghouses,

Subcontractors)

C&S Data

Warehouse and

Analytics

(SMART)

All Data

The Commonwealth sends the enrollment /

disenrollment files to UnitedHealthcare

834 is validated for HIPAA compliance and is run

through business rules

Facets service updates the Enrollee�s demographics

eligibility. Errors are captured and routed to Enrollee

Services for review

Electronic Communication Gateway (ECG) receives the

files over a secure connection

1

2

3

5

6

7

4

9

ALVAR monitors the activity for the incoming and

outgoing files

Operations and state specific reports are generated and

distributed using ECG

8

Enterprise Service

Layer

(B2B)

270/271

Portals, IVR

(UnitedHealthcare,

myuhc.com, Link,

etc)

Claims Platform

Intake

(ECG/B2B)

Pre-Processing

(EEMS/

CSP Facets)

Enrollment &

Assignments

(CSP Facets)

Facets

Inquiry &

ResponseEligibility

Reporting

(CSP Facets)834

2 3

Activity Monitoring

(ALVAR)

4

5 6

PCP assignment occurs based on business rules

11

SMART loads data from claims systems and other sources for

reporting and analytics use

Enrollee Services reviews inquiries and updates CSP Facets.

10

11

12

Data is shared with downstream systems such as the 270/271

transaction, IVRs, portals, and mobile applications.

Subcontractors

(e.g. Rx, Dental,

Vision)

834 or Proprietary

Internal Systems

(CDB, Clinical)

Fulfillment

(ID Cards,

Welcome Kits)

12

Enrollment and Eligibility updates are shared with downstream

applications and subcontractors using ECG

Workflow Mgmt.

(MACESS)

Enrollee Services

(e.g. PCP

Changes)

Inquiry &

Changes

Exception

Handling

(BPM)

PCP Assignment

(PRE)

7

8 9

10

Enrollee Services corrects errors and submits records for

reprocessing

KY State Reports

Enrollment

Errors




Information System

RFP 758 2000000202 of 31

C.6.a. ii Third Party Liability (TPL) Subsystems Our third party liability (TPL) subsystems work in conjunction with our claims and utilization review subsystems to continually mine for TPL and to apply coordination of benefits (COB) edits, making sure that Medicaid is the payer of last resort. The table below provides a summary of our TPL subsystems. The flowchart following the table depicts how claims flow through our claims platform, CSP, to be adjusted due to TPL, COB, subrogation and similar cost avoidance activities.

Table C.6.a.ii.: Third Party Liability Subsystem Descriptions


Subsystem: Third Party Liability












Information System

RFP 758 2000000202 of 31

Claims Platform

COB Verification on Claim

(CSP Facets)

TPL Files /COB Information

(DMS, Others)

Third Party Liability Subsystems

Claims

Verify Enrollee COB

(CSP Facets)

4

COB Claims

COB Claims

Continue Claim Adjudication

(CSP Facets)

9

Claims Payment(CSP Facets)

10

Apply COB Information

(CSP Facets)

8

Claim is loaded into Facets pre-processer. Enrollee and Provider on the claim are identified

Verify if COB information is submitted on claim

1

2

3

4

7

11

8

CSP Facets finalizes and pays claim

5

Provider submits claims via either clearinghouse or directly. Submitted are transmitted to CSP Facets

Verify if Enrollee has COB information loaded within CSP Facets and pend claim

Review COB to validate the COB information on claim in CSP Facets

Apply appropriate COB information to claim in CSP Facets

CSP Facets completes adjudication and readies claim for payment

Claim Submission

1

Pend Claim for Review

(CSP Facets)

5

Review Claims per COB

Guidelines(CSP Facets)

6

9

TPL and COB information from the Commonwealth and other entities are loaded into CSP Facets via ECG

7

Subcontractors(Rx, Vision, Dental, etc.)

11

Enrollee COB/TPL Information

(Commonwealth)

12

6 CSP Facets pends the claims for COB review

10

We continually update COB information and share those updates with the Commonwealth via ECG

12

TPL updates are shared with our subcontractors

Claims Pre-Processing

(CSP Facets)

2

3




Information System

RFP 758 2000000202 of 31

C.6.a.iii Provider Data Management Subsystems The flowchart following the table below illustrates how provider data is collected from internal and external sources, and then loaded into other subsystems for day-to-day business operations, such as provider directories, claims, contracting and our secure provider portal, Link. Our Provider Subsystem supports online inquiry screens and external interfaces with the Department and other governmental agencies to receive licensure information. The table below describes the systems supporting our provider data management system as a whole.

Table C.6.iii.: Provider Data Management Subsystem Descriptions


Subsystem: Provider Data Management

Aperture

Manages workflow and stores provider credentialing information for all UnitedHealthcare participating providers


Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties

CSP Call Center Supports Enrollee services center operations in assisting providers with common inquiries (e.g., verifying Enrollee eligibility and verifying claims status)

Exari

Manages provider contracting workflow and stores contract information for most UnitedHealthcare participating providers

Interactive Voice Response (IVR) System

Enterprise voice portal handles basic provider inquiries (e.g., Enrollee eligibility/enrollment status and claims status) and directs incoming calls to the most appropriate provider services center professional

Link Secure provider portal providing a central access point where enrolled providers have access to eligibility and benefits, claims management, claims reconsiderations, enhanced online authorizations and gaps in care, and where they can update their practice profile. Additionally, providers can view and provide feedback on the initial health risk screening and care plans in CommunityCare.

Network Database (NDB) Our single enterprise repository of all information related to provider network management

Provider Elastic Search Tenant (PES) PES leverages the UnitedHealthcare Big Data Platform to return real-time, current provider data to client-facing applications.

uhccommunityplan.com UnitedHealthcare public web presence used for posting general information, handbooks and bulletins and serves as a common entry point for providers




Information System

RFP 758 2000000202 of 31


UHCprovider.com UHCprovider.com is UnitedHealthcare's home for provider information. With access to Link’s self-service tools 24 hours a day, seven days a week, current medical policies and the latest news bulletins, this site also has a great library of resources to support administrative tasks including eligibility, claims and prior authorizations and notifications. UHCprovider.com includes a powerful internal search tool to help care providers locate the information they need quickly. The site also offers care providers the opportunity to submit feedback on their experience to help identify opportunities to improve or enhance how we work together.




Information System

RFP 758 2000000202 of 31

Online and

Mobile Provider

Directories

(Find Care)

Interactive

Voice Response

(Enterprise Voice

Portal)

Encounters

Processing

(NEMIS)

10

Credentialing

(Aperture and

Provider

Onboarding)

Commonwealth

(KY)

Secure

Provider Portal

(Link)

Commonwealth�s

Provider Data

(KY)

Reconcile Provider

Data

(CAQH)

Provider

Contracting

(Exari)

3

2

Provider contracts with UnitedHealthcare

Provider data is received from the Commonwealth and loaded to

NDBSource of Truth for Provider Data

Encounters are created for paid claims and are validated prior to

sending them to the Commonwealth

Providers can obtain claims status, claim payment information,

member eligibility, data validation, reports, authorizations, and

more on secure provider portals

Council for Affordable Quality Healthcare's (CAQH) data is

received and reconciled with UnitedHealthcare�s provider data in

NDB

1

2

4

5

7

8

9

Provider data is sent daily to our online provider directories

10

Provider Subsystem

Provider

Demographics,

Credentials, and

Contracts Loading

(NDB)

1

Provider Load and

Claims Processing

(CSP Facets)

5

8

9

Data Warehouse

and Analytics

(SMART)Provider Data

6

4

Provider data is loaded daily to the CSP Facets Claims Platform6

Provider and claims data is loaded into the Data Warehouse for

analytics and reporting

11

HEDIS Measures

and Gaps in Care

(ClaimSphere)

11

12

13

CAQH Data

Contract Data

Demographics,

Credentials,

and Contract

Data

837

NCPDP

Processed

Claims

Web Services

Provider

Demographics

All Claims

and Provider

Data

Web Services

Providers can obtain claims status, member eligibility, and more

via the IVR system

13

12

Claims and

Provider Data

Provider and claims data is sent to ClaimSphere to calculate

HEDIS Measures

Credentials and

Primary Source

Verification data

Provider credentials are verified and data is loaded in NDB3

Provider Search

Tenant

(PES)

7

Provider data is loaded daily to the search tenant for use by other

systems




Information System

RFP 758 2000000202 of 31

C.6.a.iv Reference Subsystems Interwoven with each relevant operational need for data (e.g., claims, utilization, quality management) are contract-specific reference sources and the detailed information needed to manage and maintain up-to-date pricing files as well as procedure codes and diagnosis codes (i.e., reference data) specific to that contract. Also, our Reference Subsystems support online inquiry screens and interfaces with critical reference data from external sources, such as but not limited to ADA (dental) codes, CMS-HCPCS updates, CPT4, ICD-9, ICD-10, diagnosis surgery codes (e.g., DSM), and NDC codes.

Table C.6.iv.: Reference Subsystem Descriptions


Subsystem: Reference Subsystems









NetworX Supports rules-based provider contract configuration and claim pricing




Information System

RFP 758 2000000202 of 31

C.6.a.v. Claims Processing Subsystem (including Encounter Data) Working in conjunction with our TPL and SURS subsystems described and provided in this attachment, our claims processing and encounter data systems bring workstreams together to enable effective management of each process. Following the table below, we provide two flowcharts that depict how our encounter data processing and our claims processing systems interconnect.

Table C.6.a.v.: Claims and Encounters Processing Subsystem Descriptions


Subsystem: Encounter Data and Claims Processing



Claims Processing Engine (CPE) Application that enables universal claim intake and routing into CSP Facets

Claims Rules Engine (CRE) Application to support the business rules and validations used during claim adjudication.









Escalation Tracking System (ETS)

Facilitates administration and escalation management and processing of claim disputes, grievances and appeals. ETS:

Manages, provides status and tracks resolution on submitted grievances and appeals against policy-mandated time frames for Enrollee contact and appeal or grievance resolution

Generates reports related to the outcomes of grievances, complaints and appeals

Provides flexibility to easily customize data elements according to the Commonwealth’s needs

MACESS Workflow application that facilitates claim processing, including viewing of paper claims and supporting documentation in EDMS, and routing of claims to our claim processors




Information System

RFP 758 2000000202 of 31



Strategic, internally developed encounter data submission and reporting system that initiates submission of encounters, tracks responses, provides error correction and resubmission of Medicaid encounters to the Commonwealth in a format to be specified by the Commonwealth.



Optum Transaction Validation Manager (OTVM)

Electronic data interchange (EDI) validation that enables us to test and certify HIPAA transaction sets and verify compliance with standards and regulations on inbound claims.




Information System

RFP 758 2000000202 of 31

Subcontractor Integration

(Vision, Dental, RX)

Claims Platform

Acknowledgement sent to Provider

Paper Claims via RMO

2

Claims Subsystem

Claims Routing(CHWY/CPE)

997/999ACK

837 Claim

EDI Claims via Clearing House(Optum ENS)

1

HIPAA SNIP Validations

(OTVM)

3


(CSP Facets)

7

Claims Adjudication(CSP Facets)

9


10

Encounters Processing(NEMIS)

11

Adjust and Recovery

Operations(ARO)

12

837 Claim

Processed ClaimsWorkflow Mgmt.

(MACESS & Facets Workflow)

NSF/UB Claim

8

All Claims

Claims with Pre-Processing errors

Commonwealth(KY)

Single and Batch

Adjustments

4

Claims Rules Engine (CRE)

Encounters Reporting

HIPAA Compliant EDI claims are received at clearinghouse.

Electronic claims are checked for compliance and are validated with HIPAA SNIP validations

Claims are routed to appropriate claims system based on the Enrollee identifiers

Claims with pre-processing errors are routed to MACESS or Facets Workflow for manual review and updates. Updated claims are processed in the next cycle

Adjudication ready claims are picked up and processed. Claim editing rules are applied. Authorization is verified. Provider contract and pricing is determined. Enrollee benefits, co-pays, deductible, and max out of pocket are verified and applied

Paper claims are scanned and converted to electronic form. Basic validations are applied

Check creation / EFT generation

1

2

3

4

8

9

10

Encounters are created for finalized claims and are validated prior to sending to the Commonwealth

11

Applicable claims amounts are applied to an enrollee�s deductible and copayment account details are applied for subcontractor claims

6 12 Adjustments are categorized into single and batch. Single adjustments are done directly via Facets online application. Batch adjustments are done via bulk adjustment tool

5

Claim is checked against various claim edits, validations, and rules.

5

6

Claims


7




Information System

RFP 758 2000000202 of 31

Encounters Subsystems

UnitedHealthcare HIPAA Validation

(OTVM)

Claims Adjudication

Engine(CSP)

3

Encounter System(NEMIS)

4

Commonwealth Processing

(KY)

5

Claims Claims 837 FilesNCPDP

Encounters Response

2

Response Processing(NEMIS)

Encounters Triage & Correction

(NEMIS)

67

Corrections

Claims Intake(Clearinghouse /

Paper)Claims

1

Enrollee Files (834)

Provider Data(NDB)

Claims Intake(Subcontractor

Claims – Vision, Dental, Rx)

Subcontractor Claims

(Vendor DB)

SubcontractorClaims

Corrections

EDI and paper claims are received

Encounters are created for finalized claims and are validated prior to sending them to State

The Commonwealth processes submitted encounters and sends response via ECG

Response received from the Commonwealth is processed. Encounters are identified for corrections

Adjudication ready claims are processed and payments made

Identified encounters are triaged, corrected, and resubmitted for processing. Root causes identified. Subcontractor encounter identification and notification

1

3

4

5

6

7


2

Triage Solutions

Adjustments

Payment Integrity Edit / Recoveries

Claims Processing Procedure Changes

Configuration Changes

Provider Data Collection

Clearinghouse Edits

IT Claim Edits

Subcontractor Error Notification and Correction

Subcontractor Encounter ErrorsAncillary

Subcontractors

State Provider Data

Encounter Response Triage

Root Cause Analysis

Validate with Companion Guide

Validate against other State rules / requirements

Subcontractor encounter error Identification




Information System

RFP 758 2000000202 of 31

C.6.a.vi. Financial Subsystem The flowchart below depicts how our financial subsystems interconnect with our claims platform, payment and invoicing, pricing, reporting and other systems related to finance management and business accounting practices. Following the summary table below, we provide a flowchart that illustrates the subsystems that interconnect with subsystems for operational support regarding finance, accounting, pricing and similar financial management practices and activities.

Table C.6.a.vi.: Financial Subsystem Descriptions


Subsystems: Financial











Financial Summary Database (FSDB) Manages financial transactions to our general ledger and reserving process

Financial Tagging Service (FTS) The FTS increases the consistency and quality of financial tags in analytic data warehouses and financial tools


Strategic, internally developed encounter data submission and reporting system that initiates submission of encounters, tracks responses, provides error correction and resubmission of Medicaid encounters to the Commonwealth in a format to be specified by the Commonwealth.

Payment Engine Processes and generates consolidated check and electronic payments (EFT) to providers along with provider remittance advices (PRA) and electronic remittance advices (ERA) per provider preference.

PeopleSoft Enterprise financial management solution containing modules, such as general ledger, asset management, purchasing, accounts payable and accounts receivables, to provide a consolidated view of financial data

Revenue Accuracy Manager (RAM) RAM reconciles Enrollee records to capitation payments and documents receipt and distribution of capitation payments




Information System

RFP 758 2000000202 of 31

Claims Platform

Financial Subsystems

Claims Pre-

Processing

(CSP Facets)

1

Claims

Adjudication

(CSP Facets)

2

Claims Payment

(CSP Facets)

3 Claims,

Payments

Corporate Finance and General Ledger

GL Tagging

(FTS, UDW)

7

Financial

Reporting

(FSDB)

8

Treasury

(PeopleSoft)

9

ACHElectronic Remits

(EPS)

4

835 Paper

Remits

Paper Remits

(Print Services)

5

Check Printing

(Print Services)

6

Checks

Send EFT

Payment

(MCO�s Bank)

10

EFT

Receive EFT

Payment

(Provider�s Bank)

11

Revenue

Reconciliation

(RAM)

13

820Eligibility,

Rate Cell

Payments & invoices

C&S Data

Warehouse and

Analytics

(SMART)

12Claims, Eligibility,

Providers, Finance

Print physical check and send them to providers

Adjudication-ready claims collected and processed according to

contract/provider/claims-specific rules and configurations (e.g.,

authorizations, pricing, benefits)

Run payment cycle and generate 835 to Payment Engine.

Payment Engine generates EFT and remit data

1

2

3

4

6

7

8

Corporate treasury functions9

5

MCO�s bank sends EFT payment through Automated Clearing

House (ACH) transaction10

Claim is loaded into Facets pre-processor. Enrollee and Provider

on the claim are identified

Processing electronic remits (835) and send them to providers

Print paper remits (provider EOB) and send them to providers

Perform GL tagging and make data available to FSDB

Financial reporting and forecasting

Providers bank receives EFT payment through Automated

Clearing House (ACH) transaction11

13 Invoice per Enrollee is generated and matched against payment

from State to perform revenue reconciliation

14

Data Warehouse and Business Intelligence (BI) reporting12

Payment

Processing

(Payment Engine)

835

Payments to

Commonwealth

(KY)

The Commonwealth sends payments (820 file) to

UnitedHealthcare

14




Information System

RFP 758 2000000202 of 31

C.6.a.vii. Utilization/Quality Improvement Subsystem Following the table below, we provide flowcharts that depict how our utilization data and quality improvement subsystems are interconnected, enabling our population health management teams to have access to historic, current and trending utilization and outcomes data to guide their approach to implementing or adjusting utilization management and quality improvement initiatives at a population-specific level.

Table C.6.a.vii.: Utilization Data and Quality Improvement Subsystem Descriptions


Subsystem: Utilization Data and Quality Improvement

Blended Census Reporting Tool (BCRT)

The Blended Census Reporting Tool (BCRT) is a census report tool that tracks open cases and discharges daily by minor market and region. It serves as an operational and analytical tool to support bed day management initiatives.



ClaimSphere HEDIS ClaimSphere™ HEDIS is Cognizant’s NCQA-certified HEDIS solution. ClaimSphere:

Provides the foundation for medical quality management and improvement programs like provider profiling and gaps-in-care analysis

Performs detailed measure analysis with access to Enrollee detail and information on specific Enrollees qualified for each measure

Standard system views provide us with insight through line of business analysis, gaps-in-care reporting, provider scorecards and drill down capabilities. With this information transparency insight, we can analyze poorly performing measures to take appropriate action.

We broadcast gaps in care via our secure provider and Enrollee portals, mobile app, EDI eligibility transactions and CommunityCare.




Information System

RFP 758 2000000202 of 31


CommunityCare This tool enables care coordination, medication management and quality management by giving providers updated and shared access to Enrollee’s (i.e., their patient’s) care plan and supports alignment of clinical problems, goals and interventions. It provides electronic access for the care team, primary care coordinators, providers, specialists, Enrollees, caregivers and others, as permitted by the Enrollee. Containing claims information from CSP and authorization data from ICUE, CommunityCare includes our Population Registry and gives providers and care communities a comprehensive view of the services used by any given care population. Using the Enrollee view within the Population Registry, providers have the clinical history of the whole person. CommunityCare:

Provides automated notifications of care transitions

Receives authorizations from ICUE for reference by the care team

Supports Direct for secure clinical data exchange with providers and HIEs

Supports import, parsing and attachment of C-CDA, ADT, LOINC and other standard formats









eVisor/Impact Pro PP

TM PP (IPRO) eVisor synchronizes claims data with evidence-based medicine guidelines to identify engagement opportunities.

Impact Pro is a key analytical engine within the eVisor analytics platform. Impact Pro is a multidimensional, episode-based predictive modeling and care management analytics solution that enables our nurse care managers to use clinical, risk and administrative profile information to provide targeted health care service to Enrollees. Impact Pro:

Identifies individuals who have not obtained appropriate preventive care and screening and who are at risk for developing costly and debilitating health conditions

Provides Enrollee risk stratification and scoring to target specific populations/individuals for different levels of care management intensity managed through CommunityCare and ICUE

Provides results through CommunityCare




Information System

RFP 758 2000000202 of 31


Healthify Web-based tool that helps us connect enrollees to relevant and available social resources that deliver services (e.g., food, housing, legal resources, employment assistance, energy, support groups, child care and clothing) to individuals at risk for poor health outcomes or inappropriate use of health care services.

ICUE ICUE (Integrated Clinical User Experience) is our clinician-facing web-based clinical platform that enables and delivers a coordinated, integrated experience to our Enrollees and the health care communities that support them. ICUE features consolidated data, functions and user experience and serves as a single source of truth for clinical operations transactional data. System users have access to all of the categories of data they need, such as Enrollee eligibility, benefits, provider information, claims data and clinical resources.

Link Secure provider portal providing a central access point where enrolled providers have access to eligibility and benefits, claims management, claims reconsiderations, enhanced online authorizations and gaps in care, and where they can update their practice profile. Also, providers can view and provide feedback on the initial health risk screening and care plans in CommunityCare.


Secure Enrollee Portal (myuhc.com) Secure health and wellness information is available 24 hours a day, seven days a week through our Enrollee portal. Enrollees register for online access by setting up a secure HealthSafe ID™ and password. The personalized and easy-to-navigate digital experience allows Enrollees to search for covered benefits (medical, dental, vision, pharmacy and mental health), manage personal preferences, update contact information (including email addresses for facilitating contacts and information exchange), view/print and request we mail an ID card, change their PCP and locate providers through a searchable provider directory. Also, the portal offers personalized health and wellness content such as seasonal reminders (i.e., flu shots), personalized care recommendations, links to plan programs, and links to online resources and tools.











Information System

RFP 758 2000000202 of 31

Risk Stratification(IPRO)

Clinical Platforms

ICUE

6

CommunityCare

Secure Provider Portal

(Link)

Auths

Claims System(CSP Facets)

HEDIS Measures(ClaimSphere)

HRAPlan of CarePrior Auths

278 Auth

Notifications

Risk Scores

UM, CM Data

CommunityCare tool supports care coordination

Authorizations fed to claims system to support adjudication. Enrollee and network data fed to clinical systems

2

3

4

5

8

9

Providers can submit 278 EDI authorization. Acknowledgements are sent from B2B

Providers can submit authorization requests, view status and more on various Link applications

Utilization Management, assessments and reviews

10

Clinical Reporting and Analytics

Secure Enrollee Portal

(myuhc)

1

Enrollees can view or update HRA, Plan of Care, IHR, and more on myuhc.com

11

12

Healthify tool supports social determinates of health

Utilization Data and Quality Improvement Subsystems

ProviderProvider Data

(NDB)

10

Claims, Providers, Enrollees

Data Warehouse and Analytics

(SMART)

13

13

Risk stratification of Enrollees. Risks shared with CommunityCare for high risk Enrollees

Provider,Enrollee,Claims

11

ADT, CM Data

Enrollee, Provider, Claims,

2

3

5

6

7

HIE, EMR connections, and other systems deliver ADT and CM data via ECG

Provider data is made available to clinical systems

7

KHIE, HIEs, Provider Groups,

Hospitals

1

Blended Census Reporting Tool

(BCRT)

9

Prior Auth Intake(B2B, EDI,

Clearinghouse, Portals)

412

Healthify

8

Claim, Enrollee, Provider, RX, Labs, and supplemental data loaded for HEDIS in ClaimSphere

Notifications sent from BCRT tool to Clinical Platform




Information System

RFP 758 2000000202 of 31

C.6.a.viii. Surveillance Utilization Review Subsystem Our comprehensive Surveillance Utilization Review Subsystem (SURS) captures enrollee-specific and provider specific information (including subcontractor information) and complies with the requirements of 42 CFR 455. The diagram following the table below shows how our SURS supports a multitude of quality improvement, utilization management, profiling, reporting, investigating, and monitoring activities aimed at reducing fraud, waste and abuse and continuous quality improvement.

Table C.6.a.viii.: Surveillance Utilization Review Subsystem Descriptions


Subsystem: Surveillance Utilization Review



Claims Processing Engine (CPE) Application that enables universal claim intake and routing into CSP

Cotiviti Clinical edit system which analyzes provider health care claims based upon business rules and edits.









Escalation Tracking System (ETS)

Facilitates administration and escalation management and processing of claim disputes, grievances and appeals. ETS:

Manages, provides status and tracks resolution on submitted grievances and appeals against policy-mandated time frames for Enrollee contact and appeal or grievance resolution

Generates reports related to the outcomes of grievances, complaints and appeals

Provides flexibility to easily customize data elements according to the Commonwealth’s needs

MACESS Workflow application that facilitates claim processing, including viewing of paper claims and supporting documentation in EDMS, and routing of claims to our claim processors

MedReview Reviews the validity and appropriateness of high-dollar claims




Information System

RFP 758 2000000202 of 31



OptumInsight Claim Edit System (iCES)

Clinical edit system that analyzes provider health care claims based upon business rules that automate reimbursement policy and industry standard coding practices

Optum Transaction Validation Manager (OTVM)

Electronic data interchange (EDI) validation that enables us to test and certify HIPAA transaction sets and verify compliance with standards and regulations on inbound claims.

Prospective 2.0 Identifies fraud and abuse prior to claims payment allowing a greater recovery than post-payment

Sanctions DB Monitors provider sanctions and disciplinary actions.

Smart Audit Master (SAM) Claims payment validation tool that screens for the most common errors





Includes consolidated patient census (common store of enrollees receiving care)






Information System

RFP 758 2000000202 of 31

Claims Platform

Acknowledgement sent to Provider

Paper Claims via RMO

2

Surveillance Utilization Review Subsystem (SURS) Subsystem

997/999ACK

837 Claim

EDI Claims via Clearing House(Optum ENS)

1

HIPAA SNIP Validations

(OTVM)

3


(CSP Facets)

8

Claims Adjudication(CSP Facets)

9


10

Reporting and Analytics(SMART)

837 Claim

NSF/UB Claim

All Claims

State Reports(Commonwealth)

Claims Routing(CHWY/CPE)

HIPAA Compliant EDI claims are received at clearinghouse.


Claims are routed to appropriate claims system based on the Enrollee identifiers

Claims are picked up and processed. Claim editing rules are applied. Authorization is verified. Sanctioned providers claims are denied. Provider contract and pricing is determined. Enrollee benefits, co-pays, deductible, and max out of pocket are verified and applied.

Paper claims are scanned and converted to electronic form. Basic validations are applied

Randomly sampled claims routed to auditors, transaction operations and quality which opens claims, review errors and determine a claim's accuracy assessment. DRG Payment Accuracy is assessed

1

2

3

4

9

10

11

12

6

Single adjustments are done directly via Facets online application. Batch adjustments are done via bulk adjustment tool

13

14

5

Claim is checked against various claim edits, validations, and rules. 5


7

Claims Auditing(SAM,

MedReview)

13

Clinical editing and reimbursement policies are applied to claims.

8

15

Flagged claims are processed/denied due to fraudulent or abusive activity

Check creation / EFT generation

4

Clinical Edits(Cotiviti and ICES)

14

Detect Fraud, Waste and Abuse

(P2)

11 Pricing and Groupers(Networx/Webstrat/

EasyGroup)

12

Provider Sanction Check

(Sanctions DB)

7Initial Screen for

Fraud, Waste and Abuse

(Prospective 2.0)

6

Claims Rules Engine (CRE)

5

Claims are priced and classified

Claim is flagged if fraud, waste, or abuse is detected

Claim is flagged if provider has been sanctioned

16Claims information is copied into Data Warehouse and to adjustment recovery operations for analytics and reporting

Adjust and Recovery

Operations(ARO)

15

Single and Batch Adjustments

16




Information System

RFP 758 2000000202 of 31

C.6.a.ix. Reporting Subsystems The flowcharts following the table below depict current and next generation systems for how enrollee, provider, internal and external (i.e., state data intake, subcontractor) data from our eligibility, enrollment, claims, and utilization management subsystems is extracted, transformed and loaded into our SMART data warehouse. Our business intelligence team and end-users access SMART and use its data analytics toolset to analyze data and to produce reports that are shared internally and externally. The table below provides a summary of SMART and our electronic communication gateway (ECG) that supports reporting and secure data transactions with external parties.

Table C.6.a.ix.: Reporting Subsystem Descriptions


Subsystem: Reporting

Artificial Intelligence and Machine Learning

Information is extracted from data automatically through computational and statistical methods for use in Natural Language Processing, ChatBots, Robotic Process Automation, Expert Systems and Recommendation Engines



Data Fabric A standardized technological approach to transport, transform, integrate and enrich source data on the way to being stored

Data Services Layer The Data Services Layer provides access to our processed information through the use of application programming interfaces (APIs), for use by internal applications and other tools

Hotspotting Tool Analytical tool used to identify enrollees to target for specific interventions.











Information System

RFP 758 2000000202 of 31

Predictive Modeling and Stratification(ImpactPro)

SMART Analytics Toolset (MicroStrategy,

Crystal, Excel, etc)

Data Warehouse and Analytics

(SMART)

Reporting Subsystem

Provider, Enrollee, and

Claims Processing(CSP Facets)

Subcontractor Data ( Vision,

Dental, Rx, Lab, etc.)

Processed Claims

1

2

Claims, Providers, Enrollee Data

Utilization and Care

Management (ICUE,

CommunityCare)

3

Operational Environment

Inpatient/Outpatient

Auths

Extract, Transform, and Load Process

Reports and Data Analysis

Data is extracted and loaded into ClaimSphere for calculations of our HEDIS scores and Gaps in Care

Data is extracted and loaded into ImpactPro used in predictive modeling and stratification

1

2

3

5

6Subcontractor Claims (pharmacy, vision, dental, lab, etc.) are sent to SMART

Medical claims, behavioral claims, Enrollee demographics, provider demographics are sent to SMART

Utilization and Care Management are sent to SMART

7

7

The Business Intelligence team and end-users will access SMART and Operational systems using the Analytic Toolsets

5

HEDIS Measures and Gaps in Care

(ClaimSphere)

6

Commonwealth�s Data(KY)

Historical Data

Enrollee Segmentation and

Targeting(Hotspotting Tool)

4

8

Historical Commonwealth data can be loaded into SMART for analytical purposes

4 Data is loaded to our Hotspotting tool which identifies and targets enrollees for specific intervention

8




Information System

RFP 758 2000000202 of 31

Artificial

Intelligence and

Machine Learning

Data Services

Layer

Cloud-based Data

Storage

Reporting Subsystem: Next Generation

Provider,

Enrollee, and

Claims Processing

(CSP Facets)

Subcontractor

Data ( Vision,

Dental, Rx, Lab,

etc.)

Processed

Claims

1

2

Claims, Providers,

Enrollee Data

Utilization

and Care

Management

(ICUE,

CommunityCare)

3

Operational

Environment

Inpatient/

Outpatient

Auths

Data Fabric

(Data Intake)

Data available for

application and

reporting

consumption

Data loaded into virtually unlimited UnitedHealthcare�s

Cloud-based storage

Information is extracted from data automatically through

computational and statistical methods for use in Natural

Language Processing, ChatBots, Robotic Process

Automation, Expert Systems and Recommendation

Engines

1

2

3

5

6

Subcontractor Claims (pharmacy, vision, dental, lab,

etc.) are sent to Big Data storage

Medical claims, behavioral claims, Enrollee

demographics, provider demographics are sent to Big

Data storage

Utilization and Care Management are sent to Big Data

storage

8

8

A standardized technological approach to transport,

transform, integrate and enrich source data on the way

to being stored

5

Data Warehouse

and Analytics

(SMART)

Analytic Tools

4

9

Existing data in SMART system is made available to the

Big Data platform

4 Many tools are available for the review and analysis

including Splunk, Talend, MapR, MarkLogic, Tableau

9

10

6

Big Data Environment

Provides access to our processed information through

the use of application programming interfaces (APIs),

for use by internal applications and other tools.

10

Enriched Data

Repository

7

Data is enhanced, refined, and improved creating a

valuable asset for use in analytics and reporting

7




Information System

RFP 758 2000000202 of 31

C.6.a.x. Testing Subsystems The diagram following the table below depicts our systems testing methodology. Following the diagram, we provide a flowchart of our encounter data testing processes. The summary table below provides descriptions of our subsystem testing methodologies, including those for ensuring encounter data is complete, accurate, and delivered on time.

Table C.6.a.x.: Testing Subsystem Descriptions


Subsystem: Testing Methodology

Automated Testing To help improve quality while reducing cost, this effort advocates the expansion of automated testing within UnitedHealth Group information technology leveraging consistent, advanced frameworks.

Client Acceptance Testing Client acceptance testing occurs after all the validation of any new capabilities is complete. This ends the cycle and provides consent to promote the software for production use.

Client Integration and Regression Testing

Once internal testing of the changes is complete, client integration (for new items) and client regression testing is executed. Any issues uncovered are reported and, in needed, added to the sprint backlog to be addressed.

Software Development Life Cycle (SDLC)

Our SDLC approach affords a smooth and timely implementation of new health plan programs or system modifications. We use an Agile software development framework (Scalable Agile Method) comprising intellectual capital and assets for processes, tools, metrics and training for reliable changes with minimum time to deployment.

Sprint Throughout the sprinting phase, the development team completes a series of short sprints to create and release working software according to backlog specifications and the program increment milestones. This includes analysis, design, coding and testing of the item from the sprint backlog. Issues uncovered during the testing are placed on the sprint backlog to be addressed.

Encounters System Test Example This is an example of testing points using the Encounters subsystem. Refer to C.6.a.iii for Encounter Subsystem definitions.

Testing Standards/Best Practices We define the optimum methodologies and approaches for quality assurance in a manner that can adapt to multiple technologies and implementation approaches. We also capture and communicate successful approaches, or best practices that we can better leverage throughout the organization.




Information System

RFP 758 2000000202 of 31

User Story Analysis

Software Design and Test Design

Software Build

Test Execution

Defect Reporting

(placed on sprint backlog)

Sprint Tasks

KY Acceptance

Testing

KY Integration and

Regression

Testing

Backlog

KY Defect

Reporting

UnitedHealthcare Scaled Agile Method

Testing Subsystem

Testing Subsystem

UnitedHealthcare uses an Agile approach to developing software leveraging Acceptance Test Driven Development (ATDD). In applying ATDD, teams build

testing into the software delivery lifecycle. User stories provide the backdrop for the testing scenarios needed to validate the desired functionality. Coding

changes are validated through a combination of manual and automated testing as defined in the user stories, after each software build. Defects found are placed

back on the sprint backlog to be remediated. Once unit and functional testing is complete, client integration testing can begin. Security, performance and

scalability are validated throughout the testing lifecycle to ensure the highest quality deliverables.




Information System

RFP 758 2000000202 of 31

Testing Points within the Encounters Subsystem

UnitedHealthcare

Front End /

HIPAA Edits

(OTVM)

Claims

Adjudication

Engine

(CSP)

Encounter System

(NEMIS)

2

Commonwealth

Processing

(KY)

1

Claims Claims

837's

NCPDP

Encounters

Response

2

Response

Processing

(NEMIS)

Encounters Triage

& Correction

(NEMIS)

Corrections

Claims Intake

(Clearinghouse /

Paper) Claims

Enrollee Files

(834)

Provider Data

(NDB)

Claims Intake

(Subcontractor

Claims – Vision,

Dental, Rx)

Subcontractor

Claims

(Vendor DB)

Subcontractor

Claims

Corrections

Subcontractor Encounter ErrorsAncillary

Subcontractors

Contains functional tests for stories, features, and capabilities, to validate that they work the way the Product Owner (or

Customer/user) intended. Feature-level and capability-level acceptance tests confirm the aggregate behavior of many user

stories. This is testing for new functionality or connectivity. This includes unit, component and connectivity testing

Contains system-level acceptance tests to validate that the behavior of the whole system meets usability and functionality

requirements, including scenarios that are often encountered during system use. This is testing of systems that have no change

or only configuration-based changes. This includes business oriented system integration, usability and user acceptance testing

1

2

Contains system qualities testing to verify the system meets its Nonfunctional Requirements (NFRs), such as load and

performance. This is testing that is used to ensure that connectivity to external entities is secure and performant. This includes

performance load and security testing

3

2

3

1 2

3

1 2

3

1 2

3

2

22

2

1 2

3

1

3

1

3

State Provider Data




Information System

RFP 758 2000000202 of 31

C.6.a.xi. Information Systems Management ServiceNow is our IT service management platform for our IT Support/Request Center and IT service management processes, including system monitoring and reporting of critical incidents. It supports all UnitedHealth Group employees, providers, subcontractors and the Department’s representatives by providing web-enabled forms for submitting business requests and incidents to the technology team. The Request Center is a module within our ServiceNow ITSM tool. A Request Item (RITM) and Request Task(s) (SCTASK) are created based upon the request made via the corresponding Request Center request item. All requests are properly logged, triaged, prioritized, assigned and managed to resolution using our other ITSM processes, such as incident and problem management.