DMHC_Demo_Use_Case_Workflow.pdf
PDF 201 KB Posted
- Solicitation number
- 0000037114
- Issued by
- California
About this file
This document contains two workflow diagrams illustrating case management processes for the Department of Managed Health Care (DMHC). The workflows depict the standard case workflow and the bulk submission case workflow, which are designed to manage complaints and appeals related to health plan coverage and claims decisions.
Both workflows outline the complete lifecycle of case management, beginning with customer intake and account creation, proceeding through case validation to determine DMHC jurisdiction and completeness of required fields and documentation. Following submission, cases are automatically assigned to analysts who review case materials and send requests for health plan information (RHPI) to the relevant health plan. The analyst then reviews the health plan response for completeness and communicates with customers if additional information is needed. Once the analyst completes their review, they make a determination classified as either overturned, upheld, or partially overturned, and assign the case to a manager for approval. The manager either approves the determination and advances the case to resolution or reassigns it for additional review. The bulk submission workflow includes an additional step that creates subcases when more than 50 claims are attached to a single case, with multiple analysts assigned to handle the volume. Both workflows conclude with resolution communication to the health plan and customer, case closure, and reporting on case details. Throughout both processes, the workflows identify three key stakeholders: consumers or providers, DMHC, and health plans, with color coding indicating which entity is responsible for each step.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| DMHC_CalMaCCS_Mid-Level_Requirements.xlsm | XLSM spreadsheet | |
| DMHC_CalMaCCS_RFI_Response_Template.xlsx | XLSX spreadsheet | |
| DMHC_CalMaCCS_Demo_Use_Cases.xlsx | XLSX spreadsheet | |
| CalMaCCS_Request_For_Information.docx | DOCX document |
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Text version
Help Center Standard Case WorkflowHelp Center Standard Case Workflow C re a te
C a s e
C re a te
C a s e
In ta k e
In ta k e
S c re e n C a s e
S c re e n C a s e
R e q u e s t/ R e c e iv e I n fo rm a ti o n R e q u e s t/ R e c e iv e I n fo rm a ti o n T ri a g e C a s e
T ri a g e C a s e
C o m m u n ic a te
C a s e
C o m m u n ic a te
C a s e
A n a ly z e C a s e
A n a ly z e C a s e
R e p o rt o n
C a s e
R e p o rt o n
C a s e
R e s o lv e C a s e
R e s o lv e C a s e
PhasePhase
New
Submission
Case Has
Attachments?
Customer
Uploads
Attachments
Case
Validation No
Yes
Customer enters Case website
Customer creates
Account and sets up MFA
Customer chooses if he is entering for self or on behalf of another (authorized advocate)
Customer is shown
Mandatory fields and
Required documents needed to complete case
Customer is given Guidance to Fill in the
Form
Case Validation
DMHC jurisdiction?
No
Case closed.
Are all required fields complete?
No
Yes Customer
Submits Case
Case Submitted
Case Auto-
Assigned to
Analyst
Analyst Notified
Upon Case
Assignment
Analyst
Reviews Case and
Attachments
Analyst sends
RHPI to Health
Plan
Analyst
Reviews Health
Plan Response
Is the
Response
Complete?
Analyst Rejects
Response and
Requests
Additional
Information
No
Yes
Analyst Accepts
Response and
Reviews
Does Analyst Need
Additional Information from
Customer?
Customer
Communication Yes
Communication
Loop with DMHC/
Customer
No
Analyst
Reviews
Case
Information
Analyst Makes
Determination
(Overturned, Upheld, or
Partial
Overturn)
Case
Resolution
Updated
Analyst Assigns
Case to
Manager for
Approval
Determination
Accepted by
Manager?
Case Reassigned to Analyst for
Additional Review
Manager
Advances Case to Resolution
Yes
No
Resolution
Communicated to
Health Plan and
Customer
Case Closed
Case Details
Captured and
Reported on
Key:
Consumer/Provider
DMHC
Health Plan
Key:
Consumer/Provider
DMHC
Health Plan
Does Health Plan
Respond?
Yes
Refer to Legal
No
Help Center Standard Case WorkflowHelp Center Standard Case Workflow C re a te
C a s e
C re a te
C a s e
In ta k e
In ta k e
S c re e n C a s e
S c re e n C a s e
R e q u e s t/ R e c e iv e I n fo rm a ti o n R e q u e s t/ R e c e iv e I n fo rm a ti o n T ri a g e C a s e
T ri a g e C a s e
C o m m u n ic a te
C a s e
C o m m u n ic a te
C a s e
A n a ly z e C a s e
A n a ly z e C a s e
R e p o rt o n
C a s e
R e p o rt o n
C a s e
R e s o lv e C a s e
R e s o lv e C a s e
PhasePhase
New
Submission
Case Has
Attachments?
Customer
Uploads
Attachments
Case
Validation No
Yes
Customer enters Case website
Customer creates
Account and sets up MFA
Customer chooses if he is entering for self or on behalf of another (authorized advocate)
Customer is shown
Mandatory fields and
Required documents needed to complete case
Customer is given Guidance to Fill in the
Form
Case Validation
DMHC jurisdiction?
No
Case closed.
Are all required fields complete?
No
Yes Customer
Submits Case
Case Submitted
Case Auto-
Assigned to
Analyst
Analyst Notified
Upon Case
Assignment
Analyst
Reviews Case and
Attachments
Analyst sends
RHPI to Health
Plan
Analyst
Reviews Health
Plan Response
Is the
Response
Complete?
Analyst Rejects
Response and
Requests
Additional
Information
No
Yes
Analyst Accepts
Response and
Reviews
Does Analyst Need
Additional Information from
Customer?
Customer
Communication Yes
Communication
Loop with DMHC/
Customer
No
Analyst
Reviews
Case
Information
Analyst Makes
Determination
(Overturned, Upheld, or
Partial
Overturn)
Case
Resolution
Updated
Analyst Assigns
Case to
Manager for
Approval
Determination
Accepted by
Manager?
Case Reassigned to Analyst for
Additional Review
Manager
Advances Case to Resolution
Yes
No
Resolution
Communicated to
Health Plan and
Customer
Case Closed
Case Details
Captured and
Reported on
Key:
Consumer/Provider
DMHC
Health Plan
Key:
Consumer/Provider
DMHC
Health Plan
Does Health Plan
Respond?
Yes
Refer to Legal
No
Help Center Bulk Submission Case WorkflowHelp Center Bulk Submission Case Workflow C re a te
C a s e
C re a te
C a s e
In ta k e
In ta k e
S c re e n C a s e
S c re e n C a s e
R e q u e s t/ R e c e iv e I n fo rm a ti o n R e q u e s t/ R e c e iv e I n fo rm a ti o n T ri a g e C a s e
T ri a g e C a s e
C o m m u n ic a te
C a s e
C o m m u n ic a te
C a s e
A n a ly z e C a s e
A n a ly z e C a s e
R e p o rt o n
C a s e
R e p o rt o n
C a s e
R e s o lv e C a s e
R e s o lv e C a s e
PhasePhase
New
Submission
Complaint Has
Attachments?
Customer
Uploads
Attachments
Case/
Subcase
Validation
No
Yes
No
Customer enters
Complaints website
Customer chooses if he is entering for self or on behalf of another (authorized advocate)
Customer is shown the mandatory fields and required documents needed to complete the case
Customer is
Given
Guidance to Fill in the Form
Case/Subcase
Validation
DMHC jurisdiction?
No
Case closed.
Are all required fields complete?
No
Yes
Customer
Submits Case/
Subcase
Case Submitted
Case/Sub-
Cases Auto-
Assigned to
Analyst
Analyst/s Notified
Upon Case
Assignment
Analyst/s Review
Case/Sub-cases and
Attachments
Analyst sends
RHPI to Health
Plan
Analyst
Reviews Health
Plan Response
Is the
Response
Complete?
Analyst Rejects
Response and
Requests
Additional
Information
No
Yes
Analyst Accepts
Response and
Reviews
Does Analyst Need
Additional Information from
Customer?
Customer
Communication Yes
Communication
Loop with DMHC/
Customer
No
Analyst
Reviews Case/
Sub-case
Information
Analyst Makes
Determination
(Overturned, Upheld, or
Partial
Overturn)
Case
Resolution
Updated
Analyst Assigns
Case to
Manager for
Approval
Determination
Accepted by
Manager?
Case/Sub-case
Reassigned to
Analyst for
Additional Review
Manager
Advances
(parent) Case to Resolution
Yes
No
Resolution
Communicated to
Health Plan and
Customer
Case Closed
Case Details
Captured and
Reported on
Key:
Consumer/Provider
DMHC
Health Plan
Key:
Consumer/Provider
DMHC
Health Plan
Does Health Plan
Respond?
Yes
Refer to Legal
No
More than 50 claims attached?
Yes
Create Subcases and link associated claims from the case
Customer creates
Account and sets up MFA
Are all Sub-Cases resolved by
Analyst/s ?
Yes
No
Help Center Bulk Submission Case WorkflowHelp Center Bulk Submission Case Workflow C re a te
C a s e
C re a te
C a s e
In ta k e
In ta k e
S c re e n C a s e
S c re e n C a s e
R e q u e s t/ R e c e iv e I n fo rm a ti o n R e q u e s t/ R e c e iv e I n fo rm a ti o n T ri a g e C a s e
T ri a g e C a s e
C o m m u n ic a te
C a s e
C o m m u n ic a te
C a s e
A n a ly z e C a s e
A n a ly z e C a s e
R e p o rt o n
C a s e
R e p o rt o n
C a s e
R e s o lv e C a s e
R e s o lv e C a s e
PhasePhase
New
Submission
Complaint Has
Attachments?
Customer
Uploads
Attachments
Case/
Subcase
Validation
No
Yes
No
Customer enters
Complaints website
Customer chooses if he is entering for self or on behalf of another (authorized advocate)
Customer is shown the mandatory fields and required documents needed to complete the case
Customer is
Given
Guidance to Fill in the Form
Case/Subcase
Validation
DMHC jurisdiction?
No
Case closed.
Are all required fields complete?
No
Yes
Customer
Submits Case/
Subcase
Case Submitted
Case/Sub-
Cases Auto-
Assigned to
Analyst
Analyst/s Notified
Upon Case
Assignment
Analyst/s Review
Case/Sub-cases and
Attachments
Analyst sends
RHPI to Health
Plan
Analyst
Reviews Health
Plan Response
Is the
Response
Complete?
Analyst Rejects
Response and
Requests
Additional
Information
No
Yes
Analyst Accepts
Response and
Reviews
Does Analyst Need
Additional Information from
Customer?
Customer
Communication Yes
Communication
Loop with DMHC/
Customer
No
Analyst
Reviews Case/
Sub-case
Information
Analyst Makes
Determination
(Overturned, Upheld, or
Partial
Overturn)
Case
Resolution
Updated
Analyst Assigns
Case to
Manager for
Approval
Determination
Accepted by
Manager?
Case/Sub-case
Reassigned to
Analyst for
Additional Review
Manager
Advances
(parent) Case to Resolution
Yes
No
Resolution
Communicated to
Health Plan and
Customer
Case Closed
Case Details
Captured and
Reported on
Key:
Consumer/Provider
DMHC
Health Plan
Key:
Consumer/Provider
DMHC
Health Plan
Does Health Plan
Respond?
Yes
Refer to Legal
No
More than 50 claims attached?
Yes
Create Subcases and link associated claims from the case
Customer creates
Account and sets up MFA
Are all Sub-Cases resolved by
Analyst/s ?
Yes
No
| DMHC Demo Use Case Workflow.vsdx |
| Standard |
| Bulk Submission |
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