DOC001_WV 2022 MITA_SS-A AU Report_Final (2).pdf

Medicaid Information Technology Architecture (MITA)

3.0 State Self-Assessment (SS-

A) 2022 Annual Update Report Version 1.1

Submitted by:

Berry, Dunn, McNeil & Parker, LLC 300 Capitol Street Charleston, WV 25301 207.541.2244

Cindy Beane, Commissioner Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3709 cynthia.e.beane@wv.gov

Nicole Becnel, Principal Berry, Dunn, McNeil & Parker, LLC nbecnel@berrydunn.com Ebony Carter, Project Lead Berry, Dunn, McNeil & Parker, LLC ebony.carter@berrydunn.com

Submitted On:

March 07, 2025 mailto:cynthia.e.beane@wv.gov mailto:edaranyi@berrydunn.com http://www.google.com/url?sa=i&rct=j&q=West+Virginia+seal&source=images&cd=&cad=rja&docid=2viod5iLbpCFlM&tbnid=6SnaQDvl2J7REM:&ved=&url=http://en.wikipedia.org/wiki/Seal_of_West_Virginia&ei=TXRtUYGeOI_DyAGYgIHIBg&bvm=bv.45175338,d.aWc&psig=AFQjCNET_e7lItHczBoRIZaIylXmK6UYzA&ust=1366214094383460

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Revision History

Version Date Update Reason V1.0 March 07, 2025 Initial draft delivered to client.

V1.1 April 30, 2025 Revised draft and delivered to client.

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Table of Contents

1 Executive Summary 2 MITA State Self-Assessment (SS-A) Background

2.1 The State’s Medicaid and WVCHIP Enterprise (Enterprise)

2.2 MITA 3.0 SS-A 2022 AU

3 2022 AU Project Tools

3.1 MITA 3.0 SS-A Toolkit

3.2 MITA Database

4 Concept of Operations (COO)

4.1 Vision for the Medicaid and WVCHIP Enterprise

4.2 Stakeholders and Data Exchanges

4.3 Information and Data

4.4 Drivers and Enablers

4.5 AS-IS Operations

4.6 TO-BE Environment

4.7 Business Improvements

5 MITA 3.0 SS-A 2022 AU Assessment Results

5.1 Business Assessment Overview

5.2 BA Profile

5.3 BA Ownership

5.4 BA Development

5.5 Gap Analysis

5.6 Business Assessment Summary

5.6.1 Business Relationship Management (BR)

5.6.2 Care Management (CM)

5.6.3 Contractor Management (CO)

5.6.4 Eligibility and Enrollment Management (EE)

5.6.5 Financial Management (FM)

5.6.6 Member Management (ME)

5.6.7 Operations Management (OM)

5.6.8 Performance Management (PE)

5.6.9 Plan Management (PL)

5.6.10 Provider Management (PM)

6 IA Update

6.1 DMS

6.2 CDM

6.3 LDM

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6.4 ICM

7 TA Update

7.1 TMS

7.2 Business Services

7.3 Technical Services

7.4 AA

7.5 Technology Standards

7.6 TCM

8 Seven Conditions and Standards Update 9 Next Steps Appendix A: BA Ownership Appendix B: Acronym List Appendix C: Glossary of Terms Appendix D: WV MITA 3.0 SS-A History

2016 SS-A AU

2017 SS-A AU

2018 SS-A AU

2020 SS-A AU

2021 SS-A AU

MITA State Self-Assessment Periods

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1 Executive Summary The Centers for Medicare & Medicaid Services (CMS) MITA Framework provides a common foundation for all Medicaid stakeholders to modernize the Medicaid Information Technology (IT) systems and processes to become more stable and standardized while lowering the risk for technology implementations.

For this assessment period, the West Virginia (WV, State) Bureau for Medical Services (BMS) assessed the Medicaid Enterprise between January 1, 2023, through December 31, 2023.

During the assessment period, BMS was under the West Virginia Department of Health and Human Resources (DHHR). Beginning January 1, 2024, the DHHR was divided into three separate departments per the approval of House Bill 2006, and at such time, BMS became part of the Department of Human Services (DoHS). BMS continues to be the stand-alone Medicaid agency required by the WV Medicaid State Plan. In addition, to assessing the Medicaid business processes the team also researched and reviewed the WV Children’s Health Insurance Program (CHIP, WVCHIP) business processes. WVCHIP transitioned to BMS operations in July 2022. WVCHIP is required by the WVCHIP State Plan.

The BMS is using the MITA Framework to:

• Focus BMS information transformation

• Build common and shared services across the Medicaid and CHIP Enterprise (which will be referred to here on out as the Enterprise)

• Improve how BMS operates and delivers care to West Virginians

• Eliminate inefficiencies and reduce costs

• Expand the reach of services

Through MITA, BMS has adopted an enterprise-driven view when assessing business needs and a service-oriented approach when conducting technology planning. BMS has formally documented extensive business process information, providing a standard view of each business process flow and opportunities to identify areas for increased efficiency and effectiveness.

The initial report, which was the Medicaid 2014 MITA 3.0 SS-A Report (accepted by CMS in December 2015), must be updated annually to measure the achievement of business goals and objectives in an ongoing, iterative process. This is the sixth MITA 3.0 SS-A Annual Update (AU) for the State’s continuing MITA efforts, which includes the MITA 3.0 SS-A 2022 AU Roadmap.

These documents serve as a detailed guide to achieving specific State goals for business improvement within the MITA 3.0 Framework. BMS will use the business process documentation contained in the MITA 3.0 SS-A 2022 Report AU and the MITA 3.0 SS-A 2022 AU Roadmap to monitor project progress, outcomes, and achievement of target capabilities.

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Since the MITA 3.0 SS-A 2021 submission, BMS has developed or continues to develop:

• A Technical Management Strategy (TMS) to outline the technical strategy, services, and systems throughout the Enterprise Systems and Programs.

• A Data Management Strategy (DMS) to outline the Information Architecture (IA) across the Enterprise.

• A State MITA database to increase automation, accuracy, and efficiency and to serve as a source-of-truth repository.

• Scorecards to measure process improvements achieved by technology investments.

• Updated documentation for the Business Architecture (BA), Information Architecture (IA), Technical Architecture (TA), and the Seven Conditions and Standards.1

The MITA 3.0 SS-A 2022 AU, which assessed the Enterprise based upon an AS-IS environment timeframe between January 1, 2023, and December 31, 2023, findings resulted in changes in the AS-IS maturity levels in business processes within the Financial Management, Operations Management, and Performance Management business areas. All assessed MITA 3.0 business areas have remained the same in maturity levels for the TO-BE environment during the MITA

3.0 SS-A 2022 AU with the AS-IS maturity level improving in the Financial Management business area. Future business process improvement and technology investment initiatives, which can also be found in the MITA Roadmap, will lead the State to greater maturity for the Enterprise.2 Because the TO-BE environment envisions the Enterprise in five years, this means the Enterprise met or exceeded expectations for 2025 maturity during the MITA 3.0 SS-A 2022 AU in the following business areas:

• Business Relationship Management (BR): Met expectations

• Care Management (CM): Met expectations

• Contractor Management (CO): Met expectations

• Eligibility and Enrollment Management (EE): Met expectations

• Financial Management (FM): Exceeded expectations

• Operations Management (OM): Exceeded expectations

• Performance Management (PE): Exceeded expectations

1 For more information about these efforts, please see Section 3: 2022 Annual Update Project Tools, Section 5.0:

MITA 3.0 SS-A 2022 Annual Update Assessment Results, and Section 6.1: Data Management Strategy.

2 For more information about these initiatives and the MCES, please see Section 2.1: The State’s Medicaid and CHIP Enterprise and Section 5.0: MITA 3.0 SS-A 2022 Annual Update Assessment Results.

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• Plan Management (PL): Exceeded expectations

• Provider Management (PM): Met expectations

Assessment guidance for the final MITA business area Member Management (ME) is pending from CMS; therefore, this area could not be assessed.

Upon completion and approval of the MITA 3.0 SS-A 2022 AU which will assess the Medicaid and CHIP Enterprise Systems (MCES) based upon an AS-IS time frame between January 1, 2024, and December 31, 2024. The MCES will continue to develop MITA tools and documentation and utilize the SS-A to improve business processes and guide technology investments.

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2 MITA State Self-Assessment (SS-A) Background

2.1 The State’s Medicaid and WVCHIP Enterprise (Enterprise)

The Enterprise encompasses all DoHS agencies and system interfaces that share information for operations to conduct Medicaid and CHIP business for which CMS provides federal matching funds. The DoHS agencies include:

• BMS: BMS is the designated single state agency responsible for the administration of the State Medicaid and WVCHIP program.

• Bureau for Behavioral Health (BBH): BBH is the designated State authority for mental health and substance use, as well as the lead agency for intellectual and developmental disabilities.

• Bureau for Child Support Enforcement (BCSE): BCSE establishes, modifies, collects, and disburses child, medical, and spousal support.

• Bureau for Family Assistance (BFA): BFA is the State authority for assistance programs that can provide food and shelter costs, help paying utility bills, and educational resources for which families with children may be eligible.

• Bureau for Social Services (BSS): BSS is the designated State authority for Child Welfare and Adult Services policy.

• Office of Drug Control Policy (ODCP): ODCP works to improve drug overdose surveillance and help strengthen the response with the development of a central repository that houses drug overdose data.

Additionally, the State has a network of business, information, and technology resources governed by the West Virginia Office of Technology (WVOT). The WVOT also provides support to department-level information management offices. This includes the systems and resources that support the Enterprise, which during this assessment period were managed under the authority of the DoHS Office of Management Information Services (OMIS).

The systems that support the business operations of the Enterprise include:

• Medicaid Management Information System (MMIS): The MMIS provides the core technical components of the Enterprise. This system is used to process Medicaid and WVCHIP claims at a state level and perform other supporting functions associated with Medicaid medical and pharmacy claims processing. The Fiscal Agent (FA), Gainwell Technologies, operates its MMIS solution, Healthcare Payer Administration Solution (HealthPAS) 5.0, on behalf of and in partnership with the State.

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• Enterprise Data Solution (EDS): The Enterprise utilizes IBM®’s EDS for data analytics and fraud, waste and abuse detection. The EDS is comprised of Cognos Data Analytics, Cloud Pak for Data (CP4D), i-Sight Case Management System, and the Java Surveillance and Utilization Review Subsystem (J-SURS) fraud and abuse detection system.

• WV People’s Access to Help (PATH): The State’s integrated automated benefit eligibility system for administering federal public assistance programs at the state level.

PATH is a public portal that serves as a crucial tool for WV residents by enabling them to determine and track eligibility for assistance programs, while also supporting DoHS staff in investigating child welfare cases, managing child support workflows, and processing payments to providers who care for and manage the State’s most vulnerable populations. The following systems will transition to PATH:

o Recipient Automated Payment and Information Data System (RAPIDS) transitioned to PATH in 2023 - 2024. RAPIDS includes:

Temporary Assistance for Needy Families (TANF)

WV WORKS

Medicaid

Supplemental Nutrition Assistance Program (SNAP) o Families and Children Tracking System (FACTS): FACTS transitioned to PATH in 2023 - 2024 from a federally funded Statewide Automated Child Welfare Information System (SACWIS) to the federally required Comprehensive Child Welfare Information System (CCWIS) and supports the following State and federal programs administered by DoHS:

Adoption

Adult Protective Services (APS)

Adult Residential Services

Child Protective Services (CPS)

Family Preservation

Foster Care

Independent Living

Interstate Compact for Placement of Children

Legal Guardianship

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West Virginia School Clothing Allowance

Youth Services o Online Support Collection and Reporting (OSCAR): OSCAR transitioned to PATH in 2024.

• Electronic Visit Verification (EVV): In response to the 21st Century Cures Act, the State needed assistance in developing requirements exploring possible EVV solutions to meet required outcomes, researching vendor capabilities, and collecting information to build stakeholder involvement. The EVV system, from HHAeXchange, supports automation of in-home service claims at the point of service, leading to improved claims processing and encounter adjudication.

• WV Our Advanced Solution with Integrated Systems (wvOASIS): wvOASIS is the State’s integrated systems management solution for vendor payments, time and attendance tracking, and payroll (among other functions).

Additionally, vendors and their systems support the Enterprise, including:

• Health Management Systems (HMS): Third-Party Liability (TPL) and Recovery Audit Contractor (RAC) vendor

• Acentra: Utilization Management (UM) vendor

• Myers and Stauffer: Actuarial and Managed Care Program Administration vendor

• QLARANT: External Quality Review organization (EQRO)

• Maximus: Managed Care Enrollment broker

• Aetna Better Health® of West Virginia, The Health Plan (THP) of West Virginia, Highmark Health Options, and Wellpoint (formerly known as Unicare), West Virginia: The State’s Managed Care Organizations (MCOs)

Enterprise data also flows through the MMIS HealthPAS-Online portal, where providers and members can log on for individual claims review, enrollment, reports, and other helpful tools and information.

During this assessment period for January 2023 through December 2023, the EDS completed design, development, and implementation (DDI) and went live in April 2023 and received CMS certification on April 11, 2024, retroactively. RAPIDS and FACTS began transitioning to PATH in 2023 and completed transition in 2024. The OSCAR system transitioned to PATH in 2024.

The MITA 3.0 SS-A 2022 AU Roadmap has been updated to reflect current and planned Enterprise projects and systems.

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For more information about the Enterprise, please see Section 4.0.

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Figure 1 represents the Medicaid and CHIP Enterprise AS-IS Environment.

Figure 1: Medicaid and CHIP Enterprise AS-IS Environment

2.2 MITA 3.0 SS-A 2022 AU

The MITA 3.0 SS-A 2022 AU assessed the Enterprise based upon an AS-IS environment for the time frame between January 1, 2023, and December 31, 2023. Findings resulted in changes in the AS-IS maturity levels in the following business processes:

• FM16-Formulate Budget

• OM04-Submit Electronic Attachment

• OM29-Process Encounters

• PE01-Identify Utilization Anomalies

• PE02-Establish Compliance Incident

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• PE03-Manage Compliance Incident.

The AS-IS maturity level improved in the Financial Management business area. All business areas assessed remained the same in maturity levels for the TO-BE environment during the MITA 3.0 SS-A 2022 AU. Future business process improvements and technology investment initiatives will lead the State to greater maturity for the Enterprise. The TO-BE environment envisions the Enterprise in five years, this means the Enterprise met or exceeded expectations for 2025 maturity during the 2022 AU.

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3 2022 AU Project Tools

Several project tools, listed in the sections below, have been updated to support the MITA 3.0 SS-A 2022 AU Report. These tools increase the efficiency, consistency, and/or automation of the assessment and resulting documentation.

3.1 MITA 3.0 SS-A Toolkit

The MITA 3.0 SS-A Toolkit is used by the MITA assessment team to simplify the process of capturing, documenting, and updating SS-A documents—includes planning tools, checklists, and workflows in support of the MITA 3.0 SS-A 2022 AU Report. The toolkit contains eight sections:

• Project Planning and Management

• Training

• Visioning

• Assessment Templates

• Meetings

• Validation

• Database

• Deliverables

Additionally, the BerryDunn team created the business area narrative summary template for each of the business areas. This template collects all of the business area findings for each of the business processes that have been assessed during the assessment period.

3.2 MITA Database

BerryDunn worked with the State to develop a database that aggregates and stores the MITA SS-A information and automates the generation of scorecards, business area profile reports, and a Gap Analysis Report. The database contains capability maturity tables for each architecture, and the Seven Conditions and Standards. It enforces a consistent set of data standards that encompass not only the titles of each business process but also capability descriptions for each of the five levels of maturity. Each business process has standardized component descriptions to further reduce error rates that can occur when spreadsheets are used, and data is manually entered by various individuals. The database presents the data in a uniform and intuitive manner across the enterprise, allowing multiple users to have access to assessment data.

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The MITA database has several improvements incorporated into the MITA 3.0 SS-A 2022 AU.

Each assessor’s review comments can now be entered into the database rather than using Microsoft (MS) Word documents as in previous years. After completion of the assessment entries, the data can be archived into a database generated portable document format (PDF) documents for storage on the State’s SharePoint site. Within the MITA database there are reports that can be generated including but not limited to:

• MITA 3.0 Business Process Forms (PDF)

• MITA SS-A Profile Tables (PDF or Joint Photographic Group [JPG])

• MITA SS-A Capability Maturity Models (CMMs) (Excel)

• MITA 3.0 Scorecards (PDF)

• MITA SS-A Gap Analysis (Excel)

• WV System and Application Inventory

• WV System and Application MITA SS-A Business Process Map (Excel)

• MMIS Interface Inventory (Excel)

• WV Data Sharing Architecture (Excel)

MITA Access database system documentation continues to be updated. Additionally, the MITA Dashboard developed for WV MITA SS-A can generate graphic representations of the MITA 3.0 SS-A updates for year-by-year or year-over-year comparisons.

Excel-generated bar graphs are available to provide a quick view of the four architectures’ maturity levels depicting AS-IS and TO-BE values for not only the present assessment period but also prior periods. Assessment periods are selectable by the user based on the current and prior periods for comparison purposes. Each of the nine business areas assessed for each of the four architectures are depicted in the graphs.

BerryDunn’s assessment team implemented Content and Deliverable Review “trackers” in Jira’s Confluence module, a cloud-based and browser-based application, this period to assist with achieving SS-A deadlines. The tracker’s information includes staff assignments and due dates that are visualized on kanban boards and timelines (aka roadmaps). Business Process documents, both current and historical, are also stored in Confluence.

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4 Concept of Operations (COO)

The COO helps frame the State’s vision and showcases its target TO-BE environment. The COO is a compilation of information that supports department, and agency plans for the future state of its Medicaid and WVCHIP programs and services, as well as aligns the BA, IA, and TA with the MITA Framework. The COO forms the basis of the Medicaid MITA Roadmap Transition Plan for eliminating the gaps and establishing the transformation pathway, helping to achieve the goals and objectives of the COO through the management of MITA business process improvement.

The COO consists of these components:

• Vision for the Medicaid Enterprise – Information on the agency’s vision for a future that meets Medicaid and WVCHIP goals as defined by the State Medicaid Agency (SMA) and CMS.

• Stakeholders and Data Exchanges – A description of Medicaid and WVCHIP Enterprise stakeholders, as well as data exchanges that occur among stakeholders.

• Drivers and Enablers – Information that provides a summary of drivers or enablers of technology that propels and supports the transformation of the SMA.

• AS-IS Operations, TO-BE Environment, and Business Improvements – Information that describes the AS-IS operations, validates the levels of operational maturity found in the State today, and describes both the target vision over a time frame and the impacts of the transformation to each of the identified stakeholders.

4.1 Vision for the Medicaid and WVCHIP Enterprise

BMS is responsible for administering the State’s Medicaid and WVCHIP programs. As a bureau under the administration of DoHS, BMS has a clear mission statement reflecting its dedication to providing appropriate healthcare for State residents who are eligible for Medicaid and

WVCHIP:

The Bureau for Medical Services is committed to administering the Medicaid and WVCHIP Programs, while maintaining accountability for the use of resources, in a way that assures access to appropriate, medically necessary, and quality healthcare services for all members; provide these services in a user-friendly manner to providers and members alike; and focus on the future by providing preventive care programs.

Accountability, quality healthcare, and the future are critical components of BMS’ mission statement as the SMA aligns itself to the MITA mission “of enabling technologies and processes that support improved program administration for the Medicaid Enterprise, and for stakeholders

MITA 3.0 SS-A 2022 Annual Update Report Final | March 7, 2025 15 dedicated to improving healthcare outcomes and administrative procedures for Medicaid beneficiaries.”3

In continued support of the MITA mission, DoHS has committed resources to adopting and adhering to the MITA Framework to conduct DoHS’s business and organize its enterprise to comply with federal regulations and industry best practices.

In the MITA Framework, CMS identifies MITA as a primary enabler of the Medicaid mission. As such, MITA has its own goals and objectives. The MITA goals and objectives provide the platform for the transformation defined in the COO. The BMS leadership team established goals, associated objectives, and targeted capabilities for the State Medicaid and WVCHIP programs during the MITA Visioning session conducted for the MITA 3.0 SS-A 2022 AU and the MITA 3.0 SS-A 2022 AU Roadmap. The MITA Visioning session is held with the SMA leadership staff to establish the TO-BE vision for the Medicaid and WVCHIP Enterprise from the point in time that the session is held.

The business areas identified aligned to the MITA 3.0 framework, goals, and objectives. An additional category of “High-Level Administrative and Management Goals and Objectives” is mapped to the State’s goals and objectives. Major strategic initiatives identified in the State BMS 2019 – 2024 Strategic Plan developed by BMS in December 2018 are as follows:

• Promotion Initiative

• Personnel Initiative

• Technology Initiative

• Benefits Plans and Care Management Initiatives

These initiatives and the BMS goals and objectives drive the current vision for the Enterprise and were used to scope and guide the assessment of the TO-BE environment presented in this SS-A. The MITA 3.0 2022 AU 3.0 Roadmap Annual Update is a Transition and Sequencing Plan for reaching these goals and objectives through projects and solutions identified and prioritized by the State that align with the initiatives. A specific mapping of BMS MITA 3.0 goals to the CMS MITA goals is as follows below.

Table 1: BMS Goals and Objectives

BMS Goals and Objectives Descriptions

MITA Goal – Develop seamless and integrated systems that communicate effectively to achieve common Medicaid goals through interoperability and common standards.

Support MMIS Roadmap to support future business needs.

3 “Front Matter, FM 5 – Overview of MITA Initiative.” Medicaid.gov. Centers for Medicare & Medicaid Services, February 2012, Version 3.0, page 9.

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BMS Goals and Objectives Descriptions

• Implement performance management and measurement principles within BMS.

Leverage technology and services to enhance performance and decision-making.

• Enhance reporting capabilities to allow for more efficient and effective performance monitoring.

• Improve data access, analysis, and reporting to support decision-making.

Enhance the security, timeliness, and accuracy of data exchanged with authorized and authenticated business partners.

• Document business relationship management roles and responsibilities.

• Standardize processes for data validation and reconciliation.

• Standardize processes for capture of reporting and data-exchange requirements.

Improve interoperability for Eligibility and Enrollment Management.

• Simplify and streamline determination to enhance access to care.

• Improve provider enrollment and administrative processes.

Establish integration with other entities to further reduce the potential for redundancy of service and payment.

Simplify the process for the submission of provider information.

• Improve provider enrollment and administration processes.

• Provide capability for online submission of standard forms and reports by providers.

• Maintain an automated prior authorization capability to provide approval or rejection of routine prior authorization.

• Integrate automated prior authorization capability to provide real-time approval or rejection of routine prior authorizations. Both the pilot and planned integration of this functionality will apply to pharmacy, not medical/dental.

MITA Goal – Promote an environment that supports flexibility, adaptability, and rapid response to changes in programs and technology.

Improve BMS effectiveness and efficiency.

• Align resources with core business functions.

• Secure necessary resources.

• Establish and provide the necessary professional education and training to enhance staff performance.

• Implement performance management and measurement principles.

• Support the MMIS Roadmap to support future business needs.

Leverage technology and services to enhance performance and decision-making.

• Enhance reporting capabilities to allow for more efficient and effective performance monitoring.

• Improve data access, analysis, and reporting to support decision-making.

Improve operational efficiency and reduce costs in the healthcare system.

• Document Operation Management roles, responsibilities, and business processes.

• Implement an Operation Management organization structure to align resources with core business functions.

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Improve the effectiveness and efficiency of Performance Management function.

• Analyze the Performance Management business area structure to align roles and responsibilities, identify necessary skill sets, and appropriately assign resources.

• Improve tools and provide training to automate and streamline investigations and case management.

• Monitor Medicaid and WVCHIP security and controls.

Improve provider access to real-time data.

• Enhance the provider portal to support clinical decisions and to provide real-time access to cost settlement and rebate data.

• Implement real-time access to data based on claim adjudication results.

Improve consistency of Program Management processes and effective communication of policy.

• Document Program Management roles, responsibilities, and business processes.

• Establish reporting capabilities to measure compliance with performance measures.

• Design a policy management workflow to ensure alignment of law/regulation, policy, system processing, and provider communication.

MITA Goal – Promote an enterprise view that supports enabling technologies that align with Medicaid business processes and technologies.

Leverage technology and services to enhance performance and decision-making.

• Enhance reporting capabilities to allow for more efficient and effective performance monitoring.

• Improve data access, analysis, and reporting to support decision-making.

Design and configure systems and processes to support the Quality Management Plan.

Improve interoperability for Eligibility and Enrollment Management.

• Simplify and streamline determination to enhance access to care.

• Improve provider enrollment and administrative processes.

Improve access to information necessary for Financial Management.

• Enhance cost avoidance capability by improving access to accurate other third-party payer information.

• Establish integration with other entities to further reduce the potential for redundancy of service and payment.

Improve the effectiveness and efficiency of Performance Management function.

• Analyze the Performance Management business area structure to align roles and responsibilities, identify necessary skill sets, and appropriately assign resources.

• Improve tools and provide training to automate and streamline investigations and case management.

• Monitor Medicaid and WVCHIP security and controls.

MITA Goal – Provide data that is timely, accurate, usable, and easily accessible in order to support analysis and decision-making for healthcare management and program administration.

Implement performance management and measurement principles within BMS.

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Enhance the security, timeliness, and accuracy of data exchanged with authorized and authenticated business partners.

• Document business relationship management roles and responsibilities.

• Standardize processes for data validation and reconciliation.

• Standardize processes for capture of reporting and data-exchange requirements.

Increase the use of evidence-based clinical and appropriate services.

• Provide technical capacity for the Pay-for-Performance reimbursement model.

• Increase meaningful use of Electronic Health Records (EHRs) among Medicaid providers.

Enhance BMS’ ability to monitor contractor performance against approved measures.

• Establish reporting capabilities to measure contractor compliance with performance measures.

• Create automated functions to establish and monitor corrective action plans for contractors not meeting approved performance measures.

• Include deliverable expectations and quality indicators as a part of solicitations and resulting contracts in alignment with the Quality Management Plan.

Improve access to information necessary for Financial Management.

• Enhance cost avoidance capability by improving access to accurate other third-party payer information.

• Establish integration with other entities to further reduce the potential for redundancy of service and payment.

Improve the effectiveness and efficiency of Performance Management function.

• Analyze the Performance Management business area structure to align roles and responsibilities, identify necessary skill sets, and appropriately assign resources.

• Improve tools and provide training to automate and streamline investigations and case management.

• Monitor Medicaid and WVCHIP security and controls.

Integrate reconciled claims data with clinical data.

Improve tools and provide training for data analysis to help improve healthcare decision-making.

Establish reporting capabilities to measure compliance with performance measures.

Improve consistency of Plan Management process and effective communication of policy.

• Document Program Management roles, responsibilities, and business processes.

• Establish reporting capabilities to measure compliance with performance measures.

• Design policy management workflow to ensure alignment of law/regulation, policy, system processing, and provider communication.

MITA Goal – Provide performance measurement for accountability and planning.

Implement performance management and measurement principles within BMS.

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Enhance reporting capabilities to allow for more efficient and effective performance monitoring.

Improve data access, analysis, and reporting to support decision-making.

Verify and monitor MMIS and Fiscal Agent operations to ensure transactions are processed in accordance with all relevant federal laws and regulations.

Enhance the ability to measure compliance with quality measures.

Enhance the ability to measure the quality of healthcare outcomes for members.

Improve the effectiveness and efficiency of Performance Management function.

• Analyze the Performance Management business area structure to align roles and responsibilities, identify necessary skill sets, and appropriately assign resources.

• Improve tools and provide training to automate and streamline investigations and case management.

• Monitor Medicaid and WVCHIP security and controls.

Enhance BMS ability to monitor contractor performance against approved measures.

• Establish reporting capabilities to measure contractor compliance with performance measures.

• Create automated functions to establish and monitor corrective action plans for contractors not meeting approved performance measures.

• Include deliverable expectations and quality indicators as a part of solicitations and resulting contracts in alignment with the Quality Management Plan.

MITA Goal – Coordinate with public health and other partners and integrate health outcomes within the Medicaid community.

Enhance the security, timeliness, and accuracy of data exchanged with authorized and authenticated business partners.

• Document business relationship management roles and responsibilities.

• Standardized processes for data validation and reconciliation.

• Standardized processes for capture of reporting and data-exchange requirements.

Establish access to data from sister agencies and programs within the DoHS and other agencies in the Department of Health (DH) and Department of Health Facilities (DHF).

MITA Objective – Adopt industry standards for data exchange.

Assess, implement, and monitor compliance with all relevant federal laws and regulations (e.g., the Patient Protection and Affordable Care Act [PPACA], State Medicaid Manual, and Health Insurance Portability and Accountability Act [HIPAA]).

• Maintain a team and process for accessing compliance with new laws and regulations.

• Maintain a team and process for implementation of changes necessary to comply with new laws and regulations.

• Maintain a team and process for monitoring compliance with laws and regulations.

• Verify and monitor MMIS and Fiscal Agent operations to ensure transactions are processed in accordance with all relevant federal laws and regulations.

MITA 3.0 SS-A 2022 Annual Update Report Final | March 7, 2025 20 business partners.

• Document business relationship management roles and responsibilities.

• Standardize processes for data validation and reconciliation.

• Standardize processes for capture of reporting and data-exchange requirements.

Design policy management workflow to ensure alignment of law/regulation, policy, system processing, and provider communication.

MITA Objective – Promote reusable components through standard interfaces and modularity.

Support MMIS Roadmap to support future business needs.

MITA Objective – Promote efficient and effective data sharing to meet stakeholder needs.

Leverage technology and services to enhance performance and decision-making.

• Enhance reporting capabilities to allow for more efficient and effective performance monitoring.

• Improve data access, analysis, and reporting to support decision-making.

Enhance the security, timeliness, and accuracy of data exchanged with authorized and authenticated business partners.

• Document business relationship management roles and responsibilities.

• Standardize processes for data validation and reconciliation.

• Standardize processes for capture of reporting and data-exchange requirements.

Establish integration with other entities to further reduce the redundancy of service and payment.

Explore capabilities to establish and allow member access to a personal health record.

Empower members by providing access to information and tools that can be used to improve their health.

Improve provider access to real-time data.

• Enhance provider portal to support clinical decisions and to provide real-time access to cost settlement and rebate data.

• Implement real-time access to data based on claim adjudication results.

• Integrate automated prior authorization capability to provide real-time approval or rejection of routine pharmacy prior authorizations.

• Enhance and automate reporting capabilities to measure compliance with operational performance measures.

MITA Objective – Provide a beneficiary-centric focus Ensure Program Quality.

• Develop and execute a Quality Management Plan.

• Design and configure systems and processes to support the Quality Management Plan.

• Enhance the ability to measure compliance with quality indicators.

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Improve healthcare outcomes for members.

• Establish access to data from sister agencies and programs within the DoHS and other agencies in the DH and DHF.

• Improve access to clinical and encounter data.

• Enhance the ability to measure the quality of healthcare outcomes for members.

• Evaluate alternatives to enhance care management capabilities.

Increase the use of evidence-based clinical and appropriate services, including preventive services.

• Provide technical capacity for Pay-for-Performance reimbursement model.

• Increase meaningful use of EHRs among Medicaid providers.

Improve interoperability for Eligibility and Enrollment Management.

• Simplify and streamline eligibility determination to enhance access to care.

• Improve provider enrollment and administrative processes.

Enhance ability for members to participate in and exercise responsibility for personal health choices.

• Explore capabilities to establish and allow member access to a personal health record.

• Provide automated administration of a member incentive program as designed by BMS and approved by CMS.

• Empower members by providing access to information and tools that can be used to improve their health.

• Provide for automated administration of personal Health Improvement Plans.

• Simplify and streamline eligibility determination to enhance access to care.

MITA Objective – Support interoperability, integration, and an open architecture.

Improve interoperability for Eligibility and Enrollment Management.

• Simplify and streamline determination to enhance access to care.

• Improve provider enrollment and administrative processes.

Establish integration with other entities by improving access to accurate other third-party payer information.

Establish integration with other entities to further reduce the potential for redundancy of service and payment.

MITA Objective – Promote secure data exchange.

Assess, implement, and monitor compliance with all relevant federal laws and regulations (e.g., Patient Protection and Affordable Care Act [PPACA], State Medicaid Manual, and HIPAA).

• Maintain a team and process for accessing compliance with new laws and regulations.

• Maintain a team and process for implementation of changes necessary to comply with new laws and regulations.

• Maintain a team and process for monitoring compliance with laws and regulations.

• Verify and monitor MMIS and Fiscal Agent operations to help ensure transactions are processed in accordance with all relevant federal laws and regulations.

MITA 3.0 SS-A 2022 Annual Update Report Final | March 7, 2025 22 business partners.

• Document business relationship management roles and responsibilities.

• Standardize processes for data validation and reconciliation.

• Standardize processes for capture of reporting and data-exchange requirements.

Monitor Medicaid and WVCHIP Enterprise security and controls.

MITA Objective – Promote good practices (e.g., CMM and data warehouse).

Improve BMS effectiveness and efficiency.

• Align resources with core business functions.

• Secure necessary resources.

• Establish and provide necessary professional education and training to enhance staff performance.

• Support the MMIS Roadmap to support future business needs.

• Implement performance management and measurement principles within BMS.

Leverage technology and services to enhance performance and decision-making.

• Enhance reporting capabilities to allow for more efficient and effective performance monitoring.

• Improve data access, analysis, and reporting to support decision-making.

Assess, implement, and monitor compliance with all relevant federal laws and regulations (e.g., PPACA, State Medicaid Manual, and HIPAA).

• Maintain a team and process for accessing compliance with new laws and regulations.

• Maintain a team and process for implementation of changes necessary to comply with new laws and regulations.

• Maintain a team and process for monitoring compliance with laws and regulations.

• Verify and monitor MMIS and Fiscal Agent operations to ensure transactions are processed in accordance with all relevant federal laws and regulations.

Enhance the security, timeliness, and accuracy of data exchanged with authorized and authenticated business partners.

• Document business relationship management roles and responsibilities.

• Standardize processes for data validation and reconciliation.

• Standardize processes for capture of reporting and data-exchange requirements.

Improve operational efficiency and reduce costs in the healthcare system.

• Document Operations Management roles, responsibilities, and business processes.

• Implement Operations Management organization structure to align resources with core business functions.

Improve effectiveness and efficiency of Performance Management function.

• Analyze the Performance Management business area structure to align roles and

MITA 3.0 SS-A 2022 Annual Update Report Final | March 7, 2025 23 responsibilities, identify necessary skill sets, and appropriately assign resources.

• Improve tools and provide training to automate and streamline investigations and case management.

• Monitor Medicaid and WVCHIP Enterprise security and controls.

Improve access to information necessary for Operations Management.

• Enhance cost avoidance capability by improving access to accurate other third-party payer information.

• Establish integration with other entities to further reduce the potential for redundancy of service and payment.

Minimize risk and maximize value from contracted services and products.

• Streamline and improve procurement business functions.

• Continuously improve project management capabilities.

• Implement performance management and measurement principles.

Enhance the security, timeliness, and accuracy of data exchanged with authorized and authenticated business partners.

• Document business relationship management roles and responsibilities.

• Standardize processes for data validation and reconciliation.

• Standardize processes for capture of reporting and data-exchange requirements.

Improve operational efficiency and reduce costs in the healthcare system.

• Document Operations Management roles, responsibilities, and business processes.

• Implement Operations Management organization structure to align resources with core business functions.

4.2 Stakeholders and Data Exchanges

Several stakeholders in the State that exchange information with BMS. In accordance with the MITA 3.0 framework, these data-exchange stakeholders are comprised of beneficiaries, providers, payer agencies, regulators, legislators, and the public. The information that these stakeholders provide is critical to the operations and success of the Medicaid program. Table 2 identifies the key stakeholders and major data exchanges.

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Table 2: Key Stakeholders and Major Data Exchanges

Key Stakeholder Major Data Exchanges

Providers – Providers of services include physicians, pharmacists, hospitals, case managers, and home and community-based caregivers serving the Medicaid and WVCHIP population. Includes services rendered by other State agencies such as BBH.

• Providers submit enrollment applications via the provider portal.

• Providers submit claims for reimbursement electronically using HIPAA standard transactions and paper.

• Medicaid responds to providers electronically or via the provider portal.

• Paper is still used to exchange some information with providers.

• Providers receive electronic payments via Electronic Funds Transfer (EFT).

MCOs – Organizations that contract with the State to provide Medicaid and WVCHIP recipients with a defined set of services. Current MCOs are Aetna Better Health® of West Virginia, The Health Plan of West Virginia (THP), Highmark Health Options, and Wellpoint (formerly known as Unicare), West Virginia.

• Medicaid Enterprise sends enrollment data to MCOs electronically using the X12N 834 standard transaction and a supplemental file.

• X12N 834 transactions are sent to MCOs monthly.

• X12N 820 transactions are sent to MCOs weekly.

• MCOs submit encounter data to Medicaid using the X12N 837 standard transactions.

• MCOs submit encounter data no later than 90 days after the end of the quarter in which the encounters occurred.

Members – State residents who apply for or receive Medicaid or WVCHIP benefits.

• Applicants submit applications by phone, fax, mail, or enter directly through the Health Insurance Marketplace or PATH.

• Members submit eligibility verifications in electronic and paper format.

• Members receive multiple notices regarding eligibility from the Medicaid, WVCHIP and the MCO.

CMS – A branch of the U.S. Department of Health and Human Services (HHS). CMS is the federal agency that administers Medicare, Medicaid, and HIP. CMS provides information for health professionals, regional governments, and consumers.

• BMS submits invoices and Transformed Medicaid Statistical Information System (T- MSIS) reports via an interface.

• BMS electronically submits CMS budget reports using the Medicaid Budget and Expenditure System/State WVCHIP Budget

MITA 3.0 SS-A 2022 Annual Update Report Final | March 7, 2025 25 and Expenditure System (MBES/CBES).

Other Payers – Other payers with liability to cover medical costs for Medicaid or WVCHIP Members. Includes private insurers.

Benefit information is exchanged prospectively.

Mental/Behavioral Health Providers – The integration of physical and behavioral healthcare can improve quality and decrease costs, especially for Medicaid members with complex healthcare needs.4

Integration of physical and behavioral health models that data exchange/interoperability can support:

• Managed Care

• Enhanced Care/Case Management

• Patient-Centered Medical Home

• Accountable Care Organizations (ACOs)

Opioid Crisis Response Collaborators – The Opioid Crisis Response Act of 2018 (S. 2680), puts a premium on leveraging IT, such as EHRs, telemedicine, and Prescription Drug Monitoring Programs (PDMPs). Though Substance Abuse and Mental Health Service Administration (SAMHSA) Part 2 rules restrict the way substance abuse data can be exchanged. There are numerous opportunities to use health data and information technologies to address the opioid crisis.

• Utilizing syndromic surveillance/hospital discharge data to identify and analyze opioid-related events in hospital emergency departments.

• Establishment of a State Opioid and Heroin Data Center where relevant data sets can be analyzed to develop and evaluate strategies.

Stakeholder data sets could include DoHS (syndromic surveillance/hospital discharge data), West Virginia Health Information Network (WVHIN) (clinical/encounter data), law enforcement (overdose data), and WV Board of Pharmacy Controlled Substance Automated Prescription Program (CSAPP) data.

CMS Innovation Projects – The CMS Innovation Center supports testing various payment and service delivery models that aim to achieve better care for patients, better health for communities, and lower costs through healthcare system improvement. Many of the innovation projects can be enhanced with the exchange/use of healthcare data. Current WV CMS innovation projects can potentially benefit by exchanging/using healthcare data.

Active CMS innovation projects that could benefit from data exchange/interoperability:

• Transforming Clinical Practice Initiative

• Accountable Health Communities Model

• Million Hearts®: Cardiovascular Disease Risk Reduction Model

• Strong Start for Mothers and Newborns

• Oncology Care Model

4 Assessing Changes to Medicaid Managed Care Regulations: Facilitating Integration of Physical and Behavioral Health Care, Commonwealth Fund, Elizabeth Edwards, October 24, 2017.

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ACOs – States are increasingly turning to Medicaid ACOs to improve patient outcomes and control costs by shifting accountability for risk and quality to providers.5 Nationally, the number of ACOs has steadily increased. ACOs have shown they can play a vital role for the State providers in the transition from fee-for-service (FFS) to a value-based reimbursement model.

The goal of coordinated care is to help ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.