Matriz general de impactos

ENROLL AND UPDATE PROVIDER INFORMATION (3.1.1)

MAC Enrollment application received Enrollment change information received Reassignment request received Electronic access request received

Coordinate with internal and external components

Update front and backend processing Update other systems

Update HIGLAS Obtain provider IDs

(UPIN and/or NPI) Enter/update PECOS

Verify data

Enrollment information updated

Events

Enrollment application received—MAC receives enrollment applications submit- ted on CMS or MAC websites or in hard copy. (MAC also can mail out applica- tions to potential providers.)

Enrollment change information received—MAC receives changes to existing in- formation submitted by a Part B individual practitioner or clinic.

Reassignment request received—MAC receives new billing information submit- ted by provider.

Electronic access request received—MAC receives request from provider (or agent of provider) to submit electronic claims and/or receive electronic funds transfer.

Process Steps

Verify data—MAC verifies and documents provider enrollment information, us- ing tools such as Qualifier.Net.

Enter/update PECOS—MAC enters all new application information (e.g., for new providers or changes of information) into PECOS.

Obtain provider IDs (UPIN and/or NPI)—MAC obtains or validates provider’s identification.

Coordinate with other internal and external components—MAC furnishes infor- mation, as necessary, to other MAC components, e.g., appeals, provider educa- tion, professional relations. MAC furnishes participation data to Railroad Retirement Board (RRB) and CMS.

Update HIGLAS—MAC updates EFT and payee information in HIGLAS. Update other systems—MAC enters provider information, e.g., specialty codes, into shared systems or other common systems. Also, MAC enters information for special processing or claims payment adjustments, such as HPSA or PSA.

Update front- and back-end processing—MAC enrolls provider and provides in- formation for EDI.

Results

Enrollment information updated—All relevant systems have been updated, and provider is able to submit and process claims.

PROVIDE EDUCATION TO PROVIDERS (AS GROUPS) (3.1.2) MAC Provider education need identified Education delivered to group of providers Attend Provider

Outreach and Education (POE) Program training

event

Post on educational web site and 'Ask the

Contractor' teleconferences Disseminate provider information at workshops, seminars, etc. Produce educational bulletins Develop provider education materials and information Determine appropriate educational method Analyze data and

problem-specific data

Events

Provider education need identified—Providers need routine education, education as described in MAC’s Local Provider Education and Training (LPET) plan, or education due to policy changes or as a result of claims analysis.

Process Steps

Analyze data and problem-specific data—MAC educates providers based on CMS- and MAC-developed strategies or as a result of recurrent issues in process- ing claims, advice of other functional contractors such as the PSC, or provider inquiries and feedback. For example, both Part A and B providers will be notified of CERT issues. In addition, the MAC will notify providers of newly applicable limits and caps.

Determine appropriate educational method—MAC delivers education through websites, presentations, bulletins, mass mailings, bulletin boards, and seminars and any other appropriate delivery forum.

Develop provider education materials and information—MAC develops materials based on issue being addressed and on the delivery mechanism.

Produce educational bulletins—MAC publishes an educational bulletin.

Attend Provider Outreach and Education (POE) Program training event—MAC participates in provider communications (PCOM) training programs.

Post on educational website and ‘Ask the Contractor’ teleconferences—MAC uses website and teleconferences to disseminate information.

Disseminate provider information at workshops, seminars, etc.—MAC uses work- shops and seminars to disseminate information.

Results

Education delivered to group(s) of providers—Providers have been educated in FFS topics.

PROVIDE EDUCATION TO INDIVIDUAL PROVIDERS (3.1.3)

MAC

Education delivered Problem-specific

data received and analyzed

Hold educational meeting with presence

of clinical staff Develop/produce educational information Determine appropriate educational method Events

Problem-specific data received and analyzed—CERT data, edit data, or MR data indicates inappropriate billing practices by a provider.

Process Steps

Determine appropriate educational method—MAC tailors educational method for specific providers based on need. Examples of delivery methods are letters, e- mails, teleconferences, visits, and invitations to training.

Develop/produce educational information—MAC produces and delivers educa- tion to the provider.

Hold educational meeting with presence of clinical staff—MAC trains provider staff.

Results

PROCESS PROVIDER INQUIRIES (3.1.4) MAC Inquiry answered Provider written inquiry received Inquiry maintained in tracking system Provider telephone inquiry received

Inquiry routed through IVR

Respond to inquiry Send requested information and make

follow-up calls Analyze inquiry

Complete internal paperwork and input data into the system

no script

Simple inquiry

Script

Events

Provider written inquiry received—MAC CSR receives written inquiry. Provider telephone inquiry received—MAC customer support representative (CSR) receives call.

Process Steps

Receive inquiry routed through IVR—MAC receives inquiry through Interactive Voice Response (IVR) equipment.

Complete internal paperwork and input data into the system—CSR records in- quiry in MAC’s tracking system.

Analyze inquiry—CSR determines information needed or researches problem. Provider relations research specialists review complex requests.

Send requested information and make follow-up calls—CSR sends written mate- rial, if requested, and follows up by phone, if needed.

Respond to inquiry—CSR responds to verbal questions. Results

Inquiry answered—Provider receives information.

Inquiry maintained in tracking system—Inquiry has been addressed and informa- tion about it recorded for further analysis.