TABLE OF CONTENTS
This users manual describes how Department of Human Services (DHS) staff use the application processing features of the Oregon Medicaid Management Information System (OR MMIS). The manual focuses on the navigation, access, and usage functions of the OR MMIS application and supports the business processes carried out by the DHS staff.
This manual describes the system as a whole. The OR MMIS includes the following subsystem areas:
· Buy-In Data Maintenance
· Contact Tracking Management System (CTMS)
· Claims and Encounter Data
· Electronic Data Interchange (EDI) and Claim Capture
· Decision Support System (DSS) Data Warehouse and Surveillance and Utilization Review (SUR)
· Drug Rebate
· Electronic Document Management System (EDMS), 2007
· Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
· Financial
· General Systems (Infrastructure, Internet, Security Management, System Wide)
· Management Administrative Reporting (MAR)
· Managed Care
· Plan of Care (POC)
· Prior Authorization
· Prospective Drug Utilization Review (PRO-DUR)
· Provider Data Maintenance
· Recipient Data Maintenance
· Reference Data Maintenance
· Third Party Liability (TPL)
The 5.4 Users Manual deliverable is comprised of a series that collectively document the features and functionality of the OR MMIS. The deliverables can stand alone so that users may focus on particular areas. The first volume, OR MMIS General System Overview, addresses information that is common to all areas, and information that is essential to understanding each area’s deliverable. The General Systems deliverable should be read prior to reading any of the individual area users manuals to provide a basic working knowledge of the system’s functions. The following diagram illustrates the organization of this deliverable.
This users manual describes functions, pages and panels, and reports in the OR MMIS system. This manual, along with the 3.1.b Desk Level Business Processes document is intended to be used by Oregon Department of Human Services (DHS) staff as a reference and as a guide to how to perform MMIS tasks.
Business processes that are carried out by DHS staff are documented in the 3.1.b Desk Level Business Processes document. The desk level processes specifically reference the panels, pop-up windows and messages that are presented in this users manual, and the two documents can be used together to help you learn the system and to verify the steps you must take to perform tasks using the OR MMIS.
The Users Manual and the Desk Level Business Processes documents are available for review online. For the OR MMIS implementation, users are trained to access these documents and to quickly move through them to find the information they need to complete their work tasks. As the OR MMIS implementation approaches, users are trained to access these documents using the MMIS Project Workbook (PWB).
Data within the MMIS is received in a variety of methods. These methods include submissions from providers (claims), data downloaded from external sources (HCPCS procedure files), data received from other systems (Provider License Data) and data created directly within the MMIS. To a great extent, most of this data is maintained by authorized users within the MMIS. The MMIS security system restricts updates to data for select users identified by DHS as the persons responsible for maintaining that data. Some data elements (e.g., claims data) my have a wide range of individuals that are authorized to perform updates. Other data (e.g., pricing rates) may be restricted to just a handful of individuals.
The MMIS contains multiple code tables that are used throughout the system. These code tables include items such as provider type, type of bill, gender, explanation of benefits (EOB), etc. These tables are generally updated without the need for programmer intervention. Users authorized by DHS can be granted the ability to update one or more of these code tables. The updated data is then immediately available to all users of the MMIS.
Some data is updated on a regular basis by receiving or retrieving information from outside entities. This can include regular feeds from external systems (e.g., eligibility updates) or by downloading data from external sources. Data received from external sources may not be updated within the MMIS if the external entity owns the data. A good example of this is individual eligibility segments that state a client is eligible for a certain set of dates. This data is owned by the State’s eligibility system and should be updated there to avoid conflicts in data between the two systems. Other data, like the annual HCPCS update, is downloaded from an external source and then manipulated within the MMIS to accommodate Oregon’s specific needs.
Some data items drive system capabilities and therefore require programmer intervention to perform updates. An example of this type of data would be adding a claim type. There are modifications required for the MMIS to accept a new claim type that cannot be accomplished simply by updating tables. In this instance, a Customer Service Request (CSR) would need to be created that outlines the change to be made. The CSR would be created and approved by DHS management and would be submitted to EDS for review. EDS reviews the CSR and develops any questions or concerns concerning the requested change. Working collaboratively, DHS and EDS identify details for the CSR and create an estimate for the effort and duration required to complete the change.
When using the OR MMIS, DHS staff, with proper identification and clearance, can display protected health information (PHI) specific to individual Medicaid clients. This includes images of claims and other DHS forms, which contain information that must be protected from unauthorized public view. Under the Health Insurance Portability and Accountability Act (HIPAA), DHS staff is responsible for the appropriate use and distribution of PHI. OR MMIS is designed to comply with the HIPAA regulations, as well as the security guidelines of the Oregon State Security Office. OR MMIS is only accessible through the DHS network; it is not available for public access, and it is not available over the Internet.
Security within the MMIS is a role based security model that restricts access and capabilities based on the role that a user is assigned to perform. The system can have an unlimited number of roles, and users of the system can be assigned to an unlimited number of roles. To be valid in the system, a user must be assigned to at least one role.
Each role is defined by DHS to accommodate a select set of individuals. The role definition includes a list of the panels within the MMIS that the role will be allowed to access and the data elements within each of those panels that the role will be allowed to view. Further, the update capability of the role is also defined. If a particular role is allowed to view a panel, the definition also indicates if that role can update the panel data. It is allowable for a role to have view only access to panels. In that case, the users assigned that role will be able to view the data, but they will be unable to update the data. This capability extends to the data elements on a particular panel.
When users are added to the MMIS security system, they are assigned one or more roles. In the instances that the user is assigned to multiple roles and there is overlap within the role, then the more restrictive role takes precedence. In other words, if a user is assigned to Role 1 and Role 2, and Role 1 allows the user to update a particular panel but Role 2 does not allow that action, then the Role 2 restriction would take precedence and the user would not be allowed to update the panel.