| | Exhibit 300 (BY2009) for CMS Part A Claims ProcessingPART ONE
OVERVIEW
- 1. Date of Submission:
- 2008-02-04
- 2. Agency:
- 009
- 3. Bureau:
- 38
- 4. Name of this Capital Asset:
- CMS Part A Claims Processing
- 5. Unique Project Identifier:
- 009-38-01-02-01-1130-00
- 6. What kind of investment will this be in FY2009?
- Operations and Maintenance
- 7. What was the first budget year this investment was submitted to OMB?
- FY2001 or earlier
- 8. Provide a brief summary and justification for this investment, including a brief description of how this closes in part or in whole an identified agency performance gap.
- The Fiscal Intermediary Shared System (FISS) software is a critical component of the Fee For Service (FFS) program, processing millions of Medicare claims a year, supporting Medicare's mission to provide quality health care to beneficiaries. The FISS software directly supports the PMA Improved Financial Performance, as it is an essential component for ensuring that accurate Part A payments are made for medically necessary services and provided to eligible Beneficiaries by qualified providers of care. The impact of not funding FISS would be detrimental to Medicare, causing harmful delays in processing/ payment of Part A claims, reducing the access, availability, and provision of health care services to Medicare beneficiaries. The FISS is one of the shared systems used to process Medicare Part A claims, including outpatient claims submitted under Part B. It interfaces directly with the Common Working File (CWF) System for verification, validation, and payment authorization. Claims are entered, corrected, adjusted, or canceled. Inquiries for status of claims, for additional development requests, or for eligibility and various codes are processed. The FISS meets CMS' core requirements for processing Medicare Part A claims, to include: data collection and validation, claims control, pricing, adjudication, correspondence, on-line inquiry, file maintenance, reimbursement, and financial processing. The FFS claims processing environment is distributed across four claims processing modules and one integrated testing module. The FISS has four quarterly releases that control, implement, and update software changes due to legislative mandates that dictate the amount of payment for services or coverage levels. Additionally, FISS must also implement changes needed to support the Medicare Administrative Contractor (MAC) authority for the Medicare FFS Program. Software changes for the claims processing operations are managed in quarterly releases developed through a change control process that begins with the Medicare Change Control Board (MCCB) review and prioritization of pending requests. The FFS Operations Board approves the quarterly releases with oversight by the FFS Governance Council and manages/integrates day-to-day operations of the FFS program across CMS. Error-free releases that implement legislative mandates with minimal interruption to processing ensure that beneficiaries receive the correct service and providers receive the correct payment.
- 9. Did the Agency's Executive/Investment Committee approve this request?
- yes
- 9.a. If "yes," what was the date of this approval?
- 2007-06-26
- 10. Did the Project Manager review this Exhibit?
- yes
- 11.a. What is the current FAC-P/PM certification level of the project/program manager?
- TBD
- 12. Has the agency developed and/or promoted cost effective, energy-efficient and environmentally sustainable techniques or practices for this project.
- yes
- 12.a. Will this investment include electronic assets (including computers)?
- no
- 12.b. Is this investment for new construction or major retrofit of a Federal building or facility? (answer applicable to non-IT assets only)
- no
- 13. Does this investment directly support one of the PMA initiatives?
- yes
- If yes, select the initiatives that apply:
Initiative Name |
---|
Financial Performance |
- 13.a. Briefly and specifically describe for each selected how this asset directly supports the identified initiative(s)? (e.g. If E-Gov is selected, is it an approved shared service provider or the managing partner?)
- The Part A claims processing system directly supports the PMA goal of Improved Financial Performance by reducing erroneous payments through accurate and timely claims processing for millions of beneficiaries, increasing health care service availability / accessibility, and improving health care quality, safety, cost and value. The system is essential to ensure that accurate payments are made for only medically necessary services, provided to eligible beneficiaries by qualified providers of care.
- 14. Does this investment support a program assessed using the Program Assessment Rating Tool (PART)?
- yes
- 14.a. If yes, does this investment address a weakness found during the PART review?
- yes
- 14.b. If yes, what is the name of the PARTed program?
- 2003: CMS - Medicare Program
- 14.c. If yes, what rating did the PART receive?
- Moderately Effective
- 15. Is this investment for information technology?
- yes
- 16. What is the level of the IT Project (per CIO Council's PM Guidance)?
- Level 3
- 17. What project management qualifications does the Project Manager have? (per CIO Council's PM Guidance)
- (1) Project manager has been validated as qualified for this investment
- 18. Is this investment identified as high risk on the Q4 - FY 2007 agency high risk report (per OMB memorandum M-05-23)?
- no
- 19. Is this a financial management system?
- no
- 20. What is the percentage breakout for the total FY2009 funding request for the following? (This should total 100%)
Area | Percentage |
---|
Hardware | 0 | Software | 0 | Services | 100 | Other | 0 |
- 21. If this project produces information dissemination products for the public, are these products published to the Internet in conformance with OMB Memorandum 05-04 and included in your agency inventory, schedules and priorities?
- n/a
- 22. Contact information of individual responsible for privacy related questions.
Name | Maribel Franey | Phone Number | 410-786-0757 | Title | Director, Privacy Compliance | Email | Maribel.Franey@cms.hhs.gov |
- 23. Are the records produced by this investment appropriately scheduled with the National Archives and Records Administration's approval?
- yes
- 24. Does this investment directly support one of the GAO High Risk Areas?
- yes
SUMMARY OF SPEND
- 1. Provide the total estimated life-cycle cost for this investment by completing the following table. All amounts represent budget authority in millions, and are rounded to three decimal places. Federal personnel costs should be included only in the row designated Government FTE Cost, and should be excluded from the amounts shown for Planning, Full Acquisition, and Operation/Maintenance. The total estimated annual cost of the investment is the sum of costs for Planning, Full Acquisition, and Operation/Maintenance. For Federal buildings and facilities, life-cycle costs should include long term energy, environmental, decommissioning, and/or restoration costs. The costs associated with the entire life-cycle of the investment should be included in this report.
All amounts represent Budget Authority
Note: For the cross-agency investments, this table should include all funding (both managing partner and partner agencies).
Government FTE Costs should not be included as part of the TOTAL represented. Cost Type | Py-1 & Earlier -2006 | PY 2007 | CY 2008 | BY 2009 |
---|
Planning Budgetary Resources | 0.000 | 0.000 | 0.000 | 0.000 | Acquisition Budgetary Resources | 0.000 | 0.000 | 0.000 | 0.000 | Maintenance Budgetary Resources | 17.275 | 15.181 | 13.633 | 17.835 | Government FTE Cost | 0.377 | 0.194 | 0.200 | 0.212 | # of FTEs | 4 | 2 | 2 | 2 |
- 2. Will this project require the agency to hire additional FTE's?
- no
PERFORMANCE In order to successfully address this area of the exhibit 300, performance goals must be provided for the agency and be linked to the annual performance plan. The investment must discuss the agency's mission and strategic goals, and performance measures (indicators) must be provided. These goals need to map to the gap in the agency's strategic goals and objectives this investment is designed to fill. They are the internal and external performance benefits this investment is expected to deliver to the agency (e.g., improve efficiency by 60 percent, increase citizen participation by 300 percent a year to achieve an overall citizen participation rate of 75 percent by FY 2xxx, etc.). The goals must be clearly measurable investment outcomes, and if applicable, investment outputs. They do not include the completion date of the module, milestones, or investment, or general goals, such as, significant, better, improved that do not have a quantitative measure.
- Agencies must use the following table to report performance goals and measures for the major investment and use the Federal Enterprise Architecture (FEA) Performance Reference Model (PRM). Map all Measurement Indicators to the corresponding Measurement Area and Measurement Grouping identified in the PRM. There should be at least one Measurement Indicator for each of the four different Measurement Areas (for each fiscal year). The PRM is available at www.egov.gov. The table can be extended to include performance measures for years beyond FY 2009.
Row | Fiscal Year | Strategic Goal Supported | Measurement Area | Measurement Grouping | Measurement Indicator | Baseline | Planned Improvement to the Baseline | Actual Results |
---|
1 | 2006 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | 5% | 10% | 1.4% | 2 | 2006 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Cumulative percentage of release hours per problem | 10% | 2% | 4% | 3 | 2006 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | 4 | 4 | 4 | 4 | 2006 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | 98% | 98% | 98% | 5 | 2007 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | 1.4% | 10% | TBD | 6 | 2007 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Cumulative percentage of release hours per problem | 4% | 2% | TBD | 7 | 2007 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | 4 | 4 | TBD | 8 | 2007 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | 98% | 98% | TBD | 9 | 2008 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | TBD | 8% | TBD | 10 | 2008 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Cumulative percentage of release hours per problem | TBD | 2% | TBD | 11 | 2008 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | TBD | 4 | TBD | 12 | 2008 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | TBD | 98% | TBD | 13 | 2009 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | TBD | 8% | TBD | 14 | 2009 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Cumulative percentage of release hours per problem | TBD | 2% | TBD | 15 | 2009 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | TBD | 4 | TBD | 16 | 2009 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | TBD | 98% | TBD | 17 | 2010 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | TBD | 7% | TBD | 18 | 2010 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Cumulative percentage of release hours per problem | TBD | 2% | TBD | 19 | 2010 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | TBD | 4 | TBD | 20 | 2010 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | TBD | 98% | TBD | 21 | 2011 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | TBD | 7% | TBD | 22 | 2011 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Reduction in the cumulative number of hours spent fixing errors | TBD | 2% | TBD | 23 | 2011 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | TBD | 4 | TBD | 24 | 2011 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | TBD | 98% | TBD | 25 | 2012 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | TBD | 6% | TBD | 26 | 2012 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Reduction in the cumulative number of hours spent fixing errors | TBD | 2% | TBD | 27 | 2012 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | TBD | 4 | TBD | 28 | 2012 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | TBD | 98% | TBD | 29 | 2013 | S.O. 1.3 - Improve health care quality, safety, cost and value | Mission and Business Results | Health Care Administration | Cumulative variance in number of estimated hours vs actual hours for coding per release | TBD | 6% | TBD | 30 | 2013 | S.O. 1.3 - Improve health care quality, safety, cost and value | Customer Results | Accuracy of Service or Product Delivered | Cumulative percentage of release hours per problem | TBD | 2% | TBD | 31 | 2013 | S.O. 1.2 - Increase health care service availability and accessibility | Processes and Activities | Timeliness | Number of software releases implemented within the specified time frame | TBD | 4 | TBD | 32 | 2013 | S.O. 1.2 - Increase health care service availability and accessibility | Technology | Availability | Percentage that system is available for processing | TBD | 98% | TBD |
Enterprise Architecture In order to successfully address this area of the business case and capital asset plan you must ensure the investment is included in the agency's EA and Capital Planning and Investment Control (CPIC) process, and is mapped to and supports the FEA. You must also ensure the business case demonstrates the relationship between the investment and the business, performance, data, services, application, and technology layers of the agency's EA. - 1. Is this investment included in your agency's target enterprise architecture?
- yes
- 2. Is this investment included in the agency's EA Transition Strategy?
- yes
- 2.a. If yes, provide the investment name as identified in the Transition Strategy provided in the agency's most recent annual EA Assessment.
- CMS Part A claims Processing
- 3. Is this investment identified in a completed (contains a target architecture) and approved segment architecture?
- no
- 4. Identify the service components funded by this major IT investment (e.g., knowledge management, content management, customer relationship management, etc.). Provide this information in the format of the following table. For detailed guidance regarding components, please refer to http://www.whitehouse.gov/omb/egov/.
Component: Use existing SRM Components or identify as NEW. A NEW component is one not already identified as a service component in the FEA SRM.
Reused Name and UPI: A reused component is one being funded by another investment, but being used by this investment. Rather than answer yes or no, identify the reused service component funded by the other investment and identify the other investment using the Unique Project Identifier (UPI) code from the OMB Ex 300 or Ex 53 submission.
Internal or External Reuse?: Internal reuse is within an agency. For example, one agency within a department is reusing a service component provided by another agency within the same department. External reuse is one agency within a department reusing a service component provided by another agency in another department. A good example of this is an E-Gov initiative service being reused by multiple organizations across the federal government.
Funding Percentage: Please provide the percentage of the BY requested funding amount used for each service component listed in the table. If external, provide the funding level transferred to another agency to pay for the service. Row | Agency Component Name | Agency Component Description | Service Type | Component | Reused Component Name | Reused UPI | Internal or External Reuse? | Funding % |
---|
1 | Information Sharing | Defines the set of capabilities that support the use of documents and data in a multi-user environment for use by an organization and its stakeholders. | Knowledge Management | Information Sharing | | | No Reuse | 25 | 2 | Information Retrieval | Defines the set of capabilities that allow access to data and information for use by an organization and its stakeholders. | Knowledge Management | Information Retrieval | | | No Reuse | 25 | 3 | Data Exchange | Defines the set of capabilities that support the interchange of information between multiple systems or applications; includes verification that transmitted data was received unaltered. | Data Management | Data Exchange | | | No Reuse | 50 |
- 5. To demonstrate how this major IT investment aligns with the FEA Technical Reference Model (TRM), please list the Service Areas, Categories, Standards, and Service Specifications supporting this IT investment.
FEA SRM Component: Service Components identified in the previous question should be entered in this column. Please enter multiple rows for FEA SRM Components supported by multiple TRM Service Specifications.
Service Specification: In the Service Specification field, Agencies should provide information on the specified technical standard or vendor product mapped to the FEA TRM Service Standard, including model or version numbers, as appropriate. Row | SRM Component | >Service Area | Service Category | Service Standard | Service Specification (i.e., vendor and product name) |
---|
1 | Data Exchange | Component Framework | Data Interchange | Data Exchange | Connect:Direct | 2 | Data Exchange | Service Interface and Integration | Integration | Enterprise Application Integration | Connect:Direct | 3 | Information Sharing | Component Framework | Data Interchange | Data Exchange | Connect:Direct, FTP File Transfer Protocol | 4 | Information Retrieval | Component Framework | Data Interchange | Data Exchange | Connect:Direct, FTP File Transfer Protocol | 5 | Data Exchange | Service Access and Delivery | Service Transport | Service Transport | File Transfer Protocol (FTP) | 6 | Information Retrieval | Component Framework | Data Management | Database Connectivity | MDCN | 7 | Information Sharing | Component Framework | Data Management | Database Connectivity | MDCN |
- 6. Will the application leverage existing components and/or applications across the Government (i.e., FirstGov, Pay.Gov, etc)?
- no
PART THREE
RISK You should perform a risk assessment during the early planning and initial concept phase of the investment's life-cycle, develop a risk-adjusted life-cycle cost estimate and a plan to eliminate, mitigate or manage risk, and be actively managing risk throughout the investment's life-cycle.
Answer the following questions to describe how you are managing investment risks. - 1. Does the investment have a Risk Management Plan?
- yes
- 1.a. If yes, what is the date of the plan?
- 2007-07-13
- 1.b. Has the Risk Management Plan been significantly changed since last year's submission to OMB?
- no
COST & SCHEDULE
- 1. Was operational analysis conducted?
- yes
- 1.a. If yes, provide the date the analysis was completed.
- 2007-08-31
- What were the results of your operational analysis?
- The most recent analysis determined that this investment is continuing to achieve its milestones within budget and on-time. Contract performance metrics were reviewed to ensure that investment continues to meet customer needs and that actual operations and maintenance costs were the ones planned.
- 1.c. If no, please explain why it was not conducted and if there are any plans to conduct operational analysis in the future.
- Not Applicable.
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