On Thursday, May 23, at the request of the Government, Operations, and Audit Committee (GOAC), the South Dakota Department of Social Services (DSS) presented to the committee on the status of the Medicaid Management Information System (MMIS).
Brenda Tidaball- Zeltinger, Deputy Secretary reviewed the update. The MMIS is the system used to process Medicaid claims and supports other functions necessary to manage the program. The mainframe legacy system is being modernized in phases and includes several modules. Those modules include:
Provider Enrollment and Credentialing – This module was modernized in 2010 and is used today by providers to enroll and be approved to provide services. Since 2010, numerous federal regulatory changes have resulted in the need to enhance or make modifications to comply with federal requirements.
After a request for information (RFI) was published and analysis conducted of options to address the enhancement needs, pursuit of a partnership with another state to use their enrollment module was recommended. DSS is working with the State of West Virginia to determine if an interstate contract can be reached that will leverage their CMS certified module. If successful, both states would benefit with cost sharing of infrastructure including software/hardware, etc.
Prior Authorization – This module is used to prior authorize certain healthcare services. A Request For Proposals (RFP) was published May 7th, seeking proposals from vendors for either the prior authorization module or for a third-party vendor to manage the process, like how dental claims are managed by a third- party vendor (Delta Dental of SD). Proposals are due July 9th.
Claims Adjudication Pharmacy Point of Sale – This module of the system went live in November 2017 and is used by pharmacies to prior authorize and to submit pharmacy claims for reimbursement. The system provides pharmacies with real time approval information regarding payment status and coverage of certain drugs. The module was certified by CMS in April 2019.
Health Care Claims – DSS is exploring alternative approaches in this area including the partnership model with another state or use of a third -party administrator. The experience with provider enrollment, and outcome of prior authorization module will drive the decision in this area.
Data Analytics/Data Warehouse – Phase 1 of this implementation includes implementation of a data analytics tool developed by BIT. Development is in progress with completion expected in June 2020. This phase includes basic data reports/data marts. Exploring use of this as platform for either BIT developed fully functioning data warehouse or leveraging an already developed tool implemented in another state.
Note: Legislators requested worksheets on the total amount of funds put into the MMIS since its inception. In addition, what software programs have been capitalized and/or written off plus broken into federal and general fund categories.