122125 O3 Alivia Analytics Attachment 2 - Functional Specifications_Proprietary Redacted File 3 of 4.pdf

Bidder’s Response As bidders prepare responses to each individual requirement, the responses are expected to address the individual requirement in a manner that demonstrates to the State that the bidder understands the requirement and how the bidder will meet the specific requirement. If the bidder’s response simply repeats the requirement, acknowledges, or adds sales materials in the Bidder’s response, the State will reserve the right to deem the response as a “Non-Responsive Solicitation Response”. However, if needed to appropriately explain bidder’s response, a mix of tables, graphical details, and written narrative is acceptable

The bidder’s response to each requirement must include confirmation and a detailed explanation for the Implementation Approach taken. Bidders shall capture any assumptions, risks, or dependencies related to fulfilling each individual requirement.

Bidders shall provide specifics, such as:

• Tools or methods used.

• Estimated effort for customizations/configurations.

PROGRAM INTEGRITY - CASE IDENTIFICATION AND CREATION

Number Requirement Description

Must support manual initiation of cases.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

[Bidder’s Response]

[Bidder’s Response] Confirmation:

Must utilize Dynamic Data Population to automatically fill fields and values on all case-related forms and web-based tools including exclusionary provider data via an API.

Met the requirement: YES

Implementation Approach: Configuration

Confirmation:

Must have access to internal and external agency databases to extract data to pre-populate index fields, and/or values (e.g. MMIS, provider data, MMIS member data, Electronic Health Records). Interfaces between State Vendors for data will be arranged to facilitate the pre-population.

Met the requirement: YES

Implementation Approach: Configuration

Must suggest and supply data and information from other sources to pre-populate values (address, licensure).

Met the requirement: YES

Implementation Approach: Configuration

• Implementation-Phase Consultation:

Must identify and link related case data and activities.

Met the requirement: YES

• Merge or flag as duplicate, based on user discretion and permissions

8 Must customize case data to the State’s business processes.

Met the requirement: YES

• Coordination with other systems or vendors if case data must be synchronized or exchanged.

9 Must provide automatic notification to the investigator when a new case is assigned.

Implementation Approach: Out of Box (OOB)

10 Must utilize multi-level drop-down menus for consistent categorization and reporting.

11 Must provide viewable, printable, exportable, consolidated audit history of cases.

[Bidder’s Response]

Alivia Analytics confirms that our platform provides a consolidated audit history of each case that is viewable, printable, and exportable through our reporting functionality.

12 Must allow users to produce work management reports that include performance measures for individuals and business processes.

13 Must provide an audit trail of historical activity which includes modification activities.

• Export and Reporting:

14 Must allow managers to track investigator caseloads, missed deadlines and aging cases

Implementation Approach: Out of Box (OOB)

• Role-based access controls to ensure managers can view and act on relevant data.

15 Must maintain a complete history and audit trail of all cases.

Implementation Approach: Out of Box (OOB) data.

17 Must provide built-in time tracking and complete history/audit trails.

Assumptions:

• Time-tracking to focus on the user login and length/duration of session.

Risks:

• None known

Dependencies:

• Nebraska DHHS to confirm the level of time-tracking expected by user.

18 Must retain all data on-line for a period of time defined by the State.

PROGRAM INTEGRITY - GENERAL

Must provide a configurable rules engine that identifies potential incidents of fraud, waste, abuse, and erroneous payments. The system must facilitate automated monitoring and analysis, enabling proactive intervention while supporting seamless configuration and rapid implementation of new rules or modifications to existing rules to address evolving program integrity requirements.

Must develop, update, and maintain a comprehensive algorithm library throughout the contract's duration, evolving to accommodate industry changes and emerging fraud patterns. This library must support contributions from State staff, the Vendor, and program integrity experts to ensure adaptability.

Must incorporate advanced predictive modeling techniques, leveraging historical data to forecast outcomes and provide early warnings of potentially fraudulent activities. Predictive modeling must be integrated to enhance proactive fraud detection and prevention, enabling early warning systems for timely fraud detection and mitigation of fraud, waste, abuse, and erroneous payments.

Must provide details of any Artificial Intelligence (AI) and Machine Learning (ML) algorithms and or methodology that is used to support the program integrity requirements. Additionally, vendor must provide details on how their AI approach ensures transparency and explainability in fraud detection decisions.

Must allow authorized users to create, modify, and run the rules and algorithms with limited or no technical support.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must provide a subject matter expert, who understands the algorithms used to extract data, to testify and support an administrative State or Federal action, and the appeals process.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must include application training modules including self-paced computer-based modules, web-based training, application tutorials, and searchable help features for authorized users.

Met the requirement: YES erials.

Approach:

Must implement, maintain, and operate a configurable program integrity solution which meets all requirements for CMS certification.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must be able to differentiate and profile provider groups, independent/solo providers, and individual providers within group practices.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

• Nebraska will provide access to provider enrollment and affiliation data from existing systems.

Must perform analysis of rendering, attending, admitting, supervising, ordering and prescribing provider's billing practices to generate reports of aberrant utilization patterns.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must perform all analysis using both claims and encounter records.

Must link all services of any member based on all historical member ID numbers.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must utilize a minimal level of manual effort in providing information that reveals potential defects in level of care and quality of service.

Met the requirement: YES

Must suppress processing on an individual(s) within specified categories on a run-to-run basis.

Met the requirement: YES

Implementation Approach: Configuration raska DHHS is ready to reintroduce the suppressed individuals into the processing stream, our team will remove the suppression rules and confirm their inclusion in the next run.

Must support pattern recognition and provide an automated fraud and abuse profiling system for the ongoing monitoring of provider and member claims to detect patterns of potential fraud, waste, abuse and excessive billing.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

• Nebraska will provide access to claims, encounter, and provider/member data feeds.

• The State will define any custom risk indicators or thresholds during implementation.

Risks:

• Incomplete or delayed data feeds may impact detection accuracy. We mitigate this through data quality scoring and automated validation routines.

Dependencies:

• Integration with MMIS, MCO systems, and other MES components.

• Ongoing collaboration with State program integrity staff to refine detection logic and workflows.

Must update all reference data based on a schedule agreed upon with State. (e.g. claims, provider, member) Met the requirement: YES

Must recommend members for referral to restricted access programs.

Must perform “absence of” scenario analysis (examples include inpatient hospitalizations or prescriptions with no physician visit, durable medical equipment with no relevant diagnosis).

Met the requirement: YES

Implementation Approach: Out of Box (OOB) [Bidder’s Response]

Alivia Analytics confirms that our platform supports “absence of” scenario analysis to detect potential gaps in care, billing inconsistencies, and indicators of fraud, waste, or abuse.

Key capabilities include:

Must provide statistical models to support simple random sampling and extrapolation that complies with generally accepted statistical audit and governmental accounting standards.

(Nebraska Medicaid currently uses RAT- STATS Statistical Software) Met the requirement: YES

Implementation Approach: Out of Box (OOB) [Bidder’s Response]

Alivia Analytics confirms that our platform provides statistical models to support simple random sampling and extrapolation in compliance with generally accepted statistical audit and o

Must suggest additional projects and ideas for Program Integrity efforts to prevent or identify fraud, waste, abuse, or erroneous payments.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

• Query Builder and Innovation Workspace:

Must provide an intuitive, user-friendly interface that streamlines operations through easy navigation and responsive design, ensuring accessibility from various devices. The interface must adhere to best practices in UI/UX design, including consistency, feedback mechanisms, and accessibility standards (e.g., WCAG 2.1). Additionally, the solution must support personalization features, allowing users to customize dashboards, save frequently used queries, and set personal preferences. Guided workflows and tooltips must be available to assist users with complex tasks, reducing the learning curve and increasing efficiency.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Authorized users must be able to create, modify, and execute rules and algorithms, generate reports, and utilize results effectively without requiring State or vendor technical support.

Met the requirement: YES

Must provide post-implementation support, including a dedicated helpdesk with tiered support levels, available Monday to Friday, 7 AM to 6 PM Central Time during State business days, with defined response times for issue resolution. Vendor staff must be available to provide direct support for complex issues, ensuring timely assistance.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

• Direct Access to Experts:

For complex or high-priority issues, Nebraska DHHS will have direct access to Alivia’s technical leads, data scientists, and program integrity experts to ensure timely and informed resolution.

• Support Portal and Knowledge Base:

Users can submit and track tickets, access documentation, and view system status through our secure online portal.

Assumptions:

• Nebraska will designate primary points of contact for support coordination and participate in bi-weekly support meetings.

Risks:

• Delays in issue triage or escalation may impact resolution timelines. We mitigate this through automated ticket routing, real-time monitoring, and proactive meeting cadence.

Dependencies:

• Integration with Nebraska’s incident management protocols and communication channels.

• Ongoing feedback from users to refine support processes and documentation.

Must support a roadmap for future enhancements, including periodic updates, feature additions, and system upgrades. Vendors must provide a plan for regular reviews and quarterly updates to ensure the system remains aligned with the State’s evolving needs. Regular system health checks, performance monitoring, and updates must be part of the support package.

Met the requirement: YES

Implementation Approach: Out of Box (OOB) [Bidder’s Response]

Confirmation:

Alivia Analytics confirms that our platform supports a structured roadmap for future enhancements, including periodic updates, feature additions, and system upgrades. We also provide a formal plan for quarterly reviews and continuous system health monitoring to ensure alignment with Nebraska DHHS’s evolving needs.

Approach:

Alivia is committed to delivering a solution that evolves with the State’s program integrity goals and technology landscape. Our enhancement and support strategy includes:

• Product Roadmap and Quarterly Updates:

Alivia maintains a transparent product roadmap that could be shared and reviewed with Nebraska DHHS on a quarterly basis. These sessions would include:

o Review of recent enhancements and upcoming features o Prioritization of State-specific requests o Feedback on usability, performance, and emerging needs

• Bi-Weekly Support Meetings:

In addition to quarterly roadmap reviews, Alivia conducts bi-weekly support meetings with the State to:

o Discuss product performance and user feedback o Review model enhancements and detection logic o Identify opportunities for innovation and continuous improvement

• System Health Checks and Monitoring:

Our platform includes automated system health monitoring tools that track:

o Application uptime and performance o Data pipeline integrity o Rule execution and model performance o User activity and system load

Regular health checks are conducted by our support team, and results are shared with the State as part of our operational reporting.

• Upgrade and Release Management:

Alivia follows a structured release cycle that includes:

Must be designed to handle increased loads and additional functionalities as the State’s requirements grow. This includes supporting new data types, user roles, and regulatory changes without significant system overhauls. At a minimum, the system must allow up to 20 concurrent users to work seamlessly.

Met the requirement: YES

Must evolve with new technological advancements such as Artificial Intelligence to assist with any program integrity efforts if determined appropriate by the State.

Met the requirement: YES

Must be configurable, allowing for modifications in business rules, workflows, and user interfaces without requiring extensive system changes. The solution must be able to adapt to regulatory changes, new fraud detection techniques, and evolving business processes seamlessly.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must provide dashboards and reporting tools that allow customers and other stakeholders to monitor project progress, resource allocation, and risk management. Regular updates must be provided with detailed reports on milestones achieved, issues encountered, and steps taken to address them.

Met the requirement: Choose an item. YES

Implementation Approach: Configuration [Bidder’s Response]

Alivia Analytics confirms that we provide dashboards and reporting tools that enable stakeholders to monitor project progress, resource allocation, and risk management. We also deliver

Must provide data analytic tools to enable accurate, automated data and reporting that will meet changing business and management needs, as well as data mining services to identify previously unrecognized patterns.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must implement robust role-based access control mechanisms to safeguard sensitive case information. The system must ensure that only authorized users have access to case data, with granular permission settings based on user roles and responsibilities.

Met the requirement: YES

Implementation Approach: Configuration

Approach:

Must include an incident response plan detailing procedures for detecting, reporting, and mitigating security breaches. At a minimum, annual security drills and updates to the incident response plan must be conducted to ensure preparedness.

Met the requirement: YES

Must provide designated external stakeholders with the tools to interact seamlessly for data sharing, case tracking, and resolution.

Met the requirement: YES

Must support both structured and unstructured data to enhance fraud detection and program integrity efforts.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must meet applicable component Service Level Agreements (SLAs) and provide information to the State to monitor the vendor’s performance via State-approved media.

Performance metrics must ensure sub-second response times for user queries, high transaction processing rates, and 99.9% system uptime. The system must be engineered to support concurrent user access while maintaining optimal performance and service reliability.

Met the requirement: MET WITH DEVIATION

Implementation Approach: Configuration

PROGRAM INTEGRITY - MANAGE CASE INFORMATION

Must allow users to complete case or investigative reports using a pre-formatted report template, auto-populating information from the case file within the system.

Met the requirement: YES

Implementation Approach: Configuration [Bidder’s Response]

Must incorporate tools such as a spell-check option for all free-form data entry fields and use drop-down menus for common data elements such as date fields and provider types.

Met the requirement: YES

Implementation Approach: Out of Box (OOB) [Bidder’s Response]

Alivia Analytics confirms that our platform supports user-friendly data entry by incorporating tools such as spell-check for all free-form text fields and drop-down menus for commonly used

Must modify and adapt case management processes, procedures and functionality to business process changes and maintain up to date functionality with minimal impact to users.

Met the requirement: YES

Implementation Approach: Configuration

• Access to Nebraska’s business process documentation and stakeholder input.

• Coordination with IT and program integrity teams for testing and deployment scheduling.

Must track and manage all case management data, including adverse actions, outcomes, expenditures, payments, receivables, recoupments, and adjustments, in accordance with State guidelines. The solution should integrate a workflow-driven model to ensure seamless tracking, assignment, and management of case activities, enabling real-time visibility and accountability across all processes. This model must facilitate automated task prioritization, approval hierarchies, and notifications to streamline case management operations.

Met the requirement: YES

• Integration with the State’s MMIS, eligibility, and financial systems to ensure accurate and timely data exchange.

• Ongoing stakeholder engagement to refine workflows and approval structures.

Must provide automated alerts and support customizable workflows for case creation, investigation, and resolution, including user-friendly tools for automated case management.

Additionally, the solution must support the establishment of work queues, allowing in-process knowledge, data, and documentation to flow between workers and across solutions while ensuring compliance with consistent, defined processes. The workflow management tool must orchestrate processes and data between applications, services, and interconnected systems within the State of Nebraska's defined Medicaid Enterprise, enhancing interoperability through standardized interfaces.

Met the requirement: YES

Implementation Approach: Configuration

Must track and report Accounts Receivable /Accounts Payable (e.g., check numbers, payer, payee, date, amount, and memo).

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must capture, track, display, and maintain all provider data, including agreement and termination information and historical communications.

Must maintain, track, log, archive, display, generate and auto generate, as defined by the State, all provider communications.

Met the requirement: YES

Implementation Approach: Configuration

Must provide letter templates including the use of digital signatures for all case management letters.

Met the requirement: YES

Must provide configurable tracking for individual cases, multiple cases/projects, and policy recommendations. Each case type has a unique set of fields and events that reflect the unique characteristics and processes for that case.

Met the requirement: YES

Implementation Approach: Choose an item. Configuration

Must provide configurable tracking for individual cases, multiple cases/projects, and policy recommendations. Each case type has a unique set of fields and events that reflect the unique

Must maintain links between cases and historical scanned/uploaded documents.

Met the requirement: YES

Implementation Approach: Out of Box (OOB) [Bidder’s Response]

Alivia Analytics confirms that our platform maintains persistent links between cases and historical scanned or uploaded documents, ensuring that all relevant materials remain accessible and

Must provide customized access to cases to ensure case information is only visible to those authorized to see it, based on role level, case type, or other criteria. This will also restrict rights so that certain users can be given “read-only” access to cases and others can edit case files. The system should allow for secure vendor access in a controlled, read-only mode, enabling vendors to review case information without compromising the integrity or confidentiality of the data.

Met the requirement: YES

Implementation Approach: Configuration

Must allow users to sort and search for keywords or names throughout the case management tool.

Met the requirement: YES

Must allow users to add notes to any case

Must allow users to add files (e.g. spreadsheets, emails, scanned documents, PDFs, audio, photos, videos) to a case as attachments, or upload and assign them to a particular case/project, or multiple cases/projects. Users must also have the ability to remove and/or replace documentation attached to a case.

Met the requirement: YES

Must maintain functionality to create and export comprehensive case records to multiple external media based on configurable business rules.

Met the requirement: YES

Implementation Approach: Configuration

Must allow users to add parties to a case file either manually or by copying from other case files.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must conduct a final review of every investigation and ensure a State accepted outcome has been executed before the case is closed.

Met the requirement: YES

Implementation Approach: Configuration [Bidder’s Response]

Alivia Analytics confirms that our platform allows users to add parties to a case file either manually or by using the provider/member lookup functionality to bring individuals into the case

Must communicate actions (e.g. termination, exclusion) and outcomes to the appropriate State system (e.g. Provider Screening & Enrollment, Eligibility and Enrollment System, Special Investigation Unit) and/or investigator(s).

Met the requirement: YES

Implementation Approach: Configuration

Must provide workflow functionality to enable automated alerts and notifications to designated work queues and processing.

Met the requirement: YES

Implementation Approach: Customization

Must provide training to all current and new users initially, upon system upgrades, and whenever processes, procedures, or functionality changes. Training shall be conducted directly by the vendor for State staff and end-users to ensure effective utilization of the PICM/FADS Analytics solution. The training must include self-paced e-learning modules, instructor-led sessions, and hands-on workshops. Training materials must be readily accessible online, regularly updated to reflect system enhancements, and delivered by the vendor to ensure consistency and effectiveness.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)

Must provide user manuals with updates as appropriate.

Met the requirement: YES

Implementation Approach: Out of Box (OOB) [Bidder’s Response]

Must enable the simultaneous updating of multiple cases within a project by allowing users to select specific cases from the system, apply a designated activity, and update all selected cases in a single action.

Met the requirement: Choose an item. YES

Implementation Approach: Out of Box (OOB) o Coordinated audits or investigations

Must provide for on-line review and approval by management of key steps within the case investigation process.

Met the requirement: Choose an item. YES

Implementation Approach: Configuration

Must provide a structured workflow process that does not allow steps to be skipped without proper authorization.

Met the requirement: Choose an item. YES

Implementation Approach: Configuration

• Collaboration with Nebraska DHHS to define workflow structures and authorization rules.

• Accurate role-based access configuration.

Must provide Program Integrity - Manage Case Information in a logical, chronological format.

Met the requirement: YES

Implementation Approach: Out of Box (OOB)