122125 O3 Attachment 2 - Functional Specifications.docx.docx
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- Attached to
- Program Integrity Case Management (PICM) and Fraud Abuse Detection (FAD) Analytics Solution
- Solicitation number
- 122125 O3
- Issued by
- Blaine County, Nebraska
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Attachment 2 - Functional Specifications
RFP#: 122125 O3
Program Integrity Case Management (PICM) and Fraud Abuse Detection System (FADS) Analytics solution State of Nebraska, Department of Health and Human Services
IMPORTANT:
Please note that any additional cost must be captured in the Cost Proposal and NOT within the response of the specification.
Failure to adhere to these instructions shall result in the bidder being deemed as "Non-Responsive".
General Guidelines for Vendors
1. Thoroughly Review Requirements: Carefully read each requirement, including subpoints. Ensure responses clearly address each aspect of the requirement.
2. Provide Supporting Details: Each response should include clear descriptions, processes, tools, or diagrams demonstrating how the solution meets the requirement.
3. Organize Responses:
· Use headings and subheadings to structure responses.
· Include bullet points for clarity.
4. Use Standards and Best Practices:
· Refer to relevant standards (e.g., Section 508, NIST, FIPS, HIPAA).
· Provide details of certifications, tools, and industry-compliant processes.
5. Clarity and Precision:
· Avoid vague language or ambiguous claims.
· Use concise, professional terminology.
· Ensure responses are tailored to DHHS requirements and align with federal and state guidelines.
6. Supporting Artifacts:
· Include visuals such as diagrams, charts, and flowcharts where applicable.
· Reference external documents or standards as appropriate.
7. Testing and Validation: Detail testing approaches, validation processes, and evidence that the solution meets outlined expectations.
Specific instructions to complete Functional Specifications
Bidders are to refrain from providing a solution where that would result in additional fees and/or expressing that a feature or functionality is available at an additional cost. Any deviations to the requirements for the system must be noted in Attachment 6 - Deviations to Section VI and attached as a separate document. Bidders shall use the “Part II - Deviations to Section (VI)(A)(4)(a)” of the Attachment 6 – Deviations to Section VI to record deviations taken to any requirement within this document (Attachment 2 – Functional Specifications).
This document contains four tables for each functional requirement type. The requirement types and their descriptions are as follows:
| No. |
| Requirement Type |
| Range |
| 1 |
| Program Integrity - Case Identification and Creation |
1 – 18
| 2 |
| Program Integrity – General |
19 – 56
| 3 |
| Program Integrity - Manage Case Information |
57-86
For each requirement listed under the tables in this document, the bidder shall enter the Implementation approach and the Bidder’s Response by following the instructions provided directly below.
Met The Requirements Within each requirement there is a dropdown option to select three option to answer whether the bidder will meet the requirement or not. The available options to choose and their descriptions are as follows.
| Available Options |
| Description |
YES
The Bidder confirms that their solution meets the specified requirement
| NO |
| The Bidder confirms that their solution does not meet their requirement |
| MET WITH DEVIATION |
| The Bidder Confirms that their solution meets the specified requirement with deviation taken to the specified requirement. |
(If this option is selected, then the bidder shall utilize the Deviation form [Attachment 6 – Deviations to Section VI] to describe the deviation taken)
Implementation Approach:
The Implementation Approach requested in this document can be described as the methodology that will be utilized by the bidder to meet the specific requirement. Within each requirement there is a dropdown option provided to select your Implementation Approach from which an option must be selected. The available options to choose and their descriptions are as follows:
| Available Options |
| Description |
| Out of Box (OOB) |
| Indicates that the functionality is available in the solution without any modifications. |
| Customization |
| Refers to changes made to the base product to meet specific requirements. This may involve coding or other significant alterations |
| Configuration |
| Refers to adjustments or settings changes within the solution that do not require coding but adapt the product to meet requirements. |
| TPS |
| Met with third party software |
| NA |
| Not Available |
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 |
| 1 |
| Must support manual initiation of cases. |
Met the requirement: Choose an item.
Implementation Approach: Choose an item.
[Bidder’s Response]
| 2 |
| Must receive, record and funnel all cases into a initial queue for assessment, and assignment. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 3 |
| 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: Choose an item.
[Bidder’s Response]
| 4 |
| 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: Choose an item.
[Bidder’s Response]
| 5 |
| Must suggest and supply data and information from other sources to pre-populate values (address, licensure). |
Met the requirement: Choose an item.
[Bidder’s Response]
| 6 |
| Must identify and link related case data and activities. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 7 |
| Must include large-capacity free-form text note functionality (e.g. keyword search, sort functions) for cases. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 8 |
| Must customize case data to the State’s business processes. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 9 |
| Must provide automatic notification to the investigator when a new case is assigned. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 10 |
| Must utilize multi-level drop-down menus for consistent categorization and reporting. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 11 |
| Must provide viewable, printable, exportable, consolidated audit history of cases. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 12 |
| Must allow users to produce work management reports that include performance measures for individuals and business processes. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 13 |
| Must provide an audit trail of historical activity which includes modification activities. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 14 |
| Must provide an audit trail of historical activity which includes modification activities. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 15 |
| Must provide an audit trail of historical activity which includes modification activities. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 16 |
| Must provide an audit trail of historical activity which includes modification activities. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 17 |
| Must provide built-in time tracking and complete history/audit trails. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 18 |
| Must retain all data on-line for a period of time defined by the State. |
Met the requirement: Choose an item.
[Bidder’s Response]
PROGRAM INTEGRITY - GENERAL
| Number |
| Requirement Description |
| 19 |
| 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. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 20 |
| 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. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 21 |
| 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. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 22 |
| 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. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 23 |
| Must implement business intelligence to include aggregation, analysis, and visualization of data to inform and facilitate business management and strategy decisions. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 24 |
| Must allow authorized users to create, modify, and run the rules and algorithms with limited or no technical support. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 25 |
| Must incorporate sophisticated link analysis capabilities to uncover complex relationships among providers and members. It must extend beyond provider-to-provider relationships and detect interwoven networks, such as clustered providers, interconnected members, shared addresses, and members acting as providers. These capabilities must facilitate comprehensive fraud detection by identifying hidden patterns and anomalies within the system |
Met the requirement: Choose an item.
[Bidder’s Response]
| 26 |
| 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: Choose an item.
[Bidder’s Response]
| 27 |
| 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: Choose an item.
[Bidder’s Response]
| 28 |
| Must implement, maintain and operate a configurable exception reporting algorithms and reports developed in coordination with Department. |
Implementation Approach: Choose an item.
[Bidder’s Response]
| 29 |
| Must implement, maintain, and operate a configurable program integrity solution which meets all requirements for CMS certification. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 30 |
| Must be able to differentiate and profile provider groups, independent/solo providers, and individual providers within group practices. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 31 |
| 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: Choose an item.
[Bidder’s Response]
| 32 |
| Must perform all analysis using both claims and encounter records. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 33 |
| Must link all services of any member based on all historical member ID numbers. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 34 |
| 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: Choose an item.
[Bidder’s Response]
| 35 |
| Must suppress processing on an individual(s) within specified categories on a run-to-run basis. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 36 |
| 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: Choose an item.
[Bidder’s Response]
| 37 |
| Must update all reference data based on a schedule agreed upon with State. (e.g. claims, provider, member) |
Met the requirement: Choose an item.
[Bidder’s Response]
| 38 |
| Must recommend members for referral to restricted access programs. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 39 |
| 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: Choose an item.
[Bidder’s Response]
| 40 |
| 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: Choose an item.
[Bidder’s Response]
| 41 |
| Must suggest additional projects and ideas for Program Integrity efforts to prevent or identify fraud, waste, abuse, or erroneous payments. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 42 |
| 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: Choose an item.
[Bidder’s Response]
| 43 |
| 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: Choose an item.
[Bidder’s Response]
| 44 |
| 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: Choose an item.
[Bidder’s Response]
| 45 |
| 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: Choose an item.
[Bidder’s Response]
| 46 |
| 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: Choose an item.
[Bidder’s Response]
| 47 |
| 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: Choose an item.
[Bidder’s Response]
| 48 |
| 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: Choose an item.
[Bidder’s Response]
| 49 |
| 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.
[Bidder’s Response]
| 50 |
| 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: Choose an item.
[Bidder’s Response]
| 51 |
| 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: Choose an item.
[Bidder’s Response]
| 52 |
| 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: Choose an item.
[Bidder’s Response]
| 53 |
| Must provide designated external stakeholders with the tools to interact seamlessly for data sharing, case tracking, and resolution. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 54 |
| Must support both structured and unstructured data to enhance fraud detection and program integrity efforts. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 55 |
| Must meet applicable component Service Level Agreements (SLAs) and provide information to the State to monitor the vendor’s performance via State-approved media. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 56 |
| 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: Choose an item.
[Bidder’s Response]
PROGRAM INTEGRITY - MANAGE CASE INFORMATION
| Number |
| Requirement Description |
| 57 |
| 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: Choose an item.
[Bidder’s Response]
| 58 |
| Must provide functionality to establish and modify workload distribution to manage workloads on an as needed basis. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 59 |
| 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: Choose an item.
[Bidder’s Response]
| 60 |
| 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: Choose an item.
[Bidder’s Response]
| 61 |
| 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: Choose an item.
[Bidder’s Response]
| 62 |
| 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: Choose an item.
[Bidder’s Response]
| 63 |
| Must track and report Accounts Receivable /Accounts Payable (e.g., check numbers, payer, payee, date, amount, and memo). |
Met the requirement: Choose an item.
[Bidder’s Response]
| 64 |
| Must capture, track, display, and maintain all provider data, including agreement and termination information and historical communications. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 65 |
| Must maintain, track, log, archive, display, generate and auto generate, as defined by the State, all provider communications. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 66 |
| Must provide search capability of all current and historic case management data. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 67 |
| Must provide letter templates including the use of digital signatures for all case management letters. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 68 |
| 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: Choose an item.
[Bidder’s Response]
| 69 |
| Must maintain links between cases and historical scanned/uploaded documents. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 70 |
| 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: Choose an item.
[Bidder’s Response]
| 71 |
| Must allow users to sort and search for keywords or names throughout the case management tool. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 72 |
| Must allow users to add notes to any case |
Met the requirement: Choose an item.
[Bidder’s Response]
| 73 |
| 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: Choose an item.
[Bidder’s Response]
| 74 |
| Must maintain functionality to create and export comprehensive case records to multiple external media based on configurable business rules. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 75 |
| Must allow users to add parties to a case file either manually or by copying from other case files. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 76 |
| 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: Choose an item.
[Bidder’s Response]
| 77 |
| 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: Choose an item.
[Bidder’s Response]
| 78 |
| Must provide workflow functionality to enable automated alerts and notifications to designated work queues and processing. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 79 |
| 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: Choose an item.
[Bidder’s Response]
| 80 |
| Must provide user manuals with updates as appropriate. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 81 |
| Must provide on-line help for all features, functions and data element fields. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 82 |
| Must allow for users to see all assigned cases and identify all of their open cases and those which have deadlines that are approaching or have passed. |
Met the requirement: Choose an item.
[Bidder’s Response]
| 83 |
| 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.
[Bidder’s Response]
| 84 |
| Must provide for on-line review and approval by management of key steps within the case investigation process. |
Met the requirement: Choose an item.
[Bidder’s Response]
Must provide a structured workflow process that does not allow steps to be skipped without proper authorization.
Met the requirement: Choose an item.
[Bidder’s Response]
| 86 |
| Must provide Program Integrity - Manage Case Information in a logical, chronological format. |
Met the requirement: Choose an item.
[Bidder’s Response]
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