122125 O3 Deloitte File 8 of 9 Attachment 2 Functional Specifications (Redacted).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:

Must receive, record and funnel all cases into an initial queue for assessment, and assignment.

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.

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.

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

Must identify and link related case data and activities.

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

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

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

16 Must provide the functionality to analyze caseloads, clearance rates, dispositions and other management data.

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

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

PROGRAM INTEGRITY - GENERAL

Number Requirement Description

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 implement business intelligence to include aggregation, analysis, and visualization of data to inform and facilitate business management and strategy decisions.

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

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

Must implement, maintain and operate a configurable exception reporting algorithms and reports developed in coordination with Department.

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

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

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

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

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.

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

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).

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)

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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

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

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.

Must provide functionality to establish and modify workload distribution to manage workloads on an as needed basis.

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.

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.

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.

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 enabling 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.

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

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.

Must provide search capability of all current and historic case management data.

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

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.

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

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.

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

72 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.

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

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).

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

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.

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

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