7-Appendix F Detailed Scope of Work.pdf

APPENDIX F

DETAILED SCOPE OF WORK

Detailed Scope of Work Introduction

DOH is seeking cost-effective and innovative solutions to build an APCD system. The Offeror shall conduct data management that includes working with healthcare-related claims data submitters, data collection, data quality assurance efforts, as well as analytics and reporting services, such as developing and implementing an Analytics Master Plan, standardizing analytical reporting, and create an Analytics Environment that shall allow DOH designated users to create reports and perform analysis as described throughout the Scope of Work of this Appendix.

The Required Tasks are divided between five sections: I. Required Task - Project Management; II.

Required Task - Data Management; III. Required Task - Conversion; IV. Required Task - Analytics and Reporting; and V. Additional Services.

Innovative approaches and/or methodologies to accomplish the desired or intended results for each section are welcome and encouraged. An Offeror may propose an alternative method to address any required service or function, as long as they can clearly demonstrate that the proposed solution still accomplishes all of the goals associated with each task. However, proposals which depart from or materially alter the terms, requirements, or scope of work defined by this RFP may be deemed non-responsive and be rejected.

Offerors are encouraged to describe their experience, capacity, and technical solutions for each Task.

Innovation, efficiency, and cost-effectiveness are important to DOH and Offerors shall reflect their experience and proposed solutions for each task described within each section.

Please describe in reasonable detail how you will accomplish each of the tasks described in the Scope of Work below, referring to specific sections and tasks as appropriate in your narrative Work Plan.

The list of Tasks identifies needs or problems that need to be addressed in the Offeror’s proposed solution for that section. Please ensure that every identified “Required Bid Element” is addressed in your proposal.

The Work Plan shall concisely describe each program development and implementation task.

If applicable, the Offeror should note any tasks to be delegated to subcontractors and, if known, identify subcontractors of the related Tasks.

Offerors shall describe their proposed approach to each “Required Bid Element” within each Required Task for their bid to be considered responsive.

I. Required Task: Project Management

Project Management includes activities needed to initiate, plan, execute, monitor and control and closeout the project aspects of the work being provided to DOH under contract. DOH will have a project manager coordinating work and participation from multiple State of New Mexico agencies to successfully implement an APCD for the State. Offerors are responsible for planning and coordinating delivery of their work and coordinating with the overall project team. Offerors shall also provide status reporting and manage risks and issues relating to the work.

Task 1: Project Management, Plan, and Approach The Offeror selected to be the vendor (hereafter “the vendor”) will develop a Project Management Plan that includes at a minimum; project scope, solution architecture, integrated management control (to include scope, schedule, staffing, communication, risk, issue and quality management), and a project schedule baseline with high level tasks by phase or iteration. The vendor will coordinate, plan and manage their work. Lead, manage and facilitate the implementation of the solution, provide required project management documentation, and oversee the project from the initiation, planning, implementation and closeout of the project.

Required Bid Elements:

• The Offeror will describe their project management approach and how they will provide and maintain coordination of effort and communications throughout the project lifecycle.

o Offeror’s Response:

• The Offeror will provide example project management documents for evaluation.

o Offeror’s Response:

Task 2: Project Management Communication and Reporting The vendor will provide mechanisms/methods to communicate and report project status, issues and risks to oversight bodies and the overall project team. Lead, manage and facilitate the implementation of the solution, provide required project management documentation, and oversee the project from the initiation, planning, implementation and closeout of the project.

• The Offeror will describe their methods for project status reporting.

o Offeror’s Response:

II. Required Tasks - Data Management Data Management includes all activities related to the interaction with data suppliers, data submission, data intake, data processing, data aggregation, data quality review, data storage, data access, and preparation of data for analytic purposes. Each Scope of Work task required within Data Management is described below.

Scope of Work Required Tasks for Data Management

Task 1: Data Submission Tool

The vendor will implement an internet-based user interface (or similar technology) that allows for the secure submission and acceptance of all data to be submitted. The vendor will perform quality assurance, validations, and edit checks on all submitted data files and provide feedback to DOH and data suppliers. Data submission for NM APCD will be in a Data Submission Guide to be developed by the vendor that is based on the All Payer Claims Database-Common Data Layout (APCD-CDL™).

Performance Requirements

1) Secure Submission: Data suppliers will have access to a secure system to allow them to submit or transfer files to the vendor.

2) Provide a detailed Data Submission Guide (DSG) to assist data suppliers and that specifies the APCD-CDL™ as the required data submission format.

3) Perform payer outreach, onboard/register data submitters, establish and implement test file submission, quality assurance, and payer feedback processes.

4) Provide detailed documentation, training, and technical support for NM APCD data submitters and NM DOH staff.

5) Secure data storage: Vendor will have a secure location to store, quality check and transform acquired data.

6) Quality Assurance Priorities: The vendor will review submitted files to ensure:

a. Consistency – are the data internally consistent?

b. Timeliness – do the data reflect the covered time period?

c. Completeness – are all data from the time period for submission included?

d. Uniqueness – are the data free from unexpected duplicates?

e. Validity/Accuracy – are the data in an acceptable format and ranges and do they comply with all requirements of the data submission guide?

7) Feedback: For each submission, the vendor will provide a quality audit/error report back to the data supplier and to DOH. The vendor will also provide a monthly cross-payer submission quality report. The vendor will provide a method to communicate with data suppliers:

a. The status of their submission (received, rejected, in process, etc.)

b. A summary of the data contained in the submitted file (the number of records processed, the number of records requiring correction, and the types and counts of observed data errors in comparison with historical submissions

c. Any errors observed in the file (with examples of the error), and whether those errors will result in a rejection

d. An assessment of the data quality of the monthly submission, in the categories of Data Quality specified in 3.a above.

8) The vendor will receive and process corrected and resubmitted files, replacing or ignoring records as needed. All corrections and modifications to submitted data shall be documented and a summary provided to DOH.

9) DOH will use the APCD-CDL™ as the basis for the data submission guide (DSG). The vendor will assist the DOH in developing its DSG that incorporating rules, policies, and procedures for the collection of data into the DSG. The vendor is expected to receive files in DSG described format and make changes as needed to incorporate APCD-CDL™ updates, expected on a bi-annual basis. The data submission guide will be adjusted to include methods for acquiring capitated payments, value-based payments and other non-claims payments.

Note: payers may not have the ability to submit all desired data elements incorporated into the DSG, but the awarded Offeror and DOH will continuously work together to improve data collection efforts.

Required Bid Elements:

• The Offeror will describe their proposed intake system, indicating how performance requirements in the task description would be accomplished. Offerors will indicate whether their intake system will pre-screen data submissions and if so to what degree.

o Offeror’s Response:

• The Offeror will describe their proposed data management platform from storage of initially acquired flat files to final transformed database.

o Offeror’s Response:

• The Offeror will indicate how fast they can complete the process from submission to acceptance/rejection and provide a timeline from data intake and processing to reporting back to data suppliers. The Offeror will identify any technical limitations of their systems relating to volume, formats and structures of fields that would limit future DSG changes.

Task 2: Data Collection Management The vendor will assist DOH in administering rules, policies, and procedures for the collection of data, as established by DOH and in accordance with the most recent version DOH Data Submission Guide based on the APCD-CDL™. As described in Task 1 above the vendor will assist the DOH in developing and updating the DSG.

Performance Requirements

1) Offerors will describe their data warehouse management plan. The Offeror shall agree that the server be located in the United States. Offerors will include their approach to including data lineage tracking and providing curated data to the analytics vendor (if applicable).

2) The vendor will collaborate with data suppliers to maximize their ability to submit data that conforms to established Data Submission Guide criteria.

3) The vendor will review the Data Submission Guide with DOH and submitters bi-annually and provide specific recommendations on any existing gaps and needed changes or updates, including explanations for the proposed changes. All recommendations will be subject to DOH approval.

4) Upon request, the vendor will provide data suppliers with a comprehensive list of all data intake validation checks that will be run against their data. This list shall include all data validation and “reasonableness” checks beyond the Data Submission Guide element thresholds, including checks for out-of-range values and clinical consistency (e.g., out of country addresses, dates that are in the future, a pregnant 94- year-old man, etc.).

5) The vendor will maintain documentation of data submissions, including requests for data resubmissions and the supplier’s responses to those requests. Vendor shall make such documentation available to DOH upon request.

6) The vendor will have a plan for and execute any requested file deletion or destruction and provide certification to DOH. This may include data submitted in error as well as any other data that needs to be destroyed.

7) The vendor will review the APCD regulations and provide specific recommendations on any existing gaps and needed changes or updates.

8) The vendor will develop and provide a plan and timeline for obtaining and processing historical raw data files (2020–2025) from the current vendor.

9) Maintain all historical NM APCD data (2020–2025) including both the raw unprocessed data files as received from data submitters, as well as the vendor processed data delivered to NM

DOH.

10) Provide security and privacy protection for proprietary payer and Member/patient data in a manner compliant with HIPAA, HITECH (Health Information Technology for Economic and Clinical Health Act), HHS guidance, and applicable New Mexico law and regulations.

11) Vendor will provide detailed descriptions of their policies and procedures for protecting data Privacy and Security, including an incident response plan and process, and disclose any past information security or confidentiality breaches.

Required Bid Elements

• The Offeror will describe their experience and processes for developing data collection systems that implement Data Submission Guides (or similar documents) and communicate with suppliers the requirements for data submission.

o Offeror’s Response:

• The Offeror will describe their methods/tool for performing data validation and reasonableness checks, including assuring clinical consistency in the data. The Offeror will describe how the data validation tools can be adapted to changes in the data submission guide.

o Offeror’s Response:

• The Offeror will describe their system for documenting data submissions and resubmissions.

Task 3: Data Supplier Engagement-Onboarding The vendor will engage directly with data suppliers, in certain contexts, to provide technical assistance and coordinate overall work. Engagements will be coordinated with and approved by

DOH.

Performance Requirements

1) The vendor will develop a system to register and onboard data submitters, including the development of a data submitter portal to provide feedback to submitters.

2) The vendor will provide technical assistance to all data suppliers, including:

a. Advising them on how to map existing fields in their system to the data submission guide;

b. Processing and evaluating test data sets; and,

c. Working with the data supplier to make needed adjustments.

3) The vendor will establish a process for providing project communications and technical assistance to all data suppliers, including:

a. Participate in regular meetings

b. Providing technical assistance

4) The vendor will inform any data suppliers within 24 hours of a missed deadline for data submission. The vendor will also include DOH on any such communications. The vendor will coordinate notifications of rejections, missed deadlines, or other compliance issues with DOH and communicate to data suppliers as requested.

• The Offeror will describe the methods for engaging and training/educating suppliers on their system.

o Offeror’s Response:

• The Offeror is encouraged to provide examples of supplier meeting agendas or other documents that exemplify engagement strategies.

Task 4 Data Collection Status Reports The vendor will provide access to real-time data submission status information to DOH that includes the status of each supplier’s submissions and files. The vendor will also provide dashboards to DOH that document any communication regarding missed deadlines, rejected files, or other compliance issues.

Required Bid Elements:

• Offerors will describe their proposed approach for ensuring real time access of data submission status to DOH.

o Offeror’s Response:

• Offerors will describe their proposed method of reporting data collection issues to DOH on a regular (at least monthly) basis.

Task 5 Medicare Custodian The vendor will serve as the CMS-approved Medicare Custodian for data sets obtained through the CMS State Agency Request and other programs. This will require the vendor to agree to the non-negotiable terms and conditions required by CMS to act as a data custodian. Medicare data will not comport with the requirements of the DSG. The Vendor shall be prepared to accept Medicare data in a non-standard format as supplied by Medicare’s data representatives and perform necessary steps to map it into the APCD- CDL™ format. Vendor shall also provide a mechanism through which acquired Medicare data can be shared

Performance Requirements

1) Map and transform the Medicare data to an input structure that is compatible with the vendor’s data intake system.

2) Meet CMS requirements to serve as the Custodian of Medicare files and agree to terms and conditions and sign agreements required by CMS including the DMP-SAQ.

3) Keep Medicare data isolated as needed or required for proper handling and purposes of data release or analysis.

• The Offeror will describe their experience or proposed process working as the state Medicare data custodian and mapping Medicare data into the state APCD.

o Offeror’s Response:

• The Offeror will agree to meet CMS requirements to serve as the Medicare custodian.

o Offeror’s Response:

• The Offeror will complete the CMS Data Management Plan Self-Attestation

Questionnaire (DMP-SAQ).

Task 6 Medicaid Data The vendor will collect Medicaid data directly from the New Mexico Health Care Authority (HCA), or if necessary, from commercial payers.

Performance Requirements

1) Collect the Medicaid data directly from HCA.

2) Map and transform Medicaid data to an input structure that is compatible with the vendor’s data intake system.

3) Meet HCA requirements for data access and security, as agreed upon between DOH and

HCA.

Required Bid Elements:

• The Offeror will describe their experience or proposed process for working with Medicaid data and mapping Medicaid data into the state APCD.

o Offeror’s Response:

• The Offeror will agree to meet HCA requirements for data security and storage.

o Offeror’s Response:

Task 7 Data Collection Process Documentation The vendor will provide documentation of the processes in place for data collection and supplier engagement.

Note: This documentation is required even if proprietary tools and methods are used.

Required Bid Elements:

• The Offeror will agree to disclose any business rules around data intake and will provide documentation of the process that is clear and allows for the various steps in the process to be communicated to DOH, data suppliers, and other stakeholders. Any requested proprietary exclusions must be noted.

o Offeror’s Response:

• The Offeror will include a flow chart of the data submission and management process with sufficient detail to show how the data collection processes are being managed.

Task 8 Extract, Transform, and Load (ETL) The vendor will load all monthly submissions into a database on a regular schedule. NOTES: 1) Significant preference and bonus points will be awarded to Offerors that can perform this task monthly or more frequently. 2) The ETL task and the Data Consolidation task may be combined into a single task.

Performance Requirements

1) The vendor will execute a regularly scheduled extract, transform, and load (ETL) process that supports all required data submission feeds, each with multiple data file types (e.g.

enrollment, claims, provider).

2) The vendor will update the ETL process to accommodate bi-annual changes to the Data Submission Guide.

Required Bid Element

• The Offeror will describe their proposed ETL processes, including description of the technology platform and software used and proposed processing timeline.

o Offeror’s Response:

Task 9 Data Consolidation The vendor will consolidate claims and records contained in the database on a regular schedule.

NOTE: Consolidation must occur at least quarterly, and preference will be given to Offerors who can do it more frequently.

Performance Requirements

1) Specific data consolidation activities required under this task include:

a. Linking enrollment records across plans and time;

b. Proper linking of medical, pharmacy, and dental claims back to the enrollment files;

c. Eliminating any duplicate claims or records; and,

d. Determining the most recent status of any claim that has been submitted more than once.

2) The vendor shall coordinate with each data supplier to identify appropriate method(s) for determining the current adjudication status of all service records contained in the claims data file submissions. The vendor will then develop and execute a ‘claims consolidation’ process that utilizes these methods to identify or generate a single record that accurately reflects and designates the current disposition and costs associated with each rendered service. DOH is interested in creative or innovative solutions to this issue.

3) The vendor will maintain documentation detailing the consolidation methods and deployment. The contracted vendor will disclose to DOH their proposed methods before the initial execution of the consolidation process, and whenever new methods are deployed.

4) The vendor will consolidate service date claims and eligibility files at least quarterly covering the most recent twenty-four (24) months of claims. This time frame shall be extended to cover more months if new or updated data files are submitted that cover previous time periods on an exceptional basis if required by DOH.

5) The vendor shall incorporate into the consolidated files all submitted records that have not been subsequently replaced or deleted by a Supplier by resubmission of an entire time period (i.e., “kill and fill” or entire files replaced by a later submission must not be included).

However, the consolidated files shall include and specifically indicate those specific claim service records that do not reflect the current disposition of the original rendered service and all duplicate claim service and eligibility records.

6) The vendor shall ensure the Database is designed to allow for time specific dimensions where the descriptive meanings of codes change over time. The data will be available for direct ad hoc query and extract by DOH.

• The Offeror will describe their consolidation process and explain how it will address specific data consolidation needs and describe the database design, including a description of the technology used by the Offeror.

o Offeror’s Response:

Task 10 Patient Identity Resolution The vendor will create and provide a unique ID for every person in the database. The vendor shall provide an interface/API to other Patient indices such as the DOH Enterprise Master Patient Index and the HCA HHS 2020 Master Index.

Performance Requirements

1) The vendor will use direct patient identifiers received from suppliers (e.g. SSN, member name, member street address, etc.) to create a new, or match to an existing, unique patient identifier.

2) The resulting unique identifier shall allow DOH to perform analyses that rely on member identities.

• The Offeror shall describe in detail their approach to identity resolution and how that will be used to create a unique patient identifier.

o Offeror’s Response:

• The Offeror shall attest and certify that DOH will own the identifiers and be allowed to use them without restriction.

Task 11 Provider Directory The vendor will develop, test, and refine and maintain a Provider Directory by implementing unique health care provider and health care facility identifiers, coordinating with other possible sources for authoritative provider data.

Performance Requirements

1) This Provider Directory shall employ an open, standards-based architecture with an API or web services framework that would enable it to interoperate with third party identity management tools, such as an external Master Provider Directory.

• The Offeror shall describe in detail their approach to identity resolution and how that will be used to maintain and update a unique provider identifier.

• The Offeror shall attest and certify that DOH will own the identifiers and be allowed to use them without restriction including distribution of the identifiers to entities outside of

DOH.

o Offeror’s Response:

Task 12 Data Storage Documentation The vendor will provide documentation of all aspects of the data storage solution for collected, managed data (raw files, staging or semi-processed, fully-processed or consolidated, etc.) to DOH.

Performance Requirements

The vendor’s documentation will include:

1) Entity relationship diagrams

2) Data dictionary(ies) that includes a full description of each element and how each element was derived (where applicable)

3) An ETL source-to-target mapping

4) Documentation of the underlying hosting architecture for the data storage solution. See

APPENDIX H requirement IT43.

Required Bid Elements:

• The Offeror will provide an example of the proposed data documentation, including an ETL source to target map/diagram.

o Offeror’s Response:

Task 13 Data Access The vendor will provide access to all phases of data stored for designated DOH users.

Performance Requirements

1) The access must allow DOH analysts to track the data lineage in the data staging area.

2) The vendor will also provide role-based user access for additional DOH users with predetermined access and security levels and provide technical assistance to these DOH staff, as requested.

• The Offeror will describe proposed technology/method technology to provide role-based access, and the timeline for access to varying levels of the stages of processing.

o Offeror’s Response:

Task 14 Value-Added Components for Analytics The vendor will employ industry standard tools or methodologies to implement, test, and refine the value-added components and elements to enhance or increase the utility of the data.

Performance Requirements

1) Value-adds that accomplish the following objectives are required:

a. A methodology that identifies the latest version of claims in the Data store

b. A coordination of benefits (COB) methodology that allows a user to combine claims for a single service covered by multiple payers into a single record reflecting a “total paid” calculation.

c. Groupers that aggregate claims into distinct condition and procedure categories.

d. A methodology for a grouper to create or identify distinct episodes of care.

e. A methodology for risk assessment, to develop risk scores based on both retrospective and demographic risk. Risk scores will be used for risk adjustment calculations, and the Offeror should describe the methodology used for calculating the risk scores and the application of the scores for risk adjustment purposes.

f. A methodology to geocode addresses in claims and eligibility files. These components shall be integrated in the data store in such a way as to allow designated DOH staff to access them and include them in queries. The vendor may propose other value-added components that it offers and DOH agrees would be valuable.

Required Bid Elements

• The Offeror will include a description of each required value-added component methodology offered as a service, including a description of the methodology and approach to generation or calculation. If the Offeror uses a proprietary method for any of the value-added components, the Offeror shall agree that it will provide sufficient documentation for DOH to understand the methods being employed and that the fields added to the data set can subsequently be used by DOH without restriction.

o Offeror’s Response:

• The offeror will describe any additional value-added components it can provide for data management. DOH may choose to incorporate these components into the contract.

Task 15 Post-Load Quality Assurance and Validation The vendor will perform post-load quality assurance, validation, and edit checks after each consolidation.

Performance Requirements

1) The vendor will perform a final review of the fully processed data prior to the data being moved into the production Environment (i.e., prior to data being available to other DOH APCD vendors, prior to scheduled standard data sets to DOH, etc.).

2) At the end of each calendar year, the vendor will produce a summary file that includes at least the following data points (with the final list to be determined in consultation with DOH), in total and by payer:

a) Patient Demographics

b) Number of total claims

c) Billed charges

d) Amount paid

e) Patient responsibility

f) Top twenty procedures/diagnoses by volume and cost

3) The vendor will also provide DOH with the following validation information for each final-processed file provided to DOH:

a) Demographics (e.g. member counts, percent male, etc.)

b) Rolling aggregation figures (e.g., dollar amounts for paid services in a given month, units per enrolled member per workday, etc.)

c) Count of medical member months compared to pharmacy member months for each supplier

d) Exchange-related enrollment figures (e.g. purchased through the exchange, percent catastrophic coverage plans, etc.)

e) Number of records dropped or deleted due to each exclusion and/or business rule applied for each supplier and for the full database;

f) Pharmacy (e.g. percent refills, percent generics, etc.)

g) Provider and facility (e.g. inpatient counts, provider type, etc.)

h) Count of members covered under ERISA-eligible plans

i) Opt-out tallies

j) “Unknown” tallies

k) Quality of the Patient Identity resolution

l) Quality of the Provider Directory

4) At the same time that a final-processed data file is made available for DOH review, the vendor will provide data suppliers with validation reports showing the degree to which core DOH APCD metrics align with the suppliers’ metrics. Report content will be defined by

DOH.

• The Offeror will describe the post-load quality processes and any available “out of the box” output reports resulting from that process. Offerors are encouraged to provide specific examples.

o Offeror’s Response:

Task 16 Access to the Data Management Platform The vendor shall provide DOH analysts and any contracted vendor access to data needed for their work.

Performance Requirements

1) The vendor will make the most recent copy of the Data Dictionary available to DOH, work cooperatively with DOH to answer any questions regarding the format and/or contents of the data, and work closely with DOH to troubleshoot and trace any identified performance or data quality issues.

• The Offeror will describe the process they propose to use to permit access and provide suggested approaches to work collaboratively with DOH.

Task 17 Maintenance and Support of Data Management Platform

Ongoing Platform Maintenance The vendor will provide maintenance, operation and support of the Data Management Platform throughout the contract term, including paying all fees associated with updating and amending the Data Management Platform as needed and providing promised software, licenses, and hardware required to fully support the required functionality. See APPENDIX H Information Technology Requirements for detailed platform maintenance requirements. Vendor is not asked to pay for data sources such as CMS Medicare FFS as part of maintenance and support, Required Bid Elements:

• The Offeror shall identify potential fees, licensing and other requirements that will be part of the data analytics and reporting services as part of the maintenance agreement.

o Offeror’s Response:

Task 18 Transition Plan The vendor will participate in transitioning hosting to another entity at the end of the contract period, unless the contract for hosting is renewed. This will include developing and delivering a comprehensive Transition Plan in coordination with DOH and the new vendor.

Performance Requirements

1) This plan will identify and document the activities needed to seamlessly migrate the NM APCD data to the new vendor’s platform.

2) The plan will ensure longitudinal data integrity from the existing data at the end of the contract period to future years of data collection.

• The Offeror shall propose a comprehensive approach for developing a Transition Plan, including specific elements to be addressed in the plan. The Offeror is encouraged to describe experience in transitioning healthcare data from another vendor to their system

III. Required Task - Conversion The Offeror shall describe their proposed approach to transitioning data submitters to a new data submission process and conversion of data from the existing NM APCD.

Performance Requirements

1) Provide a detailed Data Submission Guide to assist data suppliers and that specifies the APCD-CDLTM as the required data submission format.

2) Perform payer outreach, onboard/register data submitters, establish and implement test file submission, quality assurance and payer feedback processes.

3) Create a secure online portal to collect claims files from payers on an ongoing basis.

4) Provide detailed instructions, training, and technical support for NM APCD data submitters and NM DOH staff.

5) Obtain and process historical raw data (2020–2025) files from the current vendor.

6) Develop processes to collect, transform and process ongoing data submissions from commercial payers, Medicaid, and Medicare (CMS).

7) Produce detailed documentation and provide NMDOH staff training for all aspects of new

APCD payer onboarding, data submission, and data conversion processes.

• The Offeror shall propose a detailed approach and timeline for transitioning data submitters to a new data submission process and for acquiring and converting data from the existing NM APCD into the proposed system.

IV. Required Tasks - Analytics, Reporting and Presentation DOH must be able to respond to a broad range of stakeholder requests for information based on the APCD. For example, DOH may be asked to inform legislators on cost and utilization of specific services or they may be asked to provide public health information for federal reporting. DOH is also required to create cost and quality comparison reports by geography, provider, or, perhaps, payer.

The offeror shall support the DOH analytic capacity to meet those needs quickly and efficiently by creating and maintaining an Analytics Environment.

DOH is open to a variety of possibilities for meeting this goal, including, but not limited to, a vendor that chooses to provide analytics and reporting services on their own system, a vendor that provides a tool-kit or set of programs that DOH can implement on an internally hosted system, or a variety of other approaches. Any proposed solution for creating the Analytics Environment shall allow DOH staff and other stakeholders to create reports and perform analysis using a variety of analytical / query tools (e.g. SAS, SQL Server Management Studio, etc.) as described in the following tasks.

Scope of Work Required Tasks for Analytics, Reporting and Presentation

Task 1 Consult on Development of an Analytics Master Plan The vendor will develop a comprehensive Analytics Master Plan that will guide the overall analytics approach for internal and external use of the NM APCD based on input from DOH and other stakeholders.

Performance Requirements

1) The Analytics Master Plan will support the development of an Analytics Environment that is optimized for ease of use by users with varying needs and skill sets.

2) At a minimum, the plan will:

a. Describe how data produced by the vendor will be accessed, extracted, or transferred into the Analytics Environment;

b. Outline data quality control processes for specific use-cases identified in consultation with DOH;

c. Describe how hosting needs will be addressed;

d. Address user access controls;

e. Identify any licensed software or other tools to be used;

f. Describe how data extracts or data marts can be developed to support identified analytic goals;

g. Identify specific standard analytic reports that will be generated by the analytics and reporting services and the corresponding frequency;

h. Include documentation and training for data users in the Analytics Environment;

i. Define strategies for data back-up, disaster recovery (including system failure response/ recovery times), and secure data disposal; and

j. The plan will be based on a fully mastered dataset that will be provided by the data management services.

Required Bid Elements:

• The Offeror will describe an approach for collaborative work with the DOH analytics team to develop the Analytics Master Plan.

o Offeror’s Response:

Task 2 Implementation of the Analytics Master Plan The vendor will implement key elements of the Analytics Master Plan in coordination with DOH.

Performance Requirements

1) DOH recognizes that many elements of the Plan and the division of roles between the vendor and DOH will depend on the nature of the Analytics Environment proposed. The final details of many arrangements will be determined as part of the Analytic Master Plan as outlined in the previous task. However, DOH is interested in understanding how the vendor would propose that the following specific tasks be approached, at a minimum:

a. Monthly and within no more than thirty days of the availability of the data in the Data store, ensure access to the updated NM APCD data and refresh the data available in the Analytics Environment.

b. New and/or modified data loaded incrementally into the Analytics Environment, and the offeror shall ensure point-in-time reporting capabilities are built into this layer.

c. After each refresh, perform a final review of the data available in the Analytics Environment and obtain DOH approval prior to the data being made available to internal and external stakeholders.

d. DOH will approve the final Analytics Master Plan and future changes to it.

2) The vendor will produce a set of standard data sets with documentation that can be released to qualified users for allowable purposes. For each standard data set, the vendor will produce meta-data and a data dictionary that documents applied edits and summary statistics. This will include both Limited Data Sets and Research Data Sets.

• The Offeror will describe in detail how these required functions of the Analytics Master Plan will be met in their proposed Analytics Environment and the associated timelines.

o Offeror’s Response:

• As part of the finalist presentation, the Offeror shall be prepared to showcase at least three standard reports demonstrating the depth of their solution’s capabilities.

Task 3 Analytic Reporting Platform

Performance Requirements

1) Produce a set of analytic reports, based on data available in the NM APCD Data store.

Examples may include reports, such as:

a. Emergency Department visits by region and facility;

b. Inpatient hospital admissions that result in 30-day readmissions by age, sex, plan type, and disease condition; or

c. Variation between highest and lowest paid providers by procedure codes, sites of care, and provider types.

d. Any reports that align to the Use Case interest areas defined by NM Stakeholders listed below:

Use Case Domain

Policy and Budget Information

- Program Evaluation

- Budget Planning

- Targeted Savings Interventions

Regional Variation

- Rural, Urban, Frontier comparisons of utilization, pricing, quality

Health Care Payment Reform

- Medical Home Effectiveness

- Value-based Care

- Network Adequacy Analysis

- Patient Utilization Patterns

Utilization of Services

- ED Overuse

- Risk Adjustment

Population Health

- Chronic Disease Prevalence/Costs

- Mental and Behavioral Health

- Health Care Disparities

Quality

- Readmissions

- Risk Adjustment

Consumer Price and Quality Transparency

- Public Portal/Website

• Offerors shall describe their data analytics expertise, including developing dashboards, public reports, research and conference presentations for health economics and health services research projects relevant to state data projects. Offerors will describe experience of communicating data analytics deliverables to health care stakeholders including technical and non-technical audiences.

o Offeror’s Response:

• The Offeror shall describe their methodology and experience in developing standard analytic reports.

o Offeror’s Response:

• The Offeror shall be prepared to demonstrate at least three standard reports showcasing the depth of their solution’s reporting tools and capabilities.

o Offeror’s Response:

• The Offeror shall describe their process for managing requests for new reports.

Task 4 Patient Attribution Methodology The vendor will provide a flexible methodology and tool to allow DOH to quickly and easily attribute patients to providers based on specified paradigms.

Performance Requirements

1) The patient attribution methodology must be adaptable for varying requirements such as:

a. Assigning patients to providers based on an acute care incident or episode (e.g., upper respiratory infection).

b. Assigning patients to the provider or providers responsible for managing a chronic condition (e.g., diabetes or asthma).

2) The patient attribution methodology shall be capable of designating a single, primarily responsible provider.

3) The patient attribution methodology shall be capable of producing patient-level granularity so that an analyst could determine why any given patient was assigned to a particular provider.

• The Offeror shall describe the functionality of the patient attribution methodology and proposed algorithms (if not proprietary) including a description of business rules and how they can be adjusted as needed.

o Offeror’s Response:

Task 5 Attribute Providers to Groups or Work Sites The vendor will provide a flexible methodology and tool to allow DOH to quickly and easily assign physicians (or other types of providers) to a group, clinic, or work site.

Performance Requirements

1) The provider attribution tool shall contemplate and incorporate solutions for providers that practice at multiple work locations (hospitals, clinics, offices, etc.).

2) The provider attribution tool shall provide a level of granularity that would allow an analyst to determine why any given provider was assigned to a group or work site.

• The Offeror shall describe the functionality of the provider attribution methodology including a description of how business rules are incorporated and can be adjusted as needed.

o Offeror’s Response:

Task 6 Construction or Programming of Quality Metrics The vendor will construct or program useful provider quality comparison metrics as defined by DOH that DOH can publish and disseminate.

Performance Requirements

1) The quality metrics shall be standard metrics that are designed to be calculated using administrative data only and can be constructed using claims data. DOH may also define metrics for comparisons

2) For each quality metric, DOH analysts must be able to observe whether a given person or event was included in the calculation (numerator or denominator) and why they were included or excluded from the metric.

3) DOH prefers that the vendor have an existing portfolio of metrics that can be easily calculated as needed. It is also acceptable, but not preferred, for a vendor to provide custom programming for each metric as requested.

4) The quality metric capacity of the offeror shall be flexible to be able to incorporate or add metrics associated with emerging value-based payment models.

5) The vendor may choose to provide tools that can be implemented on the DOH platform or they may propose to load an analytics file or files that would allow the metrics to be created on their own platform as long as DOH has access to the final measures at a granular level.

6) The offeror shall be able and willing to update any given metric as standards change.

Required Bid Elements:

• The Offeror shall describe their experience calculating quality metrics.

o Offeror’s Response:

• The Offeror shall describe their proposed solution for allowing DOH to easily create and publish required quality metrics.

o Offeror’s Response:

• The Offeror will be prepared to demonstrate any reporting tools or other mechanisms for communicating information about quality metrics in the Finalist Presentation.

Task 7 Quality Control The vendor shall ensure that the data used in the output of any methodology or tool is suited for each use case.

Performance Requirements

1) The Offeror shall develop and implement quality control processes that assesses the adequacy and quality of the enhanced data provided for use-cases identified in the Analytics Master Plan.

2) The vendor will propose steps to remediate any data quality issues identified during the quality control assessment.

3) The vendor will deliver findings to DOH and take any necessary action to improve the quality and completeness of source data.

4) The vendor shall ensure that any metric or summary information that is reported dynamically can also be made static if needed.

• The Offeror shall describe their experience with data quality control for specific use-cases, preferably in areas of interest identified in the Analytics and Reporting section of this RFP.

o Offeror’s Response:

• The Offeror shall describe how data quality information is communicated to data managers, stewards, and users/analysts.

Task 8 Open Source or Licensed Tools The vendor will disclose to DOH the specifics of any open source and licensed tools used in their proposed solution and provide assurances that the use of those tools is sustainable and cost effective.

Required Bid Elements:

• The Offeror shall describe the ownership of all tools in the proposed solution.

o Offeror’s Response:

• For any open-source tools, the Offeror shall describe governance of the tool and the availability of technical support to both the vendor and DOH.

o Offeror’s Response:

Task 9 Ongoing Software Maintenance The vendor will provide maintenance and operation of the Analytics Environment throughout the contract term, including paying all fees associated with updating and amending the Analytics Environment as needed and providing promised software, licenses, and hardware required to fully support the required functionality.

Required Bid Elements:

• The Offeror shall identify potential fees, licensing and other requirements that will be part of the data analytics and reporting services as part of the maintenance agreement.

o Offeror’s Response:

Task 10 Cost and Quality Consumer facing Webtool The vendor will implement a standard methodology or tool that calculates the cost information for consumers that would be included in a consumer-facing website.

Performance Requirements

1) Develop a methodology (or implement existing methodology) to develop cost reporting for consumers for selected services, in a public-facing website.

2) The vendor shall provide technical assistance and documentation to DOH users.

Required Bid Elements:

• The Offeror will describe their experience and qualifications for developing a consumer-facing website.

V. Desirable Task - Additional Services Desirable Responses: All Offerors are asked to propose solutions for the following Additional Services. The quality and creativity of the proposed additional services will be included in the technical score; however, the cost of additional services will not be included in the cost score.

Offerors may decline to propose a solution for some of the Additional Services. If declining, please indicate the services not being addressed in the proposal. DOH will have the option of requiring the winning Offeror to perform some, all, or none of the proposed additional services depending on needs and available budget. DOH will work with the vendor to develop an approach to implementing the following Additional Services.

Additional Services: Data Management

Task 1 Indian Health Service (IHS) Data The vendor will collect Indian Health Services (IHS) data directly from payers in New Mexico.

Performance Requirements

1) Collect the IHS data from New Mexico Payers

2) Map and transform IHS data to an input structure that is compatible with the vendor’s data intake system.

3) Meet IHS requirements for data access and security, as agreed upon between DOH, HCA, and HIS.

Required Bid Elements:

• The Offeror will describe their experience or proposed process for working with IHS data and mapping IHS data into the states APCD.

o Offeror’s Response:

• The Offeror will agree to meet collection and management requirements for data security and storage.

Task 2 Workers’ Compensation Data The vendor will collect Workers’ Compensation data directly from commercial payers in New Mexico that process worker compensation claims.

Performance Requirements

1) Collect Workers’ Compensation data directly from commercial payers.

2) Map and transform Workers’ Compensation data to an input structure that is compatible with the vendor’s data intake system.

3) Keep Workers’ Compensation data isolated as needed or required for proper handling and purposes of data release or analysis.

4) Meet Workers’ Compensation requirements for data access and security, as agreed upon.

• The Offeror will describe their experience or proposed process for working with Workers’ Compensation data and mapping this data into the state APCD.

o Offeror’s Response:

• The Offeror will agree to meet collection and management requirements for data security and storage.

Task 3 Alternative Payment Model Data The vendor will provide a suggested methodology to collect data from submitters on reimbursements made through alternative payment models or non-claims payments, such as incentive payments for providing high-quality and cost-efficient care in New Mexico.

• The Offeror will describe their experience with or proposed process to collect alternative payment model of non-claims payment data.

Additional Services: Data Analytics

Task 4 Episodes of Care Reporting The vendor will provide a methodology and tool that joins individual claims into an episode of care based on a chronic condition or acute encounter.

Performance Requirements

1) The vendor should anticipate that the episode of care tool will be run on each database refresh and have the output captured in the database for future use.

2) The episode of care tool should allow patients with multiple conditions to be grouped into multiple episodes.

3) The episode of care tool should be capable of producing custom episodes of care for specific research and public health purposes.

4) The output of the episode of care tool should be captured into the database for easy use by analysts and researchers.

• The Offeror should describe the methodology and logic behind their episode of care tool and clearly explain how data users could create new episodes based on specified criteria.

o Offeror’s Response:

• The Offeror will be prepared to demonstrate any reporting tools or other mechanisms for communicating information about episodes of care in the Finalist Presentation.

Task 5 Total Cost of Care Reporting The vendor will implement a standard methodology or tool that calculates the total cost of care for a given patient or set of patients.

Performance Requirements

1) The total cost of care tool shall include the following basic functions:

a. Calculate a total risk adjusted inpatient, outpatient, professional, and pharmacy cost for each person in the database.

b. Identify and flag outliers.

c. Allow the user flexibility to attribute the patient to a…