Appendix H - Business Support Services - Concept of Operations ConOps Diagram.pdf
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- Solicitation number
- BD-26-1039-EHS01-ASHWA-128591
- Issued by
- Suffolk County, Boston City, Massachusetts
About this file
This file is a Concept of Operations (ConOps) diagram for Business Support Services (BSS) provided to the Executive Office of Health and Human Services (EOHHS) and the Centers for Medicare & Medicaid Services (CMS) in Massachusetts. The diagram illustrates the comprehensive service delivery model for provider enrollment, credentialing, onboarding, reevaluation, training, education materials, fraud waste and abuse monitoring, and audit services. Key services include maintaining accurate provider lists and data, managing the provider enrollment process for Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs), processing provider claims through EDI certification and paper submission methods, ticket tracking, mailing and fulfillment operations, and operating provider portals for both authenticated and unauthenticated access. The BSS vendor solution integrates with multiple systems including the MMIS base application, document storage (EDM), a learning management system, provider data analytics, and external partners such as Optum for LTSS operations, DentaQuest for dental services, MedImpact and a new pharmacy vendor for pharmacy services, and Mercer for call center operations.
The ConOps diagram maps data flows and connections between the BSS vendor, EOHHS, CMS, MCEs, ACOs, external trading partners, and members through multiple channels including SFTP, web services, HIPAA EDI transactions, and site-to-site tunnel connections. The system facilitates the exchange of claims data, member data, provider enrollment information, provider credentials, and acknowledgement transactions. Integration points include connections to Mass.gov, the MassChoices portal, the new member portal, the virtual gateway/AIMS system, transportation systems, contact centers, and the CRM system. The diagram does not specify pricing terms, contract duration, award dates, or renewal options within the visual representation provided.
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Text version
EOHHS
CMS
MES
metrics
SFTP and or Web Services •Claims Data •Member Data •Provider Data Provider enrollment Service
SFT
EDME
Provider/ Trading Partners
Services Provided by BSS Vendor:
➢Provider Enrollment, credentialing & onboarding, reevaluation ➢Provider Training, Education Materials ➢Provider Enrollment Support for MCO and ACO ➢Provider Fraud Waste and Abuse and Audit Services ➢Managed Care provider enrollment process ➢Maintain Accurate Provider List/Data ➢Transportation portal, process and appeals ➢Business Process Support, Print/Mailing Services ➢Provider Claim Operations ➢Claims EDI certification or DDE/Paper submission ➢Trading Partner Procedures: EDI TPT Testing/Communication ➢Provider Complains, Provider Services ➢Ticket Tracking (i.e. JIRA) ➢File Transfer (i.e. MoveIT)
➢TPL via HMS
MCEs Accenture
TPL
Provider Portal Unauthenticated
EOHHS Vendors
Optum LTSS Ops
DentaQuest Dental TPA
MedImpact New
Pharmacy Vendor
Conduit Current
Pharmacy
System Integrations
External Partners
Non-Emergency Transportation System
Contact Center
CRM
Provider Claims
AHS
MH Ops
Call CenterMercer
Business Support Services - Concept of Operations (ConOps) Diagram
BSS Vendor Solution
Mailing/Fulfillment Operations
MMIS -POSC
MMIS -Base Application Site to Site Tunnel
Connection needed
EVS
Morbious Provider Remittances
EDM:
•BSS Document Storage
Provider Portal Authenticated
Provider Portal
DEXEPLSLEIE
Credentialing Entities
Learning Management
System
Provider
Data Analytics
OPTIONAL
MassChoices
IEE My Services Portal (New Member Portal)
Virtual Gateway/AIMS
Mass.gov
HIPAA Transactions (EDI)
Send:
•Provider Enrollment •Provider Credentialing/Revalidation •Provider Files Receive:
•Provider Credential
Send:
•Paper Claims •Claim Waiver Receive:
•Provider Credential
Send:
•Electronic Data Interchange (EDI) transactions •Receive:
•Acknowledgement transaction •Errors
Members
Members
TP / BI / CH
Connection to Mass.gov
Paper Claims
Provider
Provider
| Appendix I - Business Support Services - Concept of Operations (ConOps) Diagram.vsdx |
| MassRx ConOps |
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