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(T1) Standard Case Workflow
| Standard Case Workflow | | | | |
| Customer Case Creation Workflow Example | | | | |
| Workflow | | | | |
| Req No | Workflow Process | Demo Use Case Traceability | User Story | Core / Specialized / Other | |
| UW1 | Intake | 1 | The system shall allow the customer access to the Case Submission Portal | Core |
| UW1-a | Account Creation | 12 | The system shall provide the ability to the Customer to create a user account and setup Multi Factor Authentication | Core |
| UW1-b | Account Creation | 12 | The system shall provide the ability to the Customer to log in to the Case Submission Portal | Core |
| UW2 | Intake | 5, 6 | The system shall provide the ability to the Customer to choose to enter information for themself or on behalf of another (authorized advocate) | Specialized |
| UW3 | Intake | 1 | The system shall indicate the mandatory fields and documents that are required for case submission | Core |
| UW4 | Intake | 1 | The system shall assure that demographic data is entered into case submission | Core |
| UW5 | Intake | 1 | The system shall have the ability to guide the customer through a case submission wizard that validates data at the point of data entry and validates that all required documents are attached | |
| UW6 | Intake | 1 | The system shall provide the customer the ability to upload both required and optional documents to the case | Core |
| UW7 | Intake | 1 | The system shall create a case once all data validations pass and all required documents are attached | Core |
| UW8 | Account Creation | 12 | The system allows users who have created an account in the portal to be able to log in, view status and other attributes to the case, engage in case activities based on their role and permissions. | |
| Core | | | | |
| Case Analyst Case Management Workflow Example | | | | |
| Workflow Req No | Workflow Process | Demo Use Case Traceability | User Story | Core/ Specialized / Other |
| AW1 | Create Case | 9, 10, 15 | The system auto assigns the case to a Case Analyst or a Team Queue based on auto assignment rules. | |
If assigned to a Case Analyst, an email notification is sent to the analyst (case is assigned) If assigned to a Queue, an email notification is sent to all members of the queue If assigned to a Queue, a member of the Queue accepts the case (case is assigned) Specialized Other Mandatory
| AW2 | Create Case | 7, 10 | The system shall notify the Analyst when a case is assigned to them or when a response comes in/action is needed | Core |
| AW3 | Screen Case | 10 | The system allows the Case analyst to review case detail, case notes and all documents | |
| Core | | | | |
Other Mandatory AW4 Screen Case 1 By default, the system shall only allow DMHC to view documents submitted by a customer. However, case managers shall have the ability to share documents with other role players in a case workflow on an ad hoc basis (as needed) Specialized Other Mandatory
| AW5 | Screen Case | 16 | The system shall allow the Case Analyst to search the Knowledge Management System for information that may assist them in resolving the case | Core |
| AW6 | Screen Case | 11 | The system shall allow the Case Analyst to search using various filters and sort the results as needed, to determine if there are similar cases that require research | Core |
Other Mandatory
| AW7 | Screen Case | 11 | The system shall provide the ability for Case Analysts to create and save search criteria in "My Searches" to allow re-execution of saved searches | Core |
| AW8 | Request/Receive Information | 1 | The system allows Case Analyst to identify and link the Health Plan (third party) to the case record | Specialized |
| AW9 | Request/Receive Information | 10, 14 | The system allows Case Analyst to send an email to the customer to gather more information and/or documents | Core |
| AW10 | Manage Case | 10, 14 | The system allows the Case Analyst to update a due-date field to extend the time for submission, by upto 5 days | Core |
| AW11 | Manage Case | 7 | The system shall provide the Case Analyst the ability to access and use templated emails (pre-configured in the system) and case notes to speed up the time used in the analysis/triaging of a case. | |
| Core | | | | |
| AW12 | Request/Receive Information | 10, 14 | The system shall allow the Case Analyst to send a Request for Information (RFI) PDF fillable document to a Business Organization (Health Plan) that will be involved in the case, in order to acquire a formal response that pertains to the case. This can include more information and/or documents. (DMHC is also interested in methods to facilitate RFI via a web form instead of PDF document) | Specialized |
| AW13 | Triage Case | 10, 14 | The system shall allow the Case Analyst to review responses to provided by an RFI response, and either accept the response or reject the response, and then route it back to the Business Organization for additional response. | Specialized |
| AW14 | Analyze Case | 10, 15 | The system shall allow the Case Analyst to review all final responses and documents, resolve the case and set the disposition of the case. | Core |
| AW15 | Resolve Case | 15 | The system shall route the case to the Case Manager for review and approval of final disposition | Core |
| AW16 | Resolve Case | 7, 10 | The system shall allow the Case Manager to either approve and close the case or re-route it back to Case analyst for more work | Core |
| AW17 | Resolve Case | 7, 10 | Upon case close, the system shall notify all parties to the case that it has been closed and include the final disposition | Core |
| AW18 | Reporting | 17 | The system shall allow the Case Analyst to create and run customizatble queries and ad-hoc reports at any time during and after the case workflow | Core |
(T2) Specialized Case Workflow
| Specialized Case Workflow | | | | |
| Workflow Req No | Workflow Process | Demo Use Case Traceability | User Story | Core / Specialized / Other |
| PCSB1 | Intake | 1 | The system shall allow the customer access to the Case Submission Portal | Core |
| PCSB1-a | Account Creation | 12 | The system shall provide the ability to the Customer to create a user account and setup Multi Factor Authentication | Core |
| PCSB1-b | Account Creation | 12 | The system shall provide the ability to the Customer to log in to the Case Submission Portal with Multi Factor Authentication | Core |
| PCSB2 | Intake | 5, 6 | The system shall provide the ability to the Customer to choose to create a case for themself or on behalf of another person | Specialized |
| PCSB3 | Intake | 1 | The system shall have the ability to guide the customer through a case submission wizard that validates data at the point of data entry and validates that all required documents are attached | |
| PCSB4 | Intake | 4 | The system shall provide the ability to the customer to classify and upload both required and optional documents that will be attached to a case. In addition, the user can bulk upload upto 50 claims documents (claims are payments for services rendered) | Specialized |
| PCSB5 | Intake | 4 | The system shall have the ability for Customer to upload documents to support multiple sub-cases inside a case (a case may have multiple sub-cases in it) | Specialized |
| PCSB6 | Intake | 1 | The system shall provide the ability to the customer to submit a case once all data validations pass and all required documents are attached, including bulk submissions of claims documents | Core |
| PCSB7 | Create Case | 1 | Case is created | Core |
| PCSB8 | Analyze Case | 10 | The system shall auto assign the Parent Case and its linked Child Sub-cases to a Case Analyst or a Team Queue (where a member of the team takes ownership of the case) | |
| Core | | | | |
| PCSB9 | Sub-Case | 10 | The system shall allow a Case Analyst and/or Case Manager to dispatch (re-assign) the Parent Case and its Sub-cases to Case Analysts for fulfillment | Specialized |
| PCSB10 | Resolve Case | 10, 15 | The system shall provide the ability for Case Analysts to review and make determinations for each claim assigned via sub-case, and then set a sub-case status that indicates to the Parent case analyst that their actions are complete | Core |
| PCSB11 | Communicate Case | 7, 9, 10 | The system shall notify the Parent case analyst by email when each Child sub-case is completed | Specialized |
| PCSB12 | Sub-Case | 15 | The system allows Parent case analyst to review the sub-case dispositions, take any required action, communicate back to the customer and resolve/close the case and sub-case(s) | |
| Specialized | | | | |
| PCSB13 | Resolve Case | 12 | The system allows users who have created an account in the portal to be able to log in, view status and other attributes to the case, engage in case activities based on their role and permissions. | |
| Core | | | | |
(T3) Specialized Capabilities
| Specialized Case Management Capabiities | | | | |
| Workflow Req No | Workflow Process | Demo Use Case Traceability | User Story | Core / Specialized / Other |
| OM1 | Close Case | 8 | The system shall auto-close cases when a Customer fails to respond to an RFI within 7 days | Specialized |
Other Mandatory OM2 Analyze Case 9, 13 The system shall allow the Case Analyst to view case information and search associated cases and subcases for information, including content of the associated documents (meta data and content) Specialized Other Mandatory OM3 Analyze Case 14 The system shall allow the Case Analyst, Case Manager or other associated party to the case to enter notes Specialized Other Mandatory OM4 Intake 1 The system shall enable Case Analysts to upload a scanned PDF case intake form, process it through OCR, and populate required case data in support of streamlined case creation.
| When a form does not contain all the required information to create a case, or the OCR fails to identify required data, the case would be created and then assigned to an Analyst or queue for further processing. | Specialized | | | | |
| OM5 | Intake | 9 | The system shall allow Case Analysts to link cases (or auto link cases via businss rules) that are of similar type, and provide a view of all such linked cases. | Specialized |
| OM6 | Intake | 14 | The system shall enable detailed audit log for all cases; Include the following: | |
| Status Changes (Status changed from X to Y) | | | | |
| Case Data changes (changed name from X to Y) | | | | |
| Internal Notes (not visible to the customer) | | | | |
| External Notes (visible to DMHC and the customer) | | | | |
| Inbound / Outbound Emails | | | | |
| Journals | | | | |
| Sub-case information, Analyst information, date/time of assignment | | | | |
| Core | | | | |
| OM7 | Intake | 1 | The system shall have the ability to handle uploads of files up to 100MB. (Solution to demonstrate largest file upload that they can handle) | Specialized |
| OM8 | Analyze Case | 7 | The system shall have the ability to be configured to provide email notifications to any case stakeholder (analyst, consumer, third party) that are automatically sent when event criteria are met, such as case status change, data change etc | Core |
Other Mandatory OM9 Request/Receive Information 7 The system shall have the ability to be configured to provide email reminders to any case stakeholder (analyst, consumer, third party), that are automatically sent when event criteria are met, such as RFI due in 3 days, RFI due today, RFI past due etc (RFI is Request for Information) Core Other Mandatory
| OM10 | Analyze Case | 11 | The system shall have the ability to open documents from within the solution without having to first download the documents. (e.g. when clicked, PDF files open in Adobe Acrobat, Word documents open in Microsoft Word, etc) | |
| OM11 | Analyze Case | 11 | The system shall provide the ability for Case Analysts to search and filter for cases using Customer Name, Customer Date of birth, or other Customer information in order to find systemic/related issues and merge duplicate issues | Specialized |
| OM12 | Analyze Case | 15 | The system shall provide Case Managers with the ability to review a Workload Dashboard for their direct report Case Analysts, to view case workloads across the team and utilize the dashboard to level workload across all their team members | |
| The system shall provide Case Analysts and Case Managers with the ability to utlize reports that are pre-configured within the solution. | Core | | | | |
| OM13 | Resolve Case | 7 | The system shall provide the ability for a Case Analyst and/or Case manager to send email communication to customers or others, from a closed case | Core |
| OM14 | Screen Case | 1 | The system shall provide the ability for a Case Analyst and/or Case manager to dispatch a case to an independent third party review organization for review and recommendations | Specialized |
| OM15 | Third Party Referral | 1 | The system shall provide the ability for a third party organization, with whom they have shared a sub-case, to be able access that sub-case, review sub-case information and perform actions within shared sub-case, as required. | Core |
| OM16 | Optional | N/A | The solution shall describe/demonstrate Microsoft Teams Integration with the Case Management platform | |
| OM17 | Optional | N/A | The solution shall describe/demonstrate AI Capability that has been implemented as part of the Case Management platform | |
| OM18 | Manage Case | 7 | The system shall enable Case Analyst to generate a data-merged word document, populated with data from the case, into a Word Template | |
| OM19 | | N/A | The system shall be compliant with Accessibility Requirements for users that require assistive technology (WCAG 2.1 at minimum) | |
| OM20 | Manage Case | 11 | The system shall provide the ability to Case Analyst to view, from within a case, other similar cases that have similar traits, such as email | Specialized |
Other Mandatory
(T4) Mid Level Reqs Mapping
| Demo Use Case to Mid-Level Requirements Traceability | | | | |
| Demo Use Case ID | Demo Use Case | Business Process | Mid Level Requirement Traceability ID | Mid Level Requirement |
| 1 | Self-Service: Submitter interacts with a self-service complaint intake portal and the submitter is guided through the submission process. When the consumer gets to the end of the submission process, all the necessary components are validated including missing documents or pages. | Intake | 1 | Guide users through complaint management process steps via guided workflows and prompts. |
| | Intake | 3 | Upload and download attachments and communcations associated with case. |
| | Intake | 4 | Edit check data entry fields, as fields are populated. |
| | Intake | 12 | Validate that required fields are populated and required documents are uploaded prior to submission. |
| | Intake | 14 | Provide OCR ability for paper intake form submissions. |
| 2 | Expedite Process: Complaint has an immediate need for medical input (i.e.: requiring a triage process to a clinical nurse for an immediate response) | Intake | 17 | Configure criteria that activates a trigger for staff action or automated process, such as a complaint requiring immediate attention "expedite", or a violation based on days late. |
| | Create Case | 28 | Link related cases including closed cases according to configurable criteria such as complaint contact, same health plan, family of cases, mutiple consumers, or are connected but have separate needs/health plans per enrollee. |
| | Create Case | NF-8 | Transmit, store, upload/download files, audio files, and video files up to file size of XXX MB. |
| | Create Case | 35 | Capture demographic consumer data |
| | Create Case | 40 | Provide staff the ability to flag documents as confidential. |
| | Create Case | 44 | Associate document(s) to multiple cases or case families |
| | Create Case | 14 | |
| 3 | Education: The public has self-service access to online FAQs, consumer rights with health plan and provider education materials, and health plan processes | Education | 5 | Centrally integrate educational resources within solution for ease of interaction with DMHC complaints process. |
| * part of self service process where you offer help for questions; FAQs | Knowledge Base | 22 | Integrate easy to navigate and search knowledge management information within the system such as desk references, agent guided responses, policies and procedures, legislative information, and applicable laws/compliance such as Knox-Keene Act. |
| 4 | Bulk Submission: Provider submissions can accommodate bulk claims complaints in an easily managed way for DMHC staff and the submitter. | Create Case | 38 | Accept batch loads of cases from a single provider. |
| ** tie this in with Self Service | Create Case | 43 | Provide templated language, reports, letters, notifications, notes, and summaries for consistent and common communications, with the ability to auto-populate specific template fields. |
5 Third-Party Submitter: DMHC can confirm the legitimacy of the third-party submitter
6 Advocacy: Advocates can represent many different complainants and/or represent a single complainant that submits multiple complaints. Common information should be automatically populated. Advocate should be flagged for easy identification Intake 8 Clear indication of an advocate-submitted claim and who the advocate is.
| 7 | Notifications: Autogenerated and templated communications/notifications to submitters and users (internal system alerts communications) within the solution | Communicate Case | 43 | Provide templated language, reports, letters, notifications, notes, and summaries for consistent and common communications, with the ability to auto-populate specific template fields. |
| | Communicate Case | 83 | Auto-generate notifications based upon configurable criteria. |
| | Communicate Case | 69 | Automate the process of sending/receiving information requests and templatized requests, along with the abilty to retract the request. |
| | Communicate Case | 88 | Reject a response and notify the sender why it was rejected. |
| | Communicate Case | 36 | Provide alerts for case action due dates, reminders, process status changes, information requests, subcase left open, and other determined calls to action. |
| | Communicate Case | 61, 83 | Notify staff when cases are assigned to them. |
| 8 | Determination Indicators: Case data signals quick processing determinations for staff (i.e.: auto close, expedites, jurisdiction of case processing ability). Staff processing is guided via business rules | Create Case | 36 | Provide alerts for case action due dates, reminders, process status changes, information requests, subcase left open, and other determined calls to action. |
| | Resolve Case | 77 | Auto-close a case based on configurable criteria. |
| 9 | Role-Based Case Access: Multiple state staff will need to simultaneously input information into the case(s), and all need to know the cases that are linked. Advocate notifications provided in addition to staff. | Triage Case | 58 | Configurable and automatic assignment management based on criteria such as role and skill, availability, workload and case characteristics with the ability to create assignment groups. |
| | Triage Case | 58 | -same as above- |
| | Analyze Case | 100 | Allow simultaneous case viewing, analysis, and editing by multiple users without having to take ownership of the case. |
| 10 | Staff Assignment: Staff assignments are systematically established based on program needs and where needs are easily flexible based on staff availability. Escalations are visible in real-time for assignment threshold breaches (i.e. case sits too long without engagement) | Analyze Case | 58 |
| | Triage Case | 14, 58 |
| 11 | Searching/Filtering: Staff need visibility into past and current cases for knowledge input and case duplication abilities. Including document content and query case based on field parameters. | Analyze Case | NF-6 | Search case documents without opening each document. |
| | Information Resource | 59 | Manage, search and filter/sort current and closed/archived cases with the ability to save search criteria. |
| | Information Resource | 56 | View documents within the system and preview documents without opening. |
12 Status and Real-Time Awareness: Submitters and staff need transparency of case status, timeline, and communications timely and customizable. Create Case 24 Provide transparent end-to-end case processing via case status, case category, progression visibility, required timeframes, including time between statuses or between processes.
| 13 | Role-Based Case Access: For DMHC external partners working on cases, such as third-party reviewers or legal teams, there is limited access to the original case that supports their ability to analyze and provide feedback. | Analyze Case | 78 | Refer/subcase Knox-Keene Act violations or other issues to the Office of Enforcement and Office of Financial Review. |
| | Communicate Case | 32 | Provide in-system messages between staff and consumers, providers, DMHC offices working subcases, and Review org. |
| 14 | Case Logging: Staff need to know who contributed to case(s) at any time and easily update cases without official case routing requirements. | Analyze Case | 101 | Allow all users to add case notes. |
| | Communicate Case | 96 | Edit notes with an automatic logging into a viewable change history. |
| 15 | Case Auditing: Identify cases for manager review, complexity, data quality/consistent data. Auto-select cases for manager audit. | Screen Case | 36, 37 | |
| | Analyze Case | 62 | Provide customizable, sortable/filterable staff dashboard containing case and workload information. |
16 Knowledge Base: Staff have access to process and procedure tooltips and knowledge base information for case processing. Knowledge Base
| 17 | Resource Dashboards / Reporting: Scheduled and ad-hoc of staff workloads, case prioritizations, availability, case flagging, case assignments, case closure types and duration times for processing and submitter attributes. | Reporting | 62 | Provide customizable, sortable/filterable staff dashboard containing case and workload information. |
| | Reporting | 118 | Create and run customizable queries and ad-hoc reports. |