DMHC_CalMaCCS_Mid-Level_Requirements.xlsm
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- 0000037114
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- California
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Other files
| File | Type | Posted |
|---|---|---|
| DMHC_CalMaCCS_RFI_Response_Template.xlsx | XLSX spreadsheet | |
| DMHC_CalMaCCS_Demo_Use_Cases.xlsx | XLSX spreadsheet | |
| DMHC_Demo_Use_Case_Workflow.pdf | ||
| CalMaCCS_Request_For_Information.docx | DOCX document |
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Instructions
STATEWIDE INFORMATION MANAGEMENT MANUAL
SECTION 19B.3 MID-LEVEL SOLUTION REQUIREMENTS TEMPLATE TOOL
| PROJECT NUMBER: | 0000-000 | AGENCY/STATE ENTITY NAME: | (Agency/State Entity) |
| The Statewide Information Management Manual (SIMM) 19B.3 Mid-Level Solution Requirements Template tool is provided as a guideline to document functional solution requirements. For functional solution requirements, the fields included in this template are required and must be included in an Agency/state entity's requirement documentation submission. Agencies/state entities may utilize another requirement documentation tool as long as the required fields are included. Additionally, Agencies/state entities may include more fields than those provided in this template. |
INSTRUCTIONS:
Identify the Project Number and Agency/State Entity Name:
In the Instructions tab, enter the Project Number and Agency/State Entity Name. This information will automatically populate on each corresponding "Requirement Type" tab.
Enter requirements:
Enter mid-level solution requirements in the corresponding tab based on the "Requirement Type" (i.e., Functional Mandatory, Functional Desirable, Non-Functional Mandatory, Non-Functional Desirable, Project-Transition Mandatory, Project-Transition Desirable). For additional instructions , refer to the SIMM Section 19B.1 Preparation Instructions Section 2.6.
Note: Footer information may be modified based on Agency/state entity preference.
Create a combined worksheet that displays all requirements:
Click on the "Create Combined Worksheet" button to combine all the requirements from the separate "Requirement Type" tabs (i.e., Functional Mandatory, Functional Desirable, Non-Functional Mandatory, Non-Functional Desirable, Project-Transition Mandatory, Project-Transition Desirable) onto one worksheet. Do not re-select the "Create Combined Worksheet" button if a "Combined" tab already exists, as the automatic combine macro will not function correctly. To ensure proper functionality, first delete the existing "Combined" tab and then select the "Create Combined Worksheet" button to update the combined listing of requirements.
Format the "Combined" tab:
Click on the File Menu tab, select Print. In the Print Menu, use the appropriate drop down arrows to change the "Portrait Orientation" to "Landscape Orientation" and change the "No Scaling" to "Fit All Columns on One Page."
Set Print Area:
Prior to printing from a tab/worksheet, set the Print Area.
To do this, Select the entire area to be printed. Once selected, click the Page Layout Menu tab, then select Set Print Area.
Attach requirements:
Once completed and ready to submit, attach the completed requirements documentation as indicated in Section 2.6.
| REQUIREMENT TYPE TAB |
| Combined requirements = Combined tab (viewable only if the "Create Combined Worksheet" button is used.) |
| Functional Mandatory tab |
| Functional Desirable tab |
| Non-Functional Mandatory tab |
| Non-Functional Desirable tab |
| Project/Transition Mandatory tab |
| Project/Transition Desirable tab |
California Department of Technology SIMM Section 19 Mid-Level Solution Requirements B.3 Mid-Level Solution Requirements Template &P
August 2016
Create Combined Worksheet
Functional Mandatory
| Project Number: | 0000-000 | Agency/state Entity: | (Agency/State Entity) | ||||||
| Obj. Ref. | |||||||||
| (Obj. #) | Requirement Category | Requirement Number | Main Business Capability/Function | Sub Business Capability/Function | Business Process | Requirement | Requirement Type | Priority | Business Owner/ Stakeholder |
| I | 1 | Complaints Management | Consumer Complaints | Intake | Guide users through complaint management process steps via guided workflows and prompts. | Functional | Mandatory | ||
| I | 2 | Complaints Management | Consumer Complaints | Intake | Provide tool tips on data entry fields to specify the information needed. | Functional | Mandatory | ||
| I | 3 | Complaints Management | Consumer Complaints | Intake | Upload and download attachments and communcations associated with case. | Functional | Mandatory | ||
| I | 4 | Complaints Management | Consumer Complaints | Intake | Edit check data entry fields, as fields are populated. | Functional | Mandatory | ||
| I | 5 | Complaints Management | Consumer Complaints | Intake | Centrally integrate educational resources within solution for ease of interaction with DMHC complaints process. | Functional | Mandatory | ||
| I | 6 | Complaints Management | Consumer Complaints | Intake | Accept and associate audio and video files with case. | Functional | Mandatory | ||
| I | 7 | Complaints Management | Consumer Complaints | Intake | Identify/Generate trend data and reports from complaint or payment characteristics. | Functional | Mandatory | ||
| I | 8 | Complaints Management | Consumer Complaints | Intake | Clear indication of an advocate-submitted claim and who the advocate is. | Functional | Mandatory | ||
| I | 9 | Complaints Management | Consumer Complaints | Intake | Streamline & automate the intake and case creation process to be completed within 24 hours | Functional | Mandatory | ||
| I | 10 | Complaints Management | Consumer Complaints | Intake | Validate that required out-of-network medical records are included in the complaint submission. | Functional | Mandatory | ||
| I | 11 | Complaints Management | Consumer Complaints | Intake | Verify if consumer has completed the health plan grievence process prior to complaint submission and provide grievance resolution documentation. | Functional | Mandatory | ||
| I | 12 | Complaints Management | Consumer Complaints | Intake | Validate that required fields are populated and required documents are uploaded prior to submission. | Functional | Mandatory | ||
| I | 13 | Complaints Management | Consumer Complaints | Intake | Autogenerate case upon successful complaint submission. | Functional | Mandatory | ||
| I | 14 | Complaints Management | Consumer Complaints | Intake | Provide OCR ability for paper intake form submissions. | Functional | Mandatory | ||
| I | 15 | Complaints Management | Consumer Complaints | Intake | Incorporate language translation services to consumers when interacting within the system. | Functional | Mandatory | ||
| I | 16 | Complaints Management | Consumer Complaints | Intake | Prevent duplicative contact information from being created. | Functional | Mandatory | ||
| I | 17 | Complaints Management | Consumer Complaints | Intake | 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. | Functional | Mandatory | ||
| I | 18 | Complaints Management | Consumer Complaints | Intake | Validate that complaint submission is signed. | Functional | Mandatory | ||
| I | 19 | Complaints Management | Consumer Complaints | Intake | Specify standard complaints categories for selection. | Functional | Mandatory | ||
| I | 20 | Enforcement Management | OE | Intake | Centralize case documents and files to one location with the ability to tag them for searching/filtering or reporting. | Functional | Mandatory | ||
| I | 21 | Enforcement Management | OE | Intake | Customizable flags/badges of case and/or document information for priority/special viewing and action, for override of data validation, or for routing. | Functional | Mandatory | ||
| AC | 22 | Customer Service Management | Contact Center | Analyze Case | 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. | Functional | Mandatory | ||
| AC | 23 | Customer Service Management | Contact Center | Analyze Case | Guide agent based on IVR data and responses within the consumer's case. | Functional | Mandatory | ||
| C | 24 | Complaints Management | Consumer Complaints | Create Case | Provide transparent end-to-end case processing via case status, case category, progression visibility, required timeframes, including time between statuses or between processes. | Functional | Mandatory | ||
| C | 25 | Complaints Management | Consumer Complaints | Create Case | Provide role-based self-service functionality based on user type. | Functional | Mandatory | ||
| C | 26 | Complaints Management | Consumer Complaints | Create Case | Auto-generate receipt notification immediately upon case creation | Functional | Mandatory | ||
| C | 27 | Complaints Management | Consumer Complaints | Create Case | Require case documentation to adhere to standard workflow and format needs | Functional | Mandatory | ||
| C | 28 | Complaints Management | Consumer Complaints | Create Case | 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. | Functional | Mandatory | ||
| C | 29 | Complaints Management | Consumer Complaints | Create Case | Organize and centralize case communications for faster search and review, and to see when communications were sent/received. | Functional | Mandatory | ||
| C | 30 | Complaints Management | Consumer Complaints | Create Case | Select case data fields for duplication to a new case, eliminating copy/paste. | Functional | Mandatory | ||
| C | 31 | Complaints Management | Consumer Complaints | Create Case | Provide consumer/provider the ability to select preferences for communication channels such as portal, voice call, text, USPS, encrypted, unencrypted communication. | Functional | Mandatory | ||
| C | 32 | Complaints Management | Consumer Complaints | Create Case | Provide in-system messages between staff and consumers, providers, DMHC offices working subcases, and Review org. | Functional | Mandatory | ||
| I | 33 | Complaints Management | Consumer Complaints | Intake | Provide early indication of standard case and IMR needs during complaint Intake. | Functional | Mandatory | ||
| C | 34 | Complaints Management | Consumer Complaints | Create Case | Upload documents and correspondance after case creation without needing to create new case. | Functional | Mandatory | ||
| C | 35 | Complaints Management | Consumer Complaints | Create Case | Capture demographic consumer data | Functional | Mandatory | ||
| C | 36 | Complaints Management | Consumer Complaints | Create Case | Provide alerts for case action due dates, reminders, process status changes, information requests, subcase left open, and other determined calls to action. | Functional | Mandatory | ||
| C | 37 | Complaints Management | Consumer Complaints | Create Case | Set configurable trigger words, conditions, or thresholds that indicate necessary case actions | Functional | Mandatory | ||
| C | 38 | Complaints Management | Provider Complaints | Create Case | Accept batch loads of cases from a single provider. | Functional | Mandatory | ||
| C | 39 | Complaints Management | Provider Complaints | Create Case | Check that required documents are included per the complaint category or circumstancial criteria | Functional | Mandatory | ||
| C | 40 | Complaints Management | Provider Complaints | Create Case | Provide staff the ability to flag documents as confidential. | Functional | Mandatory | ||
| C | 41 | Complaints Management | Provider Complaints | Create Case | Permit staff the ability to opt a new provider complaint into existing trending case types. | Functional | Mandatory | ||
| C | 42 | Complaints Management | Provider Complaints | Create Case | Scope possible data entry selections based on prior data entry selections or business rules. | Functional | Mandatory | ||
| C | 43 | Complaints Management | Provider Complaints | Create Case | Provide templated language, reports, letters, notifications, notes, and summaries for consistent and common communications, with the ability to auto-populate specific template fields. | Functional | Mandatory | ||
| C | 44 | Complaints Management | Provider Complaints | Create Case | Associate document(s) to multiple cases or case families | Functional | Mandatory | ||
| SC | 45 | Complaints Management | Consumer Complaints | Screen Case | Provide customizable workflow automation for case management, routing, reviews, responses and closure needs. | Functional | Mandatory | ||
| SC | 46 | Complaints Management | Consumer Complaints | Screen Case | Provide average estimated process time based on case trend analysis data. | Functional | Mandatory | ||
| SC | 47 | Complaints Management | Consumer Complaints | Screen Case | Refer consumer to appropriate outside entity for non-jurisdictional complaint, quality of care closure, or other redirection need. | Functional | Mandatory | ||
| SC | 48 | Complaints Management | Consumer Complaints | Screen Case | Customize case closure scenarios according to case workflow triggers. | Functional | Mandatory | ||
| SC | 49 | Complaints Management | Provider Complaints | Screen Case | Provide book mark functionality for pinned document content and index of pins. | Functional | Mandatory | ||
| SC | 50 | Complaints Management | Provider Complaints | Screen Case | Provide case data editing and capture chronological edit log history. | Functional | Mandatory | ||
| SC | 51 | Complaints Management | Provider Complaints | Screen Case | Notify case is ready for health plan submission | Functional | Mandatory | ||
| SC | 52 | Complaints Management | Provider Complaints | Screen Case | Allow case prioritization for time sensitivity, urgency, reviewing, or other specified reason. | Functional | Mandatory | ||
| SC | 53 | Complaints Management | Provider Complaints | Screen Case | Provide for advocate submissions on behalf of providers with viewability to only their submitted cases regardless of the number of providers. | Functional | Mandatory | ||
| SC | 54 | Complaints Management | CC Legal Affairs Branch (LAB) | Screen Case | Configurable role-based case codes that are visible in workload queues. | Functional | Mandatory | ||
| SC | 55 | Complaints Management | CC Legal Affairs Branch (LAB) | Screen Case | Track and view case assignments and work queues. | Functional | Mandatory | ||
| SC | 56 | Complaints Management | CC Legal Affairs Branch (LAB) | Screen Case | View documents within the system and preview documents without opening. | Functional | Mandatory | ||
| SC | 57 | Complaints Management | CC Legal Affairs Branch (LAB) | Screen Case | Allow staff to pin or have separate location for case summaries and notes for easy identification and prioritization. | Functional | Mandatory | ||
| T | 58 | Complaints Management | Consumer Complaints | Triage Case | 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. | Functional | Mandatory | ||
| T | 59 | Complaints Management | Consumer Complaints | Triage Case | Manage, search and filter/sort current and closed/archived cases with the ability to save search criteria. | Functional | Mandatory | ||
| T | 60 | Complaints Management | Consumer Complaints | Triage Case | Auto refer to health plan when consumer health plan grievence process has not occurred. | Functional | Mandatory | ||
| T | 61 | Complaints Management | Provider Complaints | Triage Case | Notify staff when cases are assigned to them. | Functional | Mandatory | ||
| T | 62 | Complaints Management | Provider Complaints | Triage Case | Provide customizable, sortable/filterable staff dashboard containing case and workload information. | Functional | Mandatory | ||
| T | 63 | Complaints Management | CC Legal Affairs Branch (LAB) | Triage Case | Allow case to be shared among staff for processing, review, edits. | Functional | Mandatory | ||
| T | 64 | Complaints Management | CC Legal Affairs Branch (LAB) | Triage Case | Dispatch relevant case information based on the needed role participation and needed response to progress the case. | Functional | Mandatory | ||
| T | 65 | Complaints Management | CC Legal Affairs Branch (LAB) | Triage Case | Search, view, edit LAB notes regardless of case assignment history. | Functional | Mandatory | ||
| T | 66 | Complaints Management | CC Legal Affairs Branch (LAB) | Triage Case | Ensure family/related cases are assigned, processed, closed together. | Functional | Mandatory | ||
| AC | 67 | Customer Service Management | Contact Center | Analyze Case | Notify knowledge management users when content has changed. | Functional | Mandatory | ||
| I | 68 | Complaints Management | Consumer Complaints | Intake | Validate that consumer health plan is within the DMHC jurisdiction. | Functional | Mandatory | ||
| RI | 69 | Complaints Management | Consumer Complaints | Request/Receive Information | Automate the process of sending/receiving information requests and templatized requests, along with the abilty to retract the request. | Functional | Mandatory | ||
| RI | 70 | Complaints Management | Consumer Complaints | Request/Receive Information | Provide direct communication to the assigned case analyst or complaints branch. | Functional | Mandatory | ||
| RI | 71 | Complaints Management | Consumer Complaints | Request/Receive Information | Provide ability to initate and store emails and phone calls within the system. | Functional | Mandatory | ||
| RI | 72 | Complaints Management | Consumer Complaints | Request/Receive Information | Send/receive communications using the communication channels specified by the consumer/provider with the communication automatically linked to the case. | Functional | Mandatory | ||
| RI | 73 | Complaints Management | Provider Complaints | Request/Receive Information | Provide health plan the ability to confirm, add, and remove documents. | Functional | Mandatory | ||
| RI | 74 | Complaints Management | Provider Complaints | Request/Receive Information | Provide ability to configure fields to auto-populate or are required, such as the person's name or phone number. | Functional | Mandatory | ||
| RI | 75 | Complaints Management | Provider Complaints | Request/Receive Information | Provide ability to request a date extension for an information request and for the request to be approved/denied. | Functional | Mandatory | ||
| RC | 76 | Complaints Management | Consumer Complaints | Resolve Case | Automate the process of creating, verifying, and sending closing letters using letter templates.. | Functional | Mandatory | ||
| RC | 77 | Complaints Management | Consumer Complaints | Resolve Case | Auto-close a case based on configurable criteria. | Functional | Mandatory | ||
| RC | 78 | Complaints Management | Provider Complaints | Resolve Case | Refer/subcase Knox-Keene Act violations or other issues to the Office of Enforcement and Office of Financial Review. | Functional | Mandatory | ||
| RC | 79 | Complaints Management | Provider Complaints | Resolve Case | Provide QA/Auditing through an automated process and reports. | Functional | Mandatory | ||
| RC | 80 | Complaints Management | Provider Complaints | Resolve Case | Batch recover funds for multiple complaints, when paid on the same check. | Functional | Mandatory | ||
| RC | 81 | Complaints Management | Provider Complaints | Resolve Case | Batch close related cases or cases based on a determined condition. | Functional | Mandatory | ||
| CC | 82 | Complaints Management | Consumer Complaints | Communicate Case | Trigger the autogeneration of templated letters and communcations based on thresholds, analyst/system use, or other specified criteria. | Functional | Mandatory | ||
| CC | 83 | Complaints Management | Consumer Complaints | Communicate Case | Auto-generate notifications based upon configurable criteria. | Functional | Mandatory | ||
| CC | 84 | Complaints Management | Consumer Complaints | Communicate Case | Personally create communications or customize communication templates to specific needs. | Functional | Mandatory | ||
| CC | 85 | Complaints Management | Consumer Complaints | Communicate Case | Integrate explanation of benefits (EOB) calculator and required tools within the system. | Functional | Mandatory | ||
| CC | 86 | Complaints Management | Consumer Complaints | Communicate Case | Track and notify of call back requests. | Functional | Mandatory | ||
| CC | 87 | Complaints Management | Provider Complaints | Communicate Case | Provide detailed chronology and sorting/filtering of case activities/history/notes. | Functional | Mandatory | ||
| CC | 88 | Complaints Management | Provider Complaints | Communicate Case | Reject a response and notify the sender why it was rejected. | Functional | Mandatory | ||
| CC | 89 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Format note text and retain formating when copying/pasting the text. | Functional | Mandatory | ||
| CC | 90 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Send automatic response when consumer email is received regarding a closed case. | Functional | Mandatory | ||
| CC | 91 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Attach specified documents to outgoing emails. | Functional | Mandatory | ||
| CC | 92 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Clear indication of different note types, such as summary notes and phone call notes. | Functional | Mandatory | ||
| CC | 93 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Provide case notifications, alerts, priorities, and required actions within the dashboard. | Functional | Mandatory | ||
| CC | 94 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Color-code cases and notes through customizeable user preferences. | Functional | Mandatory | ||
| CC | 95 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Provide an internal chat function between case workers that can be activated/deactivated and would not be part of the permanent case record. | Functional | Mandatory | ||
| CC | 96 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Edit notes with an automatic logging into a viewable change history. | Functional | Mandatory | ||
| CC | 97 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Provide ability to change subject line of email correspondence. | Functional | Mandatory | ||
| CC | 98 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Save in-progress work as a draft, such as notes, emails, and tables. | Functional | Mandatory | ||
| CC | 99 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Save an incompleted workflow and return to it later with an indication of where you left of. | Functional | Mandatory | ||
| AC | 100 | Complaints Management | Consumer Complaints | Analyze Case | Allow simultaneous case viewing, analysis, and editing by multiple users without having to take ownership of the case. | Functional | Mandatory | ||
| AC | 101 | Complaints Management | Consumer Complaints | Analyze Case | Allow all users to add case notes. | Functional | Mandatory | ||
| AC | 102 | Complaints Management | Provider Complaints | Analyze Case | Enter Issue Summary information and data. | Functional | Mandatory | ||
| AC | 103 | Complaints Management | Provider Complaints | Analyze Case | Redefine the nature of the complaint from the provider's definition. | Functional | Mandatory | ||
| AC | 104 | Complaints Management | Provider Complaints | Analyze Case | Refer/subcase legal issues to the Legal Affairs Branch (LAB). | Functional | Mandatory | ||
| AC | 105 | Complaints Management | Provider Complaints | Analyze Case | Implement a new type of complaint as needed. | Functional | Mandatory | ||
| AC | 106 | Enforcement Management | OE | Analyze Case | Specify the number of documents and the documents associated with the subcase. | Functional | Mandatory | ||
| AC | 107 | Enforcement Management | OE | Analyze Case | Provide in-system help and faq's on how to use the system. | Functional | Mandatory | ||
| AC | 108 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Integrate the LAB memo regarding the violation into the system. | Functional | Mandatory | ||
| AC | 109 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Process SMER Provider complaints and capture SMER data within the system. | Functional | Mandatory | ||
| I | 110 | Customer Service Management | Contact Center | Intake | Allow caller to enter their case number in the IVR system, and route the call/case number to the assigned case analyst. | Functional | Mandatory | ||
| I | 111 | Customer Service Management | Contact Center | Intake | Based on the incoming phone number, determine the associated case, route the call to the assigned case analyst, and display the case on the screen. | Functional | Mandatory | ||
| T | 112 | Medical Review Management | IMR | Triage Case | Auto assign cases to nurses and receive an acknowledgment/acceptance back from the nurse. | Functional | Mandatory | ||
| T | 113 | Medical Review Management | IMR | Triage Case | Require the entry of specific data now captured in notes, such as RHPI received date, and data about why a case was expedited. | Functional | Mandatory | ||
| T | 114 | Medical Review Management | IMR | Triage Case | Send documents to the health plan and consumer before the Review Org to accepts the subcase. | Functional | Mandatory | ||
| T | 115 | Medical Review Management | IMR | Triage Case | Have more than 1 Review Org subcase associated with a case. | Functional | Mandatory | ||
| T | 116 | Medical Review Management | IMR | Triage Case | Auto-confirm that Review Org invoice is correct based on system data/IMR billing reports. | Functional | Mandatory | ||
| AC | 117 | Medical Review Management | IMR | Analyze Case | Enter data now captured in notes, such as post-service vs. pre-service, in-network vs. out of network, etc. | Functional | Mandatory | ||
| R | 118 | Complaints Management | Consumer Complaints | Reporting | Create and run customizable queries and ad-hoc reports. | Functional | Mandatory | ||
| R | 119 | Complaints Management | Consumer Complaints | Reporting | Provide a satisfaction survey for consumer feedback. | Functional | Mandatory | ||
| R | 120 | Complaints Management | Provider Complaints | Reporting | Create, save, and run customizable reports and report formats. | Functional | Mandatory | ||
| R | 121 | Complaints Management | Provider Complaints | Reporting | Provide case, analyst, and workload reports. | Functional | Mandatory | ||
| R | 122 | Complaints Management | Provider Complaints | Reporting | Provide templated queries which can be customized and saved as an analyst's favorite. | Functional | Mandatory | ||
| R | 123 | Complaints Management | Provider Complaints | Reporting | Schedule reports to run based on customizable criteria. | Functional | Mandatory | ||
| R | 124 | Complaints Management | Provider Complaints | Reporting | Send report notification and/or reports to selected users or groups. | Functional | Mandatory | ||
| R | 125 | Enforcement Management | OE | Reporting | Provide customizable, sortable/filterable metrics dashboard. | Functional | Mandatory | ||
| R | 126 | Enforcement Management | OE | Reporting | Identify data that has been audited/validated through OE self-service analytics. | Functional | Mandatory | ||
| R | 127 | Medical Review Management | IMR | Reporting | Provide customizable, sortable/filterable manager/administrator dashboard for case/queue viewing and management, and queue creation. | Functional | Mandatory | ||
| R | 128 | Medical Review Management | IMR | Reporting | Auto create/post the Review Org case summary to the public website. | Functional | Mandatory | ||
| R | 129 | Medical Review Management | IMR | Reporting | Provide automated QA workflow to post IMR information to the public website. | Functional | Mandatory | ||
| R | 130 | Medical Review Management | IMR | Reporting | Auto de-identify/mask PHI from content posted to the public website. | Functional | Mandatory | ||
| R | 131 | Medical Review Management | IMR | Reporting | Centralize the viewing and creation of reports to one source and location. | Functional | Mandatory | ||
| R | 132 | Medical Review Management | IMR | Reporting | Display all disputed treatments and diagnoses for a case on the public IMR database. | Functional | Mandatory | ||
| R | 133 | Complaints Management | CC Legal Affairs Branch (LAB) | Reporting | Organize and refer to an analyst's past cases as a knowledge base for current work. | Functional | Mandatory | ||
| R | 134 | Complaints Management | CC Legal Affairs Branch (LAB) | Reporting | Access and view closed cases and subcases. | Functional | Mandatory | ||
| I | 135 | Customer Service Management | Contact Center | Intake | Provide self-service case status through the IVR system. | Functional | Mandatory | ||
| I | 136 | Customer Service Management | Contact Center | Intake | Allow agent to edit case information up to 24 hours after a case is opened. | Functional | Mandatory | ||
| I | 137 | Customer Service Management | Contact Center | Intake | Allow caller to state their reason for calling in the IVR system and provide reason to agent. | Functional | Mandatory | ||
| I | 138 | Customer Service Management | Contact Center | Intake | Specify whether agent can relay information in the analyst notes back to the customer. | Functional | Mandatory | ||
| I | 139 | Customer Service Management | Contact Center | Intake | Chat with live agents and chatbot from the public website, with recording saved of the live chat. | Functional | Mandatory | ||
| RC | 140 | Medical Review Management | IMR | Resolve Case | Provide health care specialists/reviewers the ability to review and edit Review Org subcases. | Functional | Mandatory | ||
| RC | 141 | Medical Review Management | IMR | Resolve Case | Track post adoption authorizations, and display by actions taken and by day. | Functional | Mandatory | ||
| I | 142 | Customer Service Management | Contact Center | Intake | Allow caller to dictate, submit, and receive confirmation for an IMR complaint form through the IVR system. | Functional | Mandatory | ||
| I | 143 | Customer Service Management | Contact Center | Intake | Generate a complaint form from an video/audio submitted by a caller. | Functional | Mandatory | ||
| I | 144 | Customer Service Management | Contact Center | Intake | Select resources and email them to consumer in real time. | Functional | Mandatory | ||
| I | 145 | Customer Service Management | Contact Center | Intake | Clearly display contact information. | Functional | Mandatory | ||
| AC | 146 | Customer Service Management | Contact Center | Analyze Case | Specify a RIC/RIA Officer of the Day to support agents and ensure person/group is not overburdened. | Functional | Mandatory | ||
| AC | 147 | Customer Service Management | Contact Center | Analyze Case | Designate complaint staff to handle RIC/RIA calls. | Functional | Mandatory | ||
| AC | 148 | Customer Service Management | Contact Center | Analyze Case | Specify end dates for the flashes. | Functional | Mandatory | ||
| C | 149 | Customer Service Management | Contact Center | Create Case | Provide reasons which may cause Clinical to reject the case, so agent can correct prior to dispatch. | Functional | Mandatory | ||
| C | 150 | Customer Service Management | Contact Center | Create Case | Predict if case will be rejected by Clinical and state reason to consumer. | Functional | Mandatory | ||
| R | 151 | Access Datatase | Help Center | Reporting | Manage staff data for the Contact Center Branch (CCB). | Functional | Mandatory | ||
| AC | 152 | Access Datatase | Help Center | Analyze Case | Provide a Idea Box for staff to submit ideas for suggestions for review by management. | Functional | Mandatory | ||
| R | 153 | Access Datatase | Help Center | Reporting | Manage new hire training, create assignments, and track new hire progress for areas, such as CCB Intake and Call Center. | Functional | Mandatory |
FUNCTIONAL MANDATORY
&P of &N &D
Functional Desirable
| Project Number: | 0000-000 | Agency/state Entity: | (Agency/State Entity) | ||||||
| Obj. Ref. | |||||||||
| (Obj. #) | Requirement Category | Requirement Number | Main Business Capability/Function | Sub Business Capability/Function | Business Process | Requirement | Requirement Type | Priority | Business Owner/ Stakeholder |
FUNCTIONAL DESIRABLE
&P of &N &D
Non-Functional Mandatory
| Project Number: | 0000-000 | Agency/state Entity: | (Agency/State Entity) | ||||||
| Obj. Ref. | |||||||||
| (Obj. #) | Requirement Category | Requirement Number | Main Business Capability/Function | Sub Business Capability/Function | Business Process | Requirement | Requirement Type | Priority | Business Owner/ Stakeholder |
| AC | NF-1 | Complaints Management | Consumer Complaints | Analyze Case | Provide accurate transcription of audio files with the ability to search transcribed files. | Non-Functional | Mandatory | ||
| AC | NF-2 | Complaints Management | Consumer Complaints | Analyze Case | Provide more than 300 minutes per month for audio limits | Non-Functional | Mandatory | ||
| AC | NF-3 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Have multiple windows open for viewing and copying/pasting between windows. | Non-Functional | Mandatory | ||
| AC | NF-4 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Prohibit upload of documents with duplicate file names. | Non-Functional | Mandatory | ||
| AC | NF-5 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Open documents within the system without having to download and open using a different application. | Non-Functional | Mandatory | ||
| AC | NF-6 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Search case documents without opening each document. | Non-Functional | Mandatory | ||
| AC | NF-7 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Provide integrated system messaging, so Outlook does not have to be opened to send/receive email. | Non-Functional | Mandatory | ||
| AC | NF-8 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Transmit, store, upload/download files, audio files, and video files up to file size of XXX MB. | Non-Functional | Mandatory | ||
| AC | NF-9 | Complaints Management | CC Legal Affairs Branch (LAB) | Analyze Case | Retain/archive documents deleted from a case. | Non-Functional | Mandatory | ||
| I | NF-10 | Customer Service Management | Contact Center | Intake | Send incoming phone call/IVR data to the system as the call comes in. | Non-Functional | Mandatory | ||
| RC | NF-11 | Medical Review Management | IMR | Resolve Case | Correct grammar errors automatically. | Non-Functional | Mandatory | ||
| CC | NF-12 | Complaints Management | CC Legal Affairs Branch (LAB) | Communicate Case | Provide role-based configuration for system access and workflows, ie managers, attorneys, or individuals. | Non-Functional | Mandatory | ||
| C | NF-13 | Complaints Management | Consumer Complaints | Create Case | Send encrypted and unencrypted communications. | Non-Functional | Mandatory | ||
| I | NF-14 | Customer Service Management | Contact Center | Intake | Generate AI insights on selected documents. | Non-Functional | Mandatory | ||
| I | NF-15 | Customer Service Management | Contact Center | Intake | Provide integrated chatbot functionality. | Non-Functional | Mandatory | ||
| I | NF-16 | Customer Service Management | Contact Center | Intake | Live chat with an agent and record the chat session. | Non-Functional | Mandatory | ||
| I | NF-17 | Complaints Management | Consumer Complaints | Intake | Add new data collections fields as needed. | Non-Functional | Mandatory | ||
| I | NF-18 | Complaints Management | Consumer Complaints | Intake | Provide E-signature functionality. | Non-Functional | Mandatory | ||
| AC | NF-19 | Customer Service Management | Contact Center | Analyze Case | Provide an accessible Knoweldge Management System (KMS). | Non-Functional | Mandatory | ||
| R | NF-20 | Complaints Management | Provider Complaints | Reporting | Provide and enforce data standards on fields. | Non-Functional | Mandatory | ||
| R | NF-21 | Enforcement Management | OE | Reporting | Provide predictive trend analysis. | Non-Functional | Mandatory | ||
| R | NF-22 | Medical Review Management | IMR | Reporting | Auto de-identify/mask data based on selected characteristics. | Non-Functional | Mandatory | ||
| AC | NF-23 | Customer Service Management | Contact Center | Analyze Case | Transfer caller to leave a voicemail to a selected voicemail box. | Non-Functional | Mandatory | ||
| C | NF-24 | Customer Service Management | Contact Center | Create Case | Provide AI predictions based on selected case characteristics. | Non-Functional | Mandatory |
NON-FUNCTIONAL MANDATORY
&P of &N &D
Non-Functional Desirable
| Project Number: | 0000-000 | Agency/state Entity: | (Agency/State Entity) | ||||||
| Obj. Ref. | |||||||||
| (Obj. #) | Requirement Category | Requirement Number | Main Business Capability/Function | Sub Business Capability/Function | Business Process | Requirement | Requirement Type | Priority | Business Owner/ Stakeholder |
NON-FUNCTIONAL DESIRABLE
&P of &N &D
Project-Transition Mandatory
| Project Number: | 0000-000 | Agency/state Entity: | (Agency/State Entity) | ||||||
| Obj. Ref. | |||||||||
| (Obj. #) | Requirement Category | Requirement Number | Main Business Capability/Function | Sub Business Capability/Function | Business Process | Requirement | Requirement Type | Priority | Business Owner/ Stakeholder |
PROJECT-TRANSITION MANDATORY
&P of &N &D
Project-Transition Desirable
| Project Number: | 0000-000 | Agency/state Entity: | (Agency/State Entity) |
| Obj. |
Ref.
(Obj. #) Requirement Category Requirement Number Main Business Capability/Function Sub Business Capability/Function Business Process Requirement Requirement Type Priority Business Owner/ Stakeholder
PROJECT-TRANSITION DESIRABLE
&P of &N &D
File details come from the government source that posted it. Updated .