Section_27_Communications_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Communications (Section 27)

Central Bill Process

Communications (PWS Section 27) Requirements Specification Document

(LEGACY DRAFT)

Prepared for:

U.S. Department of Labor Office of Worker’s Compensation Programs

Revision History:

SPECIAL NOTICE: This document is a legacy draft requirements specification document developed between 2011 and 2012. As outlined in the Performance Work Statement, the Contractor will be required to review this RSD and make appropriate updates wherever necessary. (Please refer to PWS R0052 for more details.)

Table of Contents Communications – DFEC

71.1 Communications Overview – DFEC

71.1.1 Data Transmission

71.1.2 Call Center

81.1.3 Direct Electronic Access to Data

81.1.3.1 CBP Web Portal Navigation and Features

81.1.4 Telephonic IVR

91.2 Communications Business Process Description – DFEC

91.2.1 Data Transmission Process

91.2.1.1 Secure connection

91.2.2 Call Center Process

91.2.2.1 Call Flow

91.2.2.1.1 Define when approved template and scripting are appropriate

101.2.2.1.2 Call Center Live Answer Scripts

101.2.2.2 Customer Relationship Management

101.2.2.3 Call Management System

111.2.2.4 Call Recording

111.2.2.5 Reporting

111.2.3 Direct Electronic Access to Data Process

111.2.3.1 Authentication

111.2.3.2

121.2.3.3 CBP Web Portal Access

121.2.3.3.1 Government Access

121.2.3.3.2 Provider Access

131.2.3.3.3 Claimant Access

131.2.3.3.4 Federal Client Agency Access

131.2.3.3.5 General Access

131.2.4

141.2.4.1 Testing IVR Functionality

141.2.4.2 Configuration and Deployment of IVR Solution

151.2.4.3 IVR Authentication

151.2.4.4 IVR Scripting Documentation

151.2.4.5 IVR Thresholds

151.2.4.6 IVR Call Storage

161.3 Communications Business Process Flow – DFEC

161.3.1 Call Center Flow

Communications – DEEOIC

172.1 Communications Overview – DEEOIC

172.1.1

172.1.2

182.1.3

182.1.3.1

182.1.4

192.2 Communications Business Process Description - DEEOIC

192.2.1

192.2.1.1

192.2.2

192.2.2.1

192.2.2.1.1

202.2.2.1.2

202.2.2.2

202.2.2.3

212.2.2.4

212.2.2.5

212.2.3

212.2.3.1

222.2.3.2

222.2.3.3

222.2.3.3.1

222.2.3.3.2

232.2.3.3.3

242.2.3.3.4

242.2.4

242.2.4.1

252.2.4.2

252.2.4.3

252.2.4.4

262.2.4.5

262.2.4.6

272.3 Communications Business Process Flow – DEEOIC

272.3.1

Communications – DCMWC

283.1 Communications Overview – DCMWC

283.1.1

283.1.2

293.1.3

293.1.3.1

293.1.4

303.2 Communications Business Process Description - DCMWC

303.2.1

303.2.1.1

303.2.2

303.2.2.1

303.2.2.1.1

313.2.2.1.2

313.2.2.2

313.2.2.3

323.2.2.4

323.2.2.5

323.2.3

323.2.3.1

333.2.3.2

333.2.3.3

333.2.3.3.1

333.2.3.3.2

343.2.3.3.3

343.2.3.3.4

353.2.4

353.2.4.1

353.2.4.2

363.2.4.3

363.2.4.4

363.2.4.5

363.2.4.6

383.3 Communications Business Process Flow – DCMWC

383.3.1

Communications Business Requirements

394.1 Functional Requirements

454.2 Business Rules

Communications Supporting Functional Components

675.1 Initial Data Migration

675.2 Interfaces

685.3 Reports

705.4 Letters

Constraints

736.1 Assumptions

736.2 Dependencies

736.3 Issues/Open Items

Appendices

747.1 Terms & Definitions

817.2 CBP Toll Free Numbers

827.3 Call Center SLAs

847.4 Call Script Guidelines

857.5 Call Center Inquiry Responses Guidelines

927.6 Calls Documentation Guidelines & Templates

967.7 Live Calls/IVR Authentication

987.8 IVR Introduction and Setup

1 Communications – DFEC

1.1 Communications Overview – DFEC

1.1.1 Data Transmission

The Contractor will establish a secure VPN connection between DOL and CBP as the solution for providing site-to-site connections using only registered IP addresses. The VPN solution will connect geographically diverse field locations to the main processing center in the Contractor’s Data Center. The purpose of the secure connection is to facilitate file transfers between DOL and CBP. Interface files will be transmitted to the CBP ‘Landing Zone’, a secure FTP server within the the Contractor’s DOL private network.

The Contractor will also provide proactive Network Operations Center (NOC) monitoring capabilities. The Contractor will record end-to-end response times to and from network devices, services, and applications, to aid in pinpointing areas of excessive network latency or identifying service outages.

Data will be encrypted with cryptography methodology that is compliant with FIPS 140-2 and any new NIST or DOL requirements. .

1.1.2 Call Center

The Call Center will provide support functionality for claimants, providers and agencies. The Call Center will be the initial point of contact for inquiries related to bills, authorizations and defined administrative options via toll free numbers. The call center will also facilitate basic troubleshooting for callers using the Web Portal. The Call Center will offer two channels of communication, an IVR and live Call Center staff. The IVR will be a self-service option for the retrieval of basic bill related information. If the caller is unable to utilize the IVR, there will be an option for the caller to speak with a live representative during operating hours. To facilitate the IVR process, there will be a defined call flow that leads the caller through the process of looking up data after passing defined validation criteria. Defined call flows are an important component of call center design.

The Call Center will record call information in a Customer Relationship Management (CRM) system. The Contractor will integrate this with the other CBP components, including the IVR solution and the CBP Web Portal. The CRM system will enable the customer service representatives (CSRs) to collect and store information associating call data to the initial service request (SR) through activities such as outbound call follow-up, solution/information provided to the caller, and any subsequent follow-up required based upon customer needs. The CSRs will have access to the CBP information through the CRM system that will pull directly from the CBP Web Portal database, and will be synchronized every few minutes through automatic queries with the medical bill processing system. During each interaction, the CSRs will record the details of the conversation, such as the caller’s name, caller’s question/concern and what information was provided to resolve their issue in the CRM system. Also, the CSR will have the ability to enter a summary of events in a free-form text field that will provide a brief summary of the conversation and the actions taken to assist the customer.

Calls will be recorded for quality, training and audit purposes also. The CRM will house FAQs or scripts to ensure the customer service representatives (CSRs) are providing consistent answers to all customers. Escalation processes will also be defined via call scripts. The Call Center staff and IVR access will retrieve the same information so that inquiries via these communications technologies return consistent and current information.

1.1.3 Direct Electronic Access to Data

The CBP Web Portal will be the primary access point for all users. Each user will be required to provide credentials to the CBP Web Portal to gain access to the system (authentication). Once validated, user access is organized by program and user permissions for applications, and data repositories are restricted by the user role assignment (authorization). User access to information and actions permitted on the system will be applied via a “least privilege” methodology (i.e., need to know and restricted actions). For claimants and client Federal agencies, CBP will support secured access by input criteria, such as a valid case number, correct date of birth, and date of injury.

For all other nonsensitive information (e.g., public functions such as access to the Web site, provider search, and information about programs), CBP will provide unsecured access in accordance with DOL’s requirements.

1.1.3.1 CBP Web Portal Navigation and Features

The CBP Web Portal will be backed up by online help and an online tutorial for first-time or occasional users. To assist providers and claimants in obtaining needed forms, and to reduce administrative costs, CBP will provide access for users to Workers’ Compensation forms via MS Word and Adobe PDF formats (with interactive form fields) for downloading via the CBP Web Portal. The CBP Web Portal will also give users the DOL and Contractor addresses, telephone numbers, and URLs for submitting such forms, bills, or correspondence.

The Contractor will control access to CBP information based on five main categories: Government access, provider access, claimant access, Federal client-agency access, and general access.

1.1.4 Telephonic IVR

The Contractor will establish and maintain an IVR capability as required by DOL that includes but is not limited to:

· Providing sufficient capacity to handle an estimated 1 million minutes per year of IVR traffic

· Providing an isolated development environment to develop and test on the IVR scripting process

· Providing the appropriate level of transactional and information dissemination functionality required with the ability to enable claimants, providers, and pharmacies to complete transactions in the IVR without assistance from a live CSR.

The Contractor’s telephonic IVR solution will include the following components:

· Developing IVR Functionality

· Testing IVR Functionality

· Configuration and Deployment of IVR Solution

· IVR Authentication

· IVR Scripting Documentation

· IVR Thresholds

· IVR Call Storage

1.2 Communications Business Process Description – DFEC

1.2.1 Data Transmission Process

Facilities in the Contractor Data Center will include SSL termination compliant with FIPS 140-2. All site-to-site routers will employ internet VPN capability, providing secure and encrypted data transfer compliant with Federal data encryption standards such as AES 256. Further, the Contractor will establish a secure VPN connection for all secure file transfers with external entities. The network monitoring solution will aid in service level management (SLM) and SLA creation, monitoring, and reporting.

Performance data will be collected and leveraged to calculate and monitor service level compliance and breaches. All SLA and performance reports will be viewable in HTML format via the CBP Web Portal and will be represented in the management dashboard. The Contractor will also provide reports showing switch port utilization, including trunk and server-port utilization, peak utilization, average utilization, latency, and errors. The Contractor will routinely examine the performance data and, where appropriate, make recommendations to improve performance.

1.2.1.1 Secure connection

The cryptographic module used will be fully FIPS 140-2–approved, meeting all the Level 2 requirements. The Contractor will configure the VPN routers for DOL with the approved configuration settings that will place the units (and cryptographic module) into the FIPS-approved mode. DOL will be given the ability to pull or push data through a secure connection.

1.2.2 Call Center Process

1.2.2.1 Call Flow

Call Center processes will be driven by a call flow design which supports the Government-approved rules and processes. Call flows will guide callers through the IVR and live customer service interactions. Call flows will:

· Ensure compliance with all defined procedures established by the government

· Be implemented to provide a consistent, auditable experience for each caller

· Define when to track call center interactions via a call record or recording

1.2.2.1.1 Define when approved template and scripting are appropriate

The IVR will direct callers through a series of options to allow callers to access self-service bill updates. The IVR will follow a standard call flow to allow access to the status updates.

· Upon entering the IVR, callers will hear a main menu with basic program information

· Callers will be asked to select an option to provide bill status

· Callers will be asked to authenticate themselves by providing credentials consistent with credentials needed for electronic access to records

· The IVR will play a message if callers are unable to electronically authenticate themselves and transfer the callers to a live customer service representative (during operating hours) or a closed message (during afterhours)

· If the IVR is able to authenticate the credentials via validation with the information in the CBP database, the appropriate status information will be relayed to the customer

· The caller will have the ability to replay the information or be transferred to a customer service representative for additional information

1.2.2.1.2 Call Center Live Answer Scripts

During defined business hours, the Call Center will provide live customer service representatives. The representatives will use a CRM to facilitate their interactions with callers. CSRs will be trained to answer questions from all programs. The Contractor will have the ability to train CSRs to be primary on one program versus another. This allows for CSRs to become more familiar with specific program content. Cross training across all programs allows for the flexibility of coverage during program volume increases and during needed operational (e.g., team meetings, weather issues, etc.) and training coverage. The Call Center will follow a standard call flow to provide information to callers and escalate calls if appropriate.

· Callers will be transferred to live customer service representatives via the IVR

· CSRs will hear a whisper, which is a pre-recorded message that identifies the type of program call

· CSRs will use a standard greeting to open the call

· CSRs will capture basic contact information and populate a call record in the CRM

· Based on the inquiry, CSRs will provide general information about the program or specific information based on the appropriate script

· If specific bill related information is provided, CSRs will first authenticate the caller

· The caller must provide credentials consistent with credentials needed for electronic access to records

· CSRs will record that they authenticated the caller using the Web Portal interface with the medical bill processing system

· Based on the script the CSR will utilize the Web Portal interface to provide information about the claim status to the caller

· If needed, the CSR will escalate the caller or call record for additional work or clarification

· CSRs will offer additional assistance and close the call

· Using the CRM, CSRs will summarize the call and make final call notes

1.2.2.2 Customer Relationship Management

The Call Center will use a CRM to maintain call records and scripts. Call records will include non-PHI data and provide references to bill related identifiers that can be accessed via the Web Portal. The call record will provide basic call category data for reporting purposes. The knowledgebase will hold searchable government approved scripts and provide related work instructions for how to access and use the Web Portal to facilitate customer calls. The knowledgebase will also include program processes, such as escalation procedures and irate call procedures.

Call record data will be available on-line for 7 years, and then archived for retrieval as necessary.

1.2.2.3 Call Management System

The Call Center will use a call management system to route and queue callers based on selections made in the IVR. The call management system will allow for skill based routing. The call management system will also record data about the call (length, speed to answer, etc) to allow for reporting of SLAs.

1.2.2.4 Call Recording

All calls will be monitored and recorded for quality and training purposes via an enterprise call recording solution. Call recordings will be available to program staff for quality purposes and to authorized Government staff, as requested. Calls that do not contain PII or PHI may be used for training purposes to demonstrate customer service objectives.

Call recordings will be available within the Call Recording application for 30 days and then moved to a SAN storage location for easy retrieval indefinitely.

1.2.2.5 Reporting

Call Center reports will be used to monitor call center volume and defined SLAs. Reports will also provide information on the types of calls received and the scripts used to answer the calls. Reporting formats and delivery schedule will meet the government requirements.

1.2.3 Direct Electronic Access to Data Process

The Contractor’s CBP portal is not only a key component in data access and a source of information for all types of DOL stakeholders, but is a crucial element in controlling administrative costs. The CBP solution will be implemented as a secure, facilitated, data-rich environment for collaboration, with information and communications through the CBP Web Portal.

1.2.3.1 Authentication

The solution for direct electronic access is facilitated through the CBP Web Portal using single sign on technology and authentication, which is composed of the following elements:

· The Contractors CBP solution will be implemented as fully compliant with OMB and NIST standards. The solution will support assertion-based authentication through an approved federated identity management solution.

· The Authentication federation will provide credentials (i.e., usernames and passwords) that may be used to access a number of Federal information systems, including the CBP system. CBP will receive Level 1 (or higher) Authentication credentials for verifying the identities of DOL and other Federal agency users. CBP’s integration with Authentication will provide a number of benefits, including single sign-on across systems participating in the federation.

· The Contractor will enhance the portal solution to allow users to select the preferred credential service provider (CSP). The CBP Portal will submit a security access markup language (SAML) authentication request to the selected CSP. Once the CSP authenticates the DOL user, the user is redirected to the CBP application. The redirect from the CSP to the CBP is a classic case of multi-domain single sign-on (MD SSO) — an end user authenticated in one domain (the CSP) becomes known to another domain without reauthenticating.

· The Contractor will utilize SAML assertions to exchange authentication information between the CBP and CSP. The solution will support the recommendation of the eAuthentication federation to utilize SAML 2.0 SSO profile using HTTP POST (SAML 2.0 SSO) for assertion based authentication. Using SAML, which is an assertion-based identity standard for Web single sign-on (SSO), Web services authentication, and attribute exchange across domain boundaries will provide a flexible security foundation for the future.

1.2.3.2 CBP Web Portal Navigation and Features

· The CBP Web Portal will have an easy to navigate GUI, backed up by online help and an online tutorial for first-time or occasional users. During sign-on portal users will see pertinent announcements, updates, and alerts about CBP operations or DOL policy and procedural matters. The portal will maintain an archive of such postings by data and message, and will offer FAQs that are updated as new issues arise or policy changes. Among the information available to users will be the addresses of DOL-approved Government Web sites.

· To assist providers and claimants in obtaining needed forms, and to reduce administrative costs, the Contractor will provide access for users to Workers’ Compensation forms via MS Word and Adobe PDF formats (with interactive form fields) for downloading via the CBP Web Portal. These forms include, but are not limited to CMS-1500, UB-04, OWCP-915, OWCP 957, applicable EFT enrollment forms, EDI enrollment forms, provider enrollment forms, change of address forms, Adjustment Request Form, Authorization Request Form, Fee Schedule Appeal Request Form, NALC Form, ADA Dental Form, etc.

· In addition to meeting all DOL requirements, the Contractor’s CBP Portal will offer key value-added features such as bill submission for all DOL bill types (HCFAs, UBs, Travel, Dental, COP, Contract Nurse and Voc Rehab); authorization submission; electronic attachment submission for bills, authorizations, and enrollments; access to critical support tools (management dashboards, reports, other toolsets); provider message center; provider inbox (provider access to messages, letters, reports, remittance vouchers). It should be noted that claimants are not authorized to submit bills online, and providers under type 44 will submit travel services on a CMS-1500. The CBP Web Portal will support the ability for providers to electronically enroll. The portal also will post information on EFT and electronic bill submission via EDI and will describe the use and advantages of direct bill entry via the portal.

1.2.3.3 CBP Web Portal Access

The Contractor will control access to CBP information on the portal based on five main categories: Government access, provider access, claimant access, Federal client-agency access, and general access through the use of LDAP technology.

1.2.3.3.1 Government Access

The CBP Web Portal will facilitate the communication of all CBP system users and provide DOL with greater visibility into CBP operations, specifically supervisors, specialists, CEs, and CSRs. The Contractor will use role-based access to restrict access to inquiry only or inquiry plus update entry as directed by DOL based on its specific criteria list (e.g., Case number, status, Provider ID, Date(s) of service, bill identifier, RV number, Authorization date range, status of authorization) implemented through a Contractor built LDAP integrated into the portal. This solution will provide DOL with secure electronic routing of issues requiring DOL action such as certain authorizations, PPA bills, Fee Appeals, and Resolution issues as well as maintain auto dated chronological logs of the text of all communications used for such routing between Government and Contractor staff.

1.2.3.3.2 Provider Access

The portal will provide an enhanced user experience for providers of all types. Self-registration for controlled access to data via secure access will greatly reduce the time frame for registration. As with Government access,the Contractor will use role-based access to restrict access to inquiry only or inquiry plus update entry as directed by DOL. Based on DOL’s specific criteria list, medical and nonmedical providers will be required to register for electronic access via the provider enrollment process by furnishing Government-required data elements, such as DOL provider number, Tax ID, medical license number, and license expiration date for medical providers and DOL provider number, Tax ID, and ZIP code for non-medical providers. Once the required data has been entered and then verified by the Contractor, the portal presents the provider with a “terms of agreement” page detailing the rules of behavior for users. Only providers who accept the terms will be registered for access. The Contractor will assign new providers unique CBP IDs together with initial passwords in conformance with Federal security guidelines. At each log-on attempt CBP will verify that the requesting provider is listed as an active provider on the provider file. Once registered as users, providers will have access to view certain RV information, query and view bills and authorizations based on DOL criteria (Case Number, status, Provider ID, Date(s) of service, Bill identifier, RV number, Authorization date range, Status of authorization), print hard copies of their own authorizations, make claimant eligibility inquiries (after providing certain claimant identifiers), and submit attachments such as medical reports electronically. Contract nurses and vocational rehabilitation counselors will be able to submit their bills electronically. The Contractor will track all electronic bills by submission mechanism and will ensure that information submitted electronically that contains protected claimant or provider data such as PHI is encrypted.

1.2.3.3.3 Claimant Access

The portal will allow claimant access to case status data only after the entry of the required data elements on the portal log-in screen for each program: DFEC (Case Number, DOB, and DOI); DEEOIC (DOB, SSN/Member ID from MBIC), and DCMWC (DOB, SSN/Member ID from MBIC). Claimants will also be provided access to their own bills and current and prior authorizations by entering DOL-specified data elements. This access will include the ability for claimants to inquire about status of prior authorization requests, as well as eligibility status inquiries, and to print hard copies of authorizations from the CBP image repository. The Contractor will allow authorized users to access the DOL Claimant Query System (CQS) by using the claimant’s Case number, Date of Injury and DOB. This SOAP connection between the portal and CQS will incorporate a certificate for posting to the DOL trusted server list. The CBP Web Portal will issue a redirect using the URL in the DOL SOAP response.

1.2.3.3.4 Federal Client Agency Access

DOL will establish criteria for such users to query and view bills and authorizations for their employees as well as to submit eligibility status inquiries. Federal client-agency users will be provided with access to only those resources required as specified by the Government, to include inquiry-only. User access and system permissions will be granted based on assigned roles, restricted actions, and least privilege access (minimal required need to know).

1.2.3.3.5 General Access

The Contractor will provide nonsecured access to information about DOL Workers’ Compensation Programs, such as claimant and provider forms, CBP Call Center contact lists, Government Contacts, FAQs, and provider listings via a public Web site on the CBP Web Portal.

1.2.4 Telephonic IVR

The Contractor will establish and maintain an ACD and IVR capability to provide unattended services to telephone callers on a 24x7 basis. The Contractor will use an Automatic Call Distribution (ACD) functionality, configured and deployed simultaneously with the IVR functionality to provide a complete end-to-end telephony solution. Callers will be greeted by the ACD and IVR system, which will provide them with a host of self-service options and notifications of scheduled, planned, or unplanned outages and anticipated restart times of CBP components to reduce tickets into the Call Center. In addition, the Contractor will provide a default voice message anytime the ACD or IVR is down for DOL-approved scheduled maintenance.

1.2.4.1 Testing IVR Functionality

The Contractor will configure, record, and test each function within the IVR, PBX, and ACD systems. Testing will consist of the following activities, at a minimum:

· Systems testing of IVR development and functionality

· Government acceptance testing of all functionality

· Operational readiness reviews

· Pre-operations testing

· Cutover to full operations

For each activity, the Contractor will develop and define a specific set of testing criteria for each function within the IVR and larger telecommunications systems. For transactional functions, the Contractor will ensure that each transactional function can be performed in a minimum number of steps to provide claimants, providers, and other callers with the most user-friendly IVR interface. To facilitate this, the Contractor will perform a number of tests that include:

· ACD and IVR call flow testing to ensure that the caller is directed to the proper response when a prompt is selected

· ACD and IVR voice recordings verification to ensure that every voice recording that is played to callers is fully functional and plays the complete message as designed

· ACD and IVR error condition tests to ensure that if the user hits the wrong prompt the IVR responds appropriately

· Database access testing to ensure that the IVR retrieves the proper information when the IVR performs database lookups

· System load test to ensure that the ACD and IVR performs properly when subjected to a heavy load of calls

· Intuitive ACD and IVR logic test to ensure the ACD and IVR perform in a manner that allows the intuitive user to understand the prompts and navigation.

For functions requiring the IVR to transfer callers, the Contractor will develop test criteria that measures success and timeliness of the function.

1.2.4.2 Configuration and Deployment of IVR Solution

The Contractor will provide separate production, development, test, and training environments for ACD and IVR development and deployment. The Contractor will make each respective environment available to the appropriate staff and DOL personnel in order to facilitate testing and training. Based upon DOL’s ACD and IVR minutes of usage projections, the Contractor will ensure that there is sufficient capacity on a TFN to enable customers to access the IVR, obtain information, and complete transactions. The Contractor will work with DOL to develop and analyze monthly, weekly, and daily “peak hour” historical IVR demand analyses and reports. The Contractor will provide sufficient capacity to alleviate any call blocking that may occur in normal operational situations and ensure that callers are able to access the ACD and IVR at any time of the day. The Contractor will have a team of telephony engineers onsite to respond to any required changes. Once a request for change is received, the change will be reviewed to ensure it does not impact any other scripts. After the review process, the change will be assigned to a telephony engineer for implementation and testing. The Contractor will have the capacity to turn around emergency script changes within 30 minutes and nonemergency script changes within 4 to 8 hours.

1.2.4.3 IVR Authentication

The Contractor’s IVR will authenticate IVR users based upon DOL’s unique identifying criteria that each claimant, provider, and pharmacy caller is able to provide, such as case number, provider ID, and other identifying information developed and approved by DOL. Where required and possible, the Contractor will access databases for use in automatically authenticating a caller and automatically determining the caller’s intention. The Contractor’s IVR will enable providers to determine if a provider ID has been assigned by accessing the CBP medical bill processing system data and will only allow active, enrolled providers to access their own patient and provider information.

1.2.4.4 IVR Scripting Documentation

The Contractor will develop, maintain, and provide IVR scripting documentation to DOL for review, comment, and approval. The Contractor’s IVR scripts will comprise the content of each IVR menu. The Contractor will give callers broad possible choices with the first menu options and offer more specific options with subsequent menus. Callers will then be able to quickly narrow the focus of their search and access the appropriate information from the IVR. The Contractor will use industry best practices when developing IVR menus that result in user-friendly interfaces that encourage and enable customer self-service. The Contractor’s IVR solution will be able to provide callers with messaging, including periodic Government notices and updates.

1.2.4.5 IVR Thresholds

The Contractor will limit all IVR calls to the total length specified by the Government. The IVR call will be terminated when the total call length is exceeded without regard to the number of attempts. The IVR will provide callers with DOL approved messaging in these situations such as “please try again later.” This will direct callers to obtain the correct information prior to calling the IVR again. Alsothe Contractor will be able to transfer callers that have exceeded a maximum number of attempts to a live CSR rather than disconnect the caller, enabling the CSR to attempt to assist the customer rather than require the caller to call back at a later time. The Contractor will limit IVR callers to a Government-specified maximum number of attempts at entering valid data into any single field before the application terminates the call without regard to the call length. However, the Contractor will transfer the caller to a live CSR during business hours to assist rather than terminate the call. During non-business hours, the call would transfer to the closed message.

1.2.4.6 IVR Call Storage

The CBP IVR will maintain a log of all transactions. At the termination of each call, the IVR will create a record of the call and store it in a database for later retrieval and review by the Contractor for QA purposes, or for the Government as required. The Contractor will provide call logs, reports, and recordings to the Government upon request. The Contractor will store information for a Government-specified period of time, and during this time information will be accessible to the Government upon request. The Contractor will recommend a periodic archive schedule for all call logs. The Contractor will maintain IVR data created specifically for the OWCP program and will maintain data generated during operations of the DOL OWCP IVR.

1.3 Communications Business Process Flow – DFEC

1.3.1 Call Center Flow

The following diagram captures the primary functions of the Call Center flow for DFEC:

2 Communications – DEEOIC

2.1 Communications Overview – DEEOIC

2.1.1 Data Transmission

The Contractor will establish a secure VPN connection between DOL and the CBP as the solution for providing site-to-site connections using only registered IP addresses. The VPN solution will connect geographically diverse field locations to the main processing center in the CBP Data Center. The purpose of the secure connection is to facilitate file transfers between DOL and the CBP. Interface files will be transmitted to the CBP ‘Landing Zone’, a secure FTP server within the the Contractor’s DOL private network.

The Contractor will also provide proactive Network Operations Center (NOC) monitoring capabilities. The Contractor will record end-to-end response times to and from network devices, services, and applications, to aid in pinpointing areas of excessive network latency or identifying service outages.

Data will be encrypted with cryptography methodology that is compliant with FIPS 140-2 and any new NIST or DOL requirements.

2.1.2 Call Center

The Call Center will provide support functionality for claimants, providers and agencies. The Call Center will be the initial point of contact for inquiries related to bills, authorizations and defined administrative options via toll free numbers. The call center will also facilitate basic troubleshooting for callers using the Web Portal. The Call Center will offer two channels of communication, an IVR and live Call Center staff. An IVR will be a self-service option for the retrieval of basic bill related information. If the caller is unable to utilize the IVR, there will be an option for the caller to speak with a live representative during operating hours. To facilitate the IVR process, there will be a defined call flow that leads the caller through the process of looking up data after passing defined validation criteria. Defined call flows are an important component of call center design.

The Call Center will record call information in a Customer Relationship Management (CRM) system. The Contractor will integrate this with the other CBP components, including the IVR solution and the CBP Web Portal. The CRM system will enable the CSRs to collect and store information associating call data to the initial service request (SR) through activities such as outbound call follow-up, solution/information provided to the caller, and any subsequent follow-up required based upon customer needs. The CSRs will have access to the CBP information through the CRM system that will pull directly from the CBP Web Portal database, and will be synchronized every few minutes through automatic queries with the medical bill processing system. During each interaction, the CSRs will record the details of the conversation, such as the caller’s name, caller’s question/concern and what information was provided to resolve their issue, in the CRM system. Also, the CSR will have the ability to enter a summary of events in a free-form text field that will provide a brief summary of the conversation and the actions taken to assist the customer.

Calls will be recorded for quality, training and audit purposes also. The CRM will house FAQs or scripts to ensure the customer service representatives (CSRs) are providing consistent answers to all customers. Escalation processes will also be defined via call scripts. The Call Center staff and IVR access will retrieve the same information so that inquiries via these communications technologies return consistent and current information.

2.1.3 Direct Electronic Access to Data

The CBP Web Portal will be the primary access point for all users. Each user will be required to provide credentials to the CBP Web Portal to gain access to the system (authentication). Once validated, user access will be organized by program and user permissions for applications, and data repositories will be restricted by the user role assignment (authorization). User access to information and actions permitted on the system will be applied via a “least privilege” methodology (i.e., need to know and restricted actions). For claimants and client Federal agencies, the Contractor will support secured access by input criteria, such as a valid Social Security Number (SSN), correct date of birth, and member ID.

For all other nonsensitive information (e.g., public functions such as access to the Web site, provider search, and information about programs), the Contractor will provide unsecured access in accordance with DOL’s requirements.

2.1.3.1 CBP Web Portal Navigation and Features

The CBP Web Portal is backed up by online help and an online tutorial for first-time or occasional users. To assist providers and claimants in obtaining needed forms, and to reduce administrative costs, the Contractor will provide access for users to Workers’ Compensation forms via MS Word and Adobe PDF formats (with interactive form fields) for downloading via the CBP Web Portal. The CBP Web Portal will also give users the DOL and Contractor addresses, telephone numbers, and URLs for submitting such forms, bills, or correspondence.

The Contractor will control access to CBP information based on five main categories: Government access, provider access, claimant access, Federal client-agency access, and general access through the use of LDAP technology.

2.1.4 Telephonic IVR

The Contractor will establish and maintain an IVR capability as required by DOL that includes but is not limited to:

· Providing sufficient capacity to handle an estimated 1 million minutes per year of IVR traffic

· Providing an isolated development environment to develop and test on the IVR scripting process

· Providing the appropriate level of transactional and information dispensation functionality required with the ability to enable claimants, providers, and pharmacies to complete transactions in the IVR without assistance from a live CSR.

The Contractor’s telephonic IVR solution includes the following components:

· Developing IVR Functionality

· Testing IVR Functionality

· Configuration and Deployment of IVR Solution

· IVR Authentication

· IVR Scripting Documentation

· IVR Thresholds

· IVR Call Storage

2.2 Communications Business Process Description - DEEOIC

2.2.1 Data Transmission Process

Facilities in the CBP Data Center will include SSL termination compliant with FIPS 140-2. All site-to-site routers will employ internet VPN capability, providing secure and encrypted data transfer compliant with Federal data encryption standards such as AES 256. Further, the Contractor will establish a secure VPN connection for all secure file transfers with external entities. The network monitoring solution will aid in service level management (SLM) and SLA creation, monitoring, and reporting.

Performance data will be collected and leveraged to calculate and monitor on service level compliance and breaches. All SLA and performance reports will be viewable in HTML format via the CBP Web Portal and will be represented in the management dashboard. The Contractor will also provide reports showing switch port utilization, including trunk and server-port utilization, peak utilization, average utilization, latency, and errors. The Contractor will routinely examine the performance data and, where appropriate, make recommendations to improve performance.

2.2.1.1 Secure connection

The cryptographic module used will be fully FIPS 140-2–approved, meeting all the Level 2 requirements. The Contractor will configure the VPN routers for DOL with the approved configuration settings that will place the units (and cryptographic module) into the FIPS-approved mode. DOL will be given the ability to pull or push data through a secure connection.

2.2.2 Call Center Process

2.2.2.1 Call Flow

Call Center processes will be driven by a call flow design which supports the Government-approved rules and processes. Call flows will guide callers through the IVR and live customer service interactions. Call flows will:

· Ensure compliance with all defined procedures established by the government

· Be implemented to provide a consistent, auditable experience for each caller

· Define when to track call center interactions via a call record or recording

2.2.2.1.1 Define when approved template and scripting are appropriate

The IVR will direct callers through a series of options to allow callers to access self-service bill updates. The IVR will follow a standard call flow to allow access to the status updates.

· Upon entering the IVR, callers will hear a main menu with basic program information

· Callers will be asked to select an option to provide bill status

· Callers will be asked to authenticate themselves by providing credentials consistent with credentials needed for electronic access to records

· The IVR will play a message if callers are unable to electronically authenticate themselves and transfer the callers to a live customer service representative (during operating hours) or a closed message (during afterhours)

· If the IVR is able to authenticate the credentials via validation with the information in the CBP database, the appropriate status information will be relayed to the customer

· The caller will have the ability to replay the information or be transferred to a customer service representative for additional information

2.2.2.1.2 Call Center Live Answer Scripts

During defined business hours, the Call Center will provide live customer service representatives. The representatives will use a CRM to facilitate their interactions with callers. CSRs will be trained to answer questions from all programs. The Contractor will have the ability to train CSRs to be primary on one program versus another. This allows for CSRs to become more familiar with specific program content. Cross training across all programs allows for the flexibility of coverage during program volume increases and during needed operational (e.g., team meetings, weather issues, etc.) and training coverage. The Call Center will follow a standard call flow to provide information to callers and escalate calls if appropriate.

· Callers will be transferred to live customer service representatives via the IVR

· CSRs will hear a whisper, which is a pre-recorded message that identifies the type of program call

· CSRs will use a standard greeting to open the call

· CSRs will capture basic contact information and populate a call record in the CRM

· Based on the inquiry, CSRs will provide general information about the program or specific information based on the appropriate script

· If specific bill related information is provided, CSRs will first authenticate the caller

· The caller must provide credentials consistent with credentials needed for electronic access to records

· CSRs will record that they authenticated the caller using the Web Portal interface with the medical bill processing system

· Based on the script the CSR will utilize the Web Portal interface to provide information about the claim status to the caller

· If needed, the CSR will escalate the caller or call record for additional work or clarification

· CSRs will offer additional assistance and close the call

· Using the CRM, CSRs will summarize the call and make final call notes

2.2.2.2 Customer Relationship Management

The Call Center will use a CRM to maintain call records and scripts. Call records will include non-PHI data and provide references to bill related identifiers that can be accessed via the Web Portal. The call record will provide basic call category data for reporting purposes. The knowledgebase will hold searchable government approved scripts and provide related work instructions for how to access and use the Web Portal to facilitate customer calls. The knowledgebase will also include program processes, such as escalation procedures and irate call procedures.

Call record data will be available on-line for 7 years, and then archived for retrieval as necessary.

2.2.2.3 Call Management System

The Call Center will use a call management system to route and queue callers based on selections made in the IVR. The call management system will allow for skill based routing. The call management system will also record data about the call (length, speed to answer, etc) to allow for reporting of SLAs.

2.2.2.4 Call Recording

All calls will be monitored and recorded for quality and training purposes via an enterprise call recording solution. Call recordings will be available to program staff for quality purposes and to authorized Government staff, as requested. Calls that do not contain PII or PHI may be used for training purposes to demonstrate customer service objectives.

Call recordings will be available within the Call Recording application for 30 days and then moved to a SAN storage location for easy retrieval indefinitely.

2.2.2.5 Reporting

Call Center reports will be used to monitor call center volume and defined SLAs. Reports will also provide information on the types of calls received and the scripts used to answer the calls. Reporting formats and delivery schedule will meet the government requirements.

2.2.3 Direct Electronic Access to Data Process

The Contractor’s CBP portal will not only be a key component in data access and a source of information for all types of DOL stakeholders, but will be a crucial element in controlling administrative costs. The Contractor’s CBP solution will be implemented as a secure, facilitated, data-rich environment for collaboration, with information and communications through the CBP Web Portal.

2.2.3.1 Authentication

The solution for direct electronic access will be facilitated through the CBP Web Portal using single sign on technology and authentication, which is composed of the following elements:

· The Contractor’s CBP solution will be implemented as fully compliant with OMB and NIST standards. The solution will support assertion-based authentication through an approved federated identity management solution.

· The Authentication federation provides credentials (i.e., usernames and passwords) that may be used to access a number of Federal information systems, including the CBP system. CBP will receive Level 1 (or higher) Authentication credentials for verifying the identities of DOL and other Federal agency users. CBP’s integration with authentication will provide a number of benefits, including single sign-on across systems participating in the federation.

· The Contractor will enhance the portal solution to allow users to select the preferred credential service provider (CSP). The CBP Portal will submit a security access markup language (SAML) authentication request to the selected CSP. Once the CSP authenticates the DOL user, the user will be redirected to the CBP application. The redirect from the CSP to the CBP is a classic case of multi-domain single sign-on (MD SSO) — an end user authenticated in one domain (the CSP) becomes known to another domain without reauthenticating.

· The Contractor will utilize SAML assertions to exchange authentication information between the CBP and CSP. The solution will support the recommendation of the eAuthentication federation to utilize SAML 2.0 SSO profile using HTTP POST (SAML 2.0 SSO) for assertion based authentication. Using SAML, which is an assertion-based identity standard for Web single sign-on (SSO), Web services authentication, and attribute exchange across domain boundaries will provide a flexible security foundation for the future.

2.2.3.2 CBP Web Portal Navigation and Features

· The CBP Web Portal will have an easy to navigate GUI, backed up by online help and an online tutorial for first-time or occasional users. During sign-on portal users will see pertinent announcements, updates, and alerts about CBP operations or DOL policy and procedural matters. The portal will maintain an archive of such postings by data and message and will offer FAQs that are updated as new issues arise or policy changes. Among the information available to users will be the addresses of DOL-approved Government Web sites.

· To assist providers and claimants in obtaining needed forms, and to reduce administrative costs, the web portal will provide access for users to Workers’ Compensation forms via MS Word and Adobe PDF formats (with interactive form fields) for downloading via the CBP Web Portal. These forms include, but are not limited to CMS-1500, UB-04, OWCP-915, OWCP 957, applicable EFT enrollment forms, EDI enrollment forms, provider enrollment forms, change of address forms, Adjustment Request Form, Authorization Request Form, Fee Schedule Appeal Request Form, NALC Form, ADA Dental Form, etc.

· In addition to meeting all DOL requirements, the CBP Portal will offer key value-added features such as bill submission for all DOL bill types (HCFAs, UBs, and Travel); authorization submission; electronic attachment submission for bills, authorizations, and enrollments; access to critical support tools (management dashboards, reports,other toolsets); provider message center; provider inbox (provider access to messages, letters, reports, remittance…