EXHIBIT_B_Functional_Non-functional_Claims_Requirements.xlsx
XLSX spreadsheet 526 KB Posted
- Solicitation number
- 17546
- Issued by
- California
About this file
Summary
This document is a functional and non-functional requirements specification for the Electronic Awards Management System (EAMS) Claims Benefit Administration System being developed by the California Department of Industrial Relations (DIR). The EAMS system is designed to serve multiple user groups including UEBTF (Uninsured Employers Benefits Trust Fund) staff, SIBTF (Subsequent Injuries Benefit Trust Fund) staff, Workers' Compensation Appeals Board (WCAB) personnel, judges, attorneys, claims administrators, medical evaluators, and numerous other workers' compensation stakeholders across California. The system encompasses 139 functional requirements and 93 non-functional requirements covering claims management, workflow management, notifications and alerts, document management, digital communications, billing and payments, analytics and reporting, self-service portals, and role management. Key functional capabilities include automated claim creation and assignment, task management with queue-based routing, document repository and search functionality, template-based communication generation, electronic payment processing and reconciliation, recovery case management with lien administration, and comprehensive reporting and workload analytics for supervisors and managers.
The non-functional requirements establish technical, security, regulatory compliance, and performance standards that the EAMS solution must meet. Security requirements mandate FIPS 140-3 compliant encryption, role-based access controls, multi-factor authentication, comprehensive audit logging with 18-month retention, and compliance with federal standards including NIST SP 800-53 (moderate), HIPAA, FISMA, and the California DGS Cloud Computing Policy. The system must support 1,500 concurrent internal users and 5,000+ external users with near real-time data access and one-second response times. Additional requirements include ADA accessibility compliance, disaster recovery and business continuity planning, 50-year data retention capability, secure API-based file transfer using DIR-approved tools, and malicious code detection. All requirements are classified as mandatory, with bidders required to specify whether their proposed solutions meet each requirement through out-of-the-box functionality, configuration options, or customization.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| DIR_RFP_17546_Exhibit_J_Current_and_Future_Claims_Interface.xlsx | XLSX spreadsheet | |
| DIR_RFP_17546_EAMS_CLAIMS_F260102.pdf | ||
| DIR_RFP_17546_Exhibit_D_Cost_Workbook.xlsx | XLSX spreadsheet |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
2. Functional Requirements
| DIR EAMS Claims Benifit Administration System Functional Requirements | ||||||||||||
| The purpose of this document is to summarize detailed functional requirements for the new EAMS system, for a particular user group. All information is based on inputs from EAMS project team under DIR. The approaches and considerations included in this document are preliminary and may be further developed based on additional inputs from DIR/DWC EAMS Project team. | ||||||||||||
| Requirement ID | Mid-Level Requirement ID | Objective ID | Objective | Business Capability / Function | Need(s) Addressed | Requirement Description | Requested by User Group | Additional User Groups Impacted | Requirement classification | Meeting the requirement (Yes/No) | Out of the Box / Configuration (Yes/No) | Customization (Yes/No) |
| A unique ID for the requirement | Mid-Level Requirement ID | An ID for the business objective | A high-level business objective for the department as a whole | High-level category for requirements function | Specific needs by current or prospective users as well as gaps from best practices | Description of the functional requirement to describe what product / solution must do | The user group / stakeholder which requested the requirement (e.g., Applicant Attorneys) | Additional user groups with similar needs or which benefit from similar requirement | Specifies if the requirement is Mandatory | Bidder enters Yes or No to specify whether or not the solution meets the Mandatory requirement | Bidder enters Yes or No to specify whether or not the solution is out of the box / configuration | Bidder enters Yes or No to indicate the requirement is met with customization |
| Claims001 | MLCL-46 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Workflow Management | I need to be notified that UEBTF has been joined to a case, so that I can begin processing the case | The system shall, upon UEBTF being joined to a case, share relevant orders so that UEBTF can trigger appropriate claim-creation tasks (e.g., sending opening letters, assigning claim to the examiner per rules) | UEBTF WCC | OTs | Mandatory | |||
| Claims002 | MLCL-46 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Workflow Management | I need to be notified that UEBTF has been joined to a case, so that I can begin processing the case | The system shall, upon UEBTF being joined to a case, be able to alert UEBTF about the Petition/Order of joinder, share relevant information (e.g., copy of the Order of joinder), and trigger relevant workflows (e.g., inform OD Legal users, configure sign ups for alerts), so that all authorized users can track the status of Petition/Orders of joinders | UEBTF WCC | Mandatory | ||||
| Claims003 | MLCL-46 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Workflow Management | I need to be notified that an SIBTF application has been filed, so that I can begin processing the case | The system shall, upon an SIBTF application being received in the Court, share the application with SIBTF, so that SIBTF can trigger appropriate claim-creation tasks (e.g., sending opening letters, assigning claim to the examiner per rules) | SIBTF WCC | Mandatory | ||||
| Claims004 | MLCL-46 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to be notified that UEBTF has been joined to a case, so that I can begin processing the case | The system shall be able to alert UEBTF when a new ADJ case has been created to which UEBTF has been named as a party, so that UEBTF can access relevant information about a case | OTs | UEBTF WCC | Mandatory | |||
| Claims005 |
| MLCL-43 | CLM-4 | Increase benefit management efficiency. | Claim Management | I need to communicate with OD Legal regarding specific claims, so that I can collaborate with OD Legal as needed | The system shall allow authorized users to grant access to specific parts of claims (e.g., claim documents, claim comments, claim events) to authorized OD Legal users, so that they can view the relevant claim payment history (e.g., before a settlement or hearing at the WCAB) | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors, SIF | authorized OD Legal users | Mandatory | |
| Claims006 | MLCL-27 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Case Management | I need to share documents between courts and claims systems, so that I can share information with the courts system | The system shall allow secure, case specific access to documents for external users who are officially designated as parties within the DIR court or claims system (eg UEBT representatives, WCC, MSTS). Only users explicitly authorized for a a case and registered in the system with verified credentials may retreive documents, limited to information relevant to their role, ensuring confidentiality and preventing unauthorized access. | UEBTF WCCs, MSTs, SIBTF | Mandatory | |
| Claims007 | MLCL-11 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Notifications and Alerts | I need to know when I have been assigned a claim so that I know to initiate my work | The system shall allow an authorized internal users (e.g., WCCs) to assign cases (e.g., based on alphabetical, load balance, and weighted distribution), and when a claim is assigned it will notify the respective user (e.g., via email, via system notification) so that they can take steps to initiate their work | SWCC, WCCs, UEBTF Recovery Specialists | Mandatory | |
| Claims008 | MLCL-12 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to have a claim created so I can begin assigning work | The system shall be able to establish a claim within the claim system upon a claim-creation trigger occurring (e.g., UEBTF being joined to a case, SIBTF application being received) so that users can begin assigning the claim to a user to process | UEBTF WCC, SIBTF WCC | Mandatory | |
| Claims009 | MLCL-13 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to search, sort, and filter within claims and tasks assigned to me, so that I can track and perform my work | The system shall allow internal users to view claims to which they are assigned, so that they can efficiently prioritize their workload and manage time | SWCC, WCCs, UEBTF Recovery Specialists | Mandatory | |
| Claims010 |
MLCL-30
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to access a claim-specific page, consolidated with all associated information and documents so that I can quickly provide relevant information | The system shall provide authorized internal users with a view for each claim, including case events & actions, key case identification information on each case profile (e.g., injured worker ID, case number, injured worker demographic, injured worker's wage earned, and contact information), so that they can access relevant information | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory |
| Claims011 |
MLCL-26
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to access a claim-specific page, consolidated with all associated information and documents so that I can quickly provide relevant information | The system shall allow authorized users only to access key case medical information for each case (e.g., biological data, injury information including prior injuries, subsequent injury information) so that they can view and utilize relevant information | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||||
| Claims012 | MLCL-41 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to access a claim-specific page, consolidated with all associated information and documents so that I can quickly provide relevant information | The system shall allow authorized users to access key financial information for each claim (e.g., payment history to internal and 3rd party users, summary of award (connected to payments platform), balance remaining, prior awards, credit information) so that they can access and utilize relevant information | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims013 | MLCL-33 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to access a claim-specific page, consolidated with all associated information and documents so that I can quickly provide relevant information | The system shall allow users to add text-based, formatted, and timestamped notes within the case profile page so that they can reference notes for a case in the future | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims014 | MLCL-56 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need the system to automatically record actions and events in the system, so that I have a record of events in the system | The system shall track all system events and user actions that occur within a claim, and display them on the claim-specific page where they can be viewed by authorized internal users, so that events and actions are tracked in a transparent matter | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims015 | MLCL-33 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to manually add to the log of actions and events, so that I can ensure non-system events (e.g., phone conversation outcomes, general notes) are also captured in the system | The system shall provide authorized internal users a way to manually log events and actions that took place outside the system (e.g., phone conversation with an applicant attorney) and display them on the claim-specific page with an indicator that they were manually added, so that non-system events are tracked in a transparent manner | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims016 | MLCL-57 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need the system to automatically record actions and events in the system, so that I have a record of events in the system | The system shall provide a way to view the user performing all automatic and manual system events (e.g., user manually changing status of tasks, manually logged events such as phone conversation), so that users have a record of actions they have performed or logged | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims017 | MLCL-56 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need the system to automatically record actions and events in the system, so that I have a record of events in the system | The system shall allow authorized internal users to access a history of records of actions including automatic and manual system events (e.g., user manually changing status of tasks, manually logged events such as phone conversation) so that users are able to search through information | Mandatory | |||||
| Claims018 | MLCL-46 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to search, sort, and filter within claims and tasks assigned to me, so that I can track and perform my work | The system shall allow internal users to manually mark the status of tasks within a claim (e.g., not yet started, opening letter has been issued, task completed) | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims019 | MLCL-48 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to search, sort, and filter within claims and tasks assigned to me, so that I can track and perform my work | The system shall allow internal users to sort the queue of tasks assigned to them (e.g., by date, priority level) so that they can manage their workload and navigate to information quickly | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims020 | MLCL-48 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to search, sort, and filter within claims and tasks assigned to me, so that I can track and perform my work | The system shall allow internal users to search, sort, and filter tasks assigned to them (e.g., by keyword, metadata beyond name) so that they can streamline navigation | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims021 | MLCL-49 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to search, sort, and filter within claims and tasks assigned to me, so that I can track and perform my work | The system shall allow authorized internal users (e.g., supervisors) to configure fields used to sort and filter the view of open tasks (e.g., by adding and removing columns) so that they have the flexibility to add fields as needed to streamline navigation within a view of claims and tasks | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||||
| Claims022 | MLCL-33 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to be able to make comments on open tasks so that I can share context with other WCCs working on the same task | The system shall allow internal users to leave text comments on tasks so that they can streamline communication between WCCs collaborating on a task or workflow (Note: comments may be configured to be recorded in the task history) | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims023 | MLCL-47 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to search, sort, and filter within claims and tasks assigned to me, so that I can track and perform my work | The system shall provide a centralized task and deadline tracker (e.g., filter by due date or task type, sort by upcoming statutory deadlines) for tasks assigned to specific users, so that they know what deadlines are coming and what tasks need to be done | WCCs, UEBTF Recovery Specialists, WCAs | Mandatory | ||
| Claims024 | MLCL-46 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Workflow Management | I need to assign tasks to a queue, so that I can pull in work not assigned to me specifically | The system shall have the ability to assign tasks to pre-defined queues (e.g., for specific groups of users) instead of specific users, so that work that does not need to be done by a specific individual (e.g., reviews, approvals, processing payments) can be routed to the appropriate group of users | WCCs, WCAs, UEBTF Recovery Specialists | Mandatory | ||
| Claims025 | MLCL-29 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to assign tasks to a queue, so that I can pull in work not assigned to me specifically | The system shall provide a view of open tasks that can be sorted (e.g., sort by due date or task type) for tasks assigned to general queues, so that WCC staff know what deadlines are coming and what tasks need to be done | WCCs, WCAs, UEBTF Recovery Specialists | Mandatory | ||||
| Claims026 | MLCL-48 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to access work planning/task management tools so that I can prioritize and manage upcoming deadlines efficiently | The system shall allow users to navigate to claims associated with a task (e.g., by selecting the task) so that they can save time when searching for related information or documents | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims027 | MLCL-47 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to a personalized view of my tasks so that I can track and prioritize my work | The system shall, based on data in the system, automatically show deadlines for tasks where applicable (e.g., days left to make payment after settlement approval, days left to file lien after recovery referral) in applicable task and claim views, so that users have an up-to-date view of deadlines for their work | WCCs, UEBTF Recovery Specialists, WCAs, MSTs, Supervisors | UEBTF WCC, SIBTF WCC | Mandatory | |
| Claims028 | ||||||||||
| MLCL-50 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to be able to assign work and monitor workload balancing so that I can manage mine and my team's tasks | The system shall allow authorized internal users to manually reassign tasks to a specific user (e.g., by individual task or by entire case), or in bulk to multiple users, so that users can ensure cases will be assigned to an available user at all times | Supervisors, Managers | Mandatory | |||
| Claims029 | MLCL-46 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need the system programmatically manage workflows, so that tasks and notifications can be managed without manual intervention | The system shall have the ability for actions and events within the system (e.g., task assignment, document upload, document generation) to automatically trigger additional tasks or events (e.g., task reassignment, task creation, user notification) so that the system can support specific workflows | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims030 | MLCL-46 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need the system programmatically manage workflows, so that tasks and notifications can be managed without manual intervention | The system shall provide authorized internal users with the ability to create and configure workflows defining relationships between triggers and system responses, so that the system can support specific workflows that work best for users | Supervisors, Managers | Mandatory | ||
| Claims031 | MLCL-46 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need a default set of tasks for each claim, so that I have a starting point for work to be done for all claims | The system shall support predefined task lists (e.g., the case finalization checklist) that are automatically generated and assigned when a new claim is created, so that users can see all tasks that need to be done for a claim without manual input | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims032 | MLCL-49 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need a default set of tasks for each claim, so that I have a starting point for work to be done for all claims | The system shall provide authorized internal users the ability to add and configure tasks for claims, so that the system can accommodate workflows as they evolve | Supervisors, Managers | Mandatory | ||
| Claims033 | MLCL-46 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to be notified of events (e.g.,. documents added to assigned claim, task assignment), so that I know to take action where needed | The system shall automatically notify users when a relevant system event has occurred (e.g., task assignments, claim assignments), so that they can know of work that needs to be done | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims034 | MLCL-13 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Notifications and Alerts | I need to be notified of events (e.g.,. documents added to assigned claim, task assignment), so that I know to take action where needed | The system shall provide users a way to view and receive notifications within the (e.g., task assignments, claim assignments) so that they can streamline their workflow and manage incoming tasks | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims035 | MLCL-13 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Notifications and Alerts | I need to be notified of events (e.g.,. documents added to assigned claim, task assignment), so that I know to take action where needed | The system shall provide authorized internal users with the ability to configure their notifications (e.g., enabling or disabling notifications, notification frequency, notification triggers), so that they can control how the system notifies them | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims036 | MLCL-6 | |||||||||
| CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Analytics and Reports | I need to see all cases and claims under my supervision, so that I know my team’s caseload | The system shall have an automatically generated report of WCC staff workload on an office/team-wide level and an individual staff-level so that they can manage workload and utilization and offer relevant support | Supervisors, Managers | Mandatory | ||||
| Claims037 | ||||||||||
| MLCL-44 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Workflow Management | I need to see all cases and claims under my supervision, so that I know my team’s caseload | The system shall allow a system administrator to set user group visibility permissions such that the WCC staff manager can view tasks of their team members, so that managers can manage workload and utilization of their team | Supervisors, Managers | Mandatory | |||
| Claims038 | MLCL-59 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Document Management | I need to search within documents and notes, so that I can find information I need | The system shall allow users to search for a particular document, filter documents by metadata field, and sort document by metadata field, so that they reduce time spent finding the document they are looking for | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims039 | MLCL-21 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Document Management | I need to access a claim-specific page, consolidated with all associated information and documents so that I can quickly provide relevant information | The system shall include default document viewing/editing permissions by document type, but allow manual overrides, so that users can modify document permissions where appropriate | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||||
| Claims040 |
| MLCL-23 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Document Management | I need to upload files to a claim-specific file repository, so that I can store communications, files, and materials relevant to the claim | The system shall allow internal users to upload files (e.g., claim documents, communications, medical reports) to a claim-specific file repository for each claim so that all relevant materials can be accessed in one view | WCCs, WCAs, MSTs, Supervisors | Mandatory | |||
| Claims041 | MLCL-22 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Document Management | I need to access a file repository for each claim, so that I can reduce time spent searching for information | The system shall store documents for each claim in its own claim-specific document repository that can be accessed by authorized internal users or authorized external users, so that users can find documents for each claim | WCCs, WCAs, MSTs, Supervisors | WCCs, WCAs | Mandatory | |
| Claims042 | MLCL-59 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Document Management | I need to access a file repository for each claim, so that I can reduce time spent searching for information | The system shall allow users to search for documents in the document repository, so that they can find necessary information quickly | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims043 | MLCL-59 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Document Management | I need to access a file repository for each claim, so that I can reduce time spent searching for information | The system shall allow users to search, sort, and filter available documents by metadata (e.g., name, date last opened, date template was created, category of document, party, assigned WCC or court judge, injury type, doctor, body part, and Agreed Medical Evaluator) so that they can reduce time navigating the system for necessary information | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims044 | MLCL-18 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Digital Communications | I need to generate communications using existing claims and case information in the system, so that I can send key communications without needing to manually input and verify information | The system shall allow users to generate written communications from predefined templates (e.g., Letter 12s, Award Letters) that can auto-populate using data within the system, so that they can save time spent on manual processes and repetitive data entry | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims045 | MLCL-18 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Digital Communications | I need to generate communications using existing claims and case information in the system, so that I can send key communications without needing to manually input and verify information | The system shall allow users to manually edit communications once they have been generated, so that they can ensure communications have the necessary and correct information | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims046 | MLCL-17 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Digital Communications | I need to keep track of all communications sent out so that I can refer to them as needed | The system shall maintain a copy of all communications that are sent out, including itemizing all attachments, and note the method by which it was sent (e.g., mail, fax, email) so that all communications are kept track of | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims047 | MLCL-18 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Digital Communications | I need to generate communications using existing claims and case information in the system, so that I can send key communications without needing to manually input and verify information | The system shall allow users to save drafts of generated communications, so that work can be resumed without losing work in progress | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims048 | MLCL-18 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Digital Communications | I need to generate communications using existing claims and case information in the system, so that I can send key communications without needing to manually input and verify information | The system shall allow users to input necessary information (e.g., Claim ID) within communication templates portal to auto-fill relevant information associated with each claim (e.g., claim information, applicant address) so that they can save time when filling out information for multiple cases repetitively | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims049 | MLCL-16 | CLM-4 | Increase benefit management efficiency. | Digital Communications | I need to generate communications using existing claims and case information in the system, so that I can send key communications without needing to manually input and verify information | The system shall allow authorized internal users (e.g., WCC Supervisors, Managers) to add, configure, and remove communications templates, so that users can use templates to reduce time spent generating documents | Supervisors, Managers | Mandatory | ||
| Claims050 | MLCL-18 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Digital Communications | I need to generate communications using existing claims and case information in the system, so that I can send key communications without needing to manually input and verify information | The system shall allow users to mark digital communications as ready to send, and send the communications to the party responsible for sending them out (e.g., adding to task queue, sending to third-party via integration), so that they can streamline workflow management | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||
| Claims051 | MLCL-17 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Digital Communications | I need to generate communications using existing claims and case information in the system, so that I can send key communications without needing to manually input and verify information | The system shall, upon sending out a digital communication, automatically save the communication to the claim, so that the record of the communication can be persisted | WCCs, WCAs, MSTs, Supervisors | Mandatory | ||||
| Claims052 | MLCL-61 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Self-Service | I need to be able to view application status / outstanding actions so that I can easily access case information and history and don't have to call in to request status updates | The system shall provide claimants a secure and authenticated way to view status of their claim (e.g., received, processing, pending Workers' Compensation Appeals Board hearing, award calculation, and approved), payment status (e.g., date payment sent, payment processing), and WCC point of contact, so that claimant parties have a go-to view for key information, and do not have to call the call center as often | Claimant parties | Mandatory | ||
| Claims053 | MLCL-61 | CLM-1 | Cost avoidance – reduce paper storages. | Form Submission | I need to be able to upload documents directly so that I can e-file requested documentation directly with the DWC (e.g., medical documents) | The system shall enable users to file claim-related requested documents directly by filling out forms online (e.g., via an online portal) where possible so that they can streamline the process of providing documents | Claimant parties | Mandatory | ||
| Claims054 | MLCL-20 | CLM-1 | Cost avoidance – reduce paper storages. | Form Submission | I need to be able to upload documents directly so that I can e-file requested documentation directly with the DWC (e.g., medical documents) | The system shall support Optical Character Recognition (OCR) to allow users to file claim-related documents by uploading scanned documents, so that they can reduce time spent filing documents | Claimant parties | Mandatory | ||
| Claims055 | MLCL-14 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Form Submission | I need to be able to upload documents directly so that I can e-file requested documentation directly with the DWC (e.g., medical documents) | The system shall provide users with an explanation of what information and format is required for each document upload box so that they receive guidance | Claimant parties | Mandatory | ||
| Claims056 | MLCL-14 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Form Submission | I need to be able to upload documents directly so that I can e-file requested documentation directly with the DWC (e.g., medical documents) | The system shall validate form fields on online forms and show errors to users and prevent submission until they are addressed, so that they can ensure forms are submitted correctly | Claimant parties | Mandatory | ||
| Claims057 | MLCL-46 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Notifications and Alerts | I need to see and access all notifications assigned to me, so that I can track and perform my work | The system shall notify internal users of changes to tasks and claims they are assigned to (e.g., task status change, new document uploaded to claim) so that they can take the appropriate action to complete tasks in a timely manner | WCCs | Mandatory | ||
| Claims058 | MLCL-11 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Claim Management | I need to be able to assign work and monitor workload balancing so that I can manage mine and my team's tasks | The system shall support assignment rules for automatically assigning / reassigning cases to WCCs or UEBTF Recovery Specialists (e.g., round robin assignment, alpha-sort assignment, case load balance assignment based on business rules) so that WCC staff supervisors can manage their team workload and tasks | Supervisors, Managers | Mandatory | ||
| Claims059 | ||||||||||
| MLCL-6 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Analytics and Reports | I need to be able to assign work and monitor workload balancing so that I can manage mine and my team's tasks | The system shall provide a way for authorized users (e.g., Supervisors, Managers) to see reports on their team's workload and progression, so that WCC staff supervisors can manage their team workload and tasks | Supervisors, Managers | Mandatory | |||
| Claims060 | MLCL-44 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Analytics and Reports | I need to see all open tasks assigned to WCCs under my supervision, so that I know my team’s workload | The system shall allow authorized users to view a staff member's case assignment history (e.g., time taken to review claims applications, time taken to calculate and submit an adjustment) so that they can assign / reassign cases and balance workload accordingly | Supervisors, Managers | Mandatory | ||
| Claims061 | MLCL-44 | CLM-4 | Increase benefit management efficiency. | Analytics and Reports | I need to see all cases and claims under my supervision across WCCs, so that I know my team’s caseload | The system shall allow authorized internal users (e.g., supervisors) to view all cases, claims, tasks, and status of each (e.g., dashboard view) across all WCCs on their team so that they can track and mange the team's caseload effectively | Supervisors, Managers | Mandatory | ||
| Claims062 | ||||||||||
| MLCL-50 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Claim Management | I need to be able to reassign claims under my supervision to different WCCs, so that I can ensure my team’s workload is evenly distributed | The system shall allow authorized internal users (e.g., supervisors) to reassign claims, either on an individual basis or in bulk to multiple WCCs, if the original WCC is unable to do so (e.g., left the team, on vacation, out of office) so that they can manage the team's workload effectively | Supervisors, Managers | Mandatory | |||
| Claims063 | ||||||||||
| MLCL-20 | CLM-1 | Cost avoidance – reduce paper storages. | Document Management | I need to scan paper documents and upload them to a claim-specific file repository, so that I can store mailed documents relevant to the claim | The system shall allow internal users to scan paper documents (e.g., incoming mail) for manual upload to a claim-specific file repository so that they can store and manage all related documents for a claim in one view | WCCs, WCAs, MSTs | Mandatory | |||
| Claims064 | MLCL-60 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to communicate with the Disability Evaluation Unit, so that I can request a rating as needed | The system shall provide a way to request a Disability Evaluation Unit rating (e.g., by filing a request for summary, consultative with court/ADJ) so that users can gather the required information for a claim | WCCs, WCAs | Mandatory | ||
| Claims065 | MLCL-60 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to be able to request a QME or AME, so that I can get my claim evaluated | The system shall have the ability to integrate with the QME system to request QME panels and receive QME ratings, so that users can gather the required information for a claim | WCCs, WCAs | Mandatory | ||
| Claims066 | MLCL-14 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to be able to edit information in a claim, so that I can update relevant information | The system shall provide a way for authorized internal users to edit data fields (e.g., date of birth) in a claim, as permitted by business rules, so that users can keep claims up to date | WCCs, WCAs | Mandatory | ||
| Claims067 | MLCL-45 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to be notified of the agreed-upon payment (e.g., via approval of a document by a judge including settlement, F&A, lien, C&R), so that I can prepare to process the payment as described in the agreement | The system shall notify internal users to whom a claim is assigned when a settlement or payment has been approved and include the relevant settlement document when notifying of an approved settlement, so that users know they need to proceed to the next step of the claim to fulfill regulatory requirements (e.g., paying a settled claim within 25 days) | WCCs | Mandatory | ||||
| Claims068 | MLCL-7 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to perform calculations with automatic and manual inputs so that I can streamline claims adjustment process and reduce potential for error due to manual calculation | The system shall support calculation and worksheet tools (e.g., Claims Balance worksheet, Case Evaluation Worksheet, Finalization Workup, Future Medical Value, Permanent Disability Rating, with configurable calculations and inputs, so that users can reduce time spent manually inputting data across different tools | WCCs, WCAs | Mandatory | ||||
| Claims069 | ||||||||||
| MLCL-8 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need relevant claim-specific info to be auto filled so that I reduce manual, repetitive tasks | The system shall include a claims adjustment calculator that can link with a case ID to pre-populate with claim-specific information, so that WCC staff can reduce time spent and potential of error when manually inputting information | WCC staff | Mandatory | |||
| Claims070 | MLCL-18 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to perform calculations with automatic and manual inputs so that I can streamline claims adjustment process and reduce potential for error due to manual calculation | The system shall provide users with a way to automatically insert existing data in the system (e.g., inserting payout amount for a claim when writing a communication, inserting the Statewide Average Weekly Wage into a Permanent Disability Rating) and trigger bulk recalculations for open claims (e.g., new Statewide Average Weekly Wage for UEBTF, COLA for SIBTF), so that users can reduce time spent manually inputting information across different tools | WCC staff | Mandatory | ||
| Claims071 | MLCL-7 | |||||||||
| CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Workflow Management | I need to perform calculations with automatic and manual inputs so that I can streamline claims adjustment process and reduce potential for error due to manual calculation | The system shall allow authorized internal users to add and configure new calculation tools, so that new calculation tools can be added as user needs evolve | Supervisors, Managers | Mandatory | ||||
| Claims072 | MLCL-58 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Workflow Management | I need to be able to review, approve, or send back my team’s determinations for required corrections, so that I can ensure there are no issues with my team’s determinations | The system shall allow authorized internal users to programmatically submit tasks or claims for approval (e.g., claims adjustment, PFD letter, payment to Injured Worker), generating a task for supervisor roles, so that a WCC staff manager can review and approve claims and tasks within the system | WCCs, WCAs, Supervisors, Managers | Mandatory | ||
| Claims073 | MLCL-58 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Workflow Management | I need to be able to review, approve, or send back my team’s determinations for required corrections, so that I can ensure there are no issues with my team’s determinations | The system shall provide authorized internal users (e.g., supervisors or managers) a way to review and approve or reject tasks, cases, or claims that have been marked for their approval, routing rejected work appropriately, so that work can be approved or rejected as needed | Supervisors, Managers | Mandatory | ||
| Claims074 | MLCL-36 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall allow users to initiate payments via electronic funds transfer (EFT) to attorneys, injured workers, medical providers, and service providers (e.g., Bill reviewers, Utilization reviewers) from within the system, so that Claims staff can reduce manual processes related to processing payments | WCCs, WCAs | Mandatory | ||
| Claims075 | MLCL-39 | CLM-4 | Increase benefit management efficiency. | Billing and Payments | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall allow users to view real-time updated payment status information so that they can track the timeline of the payment process | WCCs, WCAs | Mandatory | ||
| Claims076 | MLCL-54 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to receive and forward Requests for Authorization, so that I can take steps to determine whether a treatment is medically necessary | The system shall provide users a way to digitally review and reject or forward on Requests for Authorization to a third-party (e.g., Utilization Reviewer), so that requested treatments can be reviewed and processed | UEBTF WCC | Mandatory | ||
| Claims077 | MLCL-3 | CLM-3 | Increase efficiency by utilizing the claims system for cases assignment. | Billing and Payments | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall be able to digitally interface with Bill Review (BR) and Utilization Review (UR) processes so that BR/UR vendors are able to access, review, and provide a response to a record of treatments/services that WCAB has approved for the Injured worker | WCCs, WCAs | Mandatory | ||
| Claims078 |
MLCL-27
| CLM-4 | Increase benefit management efficiency. | Billing and Payments | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall transmit bills processed by the BR/UR vendors to users assigned to the relevant claim, so that the user can review and process the payment. | WCCs, WCAs | Mandatory | |||
| Claims079 | MLCL-15 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall have all outboud payments automatically populate in the "amounts paid" column of the balance sheet (e.g., payments auto-populated within balance sheet will correspond to their respective pay codes), so that UEBTF staff can reduce time spent manually updating the balance sheet, and the WCC can work on the "All amounts due and payable" column of the balance sheet to see if all payments are valid | WCCs, WCAs | Mandatory | |
| Claims080 | MLCL-36 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall autofill payment amounts using data already in the system so that users do not have to spend time manually entering the amount into the system | WCCs, WCAs | Mandatory | |
| Claims081 | MLCL-61 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Self-Service | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall allow authorized internal users to set up and submit electronic payment instructions with final payment processing and direct payments to injured worker, attorney, and provider accounts via SCO so that they can conduct these payments electronically. The system shall integrate, as needed, with 3rd party payment processing systems for efficiency in processing inbound and outbound payments."The system shall be able to connect with a vendor that can securely store banking information" | |||
| WCAs | Mandatory | ||||||||
| Claims082 | MLCL-62 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Claim Management | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall have the ability to automatically identify and flag for review potential accidental, duplicate payments (e.g., a consolidated payment to a particular biller is posted back into the payment history as individual payments distributed to various claims) so that users can spend reduce time redundancies created by duplicate payments | WCCs, WCAs | Mandatory | |
| Claims083 | MLCL-2 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to be able to process payments and review billing digitally so that I can initiate electronic fund transfer and medical bill review | The system shall allow users to search within payment history (e.g., by case ID, amount paid, date range, claimant party) so that they can navigate to payments easily on one platform | WCCs, WCAs | Mandatory | |
| Claims084 | MLCL-4 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to consolidate multiple invoices in one payment while accurately tracking invoices and claims, so that I can make the required payments in fewer payments | The system shall allow users to consolidate multiple payments associated with a particular claimant or any other parties receiving several payments at the same interval, while identifying specific invoices and amounts per invoice, and send one batch amount via electronics funds transfer so that they can send all necessary payments together and reduce time spent on separate processes | WCAs | Mandatory | |
| Claims085 | |||||||||
| MLCL-35 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to verify that the payee is authorized and up-to-date (e.g., Form 204 is updated, is an authorized vendor), so that I know the payee is eligible to receive payments | The system shall have the ability to automatically generate and send a Form 204 when a payee's information is determined to be out of date, so that users can keep payment information up to date | WCAs, MSTs | Mandatory | ||
| Claims086 | MLCL-62 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to automatically validate payments for errors and duplicates upon data entry, so that I can be sure I am making the payments I am supposed to be making before submitting the payment | The system shall automatically validate outgoing payments against claims information already in the system, so that users can spend less time manually reviewing payments | WCAs, MSTs | Mandatory | |
| Claims087 | MLCL-62 | CLM-2 | Increase efficiency by reducing the amount of redundant and/or manual steps to accomplish a task | Billing and Payments | I need to automatically validate payments for errors and duplicates upon data entry, so that I can be sure I am making the payments I am supposed to be making before submitting the payment | The system shall automatically flag any validation errors in payments for review by an authorized internal user (e.g., WCC supervisor, WCC manager), so that payments can be checked and corrected before being sent out | WCAs, Supervisors | Mandatory |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .