HSS27005-EVV_appB.pdf

HSS-27-005: EVV DATA AGGREGATION, VALIDATIONS, COMPLAINCE & OVERSIGHT SERVICES

APPENDIX B: TECHNICAL REQUIREMENTS

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RFP No.: HSS-27-005 Title: ELECTRONIC VISIT VERIFICATION (EVV) DATA AGGREGATION, VALIDATION, COMPLIANCE, AND OVERSIGHT SERVICES

TECHNICAL REQUIREMENTS

1. RFP Background and Purpose The purpose of this Request for Proposal (RFP) is to solicit proposals from qualified contractors to provide Electronic Visit Verification (EVV) data aggregation, validation, compliance, and oversight services for the Department of Health and Social Services (DHSS), Division of Medicaid and Medical Assistance (DMMA), in compliance with the 21st Century Cures Act (Cures Act) and applicable federal and state requirements.

In response to the EVV requirements outlined in the Cures Act, DMMA previously implemented an Open Vendor / Open Choice EVV model, under which the State offered an optional EVV visit capture system while also allowing providers to use their own EVV solutions. Over time, providers statewide transitioned to using independently selected EVV systems that best met their operational needs, resulting in minimal utilization of the State-provided EVV capture solution.

Based on this experience, and to align policy with current provider practice, DMMA is transitioning to a Provider Choice EVV model. Under this model, providers will continue to select, contract with, and operate their own EVV visit capture systems, while the State will centrally manage EVV data aggregation, validation, compliance monitoring, reporting, and integration with Medicaid systems.

Accordingly, DMMA is seeking a Contractor to implement and operate a statewide EVV aggregation and oversight platform. The selected Contractor will not provide a provider-facing EVV visit capture solution. Instead, the Contractor will support the receipt of EVV data from multiple third-party EVV systems, normalize and validate that data in accordance with DMMA-defined standards, and support program integrity, compliance, reporting, and claims-related business processes, including sending pertinent data to the state to facilitate federal T-MSIS reporting.

The solution must be flexible, scalable, and interoperable, capable of supporting multiple EVV vendors, service delivery models (including member-directed services), Medicaid populations, and delivery settings, while ensuring compliance with the Cures Act and minimizing administrative burden on providers and members.

2. Draft EVV Requirements for RFP - Provider Choice EVV Aggregation and Oversight Solution

2.1. EVV Model and Scope

2.1.1. Provider Choice Model

A. The State shall implement a Provider Choice EVV model.

B. Providers -shall select, contract with, and operate their own EVV visit capture systems.

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C. The State shall not provide or operate an EVV visit capture, scheduling, or data collection system.

2.1.2. Contractor Scope

A. The Contractor shall provide a statewide EVV data aggregation, validation, compliance, and oversight platform.

B. The Contractor shall support interoperability with multiple provider-selected EVV systems.

C. The Contractor shall not require or promote the use of any proprietary EVV capture solution.

2.2. Compliance Requirements

2.2.1. Federal Compliance

A. The solution shall comply with all EVV requirements of the 21st Century Cures Act.

2.2.2. The solution shall support EVV for both Personal Care Services and Home Health Services. State Compliance

A. The solution shall comply with all applicable State of Delaware laws, regulations, and DMMA policies.

B. The solution shall support audit and reporting requirements imposed by DMMA and

CMS.

C. The vendor shall provide data for all CMS outcome and metric reporting, including monthly reporting requirements.

D. The vendor shall adapt to approved Change Requests affecting reporting or compliance without requiring a new procurement.

E. The solution shall support EVV for State-specified services in addition to personal care and home health.

2.2.3. CMS SMC Certification Lead

A. The vendor shall lead and coordinate the CMS SMC certification process for the EVV platform.

B. The vendor shall provide staffing, documentation, and technical support necessary to achieve certification.

C. The vendor will have a named Staff position as certification lead which must be approved by DMMA

D. The vendor will present at Certification as needed E. All certification activities shall be subject to State review and approval prior to submission to CMS.

2.3. EVV Vendor Integration and Certification

2.3.1. Vendor-Neutral Integration

A. The platform shall support integration with an unlimited number of third-party EVV vendors.

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B. The Contractor shall operate in a vendor-neutral manner and shall not restrict provider EVV vendor choice.

2.3.2. Onboarding and Certification

A. The Contractor shall support the State in onboarding and certifying EVV vendors by providing a standardized process, including technical specifications, testing environments (sandbox and user acceptance), and documentation. The Contractor shall maintain this process and assist with re-certification as requirements change, under the oversight and approval of the State.

B. The Contractor shall publish technical specifications for EVV data submission.

C. The Contractor shall provide testing environments, including sandbox and user acceptance testing (UAT).

D. The Contractor shall certify and re-certify EVV vendors as requirements change as appropriate .

2.4. Required EVV Data Elements

2.4.1. CMS-Required Elements

A. The platform shall receive and validate EVV records containing, at a minimum:

• Type of service performed

• Individual receiving the service

• Date of service

• Location of service delivery

• Individual providing the service.

o Identifiers include Social Security Numbers or other state-approved alternatives.

o Professional license number, when applicable

• Start and end times of the service

2.4.2. Configurability

A. The platform shall allow DMMA to configure required data elements by program, service, or population.

B. The platform shall support future expansion of EVV data requirements.

2.5. Data Ingestion and Processing

2.5.1. Data Submission

A. The platform shall accept EVV data via APIs and batch file submissions.

B. The platform shall support near real-time data ingestion.

2.5.2. Normalization and Validation

A. The platform shall normalize EVV data from disparate sources into a State-defined format.

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B. The platform shall validate EVV records for completeness, accuracy, and timeliness as defined by the State at DDI.

C. The platform shall generate standardized error messages and rejection notices.

2.6. Visit Validation and Exceptions

2.6.1. Visit Status

A. The platform shall apply configurable business rules to determine visit status, including verified, unverified, and exception statuses.

B. Business rules shall be configurable by service, program, and delivery model.

C. The Platform will use the Delaware EVV Services and Procedure Codes identified in

2.7.2, Part C.

2.6.2. Exceptions Management

A. The platform shall support centralized management of EVV exceptions.

B. The platform shall allow submission and tracking of supporting documentation.

C. The platform shall maintain a complete audit trail of all exception activity.

2.7. Reporting and Analytics

2.7.1. Standard Reports

A. The platform shall provide standard reports, including:

• Verified and unverified visits

• Provider compliance metrics

• Program and service utilization

• Exception trends

2.7.2. Dashboards

A. The platform shall provide role-based dashboards for State users and authorized entities.

B. Reports and dashboards shall be exportable in standard formats.

C. The vendor’s solution will support CMS Operational Metric reporting that includes but not limited to the following:

(a) Association of EVV Record to Claim/Encounter - To ensure that claims and encounters for EVV required services are associated and paid with verified visits. The percentage is calculated using the following: Numerator - # of paid claims and encounters that have complete EVV visit records associated with them; Denominator - Total number of paid claims and encounters for (PCS or HHCS) for the month.

(b) EVV Record Match Against Approved Services, Providers, and Units - To ensure linkage between authorized provider, service, units, and beneficiary for home visits. This percentage is calculated using the following: Numerator - # of procedure codes paid for which the number of units, provider, and services

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(c) EVV Records Without Manual Edits – This metric helps reduce incidence of manually entered or edited EVV records. The percentage is calculated using the following: Numerator - # of EVV records for verified visits which have no manual edits; Denominator - Total number of EVV records for verified visits received for the month

(d) EVV System Availability – This ensures the EVV system has high availability.

The percentage is calculated using the following: Numerator - Uptime outside of scheduled maintenance; Denominator – Minutes in the month not including scheduled maintenance.

(e) Open privacy and security risks - Metric data will be sourced from the POA&M(s), reported quarterly.

2.7.3. CMS Monthly Reporting

A. The platform shall provide all data required for monthly CMS reporting, including outcome metrics, operational metrics, and any additional data requested by the State.

B. The platform shall support reporting for all EVV-required services, including Personal Care Services and Home Health Services.

C. The platform shall allow export of CMS reporting data in standard formats for State review and submission.

2.8. Integration with Medicaid Systems

2.8.1. MMIS and Claims

A. The platform shall interface with the State’s MMIS/claims systems and Managed Care Organization systems

B. The platform shall support EVV data use for pre-payment review.

2.8.2. MCO Authorization and Case Management

A. The platform shall interface with Managed Care authorization and case management systems to:

• Receive service authorizations

• Track utilization against authorized units

2.8.3. T-MSIS

A. The platform shall interface with Gainwell for T-MSIS reporting and support future rule changes as defined by the State.

B. The platform shall capture, store, and securely transmit direct care worker identifiers, including Social Security Numbers or state-approved alternatives, for T-MSIS reporting in accordance with federal and state requirements.

C. Caregiver licensing functionality Implementation is expected at go-live and may be adjusted through approved change management processes.

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2.9. Security, Privacy, and Audit

2.9.1. Security

A. The platform shall comply with all applicable federal and State security standards.

9.1.2 The platform shall use role-based access controls.

B. Must include Multi-Factor Authentication

2.9.2. Audit and Retention

A. The platform shall maintain comprehensive audit logs of user activity and data changes.

B. The platform shall retain EVV data in accordance with State and federal retention requirements.

2.10. Performance and Availability

A. The Contractor shall meet State-defined service level agreements for system availability and performance.

B. The Contractor shall provide incident response, issue resolution, and ongoing system monitoring.

2.11. Change Management and Support

A. The Contractor shall support updates to technical standards, business rules, and regulatory requirements.

B. The Contractor shall provide ongoing technical support and stakeholder coordination.

C. All updates need to be discussed with and approved by the state project lead. A change management structure is required for this contract.

2.12. Explicit Exclusions

A. The Contractor shall not be responsible for:

(a) EVV visit capture or point-of-service data collection tools

(b) Scheduling or workforce management systems

(c) Provider or member devices

(d) Device installation, maintenance, or replacement

(e) Payroll or provider billing systems

3. Delaware EVV Services and Procedure Codes A. Below is a reference list of services subject to EVV in Delaware Medicaid, based on

DMMA’s existing documentation Service Procedure Code(s)

Attendant Care Services S5125 S5130 U2

Chore Services S5120 Companion Services S5135

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Service Procedure Code(s) Homemaker Services S5130 Home Health – Home Health Aide G0156 Home Health Nursing G0299; G0300, G0493, G0494, G0495, G0496

Nursing Services S9123, S9124

Physical Therapy G0151, G0157, G0159 Occupational Therapy G0152, G0158, G0160 Speech Therapy G0153, G0161, Supported Living T2013 Respite Care S5150, S9125, T1005 Private Duty/Independent Nursing T1000 Personal Care Services T1019

B.

• These codes represent the eligible services that must be verified via EVV for in-home services under Medicaid.

• EVV data must be logged for eligible services for claims to be matched and adjudicated, and data may be used by DMMA and Managed Care Organizations (MCOs) for claim validation and reporting to CMS.

• Delaware’s EVV guidance clarifies that not all home visit services are subject to EVV—for example, visits by social workers or dieticians in the home aren’t subject to EVV, nor are visits delivered outside the home (e.g., in school settings).

4. Interfaces A. The selected vendor must participate in the interfaces listed below.

(a) Incoming

(i) Interface with DMMA MMIS System

1. Provider file from MMIS

2. Member file from MMIS

3. Prior Authorization file from MMIS

(ii) Interface with DMMA MCOs

1. Prior Authorization files

(iii) Interface with Alternate EVV Vendors

1. Visit data including working information

(b) Outgoing

(i) Data Warehouse Export to MMIS that includes all visit data

(ii) Data Warehouse Export to each MCO that includes all visit data specific to that MCO

5. Name Staff

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Vendor shall provide the individuals listed below as key personnel for the performance of the services. The State shall have final approval over all personnel.

First & Last Name Role % of Involvement Project Manager Technical Lead Certification Lead

Performance and Quality Manager