PL 016.pdf

PL 016 Solution Plan – BabyNet

SCDHHS Confidential Page 1 of 68

Solution Plan – BabyNet

Version 1.2

Prepared by:

South Carolina Department of Health and Human Services (SCDHHS)

Enterprise Architecture (EA)

SCDHHS Confidential Page 2 of 68

Table of Contents

1. Intended Audience

2. Document Purpose

3. Business Motivation for the Change Initiative

3.1. Context

3.2. Project Purpose

3.3. Goals and Objectives

3.4. Alignment to Policies, Standards and Reference Architecture

4. Current State Architecture

4.1 Current State Business Architecture

4.1.1 Organizational Structure

4.1.2 Existing Business Roles and Services

4.1.3 Business Channels

4.2 Current State Systems Architecture

4.2.1 Catalog of Current State Applications

4.2.2 Applications Enabling the existing Systems Solution

4.2.3 Business and System Services Traceability

4.2.4 Current State Systems Integration

4.2.5 Current State Technology Architecture

4.2.6 Current State Challenges

4.2.7 Current State Strengths

5. Proposed Solution

5.1 Changes to Organization Structures

5.2 Future State Business Roles and Services

5.3 Organizations impacted by System Implementation

5.4 Future State Business Channels

5.5 Future State Application Architecture

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5.5.1 Application Architecture Principles

5.5.2 Changes to Application Components and Services

5.5.3 Changes to Application Components and Services

5.5.4 Application Services – Essential Functions and Features

5.5.5 Future State Systems Integration

5.5.6 Integration Patterns

5.5.7 Future State Systems Integration

5.6 Future State Data Architecture

5.6.1 Future State Domain Model

5.6.2 Data Guiding Principles

5.6.3 Data Migration/Conversion Considerations

5.7 Future State Technology Architecture

5.7.1 Future State Technologies and Infrastructure Summary

5.7.2 SCDHHS Technology and Infrastructure Architecture Evolution

5.7.3 User Community Description

5.7.4 Security and Privacy Considerations

5.7.5 Availability Considerations

5.7.6 Volume and Performance Expectations

5.7.7 Business Continuity and Disaster Recovery Considerations

5.7.8 Security: API’s, Ports, Protocols and Services

6. Solution Implementation Roadmap

6.1 Anticipated Workstreams

6.1.1 BabyNet Phase 1 (1st Iteration):

6.1.2 BabyNet Phase 2

6.1.3 Assumptions and Dependencies

6.1.4 Constraints

6.1.5 Project Risks

6.1.6 Issues to Resolve

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6.1.7 Critical Success Factors for Remainder of the Project

Appendices 66

Appendix A – Application & Business ArchiMate Legend

Record of Changes

List of Tables Table 1: Goals and Objectives Summary

Table 2. Organizations impacted

Table 3: Business Roles and Responsibilities

Table 4: Existing Business Channels Summary

Table 5: Catalog of Current State Applications

Table 6: Application Components and Services Summary .............. Error! Bookmark not defined.

Table 7: Current State Systems Integration

Table 8: Technology and Infrastructure enabling SCDHHS Systems of Record and Integration .. 28

Table 9: Future State Business Roles and Responsibilities

Table 10. Organizations impacted

Table 11: Future State Business Channels

Table 12: Application Architecture Principles

Table 13: Changes to Application Components and Services

Table 14: Essential functions and features - service center application

Table 15: Architecture principles - integration ................................ Error! Bookmark not defined.

Table 16: Integration patterns to be supported

Table 17: Future state system integration

Table 18: Future State Data Model ................................................. Error! Bookmark not defined.

Table 21: Applications Publishing and Subscribing to Data Objects Error! Bookmark not defined.

Table 20: Data Guiding Principles

SCDHHS Confidential Page 5 of 68

Table 21: Data loss mitigation planning

Table 22: Future Technology and Infrastructure enabling SCDHHS Systems of Record and Integration 52

Table 23: Technology and Infrastructure Architecture Evolution

Table 24: User community details

Table 25: Security and privacy considerations

Table 26: Systems availability considerations

Table 27: Volume and performance expectations

Table 28: Work Packages - Phase 1: <description>

Table 29: Work Packages - Phase 2: <description>

List of Figures Figure 1: Member Eligibility and Enrollment Management

Figure 2: Provider Eligibility and Enrollment Management

Figure 3: Care Management

Figure 4: Operations Management

Figure 5: Provider Management

Figure 6: As-is BabyNet Solution ..................................................... Error! Bookmark not defined.

Figure 7: Business and Systems Traceability

SCDHHS expressly restricts the distribution of this document to include only those SCDHHS staff, SCDHHS processing environment contractors, or any entity given explicit access to this document with SCDHHS executive or management approval.

SCDHHS Confidential Page 6 of 68

1. Intended Audience The Solution Plan (SP) audience includes South Carolina Department of Health and Human Services (SCDHHS) leadership and staff, including (but not limited to) representatives from the following areas:

• Bureau of Quality, including BabyNet Business team

• Eligibility and Enrollment Management

• Programs, including Bureaus of Policy and Provider and Support Services

• Office of Information Management (OIM), including BabyNet Solution Development team, Office of Information Assurance (OIA), IT Operations (ITO)

• Bureau of Strategic Planning and Research, including the Project Management Organization

(PMO)

• Data Governance & Data Operations

• Bureau of Contracts and Procurement

2. Document Purpose Solution Plans are completed when SCDHHS conceive change initiatives, to provide high-level descriptions of:

• The business motivation for the change initiative.

• The existing business and systems architecture.

• Future configuration of the business and systems architecture, as needed to realize the business goals and objectives, incorporating risks and dependencies of the existing business and systems landscape, as well as opportunities presented.

This document describes the business and technical solution needs of SCDHHS to improve the capabilities of the BabyNet operations, which enable South Carolina to meet the Federal requirements for Individuals with Disabilities Education Act (IDEA) Part C.

This document, in conjunction with the Solicitation RFP package of documents should be considered a set and describe the business motivation and architectural requirements for the SC BabyNet procurement.

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3. Business Motivation for the Change Initiative

3.1. Context

The BabyNet solution enables SCDHHS business units to support Title 20 Chapter 33, Education of Individuals with Disabilities.

Governor Nikki Haley signed Executive Order 2016-20, which transferred the BabyNet program from South Carolina First Steps to SCDHHS, effective July 1, 2017.

The program addresses Individuals with Disabilities Education Act (IDEA) Part C (also known as Part 303 and called “BabyNet” in SC).

Other parts of IDEA – which do not form part of BabyNet but included here for completeness of IDEA understanding – are:

1. Part A: outlines IDEA’s general provisions, including the purpose of IDEA and the definitions used throughout the statute.

2. Part B: Services for school-aged children with developmental disabilities (3 through 21 years of age) are provided free of charge through the public school system. Among the services covered under IDEA are special education; related services such as physical, occupational, and speech therapy; and supplementary aids and services, such as adaptive equipment or special communication systems.

3. Part D: Includes provisions for federal grants available to support activities related to improving services for children with disabilities, including personnel development, technical assistance and dissemination, technology, and parent-training and information centers.

3.2. Project Purpose

The project purpose is to enable SC to meet the requirements of the Individuals with Disabilities Education Act (IDEA) Part C.

In 2017 a decision was made to move BabyNet to SCDHHS. SCDHHS implemented and integrated the existing BabyNet Reporting & Intervention Data Gathering Electronic System (BRIDGES) in 2019.

The contract for the BRIDGES solution is reaching its end of life, and SCDHHS is publishing this competitive procurement for a BabyNet Case Management system.

https://www.scstatehouse.gov/Archives/ExecutiveOrders/exor2016-20.pdf https://www.scdhhs.gov/resource/babynet

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3.3. Goals and Objectives

BabyNet provides early intervention services for children with disabilities from birth until their third (3rd) birthday. These services are designed to identify and meet a child’s needs in Physical, Cognitive, Communication, Social or Emotional, and Adaptive developmental areas.

Implementing a BabyNet systems solution presents SCDHHS with an opportunity to achieve business goals in the areas of process improvement, automation and control, as well as user experience. The project also presents SCDHHS with an opportunity to address some of the existing end-to-end system shortcomings, as is reflected in the systems goals listed. The table below provides a summary of the business and system objectives.

Table 1: Goals and Objectives Summary

Business Goal Business Objectives for BabyNet Systems Objectives

Process automation Automate the process where operational resources manually re-enter data, i.e. for BabyNet referrals data.

Use BabyNet system to:

Receive BabyNet referrals Feed referrals to the eligibility system

Use the MES Core system to:

Enable Referral data exchanges between BabyNet Case

Management and SCDHHS systems Use the EDI Translator to:

Exchange claim/EDI related transactions between the BabyNet solution and MMIS.

Process improvement and control

Reduce turnaround time for eligibility determination/ verification.

Use MES Core to facilitate more frequent data exchanges, and thus accelerate eligibility determination/ verification process turnaround times.

SCDHHS Confidential Page 9 of 68

Business Goal Business Objectives for BabyNet Systems Objectives

Improve BabyNet claims preparation, voided and cancelled claim processes.

Use BabyNet system to:

Convert Service Notes submitted by Providers to 837 P/I transactions Deliver claims transactions to the SCDHHS claims adjudication system Receive adjudicated claims data from the SCDHHS claims adjudication system Implement Prior Authorization functionality for BabyNet benefits.

Use BabyNet system to:

Receive and process Prior Authorization requests for provider services Distribute Prior Authorization data to the SCDHHS claims adjudication system (Need to determine if MMIS or BabyNet will do

PA)

Use the MES Core system to:

Enable Prior Authorization data exchanges between BabyNet and SCDHHS systems (Answer based on above) Use the MMIS Claims function to:

Check requisite Prior Authorization records as part of the BabyNet claims adjudication process (Same as above)

Ensure IDEA Part C funds are used only as payer of last resort.

Ensure accurate claim data and coding to enable the MMIS to properly process claim adjudication and ensure SCEIS payments are processed using the correct funds. BabyNet claims are payer of last resort, after Medicaid.

Improve service experience for Members

Allow families to choose Providers for BabyNet services.

Use BabyNet system to enable recipients’ families/ representatives to choose Providers.

SCDHHS Confidential Page 10 of 68

Business Goal Business Objectives for BabyNet Systems Objectives

Improve service experience for Providers

Optimize BabyNet Providers’ access to claims and remittances information.

Use the BabyNet system to:

Create and update service notes Enable Provider modifications to submitted Service Notes to enable voided or cancel claim processing to occur Obtain Remittance data from the SCDHHS claims payment system Make Claims and Remittance data accessible to Providers

Use the MES Core system to:

Enable Remittance data exchanges between BabyNet Case

Management and SCDHHS systems Reduce costs Reduce costs, risks and timelines to implement or replace future system solutions.

Use the MES Core system to:

Enable application components modularity and interoperability Implement standards-based data exchanges (as defined in SCDHHS technical reference architecture)

It is expected that implementing the future BabyNet system solution will aid to realize the following SCDHHS strategic goals to strengthen the health and well-being of South Carolinians across their lifespan and limit the burden to provide and receive care.

https://schhs.sharepoint.com/sites/StrategicPlan/SitePages/Home.aspx

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3.4. Alignment to Policies, Standards and Reference

Architecture

The SCDHHS technical reference architecture standards govern system development projects as set out at https://schhs.sharepoint.com/teams/INTHub/ES/Standards/Forms/AllItems.aspx). The standards expected to apply to this project include:

• PL 002 TRA

• It is expected that this implementation will meet common IT Standards and Conditions such as:

o Modularity o Industry standards o Leverage existing SC technologies where appropriate o Enterprise perspective – promote an enterprise view that supports enabling technologies that align with SC business processes and technologies.

o Performance driven – make performance measurable for accountability and planning.

o Interoperability – develop systems that can communicate effectively to achieve common SCDHHS enterprise goals through interoperability and common standards.

o Flexible – promote an environment that supports flexibility, adaptability, and rapid response to changes in programs and technology.

• All applicable security and privacy laws, regulations, and policies, including:

o CMS Minimum Acceptable Risk Standards for Exchanges (MARS-E), Catalog of

Minimum Acceptable Risk Security and Privacy Controls for Exchanges o Health Insurance Portability and Accountability Act (HIPAA) o Medicaid Safeguarding, and related breach notification laws and directives.

o Centers for Medicaid and Medicare Services (CMS) Guidance and Standards

CMS.GOV - Minimum Acceptable Risk Standards CMS.GOV - Supplement o FISMA

CRST.NIST.GOV - FISMA

HHS.GOV - HIPAA

o HITECH OMNIBUS

HHS.GOV

https://schhs.sharepoint.com/teams/INTHub/ES/Standards/Forms/AllItems.aspx https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/#MinimumAcceptableRiskStandards https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Harmonized-Security-and-Privacy-Framework-ERA-Supp-v-1-0-08012012-a.pdf http://csrc.nist.gov/drivers/documents/FISMA-final.pdf http://www.hhs.gov/ocr/privacy/hipaa/administrative/combined/index.html http://www.hhs.gov/ocr/privacy/hipaa/administrative/omnibus

SCDHHS Confidential Page 12 of 68 o IRS Publication 1075

IRS.GOV

o Patient Protection and Affordable Care Act (PPACA) or (ACA)

GPO.GOV

4. Current State Architecture

4.1 Current State Business Architecture

Section 4 describes the current State Architecture and includes a table to highlight the Organizational Structure as well as diagrams for Member and Provider Eligibility and Enrollment , BabyNet Care Management, Operations Management, and Provider Management showing the business roles and business services to support the current BabyNet program.

http://www.irs.gov/pub/irs-pdf/p1075.pdf http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

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4.1.1 Organizational Structure

The table below provides a brief overview of the anticipated impact to SCDHHS organization areas:

Table 2. Organizations impacted Organization Services and Components Impact

SCDHHS

BabyNet Administration

SCSDB

SCDDSN

SaaS based solution hosted and supported outside of OIA support.

Major components include support of BabyNet system environment and operations including aspects related to family, Provider, SCDHHS staff, and Federal Reporting needs. BabyNet system support also includes the solution to support data transfers, applicant and Provider self-service interaction capabilities, workflow management, quality assurance, data access and editing audit capabilities, multi-language support, and program knowledge management.

The BabyNet platform will support users across SCDHHS departments, including, but not limited to, other state partners, and vendors involved in providing BabyNet services to providers and members.

IT & Business support staff

BabyNet Operations

Support customer service operations for the BabyNet populations.

Historic and real-time analytic capabilities to understand issues, trends, and opportunities to inform decision-making and improve the interaction with Department Stakeholders

Business support

Medicaid Eligibility, Enrollment & Member Services

Eligibility application intake and maintenance that results in the delivery of member business services. The Central Referral data team enters data into Cύram if the Baby’s data is not already present. If, the Baby applying for BabyNet is eligible for Medicaid, not already a member of Medicaid, and the family wishes to enroll in Medicaid the family will apply for Medicaid outside of the BabyNet enrollment process.

Eligibility & Enrollment

External SC Providers

Provider enrollment for Medicaid is completed using the Provider PE Portal.

Provider Enrollment in BabyNet (after enrolled in Medicaid) is completed using the BabyNet Provider Portal. IFSP and maintenance that relating to the delivery

External Provider Usability & BabyNet Operations

SCDHHS Confidential Page 14 of 68 of member services are submitted and tracked using the Claim generation by PCG for 837P is completed from Service Notes. Claims are submitted from PCG to the MMIS for Edits/Audits/Payment. Claim payment tracking is completed using the Provider Web Portal (not in BabyNet).

BabyNet Operations

Management and tracking of outbound communications from the BabyNet environment to members and providers, including tasks that involve developing and publishing standard communications, bulletins, re-enrollment notices, and other pertinent publications for Stakeholders.

Management of printing, fulfilling, and mailing (including USPS and electronic notifications) information on a scheduled, event-driven, and ad-hoc basis. This includes handling receipt of inbound mail to the Department as well as production and distribution of the Medicaid membership cards.

Collaboration and Communication

Agency C Suite leaders and

CMS

Federal reporting generated from the new BabyNet system as well as questions or audits from the Federal partner.

Reporting, Collaboration and Communication

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4.1.2 Existing Business Roles and Services

4.1.2.1 Member Eligibility and Enrollment Management

Figure 1: Member Eligibility and Enrollment Management

Business Service Description Business Role

BabyNet Referral Submittal

Web front end to allow Referrer to enter Referral data for the baby

Family member, community member, provider, etc.

Medicaid Member Eligibility Determination

Determine Medicaid Eligibility using Cúram.

1) Medicaid eligibility verification

2) Assignment of PCAT 89 for Non-

Medicaid

BabyNet Central Referral staff

Medicaid Member Enrollment

Medicaid Enrollment using MMIS (including assignment of the Recipient Specialty Program (RSP) code.

BabyNet Central Referral staff

BabyNet Member Enrollment & Disenrollment

Determine IDEA Part C Eligibility using BabyNet system. Includes the process for BabyNet Central Referral to disenroll member by end dating the BNET RSP.

BabyNet Intake Coordinator BabyNet Central Referral staff

Member Communications

Verbal or written Provider communications sent from BabyNet system or staff

BabyNet Service Coordinator or Central Referral team members

Member Maintenance BabyNet system or staff entering, updating, marking as “deleted”, and querying member information.

(ME01 – Manage Member Information)

BabyNet Service Coordinator

SCDHHS Confidential Page 16 of 68

4.1.2.2 Provider Eligibility and Enrollment Management

Figure 2: Provider Eligibility and Enrollment Management

Medicaid Provider Eligibility & Enrollment

Providers enrolling in the BabyNet program must be enrolled as a Medicaid Provider.

Provider Enrollment team Part of Medicaid Claims Control Systems (MCCS) role, currently performed BCBS MCCS, which is being managed by the Bureau of Provider & Support Service

BabyNet Provider Eligibility & Enrollment

Enrollment of BabyNet Providers to the BabyNet Case Management System

BabyNet Provider Relations

BabyNet Provider Communications Management

Verbal or written Provider communications sent from BabyNet system or staff

BabyNet Provider Relations

Provider Revalidation Provider revalidation is processed for all Medicaid (and therefore BabyNet) providers.

BCBS MCCS (Bureau of Provider & Support Service)

SCDHHS Confidential Page 17 of 68

4.1.2.3 Care Management

Figure 3: Care Management

Provider Choice Assignment

Enable enrollee to select Provider of their choice for services needed.

BabyNet Service Coordinator(TBC)

BabyNet Case Assessment

SC BabyNet staff members that review and update referral data and complete evaluation processes for BabyNet eligibility determination

BabyNet Service Coordinator

IFSP Creation and Maintenance

- Record case notes

Prepare and update the Individual Family Service Plan which indicates the services and frequencies approved for the member.

BabyNet Service Coordinator (Prepare IFSP, facilitates, maintain & update) Provider (contributes & participates)

Case Notes Creation and Edits

Notes entered by the Provider or SC BabyNet staff for a given case.

BabyNet Service Coordinator (TBC) Provider

Service Authorization (Prior Authorization)

Process to obtain Service Authorization BabyNet Service Coordinator

SCDHHS Confidential Page 18 of 68

4.1.2.4 Operations Management

Figure 4: Operations Management

Service Notes Submittal & Edits

Providers submit Service Notes to BabyNet system

Providers BabyNet Service Coordinator

Service Notes Approval (Including TPL Payments)

Agency billing specialists approve Service Notes for payment (including TPL payments), Bulk Approval

Agency Administrators (Billing Specialist at Provider location)

BabyNet Claim Preparation

Process to combine, calculate and convert Service Notes to EDI 837P claim transactions, and exclusion of Service Notes as appropriate

Data Governance Operations

(DGO)

PCG

Claims Adjudication BabyNet sends EDI transactions to MMIS for Adjudication. MMIS will perform its Adjudication process on these claims, however BabyNet should ensure the claim is as clean as possible, i.e. not a duplicate, all data is supplied, etc.

Claims Resolution team

BabyNet Claims Exceptions and Adjustments

Includes processes to scrutinize and interpret unsubmitted claim reports, MCO Carved In & Outlier Services

DGO & BabyNet Operations Claims Resolution team DGO & PCG - (Void & Replace)

BabyNet Claim Status Inquiry

Process to enable BabyNet Providers to request claim status information (270/271), to receive such requests, to obtain the requisite claims status information, and to share that claims status information with the Provider.

Provider

SCDHHS Confidential Page 19 of 68

Payment Fund Identification

BabyNet will receive indicators from external systems if the member is eligible for Medicaid or not and must store and track this information to ensure appropriate funds are used to pay Providers.

Fiscal

Claim Payment Process to calculate payment amounts due to providers, disbursing payments from the correct funding sources and reconciling paid amounts with associated claims records.

Claims Resolution team

Remittance Advices to BabyNet Providers

Process to prepare and distribute a Remittance Advice that Provider can use to reconcile their accounts.

Claims Resolution team

TPL Services The BabyNet system will communicate with the TPL system.

Office of Third Party Liability

4.1.2.5 Provider Management

Figure 5: Provider Management

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Table 3: Business Roles and Responsibilities

Provider Service Documentation

Better reporting for Providers to reconcile payments to claims, managing Provider “matrix” for MMIS Providers that are enrolled in the BabyNet program, ability to display EOB to Providers as well as the ability to accurately identify BabyNet providers

Data Governance Operations

(DGO)(TBC)

BabyNet Operations Reporting

Tracking information as needed for measuring operations performance.

BabyNet Operations Data Analytics & DGO

BabyNet Federal Reporting

Processes to prepare financial and program reports to assist with budgetary controls and to ensure that the program and benefits are meeting the needs of the beneficiaries and are adhering to legislation and meeting federal reporting requirements.

BabyNet Operations & Data Analytics

4.1.3 Business Channels

The table below provides more details of the various contact points (business channels):

Table 4: Existing Business Channels Summary

Business channel Nature of interaction Business Owner

Provider Enrollment Portal Prospective Medicaid Providers may use the online enrollment application to prepare, review and submit an application to SCDHHS.

Portal url: provider.scdhhs.gov.

Provider Enrollment team

Provider Web Tool Enrolled Providers may use the Web Tool to:

1. Update their passwords

2. Download or view payment e-remit statements online

3. Enter and submit (fee for services) claims for

Medicaid Members (CMS-1500 and UB-04 claims and associated adjustments)

4. View the Status of claims

5. Check on the eligibility of Medicaid Members

Claims Processing team

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Business channel Nature of interaction Business Owner

Provider Service Center Phone & Email Channel

Online Service Request Channel

Providers may direct telephone inquiries to the Provider Service Center by calling and following the voice prompts, depending on the nature of the inquiry.

Any available PSC Representative will be able to assist (it is not necessary to address inquiries or correspondence to an assigned representative. ) Contact no: 1-888-289-0709 Providers could also submit service requests online and a provider support representative will respond to the Provider directly.

Web form url:

http://www.scdhhs.gov/contact-us https://www.scdhhs.gov/webform/contact-provider-representative

Provider Service Center

Online BabyNet Provider Case Management Portal

Providers have online access to the case management system, to:

1. View and update the IFSP

2. View other Provider Service Notes

3. Add and update Service Notes

BabyNet Provider Relations

BabyNet Central Referral Team

Families and Professionals may refer a child to BabyNet by calling the Central Referral Team at 1- 866-512-8881.

BabyNet Eligibility

Online BabyNet Referral Website

Families and Professionals may refer a child to BabyNet by completing an online referral form.

Web form url:

https://babynet.scdhhs.gov/prebabynet/

BabyNet Eligibility

Citizen (Member) Web Portal

Enables preparation and submission of online applications to the SCDHHS eligiblity determination application (Cúram).

Enables electronic communication for members who have an account.

https://apply.scdhhs.gov/CitizenPortal/application.do

EEMS (SCDHHS), via contracted systems vendor.

http://www.scdhhs.gov/contact-us https://www.scdhhs.gov/webform/contact-provider-representative https://www.scdhhs.gov/webform/contact-provider-representative https://babynet.scdhhs.gov/prebabynet/

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4.2 Current State Systems Architecture

4.2.1 Catalog of Current State Applications

Table 5: Catalog of Current State Applications Application Description BabyNet Provider Portal

Web front end used by SC BabyNet Providers to complete functions such as submitting supplemental documentation needed to enroll as a BabyNet Provider, submitting/ deleting Service Notes, electronic IFSP interaction and other Provider functions.

BabyNet Referral Portal Web front end which allows the referrer (family, provider, therapist or any individual) to enter and submit the necessary data elements needed to begin the BabyNet enrollment process. The existing system saves the entered data in OnBase Document Management (see OnBase application description below) application and does not save the data directly to BRIDGES.

Provider Web Portal Existing SCDHHS portal used by Providers to enroll in Medicaid as well as perform functions related to claim submission, claim status inquiry/response and other Medicaid Provider functions not specific to BabyNet.

OnBase Document Management

Stores an electronic copy of the BabyNet referral. This image is used during validation of or data entry of the application into the Cúram system and can also be referenced by the CRT or other BabyNet staff throughout the life of the baby while enrolled in the BabyNet program.

Cúram The eligibility module in use at SC Medicaid and is used to determine Medicaid eligibility for prospective members. Cúram supports Member enrollment/dis-enrollment, Medicaid ID generation and assignment, account status, complaints/grievances, reporting, data sharing, and other functions typical of a Medicaid Eligibility System.

MES Core Distributes BabyNet member enrollment data from MMIS to BRIDGES. MES Core uses member data ingested from MMIS to generate an EDI X12 834 transaction, which is distributed to BRIDGES.

BabyNet Reporting & Intervention Data Gathering Electronic System (BRIDGES)

BRIDGES is a web-based, stand-alone system designed to manage child intake and program enrollment, needs assessment and service planning, documentation of service delivery, including the development of the Individualized Family Service Plan (IFSP), payment management, and federal compliance reporting. BRIDGES includes functionality to track payments made to service coordinators and therapy providers, but it does not have the native ability to manage claim submission, remittance, or payment modifications and corrections necessary to conform to SCDHHS’ case management integration standards.

Medicaid Management Information System

(MMIS)

MMIS is the State of South Carolina’s Claim processing system and is hosted and supported by Clemson Medicaid Information Technology Services (MITS). This system supports member claim status, management and adjudication, Provider creation, maintenance and revalidation, complaints/grievances, benefits inquiries, reporting, data sharing, and other https://vip.scdhhs.gov/babynet_enrollment https://cuihhsiutl12.clemson.edu/pages/viewpage.action?pageId=68714588 https://cuihhsiutl12.clemson.edu/display/EAST/Provider+Web+Portal https://cuihhsiutl12.clemson.edu/display/EAST/OnBase+Document+Management https://cuihhsiutl12.clemson.edu/display/EAST/OnBase+Document+Management https://cuihhsiutl12.clemson.edu/pages/viewpage.action?pageId=66292318 https://cuihhsiutl12.clemson.edu/display/EAST/MES+Core https://cuihhsiutl12.clemson.edu/display/EAST/BRIDGES https://cuihhsiutl12.clemson.edu/display/EAST/MMIS

SCDHHS Confidential Page 23 of 68

Application Description functions associated with a claim and provider maintenance module. The MMIS will also be used for BabyNet claims, even though BabyNet is outside the Medicaid Enterprise.

Blue Cross/Blue Shield (BCBS) provides the Medicaid Claims processing and payments business operations services for SCDHHS, using the legacy MMIS system. The claims are adjudicated on a weekly basis and payment, adjustments or denials are processed. The MMIS system also handles 278 (Prior Authorization), 276/277 (Claim Status Inquiry / Response), 834 (Enrollment & Maintenance) ** Note for Medicaid this is enrollment data sent from Cύram to MMIS but not 834 format **, 835 (Claim Remittance Advice), 837 P/I/D (Claim Submission for Professional/Institution/Dental) ** Note currently BabyNet only processes 837P but the new solution being supplied must allow for 837P and 837I **.

The MMIS also sends enrollment data to the MES Core, but not in 834 format. This data is then transformed, in MES Core, into EDI 834 layout and sent to the BRIDGES system for ingestion.

Inhouse Data Hub Exchanges billing data (generated from Provider submitted service notes) between BRIDGES and PCG. The Inhouse Data Hubintegration service is used to combine/calculate, filter and edit claimable billing records before they are distributed to PCG.

PCG Completes the process of converting service notes, submitted by the BabyNet Provider, to EDI 837P transactions. These 837P transactions are then submitted to BCBS for processing of claims. See MMIS in this section for a description of the Claim processing.

South Carolina Enterprise Information System (SCEIS)

Application used to add enrolled Providers for payments and to make the payments to these Providers.

Third Party Liability (TPL) BabyNet claims for individuals that have OHI are handled through TPL by collecting on the OHI payment prior to payments being made through the MMIS. On occasion payments are made through MMIS unaware that OHI exists. In these instances a “pay and chase” method is used where the State collects on any payment the State made that should have been paid by OHI.

BabyNet is the “payor of last resort” with BabyNet being funds used after OHI and Medicaid monies.

BCBSSC is currently contracted by SCDHHS to provide TPL business and system services, using the BCBS/ ARMS Pro system solution.

Business Intelligence System (BIS)

Reporting component of SCDHHS responsible for receiving, normalizing and storing data for BabyNet and other modules of the SCDHHS Agency.

https://cuihhsiutl12.clemson.edu/display/EAST/PCG https://cuihhsiutl12.clemson.edu/display/EAST/SCEIS https://cuihhsiutl12.clemson.edu/display/EAST/SCEIS https://cuihhsiutl12.clemson.edu/display/EAST/SCEIS https://cuihhsiutl12.clemson.edu/pages/viewpage.action?pageId=98041889 https://cuihhsiutl12.clemson.edu/pages/viewpage.action?pageId=98041889

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4.2.2 Applications Enabling the existing Systems Solution

The diagram below summarizes the existing systems solution, along with the enabling application components, services and interfaces.

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4.2.3 Business and System Services Traceability

The diagram below links the BabyNet business services to the enabling application services and components.

Figure 6: Business and Systems Services Traceability

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4.2.4 Current State Systems Integration

The diagram summarizes the information exchanged between various applications, as needed to realize the business services being provided.

The table below summarizes the data exchanges between existing systems.

Table 6: Current State Systems Integration

Information shared Source Target Automated Y/N

Protocol Format Frequency

Baby and Family Demographic Data needed for Eligibility, Enrollment into Medicaid and BabyNet Programs

BabyNet Referral Portal

OnBase SFTP Custom File Format Applicant demographic, income, OHI, and evaluation data, SCDHHS ID and status.

Daily

Medicaid Eligibility Member demographic data

Cúram MMIS SFTP Custom File Format Applicant demographic, income, OHI, and evaluation data, SCDHHS ID and status.

Daily

BabyNet Eligibility and Enrollment Member

MMIS BRIDGES SFTP Custom File Format MMIS to MES Core.

EDI X12 834 from MES Core to BRIDGES

Daily

Provider Demographic Data, Submitted Claims for Payments

MMIS SCEIS Y IF440 MMIS-SCEIS

Vendor Interface.

Daily

Service Notes BRIDGES Inhouse Data Hub

Y SFTP Custom File Format

Daily

Billing Related information Inhouse Data Hub

PCG Y SFTP Custom File Format Daily

Provider Claim data PCG MMIS Y SFTP EDI X12 837P Daily

Medicaid Provider Demographic data

MMIS Bridges Y SFTP

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Information shared Source Target Automated Y/N

Protocol Format Frequency

Claims Payment Remittance MMIS Provider Web Portal

Y SFTP Custom File Format Weekly

Provider Payment SCEIS Provider Y Weekly

BabyNet Member OHI MMIS TPL Y FTP Custom Files Format Daily & Weekly (depending on file)

BabyNet Provider Application

BabyNet Provider Portal

N Download Custom File Format As needed

BabyNet Program data BRIDGES BIS Y SFTP Custom Files Format Daily

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4.2.5 Current State Technology Architecture

The table below catalogs the technologies used to enable the application services.

Table 7: Technology and Infrastructure enabling SCDHHS Systems of Record and Integration

Vendor/Solution Application Technology Hosted at Clemson Medicaid IT Services (MITS)

Provider Enrollment Portal Note: Total user access since implementation: 104,369 (as at Feb 2022)

Custom Java application developed and operated by Clemson

Clemson University Data Center

Provider Web Tool Note: Total user access since implementation: 240,591 (as at Feb 2022)

Custom Java application developed and operated by Clemson

Clemson University Data Center

MMIS EDI Translator Actian Translator/ DataConnect Axiom TranSend Custom developed Java components

Clemson University Data Center

MMIS Mainframe Clemson University data center

MEDS Mainframe Clemson University Data Center

SCDHHS MES Core Custom Java application developed and operated by

SCDHHS

AWS

Inhouse Data Hub SQL Clemson Data Center

BabyNet Referral Portal .Net DTO, managed by

HHS

BabyNet Provider Portal Drupal Hyland OnBase Electronic Content

Management System Clemson University Data Center

IBM Cúram Java stack Clemson University Data Center

4.2.6 Current State Challenges

The following is a list of missing or difficult Functionality with the existing application:

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1. BabyNet application does not generate the 837 P directly and is dependent on an independent process to do this.

2. BabyNet application, in its entirety, does not generate 837I.

3. BabyNet Referral Portal is an independent component not supported by the

BabyNet solution provider.

4. Claim Void and Void/Replace functionality is not provided.

5. Solution relies on Inhouse Data Hub for data processing and preparation before passing this data to downstream systems.

6. Provider reconciliation between Service Notes submitted and payments received is very difficult and time consuming requiring the use of multiple applications.

4.2.7 Current State Strengths

1. In many cases, the solution uses existing integrations between major components to share data.

a. Some data sharing does use the State’s MES Core.

2. Solution allows the State to meet the Federal Requirements of IDEA Part C.

3. The solution is stable and reliable and the vendor is responsive to the State’s needs.

4. State has a very knowledgeable business team.

5. Proposed Solution This section describes various architectural components of the proposed solution.

5.1 Changes to Organization Structures

There are no anticipated changes expected to the State’s Organization Units and no anticipated change in roles or responsibilities.

5.2 Future State Business Roles and Services

Table 8: Future State Business Roles and Responsibilities Business Role Services Administrative Coordinator Provides administrative support to the BabyNet program.

BabyNet Manages the Central Referral team, oversees compliance related to the referral process, and assists the Eligibility director with process improvements.

BabyNet Eligibility Program Manager

Oversees all activities related to BabyNet referrals and eligibility.

Supervises state-level BabyNet eligibility staff and local BabyNet supervisors.

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Business Role Services Federal Reporting and Data Manager

Responsible for federal reporting (APR/SPP, 618/619 data reporting, etc.), general supervision and monitoring, data system SME. Quality Assurance and Training fall under this vertical.

Fiscal Analyst Ensures that providers are paid accurately and in a timely manner.

Assists with edit resolution and error correction.

Fiscal Manager Manages the billing/payment processes for BabyNet, the BabyNet budget, and the Part C Grant.

Operations Manager Manages the day-to-day activities of BabyNet personnel, including informal complaints and issues, and supervises the Regional Coordinators.

Part C Coordinator BabyNet program director. Responsible for oversight of the program.

Policy Manager Manages the development and updates of all BabyNet policies, procedure, and form.

Provider Relations Manager Manages the provider enrollment, provider recruitment, and provider retention processes.

Quality Assurance Specialist

Leads the program’s state level quality assurance plan. Develops reports that assist with general supervision and monitoring.

Regional Coordinator Works with local providers, service coordinators, and other stakeholders to ensure all BabyNet activities and responsibilities are met.

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5.3 Organizations impacted by System Implementation

There are several internal and external users impacted by the replacement of BRIDGES. The table below highlights the organizations, Services and Components as well as the anticipated impact to these organizations. There is not expected to be an impact to SCDHHS roles or responsibilities when the new system is implemented.

Table 9. Organizations impacted Organization Services and Components Impact SCDHHS BabyNet Administration

SCSDB

SCDDSN

SaaS based solution hosted and supported outside of OIA support.

Major components will include support of BabyNet system environment and operations including all aspects related to family, Provider, SCDHHS staff, and Federal Reporting needs. This will also require the solution provider to support data transfers, applicant and Provider self-service interaction capabilities, workflow management, quality assurance, data access and editing audit capabilities, multi-language support, and program knowledge management.

The BabyNet platform will support users across SCDHHS departments, including, but not limited to, other state partners, and vendors involved in providing BabyNet services to providers and members.

IT & Business support staff

BabyNet Operations Support customer service operations for the BabyNet populations.

Historic and real-time analytic capabilities to understand issues, trends, and opportunities to inform decision-making and improve the interaction with Department Stakeholders

Business support & Useability changes

Eligibility, Enrollment & Member Services

Eligibility application intake and maintenance that results in the delivery of member business services Eligibility & Enrollment

External SC Providers Provider enrollment, claim generation (837P & 837I) from Service Notes, claim submission, Claim payment tracking, Prior Authorization, IFSD, and maintenance that results in the delivery of member business services

External Provider Usability & BabyNet Operations

BabyNet Operations Management and tracking of outbound communications from the BabyNet environment to members and providers, including tasks that involve developing and publishing standard communications, bulletins, re-enrollment notices, and other pertinent publications for Stakeholders.

Management of printing, fulfilling, and mailing (including USPS and electronic notifications) information on a scheduled, event-driven, and ad-hoc basis. This includes handling receipt of inbound mail to the Department as well as production and distribution of the Medicaid membership cards.

Collaboration and Communication

Agency C Suite leaders Reports generated from the new BabyNet system for Program analytics and decision-making needs. Reporting, Collaboration and Communication

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CMS Federal reporting generated from the new BabyNet system and any questions or audits from the Federal partner will be followed up using the new system or data generated from it.

Reporting, Collaboration and Communication

BabyNet Family and Professionals

Individuals enrolling the Baby in the BabyNet application will have a new/different front end to navigate. Useability

BabyNet Providers Providers will have a new interface for enrollment, Service Note Submission, IFSP, Payment Reconciliation and other tasks performed by the Provider or their designated representative. Useability

DGO Data ingest from BRIDGES and export to PCG as well as transformation of Billing related data Functionality from DGO to Vendor to transformation and data exchanges will be changed to use EDI translator

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5.4 Future State Business Channels

Table 10: Future State Business Channels Business channel Operated by Change Impact BabyNet Provider Portal BabyNet Solution Provider Current Portal is supported by SC State staff. This procurement will require the BabyNet

Solution vendor to supply and maintain the Provider Portal.

BabyNet Referral Portal BabyNet Solution Provider Current Portal is supported by SC State staff. This procurement will require the BabyNet

Solution vendor to supply and maintain the Referral Portal.

BabyNet Operations / Support Staff

BabyNet Solution Provider Current Operations / Support intetrface is supported by YahaSoft, however the new interface will be supported by the BabyNet Solution vendor.

BabyNet Member Communications

BabyNet Solution Provider Existing communications (Banners, notifications, reminders) will continue to be required.

Additionally, it is expected the new BabyNet Solution will proactively scan for potentially eligible babies and communicate candidates for potential enrollment into the BabyNet Program.

5.5 Future State Application Architecture

5.5.1 Application Architecture Principles

Table 11: Application Architecture Principles Guiding Principle

Statement Rationale Implications

Ease-of-Use Applications are easy to use. The underlying technology is transparent to users, so they can concentrate on tasks at hand.

The more a user has to understand the underlying technology, the less productive that user is. Ease-of-use is a positive incentive for use of applications. It encourages users to work within the integrated information

Applications will be required to have a common "look-and-feel" and support ergonomic requirements; hence, the common look-and-feel standard must be designed and usability test criteria must be developed.

Guidelines for user interfaces should not be constrained by narrow assumptions about user

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Guiding Principle

Statement Rationale Implications environment instead of developing isolated systems to accomplish the task outside of the enterprise’s integrated information environment.

Most of the knowledge required to operate one system will be similar to others. Training is kept to a minimum, and the risk of using a system improperly is low.

location, language, systems training, or physical capability Factors such as linguistics, customer physical infirmities (visual acuity, ability to use keyboard/mouse), and proficiency in the use of technology have broad ramifications.

Interoperability Software and hardware should conform to defined standards that promote interoperability for data, applications, and technology.

Standards help ensure consistency, thus improving the ability to manage systems and improve user satisfaction, and protect existing IT investments, thus maximizing return on investment and reducing costs. Standards for interoperability additionally help ensure support from multiple vendors for their products and facilitate supply chain integration.

Interoperability standards and industry standards will be followed unless there is a compelling business reason to implement a non-standard solution.

A process for setting standards, reviewing and revising them periodically, and granting exceptions must be established.

The existing IT platforms must be identified and documented.

“Low or No Code” design preference

Software should be modular in design and present as many out of the box configuration parameters as possible, over custom coding requirements.

The platform selected should be based on the idea that the extension of the platform would entail little or no bespoke coding. This improves the reliability of the platform while simultaneously increasing the speed with which the system is implemented.

Reliance on the software manufacturer for updates and support create a partnership between the vendor, manufacturer and the agency.

Modules for accomplishing specific tasks such as a CTI module, would quickly ramp up feature sets and allow for changes to those modules to be more easily carried out.

Cloud First Design Pattern

The platform should use a Cloud first design pattern as much as possible given the other requirements.

The preference should be a SaaS (Software as a Service) or PaaS (Platform as a Service) to provide the

The use of COTS software in the cloud allows the Agency to glean the security and feature benefits of the evergreen nature of SaaS or

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Statement Rationale Implications

Agency with built-in resilience, flexibility and modularity.

PaaS while allowing configuration, minor coding and modularity to advance the needs of the HCSC core functions.

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5.5.2 Changes to Application Components and Services

The matrix below depicts the anticipated changes to application components:

Table 12: Changes to Application Components and Services https://schhs.sharepoint.com/sites/EA/Shared%20Documents/BabyNet/New%20BabyNet%20System%202022/BabyNet%20SP%20review.xlsx?web=1

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5.5.3 Changes to Application Components and Services

The table below depicts the view from the matric above, in table format. This identifies the anticipated changes to application components:

Table 13: Application Components Change Impact Assessment

Application services Current application component

Future application component

Change impact

BabyNet Case Management BabyNet Claims Exceptions BabyNet Claims Preparation BabyNet IFSP BabyNet Member Enrollment / Disenrollment BabyNet Operational Reporting BabyNet prior authorization BabyNet Provider choice assignment BabyNet Provider Communication BabyNet Provider Enrollment Federal Reporting

BRIDGES (incumbent BabyNet case management system)

BabyNet case management

Application services to be provided by the future BabyNet case management system.

Online remittances Online claims inquiry

Provider Web Tool BabyNet Provider Portal Provider Web Tool

Enable BabyNet providers to obtain information of remittances and claims status using the new BabyNet…