South Carolina Department of Health and Human Services

(SCDHHS)

Member Management Replacement Program (MMRP)

Cúram Global Income Support (CGIS) Project

Architectural Description Document

(ADD)

CGIS12 Buy-In Interface

MMRP CGIS Project ADD

CGIS12 Buy-In Interface V3.0

Version Log

The Version Log maintains a record of the changes made to the document during its life cycle.

Whole number versions are reserved to designate that the document has reached an Approved status. Changes/Revisions made to approved documents will continue with decimals numbers, until the document again reaches an Approved status.

Versio n

Date Drafted by Role Description of Change

0.1 10/03/201

Chetan Nagaraj Business Analyst

Initial Draft

0.2 11/02/201

Chetan Nagaraj Business Analyst

Incorporated review comments from DHHS

0.3 11/05/201

Ken Haas Functional Lead

QA Review of Content – Formatting updates standardization will be completed for Approval

0.4 11/15/201

Sandeep Burman

Technical Lead

Incorporated Review Comments

0.5 12/18/201

Satish Kappera Cúram Consultant

Initial TDS Draft

0.6 02/15/201

Satish Kappera Cúram Consultant

Updated below Sections:

-Section 5.1.1.27: Sequence diagram -Section 5.1.6: updated series -Section 5.1.15: Added API -Section 5.5.4 -Section 5.1.1.20 -Section 5.1.1.21 -Section 5.1.1.27 -Section 5.5.13.8.57: TASK CLOSURE TRIGGER:

0.7 03/05/201

Chetan Nagaraj/Sarfar az Ahmed

Cúram Consultant

ADD clean-up to align the format with other ADD documents

0.8 03/22/201

Biswajit Deka Business Analyst

Formatted ADD per ADD Approval template

V1.0 3/29/2019

Erin Coleman SCDHHS Process & Artifact Developme nt Manager

Updated version number, watermark, and approval date.

1.1 4/2/2019 Chetan Nagaraj Business Analyst

Incorporated the functional and technical changes for CR011 and CR031 CR11: Section 4.21.3 CR031: Section 4.14.3, 5.10.3

1.2 4/16/2019

Chetan Nagaraj Business Analyst

Incorporated review comments from second review for the changes made as a part of CR011 and

CR031

CR11: Section 4.21.3 CR031: Section 4.14.3, 4.10.3

1.3 4/30/2019 Chetan Nagaraj Business Analyst

Incorporated the functional changes for CR025 FDS Sections updated:

4.1.3 4.2.3 4.4.3 4.5.3 4.6.3 4.8.3 4.9.3 4.10.3 4.11.3 4.12.3 4.13.3 4.14.3 4.17.3 4.19.3 4.21.3 4.21.12 4.21.22 4.21.26 4.21.27 4.21.47 4.22.12

1.4 5/9/2019 Chetan Nagaraj/ Satish Kappera

Business Analyst / Cúram Consultant

Incorporated the review comments from state team for CR025 – CR Item #2 Option 2 was selected and the ADD updated to reflect.

Incorporated the technical changes for CR025 In the following sections

-5.1.1.2 BUYIN OUTBOUND CHUNKER PROCESS

5.1.1.4 Outbound Part-B – Accretion Process

5.1.1.7 Outbound Part-A – Accretion Process

5.1.1.11 BUY-IN INBOUND CHUNKER PROCESS

5.1.1.12 BUY-IN INBOUND STREAMER PROCESS

5.1.1.13 INBOUND RIC A PROCESS

5.1.1.14 INBOUND RIC B PROCESS

5.1.1.15 INBOUND RIC C PROCESS

5.1.1.16 INBOUND RIC D PROCESS

5.1.1.17 INBOUND RIC E PROCESS

5.1.1.18 INBOUND RIC F PROCESS

5.1.1.21 INBOUND FILE SPLITTING;

5.5.13.8.34 API for setting outbound data

5.5.13.8.49 getActiveOrIneditDateofDeathForICAndConcernRol eID()

5.5.47 BUYIN INBOUND CHUNKER PROCESS

5.5.48 BUYIN INBOUND STREAMER PROCESS

5.5.48.2 INBOUND RIC A PROCESS

5.5.48.3 INBOUND RIC B PROCESS

5.5.48.4 INBOUND RIC C PROCESS

5.5.48.5 INBOUND RIC D PROCESS

5.3.15 CMS RICB Billing Outbound File Flow

1.5 06/21/201

Ken Haas Quality Review Analyst

Quality review of incorporation of CR changes.

1.6 06/28/201

Chetan Nagaraj Business Analyst

Updated the FDS for CR32. The following reqs are updated:

CGIS_BUY_IN_8.10.1 to 8.10.5 CGIS_BUY_IN_11.5, 11.5.1 and 11.6

CGIS_BUY_IN_13.26, 13.27 , 14.22

1.7 07/08/201

Satish Kappera Cúram Consultant

Updated the TDS for CR32. The following Sections are updated:

-5.1.1.12 -5.1.1.15 -5.5.48 -5.5.48.4 -5.5.48.5.2.4 -5.5.48.5.3.2 -5.5.13.8.56 -5.5.13.8.57

1.8 11/4/2019 Chetan Nagaraj Business Analyst

Accepted all changes and deleted the comments

1.9 11/20/201

Chetan Nagaraj Business Analyst

The following FDS sections/requirements were added or updated:

CR173

Requirement # - CGIS_BUY_IN_8.14

CR062 – Doc Only

CR Item #1 Section 4.8.12.1

CR Item #2 Section 4.10.1

CR Item #3 CGIS_BUY_IN_22.1

CR Item #4 CGIS_BUY_IN_10.10

CGIS_BUY_IN_10.12

CGIS_BUY_IN_10.13

CGIS_BUY_IN_10.14

CGIS_BUY_IN_10.15

CGIS_BUY_IN_10.16

CGIS_BUY_IN_10.17

CGIS_BUY_IN_10.18

CGIS_BUY_IN_10.18.1

CGIS_BUY_IN_10.23

CR Item #5 CGIS_BUY_IN_1.2

CR Item #6 CGIS_BUY_IN_21.27

CR Item #7 CGIS_BUY_IN_1.14.8

CR Item #8 CGIS_BUY_IN_19.1

CR Item #9 Requirements under Section 4.21 already has the required error messages

CR Item #10 CGIS_BUY_IN_22.20

CR Item #11 CGIS_BUY_IN_1.9

CR Item #12 CGIS_BUY_IN_12.20

CGIS_BUY_IN_12.20.1

CGIS_BUY_IN_12.21

CGIS_BUY_IN_12.21.1

CR Item #13 CGIS_BUY_IN_6.8

CR Item #14 Updated Sections 3.2, 3.5, 3.8, 3.10, 3.12, 3.13, 3.14

CR Item #15 CGIS_BUY_IN_1.12

CR Item #16 Section 4.2.2

CR Item #17 CGIS_BUY_IN_7.15.4

CR Item #18 CGIS_BUY_IN_7.15.4

CR Item #19 Removed Section 4.12.7

CR Item #20 Removed Section 4.13.9

CR Item #21 Removed Section 4.16.15

CR Item #22 CGIS_BUY_IN_14.59

CR Item #23 Section 4.21.7

CR Item #24 Section 4.21.47

CR063

CR Item #1 CGIS_BUY_IN_9.1 CGIS_BUY_IN_9.2a

CGIS_BUY_IN_10.3

CGIS_BUY_IN_10.4

CGIS_BUY_IN_10.5a CGIS_BUY_IN_10.5b

CGIS_BUY_IN_11.1

CGIS_BUY_IN_11.2a

CGIS_BUY_IN_12.1

CGIS_BUY_IN_12.2

CGIS_BUY_IN_12.3a

CGIS_BUY_IN_12.3b

CGIS_BUY_IN_15.1

CGIS_BUY_IN_15.2a

CGIS_BUY_IN_16.1

CGIS_BUY_IN_16.2a

CR Item #2 CGIS_BUY_IN_7.16

CR Item #3 CGIS_BUY_IN_12.19

CGIS_BUY_IN_12.20.2

CGIS_BUY_IN_12.20.4

CGIS_BUY_IN_12.21.1

Section 4.12.12.1 (Added)

CR174

Requirement # - CGIS_BUY_IN_7.17 Requirement # - CGIS_BUY_IN_7.18 Requirement # - CGIS_BUY_IN_7.15.1

1.10 12/6/2019 Chetan Nagaraj Business Analyst

Incorporated the review comments from SCDHHS.

1.11 01/06/202

Satish Kappera Cúram Consultant

The following TDS sections were added:

CR062 – Doc Only

CR Item #3 5.1.10 Appendix E

CR Item #4 5.5.48.5.2.2 5.5.48.5.2.3 5.5.48.5.2.4

CR Item #5 5.5.13.1 5.5.13.3 5.5.13.8.35

CR Item #6 5.1.32 5.1.34

CR063

CR Item #3 CR Item #4

5.5.48.5.1 5.1.15

1.12 01/07/202

Dibyendu Karmakar

ESB

Developer

Updated the ESB TDS section for CR63,173 and

174. The following Sections are updated:

5.3.2 5.3.4 5.3.6

5.3.13 5.3.14 5.3.15

1.13 01/23/202

Dibyendu Karmakar

ESB

Developer

Updated the ESB TDS section for CR 63,173 and 17 based on Renjan’s comment. The following Sections are updated:

5.3.4 Appendix

1.14 02/18/202

Chetan Nagaraj Business Analyst

Accepted all changes and deleted all comments upon the FDS and TDS approvals for CR 62, 63, 173, and 174.

1.15 03/06/202

Dibyendu Karmakar

ESB

Developer

Added Section 5.3.16 for TDS changes in ESB for Termination Batch.

Modified Section 5.3.2 to add logic of duplicate records in Buy in Outbound.

1.16 03/06/202

Chetan Nagaraj Business Analyst

Updated the following requirements in FDS section for R14R2:

Removed:

CGIS_BUY_IN_7.15.2

CGIS_BUY_IN_7.15.6a

CGIS_BUY_IN_7.15.7

CGIS_BUY_IN_7.15.8

Updated:

CGIS_BUY_IN_7.15.4

CGIS_BUY_IN_13.8

CGIS_BUY_IN_14.14

Added:

R2_CGIS_BUY_IN_7.15.5

R2_CGIS_BUY_IN_7.15.6

R2_CGIS_BUY_IN_21.8

R2_CGIS_BUY_IN_21.8.1

R2_CGIS_BUY_IN_21.8.2

R2_CGIS_BUY_IN_21.8.3

Section 4.25

1.17 03/06/202

Satish Kappera Cúram Consultant

Updated the following requirements in TDS section for R14R2:

5.1.1.2 5.1.8 5.1.10 5.1.15 5.1.19 5.1.22 5.1.32 5.5.12 5.5.48.5.2.1 5.5.48.5.3.1

5.5.81 -Updated BuyIn_TableStructure excel to add new table MMBUYINDETETIONS details.

-Updated MMBUYINELIGIBILITYDECISION table with datasouceID column.

1.18 3/11/2020 Tiffany Ortega IBM BA Lead

The following requirements were updated per

CR193:

1. CGIS_BUY_IN_9.1

2. CGIS_BUY_IN_10.3

3. CGIS_BUY_IN_10.4

4. CGIS_BUY_IN_11.1

5. CGIS_BUY_IN_12.1

6. CGIS_BUY_IN_15.1

7. CGIS_BUY_IN_12.2

8. CGIS_BUY_IN_16.1

1.19 3/22/2020 Tiffany Ortega IBM BA Lead

Updated the following items per Review Cycle 1 for

CR193:

Section 4.9.3 #13 Section 4.12.3 #17

1.20 3/23/2020 Chetan Nagaraj Business Analyst

The following requirements were updated per

CR210:

CGIS_BUY_IN_22.17

CGIS_BUY_IN_22.18

CGIS_BUY_IN_22.19

Figure 16 Figure 2 Figure 4 Figure 8

The following requirements were updated per

CR213:

CGIS_BUY_IN_1.14

CGIS_BUY_IN_1.14.1

CGIS_BUY_IN_1.14.2

CGIS_BUY_IN_1.14.3

CGIS_BUY_IN_1.14.6

CGIS_BUY_IN_1.14.8

CGIS_BUY_IN_1.14.15

CGIS_BUY_IN_12.23

1.21 3/31/2020 Chetan Nagaraj Business Analyst

Incorporated and responded to review comments from SCDHHS review cycle 1 for R14R2 updates

1.22 4/1/2020 Chetan Nagaraj Business Analyst

Responded to review comments from SCDHHS on CR193 and aligned the validations to match the ESB validation spreadsheet.

The following requirements were updated:

CGIS_BUY_IN_9.1 - #9

CGIS_BUY_IN_10.3 - #10, #22

CGIS_BUY_IN_10.4 - #9, #21

CGIS_BUY_IN_11.1 - #9

CGIS_BUY_IN_12.1 - #8, #9, #10, #16

CGIS_BUY_IN_12.2 - #9, #15

CGIS_BUY_IN_15.1 - #9

CGIS_BUY_IN_16.1 - #9

1.23 4/6/2020 Chetan Nagaraj Business Analyst

Responded to review comments from SCDHHS on CR193 and aligned the validations to match the ESB validation spreadsheet.

The following requirements were updated:

CGIS_BUY_IN_9.1 - #21

CGIS_BUY_IN_10.3 - #24, #26

CGIS_BUY_IN_10.4 - #23, #26

CGIS_BUY_IN_11.1 - #18

CGIS_BUY_IN_12.1 - #20, #22

CGIS_BUY_IN_12.2 - #23, #25

CGIS_BUY_IN_15.1 - #19

CGIS_BUY_IN_16.1 - #20

1.23 4/6/2020 Chetan Nagaraj Business Analyst

The following requirements were updated per

CR220:

CGIS_BUY_IN_7.2.1

CGIS_BUY_IN_21.32

Figure 9

CGIS_BUY_IN_9.4

1.24 4/6/2020 Vijay Makam Tech Lead Updated ESB sections 5.3.4, 5.3.6, 5.3.7, 5.3.8, 5.3.9, 5.3.10, 5.3.11, 5.3.12, 5.3.13, 5.3.14, 5.3.15 for CR 193.

1.25 4/16/2020 Chetan Nagaraj Business Analyst

Incorporated the review comments from Review Cycle 2 from SCDHHS.

1.26 4/21/2020 Chetan Nagaraj Business Analyst

The following requirements were updated per

CR226:

CGIS_BUY_IN_8.9:

CGIS_BUY_IN_10.8:

CGIS_BUY_IN_11.4:

CGIS_BUY_IN_13.3:

CGIS_BUY_IN_14.3:

CGIS_BUY_IN_15.4:

CGIS_BUY_IN_16.4:

CGIS_BUY_IN_17.2:

CGIS_BUY_IN_21.11:

CGIS_BUY_IN_21.15:

CGIS_BUY_IN_21.24:

CGIS_BUY_IN_21.30:

CGIS_BUY_IN_21.32:

1.27 6/26/2020 Chetan Nagaraj Business Analyst

CGIS_BUY_IN_10.18.1 was updated per CR251.

1.28 7/3/2020 Tiffany Ortega IBM BA Lead

The following requirements were updated per

CR245:

CGIS_BUY_IN_8.5

CGIS_BUY_IN_10.8

CGIS_BUY_IN_13.27

CGIS_BUY_IN_14.44

CGIS_BUY_IN_14.44a

CGIS_BUY_IN_14.52

CGIS_BUY_IN_14.53

CGIS_BUY_IN_24.1

CGIS_BUY_IN_24.2

CGIS_BUY_IN_24.3

CGIS_BUY_IN_24.4

CGIS_BUY_IN_24.7

CGIS_BUY_IN_24.8

CGIS_BUY_IN_24.11

CGIS_BUY_IN_24.12

CGIS_BUY_IN_24.13

CGIS_BUY_IN_24.14

CGIS_BUY_IN_24.15

CGIS_BUY_IN_24.16

CGIS_BUY_IN_24.17

CGIS_BUY_IN_24.18

CGIS_BUY_IN_24.19

CGIS_BUY_IN_24.20

CGIS_BUY_IN_24.21

CGIS_BUY_IN_24.22

CGIS_BUY_IN_24.23

CGIS_BUY_IN_24.24

CGIS_BUY_IN_24.25

CGIS_BUY_IN_24.26

CGIS_BUY_IN_24.27

CGIS_BUY_IN_24.28

CGIS_BUY_IN_24.29

CGIS_BUY_IN_24.30

CGIS_BUY_IN_24.31

CGIS_BUY_IN_24.32

1.29 7/6/2020 Chetan Nagaraj Business Analyst

Updated Appendix G (Referenced in CGIS_BUY_IN_19.4) as a part of CR256.

1.30 7/11/2020 Tiffany Ortega IBM BA Lead

Update the following requirements per Review Cycle 1 comments for CR245:

CGIS_BUY_IN_13.27

CGIS_BUY_IN_14.44a

CGIS_BUY_IN_14.52

Updated the following items per CR254:

Section 4.8.12.1 Resolve Buy-In Transaction Inconsistencies

Section 4.10.12.1 RIC B and D: Resolve Buy-In Transaction Inconsistencies

Section 4.10.12.2 RIC B and D: Resolve Buy-In Transaction Inconsistencies

Section 4.10.12.3 RIC B and D: Resolve Buy-In Transaction Inconsistencies

Section 4.10.12.4 RIC B and D: Resolve Buy-In Transaction Inconsistencies

Section 4.12.12.1 RIC D: Buy-In Part-B No Match with Transaction Code 1165 or 1167 received

Section 4.13.12.1 RIC D and F: Buy-In Date of Death month/year is different

Section 4.13.12.2 RIC D: Resolve Buy-In Period not covered by Medicaid

Section 4.13.12.4 RIC D: Buy-In Transaction code 1759 received

Section 4.13.12.5 RIC D: Buy-In reported recipient moved to another state

Section 4.16.12.3 Task - RIC F: Buy-In Rejection Part-B Transaction code 21xx, Sub-code D received

Section 4.16.12.11 Task – RIC F: Buy-In Rejection Transaction code 21xx sub-code E received

CGIS_BUY_IN_24.33

CGIS_BUY_IN_24.34

1.31 7/24/2020 Chetan Nagaraj Business Analyst

Updated the following requirements as per CR258:

CGIS_BUY_IN_24.1

CGIS_BUY_IN_24.2

1.32 7/30/2020 Tiffany Ortega IBM BA Lead

Updated the template, spelling and grammar checks for formal approval.

1.33 8/13/2020 Chetan Nagaraj Business Analyst

Updated CGIS_BUY_IN_12.22 as a part of CR262.

2.0 8/20/2020 Erin Coleman SCDHHS Process & Artifact Developme nt Manager

Updated version number, watermark, and approval date. Accepted all track changes, updated links, and removed all comments.

2.1 8/26/2020

Chetan Nagaraj Business Analyst

Updated CGIS_BUY_IN_10.12 and CGIS_BUY_IN_13.29 as a part of CR266

2.2 9/1/2020 Chetan Nagaraj Business Analyst

Updated requirements CGIS_BUY_IN_2.5 and CGIS_BUY_IN_6.4 as a part of CR272

2.3 10/8/2020 Chetan Nagaraj Business Analyst

Updated requirements CGIS_BUY_IN_7.9 and CGIS_BUY_IN_13.7 as a part of CR284

The Review Logs maintains a record of the State personnel that performed reviews leading up to the document reaching an Approved status. These reviews do not represent final approval of the document. The Approvals are recorded in the Approval Log Section.

Functional Review Log

The Functional Review Log maintains a record of the State personnel that performed the review of the functional design, confirming the understanding of the design. That the design meets the requirements, business requirements as described and is testable.

SCDHHS Role First Review Date / Reviewer Name

Second Review Date / Reviewer Name

Third Review Date / Review Name

DDI Manager

Product Manager

Technical Lead 3/22/2020 Renjan Bhasi (Reviewed CR193 and R1-4-R2)

4/5/2020 Renjan Bhasi (R1-4-R2)

5/17/2020 Renjan Bhasi (R1-4-R2)

6/1/2020 Renjan Bhasi (R1-4-R2 final review)

Business Analyst 3/17/2020 Upendra K. – Reviewed CR193 Updates.

3/22/20- Upendra K. – Reviewed R14R2 Updates.

Documentation Specialist

Process & Artifact Development Manager

3/17/2020 Erin Coleman

4/1/2020 Erin Coleman

4/28/2020 Erin Coleman

Technical Review Log

2.4 11/5/2020 Chetan Nagaraj Business Analyst

Updated requirement CGIS_BUY_IN_25.3 as a part of CR301

2.5 11/10/202

Chetan Nagaraj Business Analyst

Updated requirement CGIS_BUY_IN_13.9a and CGIS_BUY_IN_14.14a as a part of CR297

V3.0 4/11/2021 Erin Coleman SCDHHS Process & Artifact Developme nt Manager

Updated version number, watermark, and approval date.

The Technical Review Log maintains a record of the State personnel that performed the review of the technical design, confirming the technical approach appropriately addresses the functional design.

SCDHHS Role First Review Date / Reviewer Name

Second Review Date / Reviewer Name

Third Review Date / Review Name

Technical Lead 1/9/2019 Renjan Bhasi

2/11/2019 Renjan Bhasi

2/18/2019 Renjan Bhasi

4/25/2019 – Renjan Bhasi (Reviewed CR # 11 and added couple of new comments).

Technical Lead 7/18/2019 (CR25 and 32)

7/25/2019 (CR25 and 32)

Technical Lead 1/29/2019 (CR062 and

CR063)

2/10/2019 (CR062 and

CR063)

Technical Lead 4/12/2020 Renjan Bhasi R1-4-R2

5/17/2020 Renjan Bhasi R1-4-R2

6/1/2020 Renjan Bhasi (R1-4-R2 final review)

IBM Approval Review Log

The IBM Approval Review Logs capture the IBM Project Team personnel that reviewed the completed ADD. The Functional and Technical Design Sections has been reviewed by the IBM team. The documented design, functional and technical components are understood as documented and can be validated through the Use Cases defined. This signifies that the section/document is ready for SC personnel review and Approval.

Functional Design Section

Technical Design Section

Approvals

The Approvals Section captures the Approval of the current Approved Major version (whole number per PMP). The approval tables will be copied to the Approval Appendix when changes are made that require another round of Approvals.

IBM Functional Design Review – v3.0

Role Name Date Comments

CGIS Project Manager Courtney Stevens 3/25/2021 Approved v2.5 to v3.0

CGIS BA Lead Tiffany Ortega 3/25/2021 Approved v2.5 to v3.0

CGIS Testing Lead Brian Grieves 3/25/2021 Approved v2.5 to v3.0

CGIS Business Analyst Tiffany Ortega 3/25/2021 Approved v2.5 to v3.0

CGIS Development Lead Vijay Mujumdar 3/25/2021 Approved v2.5 to v3.0

CGIS Development Team Lead Randhir Singh 3/25/2021 Approved v2.5 to v3.0

IBM Technical Design Review – v3.0

Role Name Date Comments

CGIS Development Lead Vijay Mujumdar 3/25/2021 Approved v2.5 to v3.0

CGIS Development Team Lead Randhir Singh 3/25/2021 Approved v2.5 to v3.0

Functional Design Section

The Functional Design Section captures the State personnel that reviewed and approved the functional design. Confirming that the design is understood, fulfills the requirements and is testable

Functional Design Approval v3.0

Role Name Date Approvals (✓)

SCDHHS Business Analyst Upendra Koyagura 11/13/20 11/10/20 10/13/20 09/21/20 09/03/20

Approved- FDS updates for CR297.

Approved- FDS updates for CR301.

Approved- FDS updates for CR284.

Approved- FDS updates for CR272.

Approved- FDS updates for CR266.

SCDHHS Technical Lead Renjan Bhasi

SCDHHS Product Manager Abhishek Sahu 4/7/2021 Approved V2.1

SCDHHS DDI Manager Timothy Cozine 4/7/2021 Approved V2.1

SCDHHS Process and Artifact Development Manager

Erin Coleman 4/11/2021 Approved ADD

Technical Design Section

The Technical Design Section captures the State personnel that reviewed and approved the technical design. Confirming that the technical approach to fulfilling design is understood fulfills the requirements.

Technical Design Approval v3.0

Role Name Date Approval (✓)

SCDHHS Technical Lead Renjan Bhasi

Table of Contents

1 Introduction

1.1 Background

1.2 Purpose

1.3 Scope

1.4 Key References

1.5 Definitions and Acronyms

1.6 Key Assumptions – N/A

2 Conceptual Flow

2.1 High Level Process Flow

2.2 Outbound Part-B – Accretion Process

2.3 Outbound Part-B – Deletion Process

2.4 Outbound Part-B – Simultaneous Accretion/Deletion Process

2.5 Outbound Part-B – Updation Process

2.6 Outbound Part-A – Accretion Process

2.7 Outbound Part-A – Deletion Process

2.8 Outbound Part-A – Updation Process

2.9 Inbound RIC A Process

2.10 Inbound RIC B Process

2.11 Inbound RIC C Process

2.12 Inbound RIC D Process

2.13 Inbound RIC E Process

2.14 Inbound RIC F Process

3 Requirements Matrix

3.1 Requirement Modifications

4 Function

4.1 Outbound Part-B – Accretion Process

4.1.1 Design Description

4.1.2 Functional Output

4.1.3 Design Details

4.1.4 Screen Flow – N/A

4.1.5 Screen Mockup – N/A

4.1.6 Business Rules – N/A

4.1.7 User Roles – N/A

4.1.8 Data Fields – N/A

4.1.9 Links – Navigation - N/A

4.1.10 Links – Functions/Actions – N/A

4.1.11 Validation – N/A

4.1.12 Notifications and Tasks – N/A

4.1.13 Other – N/A

4.2 Outbound Part-B – Deletion Process

4.2.1 Design Description

4.2.2 Functional Output

4.2.3 Design Details

4.2.4 Screen Flow – N/A

4.2.5 Screen Mockup – N/A

4.2.6 Business Rules – N/A

4.2.7 User Roles – N/A

4.2.8 Data Fields – N/A

4.2.9 Links – Navigation – N/A

4.2.10 Links – Functions/Actions – N/A

4.2.11 Validation – N/A

4.2.12 Notifications and Tasks – N/A

4.2.13 Other – N/A

4.3 Outbound Part-B – Simultaneous Accretion/Deletion Process

4.3.1 Design Description

4.3.2 Functional Output

4.3.3 Design Details

4.3.4 Screen Flow – N/A

4.3.5 Screen Mockup – N/A

4.3.6 Business Rules – N/A

4.3.7 User Roles – N/A

4.3.8 Data Fields – N/A

4.3.9 Links – Navigation – N/A

4.3.10 Links – Functions/Actions

4.3.11 Validation – N/A

4.3.12 Notifications and Tasks – N/A

4.3.13 Other – N/A

4.4 Converting RRB Number to Pseudo MCN

4.4.1 Design Description

4.4.2 Functional Output

4.4.3 Design Details

4.4.4 Screen Flow – N/A

4.4.5 Screen Mockup – N/A

4.4.6 Business Rules – N/A

4.4.7 User Roles – N/A

4.4.8 Data Fields – N/A

4.4.9 Links – Navigation – N/A

4.4.10 Links – Functions/Actions – N/A

4.4.11 Validation – N/A

4.4.12 Notifications and Tasks – N/A

4.4.13 Other – N/A

4.5 Outbound Part-A – Accretion Process

4.5.1 Design Description

4.5.2 Functional Output

4.5.3 Design Details

4.5.4 Screen Flow – N/A

4.5.5 Screen Mockup – N/A

4.5.6 Business Rules – N/A

4.5.7 User Roles – N/A

4.5.8 Data Fields – N/A

4.5.9 Links – Navigation – N/A

4.5.10 Links – Functions/Actions – N/A

4.5.11 Validation – N/A

4.5.12 Notifications and Tasks – N/A

4.5.13 Other – N/A

4.6 Outbound Part-A – Deletion Process

4.6.1 Design Description

4.6.2 Functional Output

4.6.3 Design Details

4.6.4 Screen Flow – N/A

4.6.5 Screen Mockup – N/A

4.6.6 Business Rules – N/A

4.6.7 User Roles – N/A

4.6.8 Data Fields – N/A

4.6.9 Links – Navigation – N/A

4.6.10 Links – Functions/Actions – N/A

4.6.11 Validation – N/A

4.6.12 Notifications and Tasks – N/A

4.6.13 Other – N/A

4.7 Generating the Outbound files and sending them to CMS

4.7.1 Design Description

4.7.2 Functional Output

4.7.3 Design Details

4.7.4 Screen Flow – N/A

4.7.5 Screen Mockup – N/A

4.7.6 Business Rules – N/A

4.7.7 User Roles – N/A

4.7.8 Data Fields – N/A

4.7.9 Links – Navigation – N/A

4.7.10 Links – Functions/Actions – N/A

4.7.11 Validation – N/A

4.7.12 Notifications and Tasks – N/A

4.7.13 Other – N/A

4.8 Receiving and Matching Inbound Records

4.8.1 Design Description

4.8.2 Functional Output

4.8.3 Design Details

4.8.4 Screen Flow – N/A

4.8.5 Screen Mockup – N/A

4.8.6 Business Rules – N/A

4.8.7 User Roles – N/A

4.8.8 Data Fields – N/A

4.8.9 Links – Navigation – N/A

4.8.10 Links – Functions/Actions

4.8.11 Validation – N/A

4.8.12 Notifications and Tasks

4.8.13 Other – N/A

4.9 Processing Inbound RIC A Records

4.9.1 Design Description

4.9.2 Functional Output

4.9.3 Design Details

4.9.4 Screen Flow – N/A

4.9.5 Screen Mockup – N/A

4.9.6 Business Rules – N/A

4.9.7 User Roles – N/A

4.9.8 Data Fields – N/A

4.9.9 Links – Navigation – N/A

4.9.10 Links – Functions/Actions – N/A

4.9.11 Validation – N/A

4.9.12 Notifications and Tasks – N/A

4.9.13 Other – N/A

4.10 Processing Inbound RIC B Records

4.10.1 Design Description

4.10.2 Functional Output

4.10.3 Design Details

4.10.4 Screen Flow – N/A

4.10.5 Screen Mockup – N/A

4.10.6 Business Rules – N/A

4.10.7 User Roles – N/A

4.10.8 Data Fields – N/A

4.10.9 Links – Navigation – N/A

4.10.10 Links – Functions/Actions – N/A

4.10.11 Validation – N/A

4.10.12 Notifications and Tasks

4.10.13 Other – N/A

4.11 Processing Inbound RIC C Records

4.11.1 Design Description

4.11.2 Functional Output

4.11.3 Design Details

4.11.4 Screen Flow – N/A

4.11.5 Screen Mockup – N/A

4.11.6 Business Rules – N/A

4.11.7 User Roles – N/A

4.11.8 Data Fields – N/A

4.11.9 Links – Navigation – N/A

4.11.10 Links – Functions/Actions – N/A

4.11.11 Validation – N/A

4.11.12 Notifications and Tasks – N/A

4.11.13 Other – N/A

4.12 Processing Inbound RIC D Accretion Records

4.12.1 Design Description

4.12.2 Functional Output

4.12.3 Design Details

4.12.4 Screen Flow – N/A

4.12.5 Screen Mockup – N/A

4.12.6 Business Rules – N/A

4.12.7 User Roles – N/A

4.12.8 Data Fields – N/A

4.12.9 Links - Navigation – N/A

4.12.10 Links – Functions/Actions

4.12.11 4.2.11 Validation – N/A

4.12.12 Notifications and Tasks

4.12.13 Other – N/A

4.13 Processing Inbound RIC D Deletion Records

4.13.1 Design Description

4.13.2 Functional Output

4.13.3 Design Details

4.13.4 Screen Flow – N/A

4.13.5 Screen Mockup – N/A

4.13.6 Business Rules – N/A

4.13.7 User Roles – N/A

4.13.8 Data Fields – N/A

4.13.9 Links – Navigation – N/A

4.13.10 Links – Functions/Actions – N/A

4.13.11 Validation – N/A

4.13.12 Notifications and Tasks

4.13.13 Other – N/A

4.14 Processing Inbound RIC D Adjustment Records

4.14.1 Design Description

4.14.2 Functional Output

4.14.3 Design Details

4.14.4 Screen Flow – N/A

4.14.5 Screen Mockup – N/A

4.14.6 Business Rules – N/A

4.14.7 User Roles – N/A

4.14.8 Data Fields – N/A

4.14.9 Links – Navigation – N/A

4.14.10 Links – Functions/Actions – N/A

4.14.11 Validation – N/A

4.14.12 Notifications and Tasks – N/A

4.14.13 Other – N/A

4.15 Processing Inbound – RIC E Records

4.15.1 Design Description

4.15.2 Functional Output

4.15.3 Design Details

4.15.4 Screen Flow – N/A

4.15.5 Screen Mockup – N/A

4.15.6 Business Rules – N/A

4.15.7 User Roles – N/A

4.15.8 Data Fields – N/A

4.15.9 Links – Navigation – N/A

4.15.10 Links – Functions/Actions – N/A

4.15.11 Validation – N/A

4.15.12 Notifications and Tasks – N/A

4.15.13 Other – N/A

4.16 Processing Inbound – RIC F Records

4.16.1 Design Description

4.16.2 Functional Output

4.16.3 Design Details

4.16.4 Screen Flow – N/A

4.16.5 Screen Mockup – N/A

4.16.6 Business Rules – N/A

4.16.7 User Roles – N/A

4.16.8 Data Fields – N/A

4.16.9 Links – Navigation – N/A

4.16.10 Links – Functions/Actions – N/A

4.16.11 Validation – N/A

4.16.12 Notifications and Tasks

4.16.13 Other – N/A

4.17 Outbound Part-B – Updation Process

4.17.1 Design Description

4.17.2 Functional Output

4.17.3 Design Details

4.17.4 Screen Flow – N/A

4.17.5 Screen Mockup – N/A

4.17.6 Business Rules – N/A

4.17.7 User Roles – N/A

4.17.8 Data Fields – N/A

4.17.9 Links – Navigation – N/A

4.17.10 Links – Functions/Actions – N/A

4.17.11 Validation – N/A

4.17.12 Notifications and Tasks – N/A

4.17.13 Other – N/A

4.18 Outbound Part-A – Updation Process

4.18.1 Design Description

4.18.2 Functional Output

4.18.3 Design Details

4.18.4 Screen Flow – N/A

4.18.5 Screen Mockup – N/A

4.18.6 Business Rules – N/A

4.18.7 User Roles – N/A

4.18.8 Data Fields – N/A

4.18.9 Links – Navigation – N/A

4.18.10 Links – Functions/Actions – N/A

4.18.11 Validations – N/A

4.18.12 Notifications and Tasks – N/A

4.18.13 Other – N/A

4.19 Sending RIC B Billing File to MMIS

4.19.1 Design Description

4.19.2 Functional Output

4.19.3 Design Details

4.19.4 Screen Flow – N/A

4.19.5 Screen Mockup – N/A

4.19.6 Business Rules – N/A

4.19.7 User Roles – N/A

4.19.8 Data Fields – N/A

4.19.9 Links – Navigation – N/A

4.19.10 Links – Functions/Actions – N/A

4.19.11 Validation – N/A

4.19.12 Notifications and Tasks – N/A

4.19.13 Other – N/A

4.20 Sending Buy-In Data to MMIS

4.20.1 Design Description

4.20.2 Functional Output

4.20.3 Design Details

4.20.4 Screen Flow – N/A

4.20.5 Screen Mockup – N/A

4.20.6 Business Rules – N/A

4.20.7 User Roles – N/A

4.20.8 Data Fields – N/A

4.20.9 Links – Navigation – N/A

4.20.10 Links – Functions/Actions – N/A

4.20.11 Validation – N/A

4.20.12 Notifications and Tasks – N/A

4.20.13 Other – N/A

4.21 Displaying Buy-In Interface Data

4.21.1 Design Description

4.21.2 Functional Output

4.21.3 Design Details

4.21.4 Screen Flow

4.21.5 Screen Mockup

4.21.6 Business Rules – N/A

4.21.7 User Roles

4.21.8 Notifications and Tasks – N/A

4.22 Displaying Requests Pending Approval

4.22.1 Design Description

4.22.2 Functional Output

4.22.3 Design Details

4.22.4 Screen Flow – N/A

4.22.5 Screen Mockup

4.22.6 Business Rules – N/A

4.22.7 User Roles

4.22.8 Data Fields – N/A

4.22.9 Links – Navigation – N/A

4.22.10 Links – Functions/Actions – N/A

4.22.11 Validation – N/A

4.22.12 Notifications and Tasks – N/A

4.22.13 Other – N/A

4.23 Sending Email Notifications

4.23.1 Design Description

4.23.2 Functional Output

4.23.3 Design Details

4.23.4 Screen Flow – N/A

4.23.5 Screen Mockup – N/A

4.23.6 Business Rules – N/A

4.23.7 User Roles – N/A

4.23.8 Data Fields – N/A

4.23.9 Links – Navigation – N/A

4.23.10 Links – Functions/Actions – N/A

4.23.11 Validation – N/A

4.23.12 Notifications and Tasks – N/A

4.24 Buy-In Reports

4.24.1 Design Description

4.24.2 Functional Output – N/A

4.24.3 Design Details

4.24.4 Screen Flow – N/A

4.24.5 Screen Mockup – N/A

4.24.6 Business Rules – N/A

4.24.7 User Roles – N/A

4.24.8 Data Fields – N/A

4.24.9 Links – Navigation – N/A

4.24.10 Links – Functions/Actions – N/A

4.24.11 Validation – N/A

4.24.12 Notifications and Tasks – N/A

4.24.13 Other – N/A

4.25 Buy-In Termination File

4.25.1 Design Description

4.25.2 Functional Output

4.25.3 Design Details

4.25.4 Screen Flow – N/A

4.25.5 Screen Mockup – N/A

4.25.6 Business Rules – N/A

4.25.7 User Roles – N/A

4.25.8 Data Fields – N/A

4.25.9 Links – Navigation – N/A

4.25.10 Links – Functions/Actions – N/A

4.25.11 Validation – N/A

4.25.12 Notifications and Tasks – N/A

4.25.13 Other – N/A

5 Technical Design

5.1 Common Technical Artifacts

5.1.1 Sequence Diagram

5.1.2 Events – N/A

5.1.3 Event Class Details – N/A

5.1.4 Domain Definitions

5.1.5 Code Tables

5.1.6 Code Table Details

5.1.7 Messages

5.1.8 Message Detailed Description

5.1.9 DMX

5.1.10 Security

5.1.11 Security Details

5.1.12 Model

5.1.13 Interfaces – N/A

5.1.14 Façades

5.1.15 Entity Layer

5.1.16 Service Layer

5.1.17 POD Definitions – N/A

5.1.18 Java Script Changes – N/A

5.1.19 CSS Changes – N/A

5.1.20 Global Configuration Changes – N/A

5.1.21 Wizard Changes – N/A

5.1.22 Menu Details – N/A

5.1.23 Evidence Configuration Changes – N/A

5.1.24 Renderers – N/A

5.1.25 Keywords (Hover Values) – N/A

5.1.26 Help Content – N/A

5.1.27 Links - Navigations – N/A

5.1.28 Links – Functions/Actions – N/A

5.1.29 Validation – N/A

5.1.30 Workflow

5.1.31 Web Services – N/A

5.1.32 Java Classes – N/A

5.1.33 Task and Work Queues

5.1.34 Reports – N/A

5.1.35 Unit Testing Scenarios

5.1.36 Cúram Unit Testing Scenarios

5.1.37 ESB Unit Testing Scenarios

5.1.38 Data Retention – N/A

5.1.39 Persistence Requirements – N/A

5.1.40 Backup Requirements – N/A

5.1.41 Archiving and Purging Requirements – N/A

5.1.42 Data Validation Checks – N/A

5.1.43 Security Considerations – N/A

5.1.44 Event Sequence Diagram – N/A

5.1.45 Coding Specifications – N/A

5.1.46 Table Names – N/A

5.1.47 Cúram Batch Component Technical Design – N/A

5.1.48 Batch Methods – N/A

5.1.49 Entity Classes – N/A

5.1.50 Entity Methods – N/A

5.1.51 Input/ Output Structs – N/A

5.1.52 Input /Output Attributes – N/A

5.1.53 Technical Dependencies – N/A

5.1.54 Source-to-Target Mapping – N/A

5.1.55 System Properties – N/A

5.1.56 Page Parameter Details

5.1.57 Links/Action Controls

5.1.58 Lists/Inline Page Details

5.1.59 Cluster Details

5.1.60 UIM Configuration Changes

5.1.61 Server Interface Details

5.2 ESB Development

5.2.1 Outbound

5.2.2 Inbound

5.2.3 Supporting Details: Record Layout

5.2.4 ESB Operational Section

5.3 Rules Development – N/A

5.3.1 Rules (Rules Area)- N/A

5.3.2 Table of Values- N/A

5.4 Batch Development

5.4.1 Batch Overview

5.4.2 Functional Summary

5.4.3 Batch Specifications

5.4.4 Data Retention – N/A

5.4.5 Batch Classes – N/A

5.4.6 Batch Methods – N/A

5.4.7 Archiving and Purging Requirements – N/A

5.4.8 Data Validation Checks – N/A

5.4.9 BUYIN OUTBOUND CHUNKER PROCESS

5.4.10 BUYIN OUTBOUND STREAMER PROCESS

5.4.11 Table Names

5.4.12 Input Table Names

5.4.13 Output Table Names

5.4.14 Table Structure

5.4.15 Batch Classes

5.4.16 Batch Methods

5.4.17 Entity Classes

5.4.18 Entity Methods

5.4.19 System Properties

5.4.20 Code Tables

5.4.21 Batch Specifications

5.4.22 Input Table Names

5.4.23 BUYIN INBOUND CHUNKER PROCESS

5.4.24 BUYIN INBOUND STREAMER PROCESS

5.4.25 Table Names

5.4.26 TABLE STRUCTURE

5.4.27 Output Table Names

5.4.28 Batch Classes

5.4.29 Batch Methods

5.4.30 Entity Classes

5.4.31 System Properties

5.4.32 Code Tables

5.4.33 Overview

5.4.34 MMBUYINMergeOutboundBatchChunker Detailed Design

5.4.35 Overview

5.4.36 Functional Summary

5.4.37 Batch Specifications

5.4.38 BUYIN MERGE OUTBOUND CHUNKER PROCESS

5.4.39 BUYIN MERGE OUTBOUND STREAMER PROCESS

5.4.40 MMBUYINPersonSearchBatchChunker Detailed Design

5.4.41 Overview

5.4.42 Functional Summary

5.4.43 Batch Specifications

5.4.44 BUYIN PERSON SEARCH CHUNKER PROCESS

5.4.45 BUYIN PERSON SEARCH STREAMER PROCESS

5.5 Non-Functional Requirements – N/A

5.5.1 Accessibility – N/A

5.5.2 Availability – N/A

5.5.3 Development Resource – N/A

5.5.4 Evolution – N/A

5.5.5 Globalization – N/A

6 Integration Points/Dependencies

7 Use Cases

7.1 Creating an outbound accretion request

7.2 Creating an outbound deletion request

7.3 Creating a simultaneous accretion/deletion request

7.4 Creating an update outbound request

7.5 Creating an outbound accretion request – Part-A

8 Appendices

8.1.1 Appendix A: Action Item Matrix

8.1.2 Appendix B: Out of Scope Requirements – N/A

8.1.3 Appendix C: Comment/Resolution Log – N/A

8.1.4 Appendix D: Approval History

8.1.5 Appendix E: User Roles and Access Levels

8.1.6 Appendix F: User Roles and Work Queue Subscriptions

8.1.7 Appendix G: RIC B to MMIS file mappings

8.1.8 Appendix H: ESB BuyIn Database Scripts

8.1.9 Appendix I: Risk and Mitigation

1 Introduction

1.1 Background

The Buy-In interface is a process through which the state Medicaid program accepts responsibility to pay Medicare Part-A and Part-B premiums for qualified Medicaid recipients.

Medicare Part A covers hospital care. Most individuals are eligible for free Medicare Part A, however there are individuals who are not eligible for free Part A. South Carolina is a Group

Premium Payer state and as a Group Premium Payer state, before we can begin paying the

Medicare Part A premium, the individual must have filed an application for actual or conditional

Medicare Part A with SSA. To conditionally enroll, the individual must indicate to SSA that they wish to enroll in Medicare Part A only if the State will pay the Part A premium. Persons who conditionally enroll do not become eligible for Part A until the State submits a Buy-In request to

CMS and that request is accepted.

Medicare Part B covers doctor’s services, outpatient care, and other medically necessary medical services. SC Medicaid covers the Part B premium when the beneficiary is eligible for full Medicaid benefits and Medicare Part B. It also covers the Part B premium when the person is eligible for

Specified Low Income Medicare Beneficiaries (SLMB) or Qualifying Individuals (QI) payment categories.

1.2 Purpose

The purpose of this document is to detail screen flows and changes needed in Cúram Global

Income Support (CGIS) to implement SC MMRP configurations, extensions and customizations to implement the MMRP CGIS solution only.

The intended audiences for this document are:

• MMRP Subject Matter Experts (SMEs)

• MMRP Cúram – Business Analysts

• MMRP Cúram – Architecture team

• MMRP Cúram – Solution Developers

• MMRP Cúram – Testing Team

1.3 Scope

The scope of this project is to perform the following:

State to CMS - Outbound files

The system identifies all Buy-In Part A and B eligibles, ineligibles and changes in information.

The system will generate requests for a Buy-In accretion, Buy-In deletion, Buy-In Updation and simultaneous accretion/deletion to CMS. The system will also have the capability for specific user roles to create manual outbound requests. Separate Part A and Part B Buy-In outbound files are sent to CMS.

CMS to State Inbound files

CMS will return a response for every Buy-In request made by the state. CMS sends separate Part-

A and Part-B inbound files to the state. Each record received will have a Record Identification

Code (RIC). The system will validate and process the information received. If there are no discrepancies, the member’s Buy-In records are created/updated where necessary. If there are discrepancies, tasks are created and assigned to work queues for manual intervention.

CMS to State Billing files

CMS sends a separate billing file for Part-A and Part-B every month. Each record received is processed based on the transaction code and the Premium Amount is updated where necessary. If there are discrepancies, tasks are created and assigned to work queues for manual intervention.

State to MMIS Claim file

The state will send a claim file to MMIS containing Part-A and Part-B billing record at the end of every month.

1.4 Key References

This section lists any key documents that might be helpful to understanding the functionality.

Document Name Location

Buy-In Interface BRD Buy-In Interface BRD

Outbound request record layout Appendix A

Part-A selection criteria and start date determination

Appendix B

Outbound Transaction Codes Appendix C

MCN to RRB Conversion Logic Appendix D

Transaction Codes for Manual Requests Appendix E

Buy-In Eligibility Codes for Manual Input Appendix F

Outbound transaction code decodes Appendix G

CMS to State Data Layout Appendix H

CMS to State Part-A Transaction Codes Appendix I

CMS to State Part-B Transaction Codes Appendix J

Decodes for outbound transaction codes Appendix K

RIC B Single Transaction Process Appendix L

RIC B Multiple Transaction Process Appendix M

RIC C System Process Appendix N https://team.scdhhs.gov/pmo/ProjectRepository/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/Forms/AllItems.aspx https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20A_State%20Input%20Record%20Layout.docx?d=w86cf0756d7a5461b9a722739c93672e9&csf=1&web=1&e=f9re2L https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20B_Logic%20for%20Selecting%20Part%20A%20Members%20and%20Identifying%20Part%20A%20Start%20Date.docx?d=wcda4162d36c843ac9e8b35adddf239d0&csf=1&web=1&e=i8N8Qy https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20C_State%20To%20CMS%20Input%20Transaction%20Codes.docx?d=wd7f953a729ff4d96bedeabd0d468c14b&csf=1&web=1&e=3KJrlQ https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20D_Format%20to%20Convert%20RRB.docx?d=wfff8a183542442baaa4a905d4cbe1e51&csf=1&web=1&e=R9oWOs https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20E_Transaction%20Code%20For%20Manual%20Input.docx?d=w7f2b6ef55c514194a53287581d404ccf&csf=1&web=1&e=2LHgWh https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20F_Buy-In%20Eligibility%20Codes%20For%20Manual%20Input.docx?d=wd07c7e6ed8004c89adfa6e5afc3ef62f&csf=1&web=1&e=g709PB https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20G_Decodes%20For%20State%20Input%20Transaction%20Codes.docx?d=w6e3bb07dbb54466a91b0b7379e802518&csf=1&web=1&e=OgTeSs https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20H_CMS%20Output%20To%20State%20Ric%20A%20Through%20Ric%20F%20Data%20Layout.docx?d=w27cea407e0d84fcc83d23bc7e0df7911&csf=1&web=1&e=nUAZ8y https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20I_CMS%20To%20State%20Output%20Part%20A%20Transaction%20Codes.docx?d=wd4a2017288d44297b25a7f242039c23c&csf=1&web=1&e=OgthV8 https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20J_CMS%20To%20State%20Output%20Part%20B%20Transaction%20Codes.docx?d=w76cfbb3a23d844c886f3d7f5cbf44aac&csf=1&web=1&e=jsFypO https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B6FC66C49-DA10-4FC0-94AD-9FECA4AFDB35%7D&file=APPENDIX%20K_Decodes%20For%20CMS%20Output%20Transaction%20Codes.docx&action=default&mobileredirect=true https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7BEDD482E1-209E-41EF-886D-30D5DADEBCB3%7D&file=APPENDIX%20L-%20RIC%20B%20SINGLE%20TRANSACTION%20SYSTEM%20ACTIONS.docx&action=default&mobileredirect=true https://schhs.sharepoint.com/:w:/r/sites/1211207/CGIS%20Business%20Requirements%20and%20Design%20Documents/APPENDIX%20M-%20RIC%20B%20MULTIPLE%20TRANSACTION%20SYSTEM%20ACTIONS.docx?d=w53f4c06881f548048307744e2ed7d027&csf=1&web=1&e=biVxz6 https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7BA38A23F7-A548-4A8D-85C5-9CC6D0EA101A%7D&file=APPENDIX%20N_RIC%20C%20System%20Actions.docx&action=default&mobileredirect=true

Document Name Location

RIC D System Process Appendix O

RIC D System Process Steps Appendix P

Work queue and Tasks Appendix Q

User Roles and Access Appendix R

State Agency Codes Appendix S

Applying Start and Stop Dates Appendix T

Email Listserv Appendix U

RIC B Single Transaction System Process Steps Appendix V

RIC B Multiple Transaction System Process Steps Appendix W

Buy-In Eligibility Codes for Part-B Appendix X

1.5 Definitions and Acronyms

Term

Meaning

BEC Buy-In Eligibility Code

BENDEX Beneficiary Earnings and Data Exchange System is an automated exchange with SSA to receive SSA benefit and Medicare information.

BIC Beneficiary Identification Code

BRD Business Requirements Document

CGIS Cúram Global Income Support

DHHS Department of Health and Human Services

DOB Date of Birth

DOD Date of Death

DSS Department of Social Services

ESB Enterprise Service Bus

HCR Health Care Reform

MCN Medicare Claim Number

MMIS Medicaid Management Information System

RIC Record Identification Code

RRB Railroad Retirement Board

SSCN Social Security Claim Number https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7BEB335835-5424-47F1-A24C-F0037583583F%7D&file=APPENDIX%20O-%20RIC%20D%20SYSTEM%20ACTIONS.docx&action=default&mobileredirect=true https://schhs.sharepoint.com/:x:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B6CB712BD-B570-4DDB-9FC1-2B8487A650AD%7D&file=APPENDIX%20P_RIC%20D%20System%20Actions%20Steps.xlsx&action=default&mobileredirect=true https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7BBEF89973-D03E-4BDB-957A-2DF7228EE186%7D&file=APPENDIX%20Q_BuyIn%20Work%20Queue%20Tasks.docx&action=default&mobileredirect=true https://schhs.sharepoint.com/:x:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B7BDBA648-B849-49C3-817C-119893D7832C%7D&file=APPENDIX%20R_User%20roles%20and%20Access%20Levels.xlsx&action=default&mobileredirect=true https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B3C8FC2C0-D555-407D-A18D-03068DCF7CD8%7D&file=APPENDIX%20S_LIST%20OF%20STATE%20AGENCY%20CODES.docx&action=default&mobileredirect=true https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B09195F80-E0C3-4CAF-A826-957B1E5BB7C0%7D&file=APPENDIX%20T_Applying%20Start%20and%20Stop%20Dates.docx&action=default&mobileredirect=true https://schhs.sharepoint.com/:w:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B36B40DA0-5516-4CA7-A0B2-3B2ED7B5558A%7D&file=APPENDIX%20U_BUYIN%20EMAIL%20LISTSERVE%20AND%20MESSAGE.docx&action=default&mobileredirect=true https://schhs.sharepoint.com/:x:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B841F6977-5455-4930-9E56-314B34FE81C0%7D&file=APPENDIX%20V_RIC%20B%20Single%20Transaction%20System%20Actions%20Steps.xlsx&action=default&mobileredirect=true https://schhs.sharepoint.com/:x:/r/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7B0A288E97-CB15-41BE-AC17-6E889C6DB532%7D&file=APPENDIX%20W_RIC%20B%20Multiple%20Transactions%20System%20Actions%20Steps.xlsx&action=default&mobileredirect=true https://schhs.sharepoint.com/sites/1211207/_layouts/15/Doc.aspx?sourcedoc=%7BD31CA046-30F7-42D3-9A59-8D768DBBE486%7D&file=APPENDIX%20X_BuyIn%20Eligibility%20Code%20for%20Part%20B.docx&action=default&mobileredirect=true&CT=1597933187200&OR=ItemsView

Term

Meaning

SEQ Number Sequence Number

TC Transaction Code

TED Transaction Effective Date

TPP Third Party Premium Payer Code

TPS Third Party System

TPM Third Party Master

DOD Date of Death

PCAT Payment Category

QCAT Qualifying Category

BI Benefit Indicator

QMB Qualified Medicare Beneficiary

QI Qualified Individuals

SLMB Specified Low-Income Medicare Beneficiary

1.6 Key Assumptions – N/A

2 Conceptual Flow

The flows captured within this section provide a high-level overview of the process. Please refer to the Functions for detailed requirements.

2.1 High Level Process Flow

# Task/Process Task ID Narration

1. Apply for Medicaid 1.1 A citizen applies for Medicaid benefits in Cúram

2. Run Cúram rules to determine member's eligibility

1.2 Upon authorize, Cúram rules are executed to

determine the Medicaid eligibility

3. Execute the daily Buy-In batch 1.3 The system executes the daily Buy-In batch to determine any Buy-In eligible or In-Eligible records

4. Create outbound request records where necessary

1.4 The Buy-In batch generated the required outbound

request records

5. Review outbound requests and add new ones if required

1.5 An authorized user validates the request records

generated and adds new ones if required

6. Approve the requests 1.6 An authorized user approves the generated request records before they are sent out to CMS

7. Send approved records to ESB 1.7 Only approved records are considered to be sent to

CMS

8. Generate separate Part-A/Part-B files and send to CMS

1.8 ESB generates separate files to send Part-A and

Part-B records to CMS

9. Receive the files and validate the records

1.9 CMS receives the records sent by the state and

validates them

10. Process records and prepare responses

1.10 CMS processes the records sent by the state and

generates inbound responses to the state

11. Add any new records 1.11 CMS adds any new records if required

12. Generate separate inbound files for Part-A/Part-B

1.13 Inbound responses are generated by CMS in

different files for Part-A and Part-B

13. Send the inbound files to the state 1.14 Inbound files are sent to the state

14. Receive files and validate records based on RIC

1.15 The inbound records received are validated based on

the CMS format

15. Add invalid records to exception report

1.16 Any invalid records are added to an exception report

16. Send valid records to Cúram for processing

1.17 Only valid records are sent to Cúram for processing

17. Receive records and store them 1.18 The records received are stored

18. Person search and match

- Decision Step

- Add unprocessed records to an Exception report

1.19 a.) Person search and match process will be triggered.

b.) If unique match is found then system will proceed to 1.20.

c.) If unique match not found then such record cannot be processed in Cúram will be added to an exception report

19. Create/Update Buy-In records for members in Cúram

1.20 The system creates or updates Buy-In records in

Cúram

20. Are all required conditions met? 1.21 System checks if all the conditions based on TCs and RIC values are met

21. Activate the Buy-In record 1.22 If there are no discrepancies the record(s) are activated

22. Send the updated Buy-In information to MMIS

1.23 Whenever a Buy-In record is created or updated, the corresponding member record is sent to MMIS

23. Should an outbound request be generated?

1.24 System checks if an outbound request needs to be

generated based the processing of an inbound record

24. Create a task for caseworker to look into it

1.25 If system is unable to update a record a task is

created for the caseworker to work on it

25. Store the tasks received from Cúram

1.26 Created tasks are sent to PathOS and worked from

there

26. Work on the tasks to make necessary updates

1.27 Authorized user makes the necessary updates

27. Send the monthly RIC B billing file 1.28 The monthly RIC B billing file is sent to the state by

CMS

28. Receive file and validate RIC B records received

1.29 The monthly file received is validated

29. Send valid records to Cúram for processing

1.30 The records that pass data validations are sent to

Cúram for processing

30. Process RIC B records and update Premium Amt

1.31 RIC B records are processed as per rules and the

premium amount is updated where required

31. Send billing records in a separate file to MMIS

1.32 A processed billing file is generated at the end of the

month and sent to MMIS

2.2 Outbound Part-B – Accretion Process

1. Apply for Medicaid 1.1 A citizen applies for Medicaid benefit in Cúram

2. Run Cúram rules to determine member's eligibility

1.2 Cúram rules are executed to determine member’s

Medicaid eligibility

3. Medicaid eligible in a Buy-In eligible PCAT/BI?

1.3 System checks if the member is eligible for Medicaid

in a PCAT/BI which is also eligible for Part-B Buy-In

4. Does member have active Part- B Buy-In?

1.4 System checks if the member has an open-ended

Buy-In Part-B record already in Cúram

5. Is there a Buy-In task open for the member?

1.5 System checks if there is a Buy-In related task in open

status for the member

6. Medicare information available for the member in Cúram?

1.6 The system checks if the member has any Medicare

information stored in Cúram

7. Does member have MCN or

RRB?

1.7 System checks if the Medicare Number stored in

Cúram is a Medicare Claim Number or Railroad Retirement Board number.

8. Medicaid and Medicare Part-B Start dates effective?

1.8 System checks if both the Medicare and Medicaid

start dates are effective as of the current date

9. Generate outbound accretion request for Part-B

1.9 An outbound accretion request is generated for the

member

10. Add the record to outbound Part- B file

1.10 The record is included in outbound request file

11. Hold request till TED is effective and re-run rules

1.11 The outbound request is generated internally but not

available for review

12. Is member still Buy-In eligible when TED is effective?

1.12 System re-runs the accretion rules to determine if the

member is still Buy-In Part-B eligible

13. Skip accretion process for the member

1.13 System skips the accretion process if the member is

determined to be ineligible for Buy-In when the TED is effective

14. Skip outbound accretion process for the member

1.14 System skips the accretion process if the member is

determined to be ineligible for Buy-In

15. Convert RRB value to a pseudo MCN value

1.15 If an RRB number exists, based on rules defined it will

be converted to a pseudo MCN number and used in the outbound request

2.3 Outbound Part-B – Deletion Process

1. Member having an active Buy-In record in Cúram

1.1 A citizen is currently receiving active Medicaid benefits and is Buy-In eligible

2. Is Medicaid case reassessed? 1.2 There is a case reassessment in Cúram

3. Member moved to a Buy-In ineligible PCAT/BI?

1.3 Did the member move to a Part-B Buy-In ineligible

PCAT/BI as a part of reassessment?

4. Generate an outbound part-B deletion request

1.4 If the required conditions are met, an outbound Part-B

deletion request is generated for the member

5. Add the record to Outbound Part B file

1.5 The request is added to the Outbound Part-B file

6. Member's Medicaid eligibility ended?

1.6 Did the member’s Medicaid eligibility end as a part of

reassessment?

7. Medicare Part-B end date added?

1.7 Was there an end date added to the member’s

Medicare Part-B evidence record (Benefit Evidence) in Cúram

8. Date of death added? 1.8 Was a date of death added for the member?

9. Invalid accretion request received from CMS?

1.9 Was an invalid accretion request record received from

CMS?

2.4 Outbound Part-B – Simultaneous

Accretion/Deletion Process

1. Member receiving Medicaid in a Buy-In eligible PCAT?

1.1 Is member currently receiving Medicaid in a Buy-In eligible PCAT in Cúram along with the Benefit Indicator?

2. Does member have a Medicare Part-B record?

1.2 Does member have Medicare information stored in Cúram

under Benefit evidence?

3. Medicaid & Medicare Part-B eligibility periods overlap?

1.3 Does the Medicaid and Medicare periods overlap?

4. Member has Buy-In for the entire overlapping period?

1.4 Does member have a Buy-In record in Cúram for the

overlapping period?

5. Record not eligible for retro accretion request

1.5 Record not eligible for retro accretion request.

6. Generate retro request for missing period(s)

1.6 Generate outbound requests for the missing Buy-In period.

7. Add…