Department Of Public Welfare Medicaid Management Information System (MMIS) Modernization Procurement Request for Information (RFI)
Date: September 29, 2014
Table of Contents PART 1: GENERAL INFORMATION........................................................................................................1 1.1 Purpose of this Request for Information ................................................................................................ 1 1.2 Request for Information Timeline .......................................................................................................... 1 1.3 Disclaimers.............................................................................................................................................. 1 PART 2: BACKGROUND .......................................................................................................................2 PART 3: VISION, GUIDING PRINCIPLES, TECHNOLOGICAL OBJECTIVES ...................................................3 3.1 Vision Statement .................................................................................................................................... 3 3.2 Guiding Principles ................................................................................................................................... 3 3.3 Technological Objectives ........................................................................................................................ 3 PART 4: REQUEST FOR INFORMATION SUBMISSION FORMAT ..............................................................4 4.1 Response Submission ............................................................................................................................. 4 4.2 Cover Letter ............................................................................................................................................ 4 4.3 Conceptual Solutions and Strategies Response/Demonstrations .......................................................... 4 PART 5: RFI DISCUSSION AREAS & QUESTIONS.....................................................................................5 5.1 Procurement Approach and Strategy ..................................................................................................... 6 5.2 MITA 3.0 ................................................................................................................................................. 7 5.2.1 Business Architecture (BA) – 10 MITA Business Areas ........................................................................ 7 5.2.2 Information Architecture (IA) ............................................................................................................ 12 5.2.3 Technical Architecture (TA) ............................................................................................................... 13 PART 6: APPENDIX............................................................................................................................15 6.1 Healthy Pennsylvania: Reforming Medicaid......................................................................................... 15 6.2 Department of Public Welfare Organization Chart .............................................................................. 16 6.3 Pennsylvania Application Lifecycle Management (ALM) ..................................................................... 17 6.4 Pennsylvania MMIS Takeover Background Information ...................................................................... 19 6.5 MITA 3.0 Business Architecture ........................................................................................................... 21 6.6 CMS 7 Standards & Conditions for MMIS Modernization .................................................................... 22 6.7 Medical Assistance Provider Incentive Repository (MAPIR) ................................................................ 23 6.8 Meaningful Use Data Collection Strategy............................................................................................. 24 6.9 Glossary of Terms and Acronyms ......................................................................................................... 26
PART 1: GENERAL INFORMATION 1.1 Purpose of this Request for Information The Pennsylvania Department of Public Welfare (“Department” or “DPW”) issues this Request for Information (RFI) to solicit information that will be used to assist with the development of a Request for Proposals (RFP) for a Medicaid Management Information System (MMIS) Modernization procurement which may be released in the future. Specifically, this request sets forth the Department’s vision and objectives, and seeks information from which the Department can formulate specifications and requirements, realistic timeframes, and cost structures. The Department desires to produce an RFP that promotes vendor competition and creative technical solutions. The Department is open to any and all ideas in relation to the vision of the MMIS Modernization and encourages alternative ideas that will help the Department better define its requirements. This RFI is an earnest attempt to become aware of and knowledgeable about current MMIS solutions available to support the requirements of the Department. This RFI will also help the Department identify vendors who are able to provide the required services to support this goal. The Department encourages vendors and other interested parties to provide feedback in response to this RFI or any part thereof. A vendor may respond to all or any of the specific questions or topics included in this RFI.
1.2 Request for Information Timeline Event Release RFI Vendor RFI Response Tentative Vendor Demonstrations (if requested by DPW)
Date September 29, 2014 October 31, 2014 November 15 – December 15, 2014
The Department is requesting that all responses to this RFI be submitted by close of business on due date. Please submit your responses electronically to
[email protected]. While it is not the intent of the Department to respond to questions or clarifications during the RFI response period, vendors may submit administrative questions related to this RFI electronically to
[email protected]. The Department may or may not respond based on the nature of the question.
1.3 Disclaimers The Pennsylvania Department of Public Welfare is not liable for any cost or expenses incurred by Vendors in the preparation of their responses related to this RFI. This RFI is issued for information and planning purposes only and does not constitute a solicitation for future business, an offer for procurement or any other type of current or future procurement action, and is only
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intended to gather information and input. The Department will not award an agreement on the basis of this RFI or otherwise pay for any of the information received. The information gathered through this process may be used in the development of future documents; however, the Department does not guarantee that this will occur. Responses to this RFI will not be returned. Respondents will not be notified of the result of the review, nor will they be provided copies of it. If a procurement document is issued, no vendor(s) will be selected, pre-qualified, or exempted based on their participation in this RFI. Respondents should be aware that the responses to this RFI will be public information and that no claims of confidentiality will be honored. The Department is not requesting, and does not require, confidential, proprietary information or other competitively sensitive information to be included as part of the RFI submission. Ownership of all data, material and documentation originated, prepared and provided to the Department during this RFI process will belong exclusively to the Department.
PART 2: BACKGROUND DPW administers Pennsylvania's Medical Assistance Program, which provides services to over 2 million individuals. Within DPW, the Office of Medical Assistance Programs (OMAP) has administrative responsibility for the Medical Assistance Program. Fiscal Year 2013 - 2014 had program expenditures of approximately $19 billion. Over 42.4 million Fee-For-Service claims were processed totaling over $8.9 billion in approved payments. Pennsylvania’s Medical Assistance Program paid out over $10.4 billion in Managed Care capitation payments and processed over 95.9 million encounters. Pennsylvania’s current MMIS, PROMISe™, was implemented in 2004. Since this time, Pennsylvania’s needs have evolved. A key driver for MMIS Modernization has been Pennsylvania’s transition from Fee-For-Service based programs to State-wide Managed Care based programs. Of the 2.2 million members enrolled in Pennsylvania Medicaid, approximately 26% were enrolled in Fee-For-Service programs and 74% were enrolled in Managed Care based programs. In the future, Pennsylvania will be adding a new Private Coverage Option (PCO) referred to as Healthy Pennsylvania (see appendix 6.1 – Healthy Pennsylvania: Reforming Medicaid for more information). In addition, the Centers for Medicare and Medicaid Services (CMS) have issued recent guidelines for MMIS Modernization with the CMS Seven Conditions and Standards and the Medicaid Information Technical Architecture (MITA) 3.0 framework. DPW is looking to acquire new MMIS technology to support both its changing business needs and to meet CMS requirements. Please refer to Appendix 6.2 Department of Public Welfare Organization Chart for more information regarding the department structure.
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PART 3: VISION, GUIDING PRINCIPLES, TECHNOLOGICAL OBJECTIVES 3.1 Vision Statement The Department envisions implementing a flexible and modular MMIS that supports both Managed Care and Fee-for-Service (FFS) processes across the evolving health care landscape; serves as an enterprise payment, invoicing, and collection module; and provides the foundation for improved health outcomes and quality of care for Pennsylvanians.
3.2 Guiding Principles The Department envisions a new MMIS that will be implemented in accordance with the following guiding principles: • • • • • • •
Aligns with the MITA 3.0 framework and the CMS Seven Conditions and Standards guidelines Maximizes the use of cost-effective, industry-related, and application-ready Commercial Off-The-Shelf (COTS) technologies wherever feasible Integrates “best-of-breed” solutions Provides flexible rules-based technology to adapt to a dynamic health care industry and evolving state and federal standards, regulations, and processes Aligns with the business objectives of the Commonwealth and with current and any future federal and state regulations Provides capabilities to support provider and member centric business models Provides comprehensive and adaptable analytic reporting capabilities to support Pennsylvania program needs
3.3 Technological Objectives The Department envisions implementing a MMIS Modernization solution that aligns with the Department’s technical standards and leverages its previous technological investments. The following information details the Department’s technological architecture objectives to be considered for MMIS Modernization solutions: 1. Application Lifecycle Management (ALM) – The Department will not require a vendor’s MMIS solutions to meet all Pennsylvania ALM standards. The selected ALM standards that MMIS solutions will need to adhere to are in process of being identified and will be included in the future MMIS Modernization RFP. A summary of current ALM standards has been provided in Appendix 6.3 for vendor consideration in responses to this RFI. 2. Web-based User Interface – The Department requests that MMIS solutions provide web-based access that is browser agnostic and allows for mobile enablement. 3. Enterprise Provider Management – The Department’s goal is to utilize one enterprise provider information management source.
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4. Electronic Client Information System (eCIS) – The Department’s eCIS will be the source of eligibility for future MMIS solutions. This system houses all information related to member eligibility for a variety of public assistance programs, including Medicaid. Future MMIS solutions will be required to interface with eCIS for eligibility information. 5. Enterprise Data Warehouse (EDW) – The Department’s EDW is an enterprise data storage and retrieval system for health care, provider, and eligibility data. It is the Department’s primary data and analytics repository. MMIS related data includes: claims, encounters, and prior authorizations. Future solutions will need to interact with the EDW. 6. Electronic Health Record (EHR) - The Department’s goal is for future MMIS vendors to integrate and support Pennsylvania’s current EHR incentive payment solution, Medicaid Assistance Provider Incentive Repository (MAPIR). 7. Agile Rules-Based Solution – The Department’s goal is to implement a flexible rules-based MMIS solution to support Pennsylvania’s dynamic Medicaid environment.
PART 4: REQUEST FOR INFORMATION SUBMISSION FORMAT Through this RFI, the Department is soliciting information and comments regarding options for its future MMIS modernization procurement. All interested vendors are asked to respond in writing to this RFI, per the items outlined below.
4.1 Response Submission Please prepare responses simply and economically, providing straightforward and concise language and descriptions. All responses should be produced in 12 point font or larger. Please limit your response to no more than 50 pages. Please refrain from sending marketing materials to the Department.
4.2 Cover Letter Please include a cover letter with the following information: 1. An introduction to the Respondent’s organization, background, and interest in Pennsylvania’s MMIS Modernization. 2. General information about your firm: Company Name, Address, Point of Contact for this RFI with Telephone and FAX numbers and E-mail address.
4.3 Conceptual Solutions and Strategies Response/Demonstrations The following provides a suggested structure for a response to this RFI. This structure is intended to minimize the effort required to develop and analyze submitted responses. Please address the following: 1. Vendor MMIS Modernization Solution a. Please describe your MMIS Modernization solution. Include any information that you believe the Department would find valuable (i.e. functionality described using MITA terminology and
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2. 3.
4.
5.
business area references, configurability of the solution, other state utilization and success, commercial or health plan utilization and success, CMS certification status or plan for certification, benefits, and technological information). The Department is interested in receiving responses from a diverse group of MMIS vendors (i.e. specialized component solution vendors, end to end MMIS vendors, commercial or health plan vendors). RFI Discussion Areas & Questions (PART 5: RFI DISCUSSION AREAS & QUESTIONS) MMIS Modernization Timeline Recommendations a. The Department’s goal is to implement a MMIS Modernization solution in a timely manner (i.e. 24 – 36 months) utilizing an incremental, staggered implementation approach while minimizing implementation risks. Please describe an ideal timeline for MMIS Modernization activities. Please include the period from RFP Release through solution implementation. Provide in your timeline, the optimal time-frames needed to respond to an RFP with your proposal, time for contract negotiations upon vendor selection announcement (based on your organizations experience) and for all other phases in your implementation approach. To the extent that Respondents base their suggestions on a set of assumptions, Respondents are encouraged to discuss and document those assumptions in their responses. Potential Challenges and Barriers of Pennsylvania’s MMIS Modernization a. Please describe any potential challenges or barriers the Respondent believes the Department may encounter during the implementation of MMIS Modernization. Please include any suggested alternatives and recommendations that you believe would be valuable for the Department to consider for its future MMIS Modernization procurement. Demonstrations a. In order to gain a better understanding of the functionality and capabilities in the marketplace to meet our current and future needs, the Department may be interested in seeing demonstrations of solutions, including best of breed. What products do you provide that align with the vision of Pennsylvania that you would like the opportunity to demonstrate? Please provide the estimated time required for your demonstration and any specific needs you would require to complete the demonstration at one of the state office locations. b. DPW, in its sole discretion, will initiate the requests for demonstrations and will determine the form of the demonstration. Tentatively, DPW has planned for vendor demonstrations to occur between November 15, 2014 and December 15, 2014.
PART 5: RFI DISCUSSION AREAS & QUESTIONS The Department is requesting that vendors with expertise send responses to the questions and topics detailed below. A vendor is not required to respond to all questions and topics. If a vendor’s solution addresses a specific functional area (i.e. care management, encounter processing, or rate setting) the vendor is encouraged to respond with details around its specific solution.
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The questions below solicit responses to the overall procurement approach and strategy and then are aligned to the CMS MITA framework for the structure of the enterprise architecture.
5.1 Procurement Approach and Strategy The following response topics and questions relate to the overall approach and strategy for the new MMIS. The Department is seeking input from vendors to take into consideration for the final RFP and contract(s).
Implementation Approach 1. CMS recommends a modular approach to modernizing MMIS functionality. The Department is interested in utilizing a modular approach where possible. Please provide how your solutions and strategy support a modular implementation approach. Describe any advantages and disadvantages you perceive with a modular approach. 2. A modular solution could allow a phased implementation, please describe how your solutions and strategy could support a phased implementation. Describe any advantages, disadvantages, risks and mitigation strategies you perceive with a phased approach. Takeover of Existing MMIS & MMIS Modernization 3. One procurement option identified is the possibility of issuing a RFP for takeover and operations of the current MMIS and future MMIS Modernization activities. Do you recommend DPW include in our strategy a takeover of the existing MMIS as part of the new RFP contract? Why or why not? Please include in your response any advantages or disadvantages you envision if the Department requires the takeover of the existing MMIS and Design, Develop and Implementation of a new MMIS solution. (Please See Appendix 6.4 - Pennsylvania MMIS Takeover Background Information for additional information.) 4. If the RFP includes takeover and Design, Development, and Implementation (DDI), do you recommend the phases be overlapped or sequential? 5. What is the interest level of your organization in responding to an RFP requiring a takeover of the existing MMIS prior to MMIS Modernization activities? Please describe what information you would need in order to consider responding to a proposal involving a takeover. Best of Breed Solutions 6. The Department is interested in procuring a contract with one or more vendors that will integrate best-of-breed products and approaches to their proposed MMIS solution, including potential partnerships with other vendors specializing in specific functional components. What strategy or approach does your organization use to meet the state's goals to integrate best-ofbreed solutions? Vision, Guiding Principles, and Technological Objectives 7. Please describe how your solution can support the Department’s Vision, Guiding Principles, and Technological Objectives outlined in PART 3: Vision, Guiding Principles, and Technological Objectives of this RFI. Please include any suggestions or concerns you have with aligning your solution to the Vision, Guiding Principles, and Technological Objectives. Fiscal Agent Services
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8.
Does your organization offer fiscal agent or staff augmentation services that could provide additional value to the Department? Please describe why the Department should consider including them in the future RFP and contract(s). The Department may be interested in understanding services around call center support and would like these and any other suggested services to be described for consideration.
5.2 MITA 3.0 The MITA Framework describes a structure for the Medicaid Enterprise that includes business operations, information exchange, and technological services. The Framework includes three (3) parts: • Business Architecture (BA) • Information Architecture (IA) • Technical Architecture (TA) Each of the architectures aligns with the CMS Seven Standards and Conditions. By utilizing best practices, industry standards, and technology advancements, the processes, and planning guidelines that build the MITA Framework provide a cohesive method for meeting Medicaid objectives.
5.2.1 Business Architecture (BA) – 10 MITA Business Areas The MITA BA describes near-term and long-term common business operations of Medicaid Enterprise. The MITA BA allows States to map their current operations and future improvements to models of a business vision, business processes, and business capabilities.
General MITA 3.0 & CMS 7 Standards and Conditions 9. Describe how your solution is aligned to the goals, objectives, and guiding principles of MITA 3.0 and the CMS 7 Conditions and Standards. (Please see Appendixes 6.5 MITA 3.0 Business Architecture and 6.6 CMS 7 Standards & Conditions For MMIS Modernization.) Business Relationship Management includes business processes that support a standards-driven, automated data exchange throughout the Pennsylvania Medicaid Enterprise and with external entities for which there is a contractual or business relationship 10. Does your solution have a component to address the requirements around the business relationship management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a thirdparty product, is part of an additional component you offer, or is not offered by your organization. 11. Does your solution include a Customer Relationship Management (CRM) component to support business relationship management? If so, please describe. 12. Does your solution have the capability to integrate to an external enterprise CRM solution if required? If so, please describe.
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Care Management includes business processes that focus on individual care management (Establish Case, Manage Case, Perform Screening/Assessment, and Manage Treatment Outcomes), Authorizations (Referrals, Services, and Treatment Plans), maintenance of registries related to specific health issues (Manage Registry), and population management (Manage Medicaid Population Health). 13. Does your solution have a component to address the requirements around the care management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 14. Does your care management solution integrate with both the Financial and the Operations business areas for budgeting, service authorizations, and utilization tracking? Please describe how and to what extent. 15. Does your care management solution support mobile technologies? If so, please describe. 16. Does your solution have capabilities for enterprise-wide care management both within and beyond Medicaid to support multiple state programs (i.e. Home and Community Services, Long Term Care, Children & Youth Services)? If so, please describe. 17. Does your solution include business partner quality management and oversight functionality, including incident/complaint management? If so, please describe. 18. Does your solution provide automated prior authorizations capabilities (i.e. pharmacy claims, medical claims, emergency travel, etc.) using predictive analysis or some other approach? If so, please describe. 19. Does your solution include Enterprise Content Management (ECM) functionality to support care management? If so, please describe. 20. Does your solution support the assessment and tracking of quality care measures across multiple state programs (i.e. Home and Community Services, Long Term Care, Children & Youth Services)? If so, please describe. 21. Does your solution support rate setting functionality that can be leveraged across the enterprise? If so, please describe. 22. Does your solution have the ability to integrate clinical care data into care management systems? Contractor Management includes business processes to manage managed care contracts or a variety of outsourced contracts 23. Does your solution have a component to address the requirements around the contractor management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 24. Does your solution include Enterprise Content Management (ECM) functionality to support contractor management? If so, please describe. 25. Does your solution include a Customer Relationship Management (CRM) component to support contractor management or does your solution integrate with an external CRM component? If so, please describe. 26. Does your solution contain an Appeals Management module? If so, please describe. Eligibility and Enrollment Management includes business processes involved in the activity for determination of eligibility and enrollment for new applicants, redetermination of existing members, enrolling new providers, and revalidation of existing providers
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27.
Have you integrated your member enrollment solution to an external solution like the DPW's member solution eCIS as outlined in the 3.3 Technological Objectives? Please provide details. 28. Does your solution have a component to address the requirements around the eligibility and enrollment management business area for provider enrollment? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 29. Does your solution support enrollment of multiple provider types including Medicaid, nonMedicaid, and non-Medical providers (such as transportation, child-care)? If so please describe. 30. If DPW chooses to require use of an external provider enrollment solution, does your overall MMIS solution support interfacing with an external provider enrollment and management solution? If so, please describe. 31. Does your solution include mobile technology capabilities for provider or member use? If so, please describe. 32. Does your solution provide built-in support for the Inquire Member Eligibility business process? Please describe if your eligibility verification solution and user interfaces have the ability to support an external eligibility information source. Financial Management includes business processes that support the finance, accounting, budgeting, and reporting functions of the Pennsylvania Medicaid Enterprise 33. Does your solution have a component to address the requirements around the financial management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 34. Does your solution have capabilities to interact with the Pennsylvania Treasury Department, banking agents or other vendors for payments and fee collections to support Affordable Care Act (ACA) transactions? If so, please describe. 35. Does your solution have invoicing and payment capabilities for non-medical services? If so, please describe. 36. Will your solution have the ability to integrate and support the Department’s current Electronic Health Record (EHR) incentive payment solution, Medicaid Assistance Provider Incentive Repository (MAPIR)? If so, please describe. (See Appendix 6.7 Medical Assistance Provider Incentive Repository (MAPIR).) 37. If your solution includes financial adjustment processing capabilities, please describe the basic functionality (i.e. original fund returns, processing, adjustment balance tracking). 38. Does your solution have 1099 processing? If so, please describe. 39. Does your solution include predictability/budgeting capabilities to analyze program change impacts? If so, please describe. 40. Does your solution include integrated third party liability (TPL) or coordination of benefits (COB) capabilities? If so, please describe. Member Management includes business processes involved in communications between the Pennsylvania Medicaid Agency and the prospective or enrolled member and actions that the agency takes on behalf of the member. This business area is responsible for managing the member data store, coordinating communications with both prospective and current members, outreach to current and potential members, and dealing with member grievance and appeals issues
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41.
Does your solution have a component to address the requirements around the member management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 42. Does your solution include the capability for DPW users to view a member’s entire utilization history (i.e. claims, prior authorizations, encounters) based on user entered parameters? If so, please describe. 43. Does your solution include the capability to generate and send correspondence to members? If so, please describe and clarify the types of correspondence generated such as paper, electronic or other. 44. Does your member enrollment solution include the capability for members to perform any selfservice activities (i.e. view claims, prior authorizations, benefits, copays, and communications)? If so, please describe. 45. Does your solution include mobile technology to support member data needs for consumer access to their care information? If so, please describe. Operations Management includes a collection of business processes that manages claims, encounter claim data, calculates payment amounts, and generates RA statements 46. Does your solution have a component to address the requirements around the operations management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 47. Describe functionality included in your claims processing solution for the support and use of bundling, groupers and Nation Correct Coding Initiative (NCCI) capabilities. Please include in your description if the functionality is built into your solution or is provided through integration to third-party product. 48. Pennsylvania has transitioned from primarily FFS based programs to primarily managed care based programs and will be adding a new Private Coverage Option (PCO). How does your solution address or support managed care and private coverage options processing versus FFS processing? (See Appendix 6.1 – Healthy Pennsylvania: Reforming Medicaid for more information.) 49. Please describe how your solution processes Managed Care Organization (MCO) and PCO encounters and FFS claims. Does your solution use the same edit and audit rule set or is processing separate for each? What advantages or disadvantages do you see with the approach to separate MCO and PCO encounter processing from FFS? 50. Does your solution include a Work flow Management component? If so, please describe. 51. Please describe how your solution supports all Health Insurance Portability and Accountability Act (HIPAA) transactions and compliance standards. Please include in your solution description if you use external third-party products for compliance checking, translation to other formats for processing by your solution, or for any other pre-processing requirements. Include in your description if any part of the solution is shared with other clients? 52. Please describe your pharmacy claims solution capabilities for pharmacy and physician billed outpatient drugs. Include components to support automated prior authorization, call tracking solution for pharmacy provider call center, prior authorization end-user entry, paperless prior authorization requests such as fax-to-desktop, prospective drug utilization review (ProDUR), drug reference file, drug pricing with capability for negotiated Specialty Pharmacy Drug
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Program pricing updates and maintenance, and ePrescribe. The solution for the above functions must enable the Department’s clinical staff to independently develop, maintain, and implement pharmacy initiatives. 53. Does your solution include mobile technology to support DPW users working remotely for accessing data needs? If so, please describe. Plan Management includes a collection of strategic planning, policymaking, benefit plan management, monitoring, and oversight business processes of the Pennsylvania Medicaid Agency. This business area is responsible for the primary data stores (e.g., Medicaid State Plan, health plans and health benefits) as well as performance measures, reference information, and rate setting data stores. The business processes include a wide range of planning, analysis, and decision-making activities 54. Does your solution have a component to address the requirements around the plan management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 55.
Please describe your solution's approach to configurability of benefit plan information. Include in your description what attributes and/or qualifying data is available to configure and define a benefit plan (i.e. health status, diagnosis, age, gender, etc.)
56.
Please describe how your solution supports the implementation of national Health Care Common Procedural Coding System (HCPCS) and Current Procedural Terminology (CPT) code set updates, including the use of automated processes. 57. Does your solution address the extraction of quality data to support the Meaningful Use Program? (See Appendix 6.8 Meaningful Use Data Collection). If so, please describe. 58. Does your solution support the collection, analysis and recording of managed care organization reporting? Please include details around provider monitoring and network coverage reporting and analysis. Please fully describe the processes, calling out any automation your solution provides. Provider Management includes a collection of business processes involved in communications between the Pennsylvania Medicaid Agency and the prospective or enrolled provider and actions that the agency takes on behalf of the provider 59. Does your solution have a component to address the requirements around the provider management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 60. Does your solution include the capability for DPW users to view a provider’s entire history (i.e. claims, prior authorizations, encounters, complaints, grievances) based on user entered parameters? If so, please describe. 61. Does your solution include the Provider self-service access to view information online (i.e. claims, prior authorizations, encounters, electronic remittance advices)? If so, please describe. 62. Does your solution include mobile technology to support provider data needs for overseeing patient care? If so, please describe. 63. Does your solution include the capability to generate and send correspondence to providers? If so, please describe and clarify the types of correspondence generated such as paper, electronic or other.
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Performance Management includes a collection of business processes involved in the assessment of program compliance (e.g., auditing and tracking medical necessity and appropriateness of care, quality of care, patient safety, fraud and abuse, erroneous payments, and administrative anomalies). 64. Does your solution have a component to address the requirements around the performance management business area? Please describe your solution and how it meets the functionality for this business area. Please include in your description if the required functionality is integrated into your core product, is provided through integration of a third-party product, is part of an additional component you offer, or is not offered by your organization. 65. Does your solution include the capability to perform and provide comprehensive analytics of MMIS data (i.e. claims, encounters, payment information)? If so, please describe. 66. Does your solution provide fraud and abuse detection capabilities to identify abusers, both providers and members? If so, please describe.
5.2.2 Information Architecture (IA) The MITA BA drives the IA. It uses a series of models to specify the key elements of information systems that the State Medicaid Enterprise uses to execute their business processes. These elements include the information itself, the applications that use the information to enable the business processes, and the combining of applications and information to support the enterprise’s business functions. The BA and the IA together map enterprise data to business processes. The IA also serves as the bridge between the BA and the TA by providing the framework to go from the BA’s information requirements to the TA’s message requirements. The MITA IA consists of the following: • • • • •
Data Management Strategy (DMS) Conceptual Data Model (CDM) Logical Data Model (LDM) Data Standards Information Capability Matrix (ICM) Information Architecture MITA Alignment 67. Describe key points of the information architecture and how it aligns with the MITA IA framework. Flexible and Timely Data Access 68. Please describe the analytic and reporting capabilities of your solution. Does your system have capabilities for users to easily perform ad-hoc querying to MMIS data? 69. Does your solution include analytics for quality measurements, performance management, outcomes measurement, and provider monitoring? If so, please describe. 70. Please describe any issues you see for requirements to interface to the external Enterprise Data Warehouse (EDW) as detailed in Section 3.3 Technological Objectives? 71. Do you have any suggestions for addressing timely user access and reporting needs requiring data that is in-progress prior to the data being received, processed and made available through the external EDW?
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5.2.3 Technical Architecture (TA) The MITA TA describes the current and future set of business and technical services, connectivity, and standards that the SMA uses to plan and specify new IT systems for a State Medicaid Enterprise. The MITA TA consists of the following: •
Technical Management Strategy (TMS)
•
Business Services
•
Technical Services
•
Application Architecture (AA)
•
Technology Standards
•
Technical Capability Matrix (TCM) Technological Architecture MITA Alignment 72.
Describe the key points of the technical architecture solution and how it aligns with the MITA TA framework. MMIS System Flexibility 73. How does your solution support the need to be able to quickly change business rules, such as edits and audits, to reflect ever-changing policies? Please describe the agility features of your solution to support Medicaid program changes. 74. Please describe what components of your solution are managed through configuration by a business user versus being developer dependent and requiring programmer involvement. Electronic Document Management 75. Do you have or does your solution support a paperless environment (i.e. claims) and include a document management system that includes workflow capabilities? Please describe if your solution is built-in or integrated to a third-party product. 76. What advantages or disadvantages do you foresee if you are required to interface with an external state enterprise document manage storage solution? Enterprise Contact Tracking 77. Does your solution include call/contact tracking capabilities? If so, please describe. 78. Can your contact tracking solution be used on an enterprise level tracking calls outside of Medicaid to support contract tracking for other state programs? If so, please describe. Automation 79. Does your solution offer opportunities for automating MMIS processes? If so, please describe. 80. Does your solution have capabilities to support automated work flow? Please describe any automated workflow that is built in your solution, what is integrated with COTS product as well as how your solution could possibly integrate with an enterprise document management if required.
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Application Lifecycle Management (See Appendix 6.3 – Application Lifecycle Management (ALM) for additional information) 81. Describe how your solution would address the requirements around Governance, Risk, and Regulatory Compliance. 82. Describe how your solution would address the requirements around Access Control, Data Protection, and Audit Logging & Monitoring. 83. Describe how your solution would address the requirements around Application, Systems and Network Security.
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PART 6: APPENDIX The information provided in this appendix has been included to assist Respondents with their response development. 6.1 Healthy Pennsylvania: Reforming Medicaid 6.2 Department of Public Welfare Organization Chart 6.3 Pennsylvania Application Lifecycle Management (ALM) 6.4 Pennsylvania MMIS Takeover Background Information 6.5 MITA 3.0 Business Architecture 6.6 CMS 7 Standards & Conditions for MMIS Modernization 6.7 Medical Assistance Provider Incentive Repository (MAPIR) 6.8 Meaningful Use Data Collection Strategy 6.9 Glossary of Terms and Acronyms
6.1 Healthy Pennsylvania: Reforming Medicaid The Healthy Pennsylvania plan is Governor Tom Corbett’s initiative focused on three key priorities: improving access; ensuring quality; and providing affordability. It is built upon common sense reforms that provide coverage options to our most vulnerable citizens in a flexible and sustainable way that protects taxpayers. It touches all areas of health care to encourage better care coordination for patients, providers, and insurers. Specifically, the Medicaid reforms and the Private Coverage Option encompassed in the Healthy Pennsylvania plan will: 1. Increase health care access for more than 500,000 Pennsylvanians through access to private market health insurance through the Healthy Pennsylvania Private Coverage Option. 2. Promote healthy behaviors, improve health outcomes and increase personal responsibility through cost sharing and encouraging employment. 3.
Ensure that benefits match health care needs.
4. Implement a strategy for aligning the current Medicaid program with the demonstration to create a sustainable Medicaid program. This involves modifying the existing Medicaid benefit designs to be consistent with the private health insurance market to assure long term sustainability of the program. In February 2014, the Department submitted a Healthy Pennsylvania waiver application to the U.S. Department of Health & Human Services. The Department received federal approval August 2014. For more information, please visit the Healthy Pennsylvania website: http://www.dpw.state.pa.us/healthypa/
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6.2 Department of Public Welfare Organization Chart
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6.3 Pennsylvania Application Lifecycle Management (ALM) Introduction Safeguarding citizen’s privacy and information is one of DPW’s core strategic goals. Whether it is the broader purview of the Health Insurance Portability and Accountability Act (HIPAA), the widespread adoption and use of Health Information Technologies (HIT) under the Health Information Technology for Economic and Clinical Health (HITECH) Act, or the implementation of state-level, electronic exchanges for health information under the purview of CMS, DPW continues to enhance its enterprise security capabilities enabling it to make effective, risk-based decisions and improve compliance posture. Solutions being considered by DPW for implementation may need to be able to meet or adhere to the following security requirements: 1) Governance, Risk, and Regulatory Compliance • Address applicable state and federal security regulatory requirements and to ensure traceability of design and test cases against requirements • Provide encryption of sensitive data at rest and in transit to address Federal Information Processing Standards (FIPS) 140-2, National Institute of Standards & Technology (NIST) 800-53 and HIPAA/HITECH Safe Harbor for Breach Notification (HTTPS, SSL/TLS, SFTP, one-way hashes) requirements • Provide a Business Continuity Plan (BCP)/Disaster Recovery (DR) plan for the proposed solution and how it will be integrated with the Commonwealth’s overall BCP/DR Plan and High Availability (HA) /DR architecture • Define a Risk Assessment approach for an internal and an independent 3rd party “external” risk assessments • Provide a security management approach including governance structure, policies and procedures, legal agreements such as: Memorandum of Understanding (MoU); Business Associate Agreement (BAA); Interconnection Security Agreement (ISA) etc.); security awareness training; security documentation (System Security Plan (SSP); Privacy Impact Assessment (PIA); Information Security Research Association (ISRA); and Security Sector Reform (SSR). 2) Access Control, Data Protection, and Audit Logging & Monitoring • Provide an approach to obfuscate production data in lower environments for the purpose of testing • Leverage the enterprise investment on IAM products - IBM Tivoli Identity Manager for employee user provisioning based on the HR job function, CA Identity Manager for business partner/citizens identity management, CA Siteminder for web access management based on the roles, CyberArk for privileged identity management, and Service Oriented Architecture (SOA) Software for web services security. • Provide a solution integration approach with user provisioning solution for roles bases access and user management, CA Siteminder Web access management for authentication and coarse-grained authorization, • Provide an audit logging, and monitoring solution according to the NIST 800-53 AU control family requirements; Describe how the proposed solution will integrate with the Splunk (security information and event management solution to meet NIST 800-53 requirements • Provide Web services security including message level authentication and authorization, encryption, and XML gateway model
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3) Application, Systems and Network Security • Provide a defense in depth approach to cybersecurity. How the network and infrastructure Security will be implemented including network trust zone architecture, Firewalls, IDS/IPS, virtualization security if using virtual servers • Provide a configuration management approach including baseline of application code and system configurations, source code management, hardening of servers and network devices according to CIS, vendor standards, and NIST standards • Provide a vulnerability management approach including secure coding guidelines, secure code review and scanning, application vulnerability testing, DB vulnerability testing, and network/infrastructure scanning • Provide for a monitoring and alerting process for security logs including a process to detect security incidents and report on them
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6.4 Pennsylvania MMIS Takeover Background Information Pennsylvania’s MMIS, PROMISe™ was developed in 2004. The system is currently maintained and operated under a contract with HP Enterprise Services (HP). The scope of work for a takeover vendor and MMIS solution development would include the four major phases as outlined below. 1. Transition Phase - This phase includes the activities required to successfully transfer, configure and install, test, and implement PROMISe™ for the Commonwealth and assume responsibility for the ongoing operations and maintenance. 2. PROMISe™ Operations Phase - This phase consists of those activities that the Contractor must perform to operate the current Pennsylvania MMIS and perform the associated tasks in the various functional areas including: Provider/Provider Preenrollment
Recipient Data
Access ID Card Production
Prior Authorization
Reference
Claims Entry
Claims Resolution
Edits and Audits including NCCI
Family Planning
Claims Pricing
Claims Adjustment
Long Term Care
Waiver
Early Periodic Screening Diagnosis & Treatment (EPSDT)
Pharmacy Point-ofSale/Prospective Drug Utilization Review/ePrescribe
Third Party Liability
Managed Care
Managed Care Encounter
Financial/MAPIR incentive
Claims Operations
Internet & Intranet
Eligibility Verification System
Management and Administrative Reporting
Enterprise Data Warehouse
Retrospective Drug Utilization Review
Drug Rebate
Fraud and Abuse Detections System
Medical Assistance Provider Service Center
Maintenance Activities
Modification Activities
Lock-in
Low Income Home Energy Assistance Program (LIHEAP) processing
3. MMIS Modernization Phase – This phase involves the Design, Development, and Implementation (DDI) activities required to implement a new Pennsylvania MMIS
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4. New MMIS Operations Phase - This phase includes the activities that the Contractor must perform to operate Pennsylvania’s new MMIS. Tasks will be similar to those listed above in 2. PROMISe™ Operations Phase.
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6.5 MITA 3.0 Business Architecture
MITA 3.0 Business Architecture
Business Relationship Management
Care Management
Contractor Management
Eligibility and Enrollment Management
Financial Management
Member Management
Operations Management
Performance Management
Plan Management
Provider Management
Standards Management
Case Management
Contractor Information Management
Member Enrollment
Accounts Receivable Management
Member Information Management
Payment and Reporting
Compliance Management
Plan Administration
Provider Information Management
Authorization Determination
Contractor Support
Provider Enrollment
Accounts Payable Management
Member Support
Claims Adjudication
Health Plan Management
Provider Support
Contract Management
Health Benefits Administration
Fiscal Management
Business Area Business Category
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6.6 CMS 7 Standards & Conditions for MMIS Modernization 1. Modularity Standard - use of a modular, flexible approach to systems development. It separates business rules from core programming to allow states to easily change and maintain systems 2. MITA Condition - requires states to align with national guidelines for technologies, information, and processes. CMS expects states to implement their MITA Roadmaps to align and advance increasingly in MITA maturity for business, architecture and data 3. Industry Standards Condition - requires states to align with and incorporate industry standards around information, business process, technology, and methodologies 4. Leverage Condition - promotes the sharing, leverage, and reuse of Medicaid technologies and systems within and among states 5. Business Results Condition - supports accurate and timely processing of claims, and effective communications with providers, beneficiaries, and the public 6. Reporting Condition - supports the production of on-demand reports, transaction data, and performance information 7. Interoperability Condition - promotes seamless interaction with exchanges, public health agencies, human services programs, and community organizations providing outreach assistance services
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6.7 Medical Assistance Provider Incentive Repository (MAPIR) Medical Assistance Provider Incentive Repository Resources also referred to as MAPIR is a system application that interfaces to the current MMIS, PROMISe™. The application is the state-level information system for the Electronic Health Record (EHR) incentive program. MAPIR will track and act as a repository for information related to payment, applications, attestations, oversight functions, and interface with CMS’s National Level Repository. For more information, please visit the Medical Assistance Provider Incentive Repository website: http://www.dpw.state.pa.us/provider/healthcaremedicalassistance/medicalassistancehealthinformationtechnol ogyinitiative/maprovincentiverepos/
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6.8 Meaningful Use Data Collection Strategy The Medicare and Medicaid Electronic Health Care Record (EHR) Incentive Programs provide incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology. The following diagrams depict the Pennsylvania Meaningful Use Quality Data Collection Strategy. The data exchange of clinical quality measures using the Quality Reporting Document Architecture (QRDA) will occur through the Pennsylvania Patient and Provider Network (P3N) Commonwealth Health Gateway.
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For more information, please visit the Department’s Meaningful Use website: http://www.dpw.state.pa.us/provider/healthcaremedicalassistance/medicalassistancehealthinformationtechnol ogyinitiative/meaningfuluse/index.htm
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6.9 Glossary of Terms and Acronyms The following list key terms and acronyms used throughout this RFI. TERM / ACRONYM AA ACA ALM BA BAA BCP DMS DPW DR CMS COB CDM COTS CQM CRM DDI DOH DUNS DPW eCIS ECM eCQM EDW EHR FIPS FFS GSA HA HCSIS HIO HIPPA HIT HITECH ICM IA ISRA ISA MAPIR MCO MITA MMIS
DESCRIPTION Application Architecture Affordable Care Act Application Lifecycle Management Business Architecture Business Associate Agreement Business Continuity Plan Data Management Strategy Pennsylvania Department of Public Welfare Disaster Recovery Centers for Medicare and Medicaid Services Coordination of Benefits Conceptual Data Model Commercial Off-The-Shelf Clinical Quality Measures Customer Relationship Management Design, Development, and Implementation Department of Health Data Universal Numbering System Department of Public Welfare Electronic Client Information System Enterprise Content Management Electronic Clinical Quality Measure Enterprise Data Warehouse Electronic Health Record Federal Information Processing Standards Fee-for-Service General Services Administration High Availability Home and Community Services Information System Health Information Organization Health Insurance Portability and Accountability Act Health Information Technologies Health Information Technology for Economic and Clinical Health Information Capability Matrix Information Architecture Information Security Research Association Interconnection Security Agreement Medicaid Assistance Provider Incentive Repository Managed Care Organization Medicaid Information Technical Architecture Medicaid Management Information System
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MOU MU NIST LDM OMAP P3N PCO PIA PROMISe™ QRDA RFP SOA SSP SSR TA TCM TMS TPL UI
Memorandum of Understanding Meaningful Use National Institute of Standards & Technology Logical Data Model Office of Medical Assistance Programs Pennsylvania Patient and Provider Network Private Coverage Option Privacy Impact Assessment Provider Reimbursement and Operations Management Information System - The Commonwealth of Pennsylvania Department of Public Welfare claims processing and management information system (MMIS). Quality Reporting Document Architecture Request for Information Service Oriented Architecture System Security Plan Security Sector Reform Technical Architecture Technical Capability Matrix Technical Management Strategy Third Party Liability User Interface
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