profiles and reports based on configurable rules. IV.N.5 Operations Phase - Must recommend members for Business Architecture referral to restricted access Overview - Program Integrity programs. Must perform of” “absence scenario analysis (examples include inpatient hospitalizations or IV.N.5 Operations Phase - prescriptions with no physician Business Architecture durable medical equipment Overview - Program Integrity with no relevant diagnosis). Must provide statistical models to support simple random sampling and extrapolation that complies with generally accepted statistical audit and governmental accounting IV.N.5 Operations Phase - standards. (Nebraska Medicaid Business Architecture currently uses RAT- STATS Overview - Program Integrity Statistical Software) Must suggest additional projects and ideas for Program Integrity IV.N.5 Operations Phase - efforts to prevent or identify fraud, Business Architecture waste, abuse, or erroneous Overview - Program Integrity payments. Must provide a real time, State of the art, configurable case management tool to identify, create, document, and manage IV.N.6.a Operations Phase - fraud, waste, abuse, and Business Architecture erroneous payments in connection Overview - Case with the State’s Program Integrity Management - General process. Must provide a solution that is IV.N.6.a Operations Phase - configurable and capable of Business Architecture supporting multiple business Overview - Case processes in addition to Program Management - General Integrity. IV.N.6.b Operations Phase - Must initiate cases from a Business Architecture referral form and must Overview - Case support manual initiation of cases.
profiles and reports based on configurable rules. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must recommend members for referral to restricted access programs. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must perform “absence of” scenario analysis (examples include inpatient hospitalizations or prescriptions with no physician durable medical equipment with no relevant diagnosis). IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must provide statistical models to support simple random sampling and extrapolation that complies with generally accepted statistical audit and governmental accounting standards. (Nebraska Medicaid currently uses RAT- STATS Statistical Software) IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must suggest additional projects and ideas for Program Integrity efforts to prevent or identify fraud, waste, abuse, or erroneous payments. IV.N.6.a Operations Phase - Business Architecture Overview - Case Management - General Must provide a real time, State of the art, configurable case management tool to identify, create, document, and manage fraud, waste, abuse, and erroneous payments in connection with the State’s Program Integrity process. IV.N.6.a Operations Phase - Business Architecture Overview - Case Management - General Must provide a solution that is configurable and capable of supporting multiple business processes in addition to Program Integrity. IV.N.6.b Operations Phase - Business Architecture Overview - Case Must initiate cases from a referral form and must support manual initiation of cases.
Revised%20Attachment%20B%20-%20Business%20and%20Technical%20Requirements%20Matrix.docx