owners, addresses, members that use the same cluster of providers. Members that are providers). Must provide a subject matter expert, who understands the algorithms used to extract data, to IV.N.5 Operations Phase - testify and support an Business Architecture administrative State or Federal Overview - Program Integrity action, and the appeals process. Must provide predictive modeling (leveraging historical information to project outcomes) and early warning capabilities and analytics for detecting fraud, waste, abuse IV.N.5 Operations Phase - and erroneous payments in Business Architecture paid claims and managed Overview - Program Integrity care entity encounter data. Must include application training modules including self-paced computer-based modules, IV.N.5 Operations Phase - training, application tutorials, Business Architecture and searchable help features for Overview - Program Integrity authorized users. Must implement, maintain and operate a configurable IV.N.5 Operations Phase - surveillance, utilization, and review Business Architecture subsystem according to Overview - Program Integrity Department business rules. Must implement, maintain, and IV.N.5 Operations Phase - operate a configurable program Business Architecture integrity solution which meets all Overview - Program Integrity requirements for CMS certification. Must profile provider groups, IV.N.5 Operations Phase - independent/solo providers, and Business Architecture individual providers within group Overview - Program Integrity Must perform analysis of rendering, attending, admitting, supervising, IV.N.5 Operations Phase - ordering and prescribing provider's Business Architecture billing practices to generate reports Overview - Program Integrity of aberrant utilization patterns.
owners, addresses, members that use the same cluster of providers. Members that are providers). IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must provide a subject matter expert, who understands the algorithms used to extract data, to testify and support an administrative State or Federal action, and the appeals process. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must provide predictive modeling (leveraging historical information to project outcomes) and early warning capabilities and analytics for detecting fraud, waste, abuse and erroneous payments in paid claims and managed care entity encounter data. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must include application training modules including self-paced computer-based modules, training, application tutorials, and searchable help features for authorized users. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must implement, maintain and operate a configurable surveillance, utilization, and review subsystem according to Department business rules. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must implement, maintain, and operate a configurable program integrity solution which meets all requirements for CMS certification. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must profile provider groups, independent/solo providers, and individual providers within group IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must perform analysis of rendering, attending, admitting, supervising, ordering and prescribing provider's billing practices to generate reports of aberrant utilization patterns.
Revised%20Attachment%20B%20-%20Business%20and%20Technical%20Requirements%20Matrix.docx