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 Program Integrity State’s 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 - Business Architecture Overview - Case Must initiate cases from a Management - Case referral form and must Identification and Creation support manual initiation of cases. IV.N.6.b Operations Phase - Business Architecture Must receive, record and funnel all Overview - Case initial cases into a queue for Management - Case assessment, assignment and Identification and Creation investigation. IV.N.6.b Operations Phase - Must assign to caseload “weights” Business Architecture cases (e.g., characteristics of Overview - Case claim, claim edits, claim Management - Case submission type, prior Identification and Creation authorization, and client).
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 Management - Case Identification and Creation Must initiate cases from a referral form and must support manual initiation of cases. IV.N.6.b Operations Phase - Business Architecture Overview - Case Management - Case Identification and Creation Must receive, record and funnel all initial cases into a queue for assessment, assignment and investigation. IV.N.6.b Operations Phase - Business Architecture Overview - Case Management - Case Identification and Creation Must assign caseload “weights” to cases (e.g., characteristics of claim, claim edits, claim submission type, prior authorization, and client).
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