Innovative AI Tools

The Vendor is required to provide AI tools, machine learning (ML), technologies, and services, as well as an organization’s general analytic, audit and recovery capabilities applicable to a program integrity program.
- Artificial intelligence
1. Identify specific AI capabilities
•    Indicate whether the approach is rules-based, machine learning-driven, deep learning-based, or a hybrid model.
•    The AI/ML techniques used (e.g., predictive modeling, anomaly detection, generative AI).
•    Describe the data sources used to power each capability
2. Clarify deployment status
•    Indicate whether each capability is currently in production, in pilot, or on your product roadmap.
•    Provide brief examples of operational use cases.
- Managed care program integrity
•    Organization’s capabilities to detect potential FWA among subcontracted or downstream provider networks
•    Organization’s experience performing analytics of managed care entity (MCE) encounters to identify potential overpayments and trends.
•    Organization’s experience performing medical record reviews and audits of managed care plans’ providers.
•    Organization’s experience performing analyses of provider utilization across FFS claims and MCE encounter data.
•    Solution summarizes or extracts key elements from medical records and clinical documentation.
•    ML/AI interprets program rules, policies or contractual requirements to identify potential non-compliance.
•    Solution supports validation of large encounter data sets to identify inaccuracies, inconsistencies, or missing information.
•    ML/AI tools’ capabilities to reconcile encounter data against other data sources.
•    ML/AI enhances efficiency and supports auditor decision-making. 
•    Clarify whether your solution functions solely as a technology platform or if it also includes a full audit delivery model 
•    Identify which components are automated and which require human intervention.
•    Sensitive data is handled, stored and protected within AI and ML workflows. 
•    Include the safeguards in place to ensure privacy, security and compliance with HIPPA and other relevant standards.
- Claims review, documentation and medical necessity
•    Organization’s experience with documentation reviews or medical necessity validation for Medicaid claims.
•    List the resources (example: subject matter expert) your organization has that would assist agency program integrity efforts with programs such as physical health and behavioral health.
•    Organization’s AI tool can be used to automate medical and administrative record reviews.
•    State whether your AI tool requires human intervention. 
•    Including at what step the human intervention occurs and the frequency and scope of the human intervention.
•    AI tool need to render a decision on if a claim coded correctly once it has reviewed the supporting documentation.