Data Management and Credentialing Verification Organization Solution

The vendor is required to provide data management and credentialing verification (PDM and CVO) department seeks to establish a centralized platform to receive applications from providers, perform primary source verification of enrollment and credentialing information, maintain provider data, manage provider communications, manage data exchanges with multiple payers and plans, and integrate into the system.
- The system to be designed and built may begin with an existing vendor solution, but will be customized, modified, configured, and enhanced to operate for department independently from any other implementation.
- PDM and CVO a vendor will:
•    Staff an agile design and development effort to provide and build information technology systems,
•    Provide hardware and software,
•    Build all required interfaces (approximately 25) and integrations (approximately 32 integration partners).
•    The interfaces will be a mix of batch and application programing interface (API) exchanges,
•    Meet state security requirements,
•    Thoroughly test all aspects of the system and operations, including end-to-end (e2e) testing,
•    Train vendor operations, state staff, and providers,
•    Establish a credentialing committee in cooperation with the state and managed care partners,
•    Handle all hearings and appeals that come from denials and terminations,
•    Allow for delegated enrollment and credentialing and monitor these processes,
•    Operate all aspects of PDM and CVO for a period of several years,
•    Integrate with the Medicaid integration system (mis) for data exchanges to communicate provider information to and from approximately 32 integration partners and system component modules,
•    Enroll and credential new providers,
•    Re-credential all providers on a five-year cycle,
•    Provide standardized reports as well as customizable ad hoc reporting,
•    Meet all requirements of the national committee for quality assurance (NCQA),
•    Provide portals for the enrollment process, for data maintenance, and for state and vendor operations,
•    Achieve federal CMS certification to maximize federal financial participation (FFP) under Medicaid,
•    Integrate with the mis for single sign_ on access across the system solutions,
•    convert provider data history and migrate related documents.
- The solution benefits will include:
•    Support for all provider data management functions including data intake, data verification, enrollment, data sharing, and data archiving;
•    Self-service and administrator-based updates;
•    Ongoing data validation;
•    Provider enrollment and credentialing;
•    Temporal location data;
•    Temporal credentialing data;
•    Event-based push and outreach capabilities for events (such as upcoming re-credentialing);
•    Configurable workflow and other functions;
•    Delegation of credentialing on behalf of a healthcare practice or organization;
•    Verification of qualifications of a provider to administer care or services;
•    Flexible access to data and metrics for analytic reporting;
•    Access to full application and credentialing history for a provider;
- The PDM and CVO solution will:
•    Provide enrollment, credentialing, and data management services for multi-payers, including state Medicaid, mental health, public health, and the office of rural health. 
•    Serve as the “single source of truth” for provider data in the system solution. 
•    Simplify the enrollment and recredentialing of providers, by facilitating access to essential services via the secure provider portal, and by streamlining the current process for capturing enrollment and recredentialing application data. 
•    Provide real-time reporting and ad hoc, on demand report capabilities, which includes in flight application reporting. 
•    Automate aspects of the work of the agency’s fraud, waste, and abuse investigations. 
•    Make available a provider directory service, which will allow other Medicaid enterprise system (MES) modules to make data available for currently enrolled providers where needed. 
•    Provide member enrollment functionality that allows the enrollee to query and select providers. 
•    Provide a secure provider portal that allows providers to:
o    Submit simplified enrollment applications.
o    Submit all other types of enrollment applications and change requests.
o    Submit simplified revalidation applications.
o    Send and receive communications.
•    Provide operational support that includes a call center and training management.