Electronic Visit Verification Solution

The Vendor is required to provide to implement, manage, and operate an Open/Hybrid Model Electronic Visit Verification (EVV) solution.
- Provide to transform its legacy Medicaid Management Information System (MMIS) into a modern, modular Medicaid Enterprise System (MES) that is highly scalable, adaptable, and capable of driving improvements in the efficiency and effectiveness of program operations and the experience of Medicaid members and providers.
- Solution they provide will offer a comprehensive suite of services that are essential for the efficient functioning of the Agency as part of a transformed, modular information system.
- These systems primarily interface through the exchange of data files, using Secure File Transfer Protocol (SFTP).
- Provide includes Claims and Encounters processing, Financial Management, Provider Services, Pharmacy Drug Management (PDM), Third Party Liability (TPL), Surveillance and Utilization Review Subsystem (SURS), and other systems operated by different Vendors (i.e. Electronic Visit Verification (EVV)).
- The operation, maintenance, and point-to-point interfaces of these legacy systems have become more complex and more costly as requirements change and the number of systems and applications increase.
- Objectives:
• Deliver processing accuracy for visit scheduling, verification, and billing activities
• Support current and predicted volumes of data exchange and visit records to ensure scalability and reliability
• Enable efficient module and external system integration, including the Aggregator, Alternate EVV systems, and state agencies
• Simplify configuration, policy, process, maintenance, and testing to ensure ease of use and adaptability
• Support services versioning, reuse, and rapid deployment to accommodate evolving requirements and technologies
- Implement an EVV solution with the following required functionalities:
• Manage Communication to facilitate effective communication between provider agencies and the EVV system for scheduling and verification purposes
• Facilitate Visit Scheduling and Recording to ensure all visits are accurately documented and verified in real-time
• Implement Visit Verification Methods to authenticate and record visits using GPS, biometrics, and/or other technologies
• Support Data Exchange and Interfaces for seamless interaction between providers, payers, Alternate EVV systems, and state agencies
• Ensure Compliance and Reporting to meet state and federal regulations and provide detailed reports for auditing purposes
- The Core Module manages healthcare claims and encounters, member management, financial operations, prescription drug services, and operational support functions like call centers and communications. The planning and procurement phase for the Core module started in 2024.
- The operations and maintenance stage encompasses business and systems operation and maintenance from the operational start date through the end of closeout and includes CMS certification, operations stabilization, enhancements, and transition responsibilities.
- Solution include:
• Solution shall include an aggregator component to collect, validate and store data from Provider Agencies that elect to use the alternate EVV systems in lieu of the agency-provided EVV system.
• Solution aggregator component shall uniquely identify each approved alternate EVV system data source.
• Solution aggregator component shall accept, process, and transmit data between EVV system and alternate EVV systems in near real time.
• Solution aggregator component shall process data collected, including, but not limited to verifying visits against service authorizations as defined by the Agency.
• Solution shall validate all EVV data is present before including visits in the claim (visit) file. Valid Claim (visit) shall be defined as including information required by CMS EVV Certification Outcome.
• Solution aggregator component shall submit claims (visit) files to the Agency Claims adjudication system.
• Solution aggregator component shall capture data that supports or informs a claim (visit) submission issue (e.g. Rejection) related to visit verification.
• Solution aggregator component shall accept inquiries from the claims system based on data elements required by CMS or the Agency.
• Solution aggregator component shall collect the following information across programs, Provider Agencies, and Members:
o Total daily and weekly hours; and
o Total daily and weekly units."
• Solution aggregator component shall communicate with an Agency specified case management system(s) or care management system, and shall be able to communicate/interact with the Agency's System Integrator (SI)
• Solution aggregator component shall provide a visit data feed to the MCOS that contains visit data from their contracted Provider Agencies that use the Vendor's EVV System.
• Solution shall ensure that data from different Provider Agencies is uniquely identifiable to enable data segregation where required.
• Solution aggregator component shall keep data for each Provider Agency logically separate when a Caregiver is using their mobile app for the Vendor EVV system to provide services for multiple Provider Agencies.
• Solution shall implement data validation rules as defined by the Agency, to detect discrepancies and ensure the accuracy and completeness of the data received from all EVV systems before sending to the Aggregator component.
• Solution shall evaluate claim (visit) information against program rules and state requirements before sending it to the EVV Aggregator.
• EVV system shall include mechanisms to detect and flag discrepancies in the data entered as part of visit verification.