DATE - New Mexico Department of Information Technology

clutteredreverandData Management

Oct 31, 2013 (3 years and 11 months ago)

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Implementation


Request for Certification and Release of Funds Form



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This is a controlled document, refer to the document control index for the

latest revision

Revision:
9
/
1/10


Page
1



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The Medicaid Management Information

System (MMIS) for New Mexico, “
OmniCaid
”, is operated,
maintained and enhanced by a Medicaid state fiscal agent who is selected by competitive
procurement
.
The state fiscal agent hosts and operates the HSD
-
owned
OmniCaid

Medicaid payment application,
organizes payment functions and operations for Medicaid payments to health care provide
r
s, and
delivers reports on the health care activities of contracted health care services.


The federal
Department of Health and Human Ser
vices,
Centers for Medicare
&

Medicaid Services
(CMS) require HSD to periodically re
-
open the Medicaid state fiscal agent contract to competition

for
the MMIS hosting, operation and administration services
. CMS has also mandated significant changes
to the

MMIS including HIPAA2 compliance and ICD
-
10 remediation. In this project, HSD combines
the satisfaction of these federal mandates with top
-
priority MMIS enhancements that improve customer
service, and increase program effectiveness.


The MMIS Re
-
Bid
of F
iscal Agent Services

re
-
procures
and implements
all existing services from the
Medicaid state fiscal agent and modifies several subsystems.
This contract has been tentatively
awarded with a transition to the new terms a
nd conditions beginning Mar 2012
,
an
d that transition
phase
completing by
Dec 2012
.



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HSD MMIS Re
-
Bid
of Fiscal Agent Services

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February
22
, 201
2

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Human Services Department

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Department of Health

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Julie Weinberg, Director

HSD Medical Assistance Division

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Sidonie Squier, Cabinet Secretary

Human Services Department

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Sean Pearson,
Chief Information Officer

HSD Information Technology Division

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Mark Pitcock,
Deputy Director

HSD Medical Assistance Division


Wayne Pendley, IT Project Manager


HSD Information Technology Division







Implementation


Request for Certification and Release of Funds Form



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This is a controlled document, refer to the document control index for the

latest revision

Revision:
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/
1/10


Page
2

Operations under the new contract are expected to span
Jan 2013

through
Dec

2016 with potential
renewals through
Dec

2019.



CMS has approved federal funding to support the following project phases:




Procurement Phase


Federal support for costs of the NM staff who conduct the procurement.



Transition Phase



Support for the transition of MMIS to the new system enhancements; and for
the transition of operation from the current, incumbent contractor to a

new state fiscal agent if
a
new contractor

is selected.



Enhancement Phase



Support for costs to remedy current system issues; improve functionality;
and prepare for potential changes required by healthcare reform legislation.



Operations Phase



Federal
support for Medicaid operational and direct services over the next
seven years.


While CMS has approved initial funding estimates for all four phases of this project,
the
final budget
amounts have not been
released

because
this
contract has not
fully
executed and

the vendor tentatively
awarded this
RFP

contract has not been announced.

HSD
expects some level of CMS approval of the
project budget with agreed federal

matching rates not later than 2/29/2012
.


U
pon PCC approval of

th
is

request

to proceed to
the
Implementation Phase
,

planning and design work on
the negotiated software enhancements can begin immediately when the contract is executed
in early

201
2
.

This concurrent processing would enable

the IV&V work, architecture design, enhanc
ement design and
development
to

begin

much earlier, and speed New Mexico’s full compliance with all HIPAA standards.


HSD will request
TARC
certification
of

this project

and the
balance of Implementation Phase funding at the
PCC review in
the second half
of

2012.


Start Date

4/01
/2012

Planned End Date

3/31
/201
4

Amount
Requested this Certification

$

1.3
M

Amount Previously Certified

$

1.5M

Remaining Appropriation not Certified

$

Tentative Pending Contract
Execution
& Federal Funding Approval

Total Appropriated Amount

$

2.
8
M











Implementation


Request for Certification and Release of Funds Form



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This is a controlled document, refer to the document control index for the

latest revision

Revision:
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/
1/10


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Date

Amount

Funding Source(s)

(use specific citations to laws, grants, etc.)

4/28/2010

$0

Initiation Phase:


No federal funds were required for the Initiation
Phase. Staffing and operations by NM state employees were funded
by the
General Appropriation Act of 2010, Second Special Session,
Chapter 6, Section 4, Subsection F, HUMAN SERVICES
DEPARTMENT, Paragraph
(1).

8/18/2011

$1.5M

Planning Phase:


IV&V services on
this project were approved
pending

CMS approval
. F
unding sources
will
include 90% federal
CMS grant and 10% state funds approved by the General
Appropriation Act of 2011; Laws 2011, Chapter 179, Section 4,
Subsection F, HUMAN SERVICES DEPARTMENT, Paragraph (1).

2/22/2012

$
1.3
M

Implementation Phase:


Estimated costs for
design and
development
work through TARC approval
and transition to the
terms and conditions of the new Fiscal Agent contract
. Funding
sources include 90% federal CMS grant for enhancements and
10% state funds approved by the General Appropriation Act of
2
011; Laws 2011, Chapter 179, Section 4, Subsection F,
HUMAN SERVICES DEPARTMENT, Paragraph (1); and 75%
federal CMS grant for transition activities and 25% state funds
approved by the General Appropriation Act of 2011; Laws 2011,
Chapter 179, Section 4, Su
bsection F, HUMAN SERVICES
DEPARTMENT, Paragraph (1).



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,




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.




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Fiscal Year

Amount

Funding Source and Appropriation language

SFY 12

SFY13

$
2.8M

All
deliverables from this project
,

including
IV&V services
,

are
funded with a combination of federal

and state funding. The
federal grant funds are provided by the Department of Health and
Human Services,
Centers for Medicare & Medicaid Services

and
vary
fro
m 50% to 90%

of
the total cost for
each project
deliverable.


The state’s portion of the funding is

approved by the General
Appropriation Act of 2011; Laws 2011, Chapter 179, Section 4,
Subsection F, HUMAN SERVICES DEPARTMENT, Paragraph (1).









Implementation


Request for Certification and Release of Funds Form



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This is a controlled document, refer to the document control index for the

latest revision

Revision:
9
/
1/10


Page
4


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Major Project Deliverable and Performance
Measure

Budget


Due Date

Project Phase

Request for Proposal (metric=Timely release)

$0

Jan 28, 2011

Planning

Request for Information for IV&V on MMIS Fiscal
Agent
Re
-
Bid (metric=Approval by CMS, DOIT
and DFA; provision for maximum available federal
match)

$1.5 M

Mar 02
, 2012

Implementation

Executed Contract for MMIS Fiscal Agent Re
-
Bid
(metric=Approval by CMS, DOIT and DFA;
provision for maximum available federal m
atch)

Pending Contract
Execution &
Federal Funding
Approval

Mar
30, 2012

Implementation

Executed Contract for IV&V on MMIS Fiscal
Agent Re
-
Bid (metric=Approval by CMS, DOIT
and DFA; provision for maximum available federal
match)

Pending Contract
Execution

&
Federal Funding
Approval

May 15
, 2012

Implementation

OmniCaid
Technical Architecture Approved by
TARC

(metric=Timely completion with minimal
transition issues)

Pending Contract
Execution &
Federal Funding
Approval

Jul 18
, 2012

Implementation

Transition
to New Contract’s Terms & Conditions

(metric=Timely Transition or implementation with
minimal transition issues)

Pending Contract
Execution &
Federal Funding
Approval

Dec
31, 2012

Implementation










Implementation


Request for Certification and Release of Funds Form



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latest revision

Revision:
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Description

FY
12

FY13


FY14 &
After

Staff
-

Internal

Most

costs will be covered by
CMS matching funds.

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval

Consulting
Services

FY12 Costs include 24
months of IV&V services;
Fiscal Agent services
document
ing

the technical
architecture for TARC
review
; and t
ransition work to
transfer Fiscal Agent services
to terms and conditions of the
new contract
.

$
2.8

M

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval

Hardware

Mainframe HW is owned by
the contractor

and located at
their data center. L
ocal HW
requirements and ownership
provisions will be
announced
at contract
execution.

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval


Software

OmniCaid

code is owned by
HSD; other SW
requirements
will be announced
at contract
execution.

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval

T
T
O
O
T
T
A
A
L
L


$
2
.
8

M

Pending Contract
Execution &
Federal Funding
Approval

Pending Contract
Execution &
Federal Funding
Approval










Implementation


Request for Certification and Release of Funds Form



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This is a controlled document, refer to the document control index for the

latest revision

Revision:
9
/
1/10


Page
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T
T
U
U
R
R
E
E
)
)


The core of the
current
Medicaid Management Information System (MMIS) is the
OmniCaid

payment
application. Currently, the application is hosted in a facility managed by the current state fiscal agent,
ACS Healthcare. Other HSD systems (TIE, ISD2, etc.) interface through the Depar
tment of
Information Technology data center.


OmniCaid

utilizes a three
-
tiered, client
-
server architecture:



Client workstations currently run Windows XP or Vista with the
OmniCaid

application’s
PowerBuilder client presentation layer. The presentation laye
r contains front
-
end edit
logic.



The middle tier uses Sybase Enterprise Application Server as a middleware application
engine. This middleware layer provides access to CICS applications and DB2 on the
back
-
end. It also provides load balancing and fail ov
er capability.



The back
-
end processor is a mainframe IBM CICS and DB2 relational database
management system. CICS connectivity is provided via MQSeries. Connectivity to DB2 is
provided to the middle tier and to the client workstations using IBM DB2 Conne
ct. The
mainframe processes all data requests from the middle tier and client workstations,
operates the claim engine, runs all batch processes and delivers a wide range of reports.


This project
has produced

a service contract
that enables

HSD to continu
e to outsource all Medicaid
state fiscal agent activities. All IT related services
are

included in this Medicaid state fiscal agent
contract. Upon contract
execution
, HSD will submit the new technical architecture to the TARC for
review and approval.










Implementation


Request for Certification and Release of Funds Form



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latest revision

Revision:
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1/10


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)



HSD intends to procure IV&V services for this project
during March 2012
in a manner
consistent with
state and CMS requirements. This includes requesting 90/10 federal funding through an
Implementation Advance Planning Document

(IAPD)
. The major deliverables of the MMIS
transition/enhancement effort
were defined during the
MMIS contract ne
gotiations

completed in
December 2011
.

Those deliverables

will be used to
scope the IAPD for

IV&V
work, the
federal
matching funds
be
secured, and an IV&V vendor
will be
engaged
at the earliest opportunity to
maximize benefit to this project
.

HSD expects
to use the state’s Request for Information process to
solicit competition among vendo牳

who have signi晩cant expe物ence with MM䥓 䥖&s and who have
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Y
Y


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/
/
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O
O
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W


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H
I
I
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S


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X
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I
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/
A
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)
)


The MMIS incorporates the
OmniCaid

claims processing component, a Pharmacy Benefits
Management

System for drug claim processing, a data warehouse, and other peri
pheral systems that
interface with
OmniCaid
. Any replacement components implemented as part of this project must
continue to interface with the core
OmniCaid

component.


OmniCaid

interfaces with the ISD2 system hosted at the NM DoIT Data Center to obtain client
eligibility data.
OmniCaid

also receives eligibility data from DOH (Children
’s Medical Services) and
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Implementation


Request for Certification and Release of Funds Form



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E
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O
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D
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E
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Revision:
9
/
1/10


Page
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1
1
:
:


Interruption of claims processing due to delayed transition or serious start
-
up issues if there is a
period between vendors (the procurement is organized to enable HSD to work with two vendors for a
one year transition period).


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O
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1
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A
:
:


Project schedule provides for a Transition Phase that can extend up to 12
months to assure adequate time to complete all tasks.

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I
I
O
O
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N


1
1
B
B
:
:


None of the system enhancements is required to be implemented before the start
of operations, redu
cing the scope of work during the Transition Phase.


R
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S
S
K
K


2
2
:
:




Failure to meet the October 1, 2013 compliance date for ICD
-
10 diagnosis and procedure
codes if the pro
curement is delayed and the contractor does not have enough time to complete its tasks.


M
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I
T
T
I
I
G
G
A
A
T
T
I
I
O
O
N
N


2
2
A
A
:
:


An ICD
-
10 assessment was completed through another project in 2009. A
number of key business decisions were finalized by HSD and several system changes are being
made early, in conjunction with the HIPAA 2 (5010) project, including all field
-
length changes
and table conversions. This has given HSD a significant head start on the 2013 deadline.

M
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I
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G
G
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A
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T
I
I
O
O
N
N


2
2
B
B
:
:


Project schedule gives the awarded contractor up to
19

months after the start of
the contract to remediate the MMIS for ICD
-
10 complianc
e.



R
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I
S
S
K
K


3
3
:
:


Project ASPEN (ISD2R) plans a series of four implementation waves spanning July 2013
through
January 2014
.

Some of the design changes made during these waves may require design
changes in
OmniCaid
, but the probability and scope is currently
unknown.


M
M
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I
T
T
I
I
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G
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A
T
T
I
I
O
O
N
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4
4
A
A
:
:


The MMIS project is communicating weekly with the ASPEN team, and
exposing design changes that may have ASPEN impact to the HSD Change Control Board.

M
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I
O
O
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N


4
4
B
B
:
:


HSD will initiate a new project with APD funding to deploy, admin
ister and
maintain a staging server for ASPEN testing of
OmniCaid

where the new ASPEN code can be
tested for
OmniCaid

errors on a live image without impacting current operations.











Implementation


Request for Certification and Release of Funds Form



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D
E
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Revision:
9
/
1/10


Page
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:
:


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C
T
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I
O
O
N
N
.
.




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U
U
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E
E


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G
E
E
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N
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C
Y
Y


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S


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U
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D


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D


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N


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I
S
S


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Y
Y
M
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N
T
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.
.


)
)


The
tentative
contract
defines
several project management sub
-
deliverables to ensure that Transition
Phase and Enhancement Phase activities are completed in a timely manner and that the systems as
deployed meet HSD requirements. The contractor
is

required to operate and maintain the sy
stems after
implementation. CMS funds MMIS
enhancements at a 90% match rate and
other

operations at

either
75%
or 50%
. The State share of
these costs

will be included in the budgets for FY 2013 and beyond.


The following table describes the software enhancements the state has negotiated into the final costs of
the tentative contract, expected to execute
with
in
the next
45

days
.


Enhancement

Description

New Web Portal

Replace the
current

Web portal with a new portal that meets the RFP’s
enhancement requirements (client eligibility span dates, client
-
facing
capabilities, web
-
based provider enrollment, and direct data entry of claims)

New Fraud and Abuse
Detection System (FADS)

Replace the

current

FADS with a new system with enhanced case management
and tracking capability

New Pharmacy Benefits
Management System (PBMS)

Replace the current PBMS with a
new system platform

for ease of
maintenance and reduced ongoing costs

Add Workflow Component to
the Electronic Document
Management System

The Workflow component will automate many document handling processes,
improve the timeliness and quality of services, and provide enhanced tracking
and reporting for fiscal agent activit
ies

HIPAA 276/277

Implement claim status inquiry and response transactions to comply with
HIPAA standards

HIPAA 270/271

Implement eligibility verification inquiry and response transactions to comply
with HIPAA standards

HIPAA 820

Implement premium
payment transactions for Managed Care Organizations to
comply with HIPAA standards

HIPAA 834

Implement benefit enrollment and maintenance transactions for Managed Care
Organizations to comply with HIPAA standards

ICD
-
10 Remediation

Meet national deadline

to convert to new ICD
-
10 diagnosis and surgical
procedure codes from the current ICD
-
9 standard. This deadline is October 1,
2013.

Electronic Billing of Other
Carriers

Replace current paper billing of other insurance carriers with electronic billing
when

it is discovered that a client has other insurance coverage

NCPDP 3.0

Implement the new National Council of Prescription Drug Programs (NCPDP)
subrogation transaction to bill other insurers for drug claims when it is
discovered that a client has other
insurance coverage