Injury - Claims

Injury - Claims Number 1 Subject Matter Area Type (Business or Technical) New /Initiating Claim Business Requirement Glossary Link 2 New /Initiating Claim Business System notification through an automatic workflow event that a new claim has been received in the system through predetermined staff assignment rules. Describe how the system will send notification through an automatic workflow event that a new claim has been received in the system through predetermined staff assignment rules. Adjusters should have viewable access to any documentation that has been received or sent with regard to a claim based on WSI business rules. Describe how the system will provide adjusters viewable access to any documentation that has been received or sent with regard to a claim. Ability to track and modify information with respect to a claim. Ability to track and modify specific information with respect to a claim such as claim status (active, denied, pending, reopen), type of injury (wage loss or medical only), nature of injury, date of injury, time of injury, cause of injury, body part, location of injury, description of injury, ICD-9, etc... This information should be readily accessible to the adjuster when managing a claim and customizable for additional categories to be added. A viewable history of this information should be available where appropriate. Ability to enter 3-point contact triage information and have the system prompt adjusters with dynamically (interactive decision tree) appropriate questionnaires based on body part and injury type. Upon completion of the questionnaire response entries, the system assigns a triage risk score on the claim according to WSI business rules. 3 General Claim Management Business 4 General Claim Management General Claim Management General Claim Management General Claim Management Business 3 point contact 5 Business 6 7 Business Business Triage risk score Ability to consolidate two matching and or duplicate claims (to include data Consolidate and imaged information). Ability to record and modify all parties with a relationship to a claim, and the ability to track their role (primary, treating, consultant), effective date, and view their legal entity. 1 of 57 Injury - Claims 8 General Claim Management Business 9 10 General Claim Management General Claim Management Business Business Ability to create, in whole or part, a claim file copy from the system through a single interface that allows the user to select claim documentation and/or data items from a list which incorporates WSI business rules and security roles. Ability to create/update multiple locations tied to one employer account. Ability to view, update and keep history of Designated Medical Provider (DMP), adjuster assignment, and employer contact information on the employer's legal entity for each employer location, based on WSI business Designated Medical Provider rules. Ability to assign a claim to one or more employers and to allocate a certain % of costs according to WSI business rules. Ability to update and track all information related to child support withholding specific to a claim and/or legal entity. Ability to set up a new claim on a closed, cancelled, uninsured, and open policy. Ability to view a claim or search for a claim by entering predefined parameters. Parameters such as: policy number, Social Security Number, injury date, etc. Ability to view policyholder's information by entering predefined parameters. Parameters such as: employer name, policy number, etc. System should display the current claim number, claimant name, and date of injury in the window/page title bar or some obvious location to indicate what claim is currently being worked on. The ability to auto adjudicate and then auto pay claims according to WSI business rules. Auto adjudicate Ability to select a benefit type according to WSI business rules (e.g. Temporary Total Disability, Permanent Total Disability, etc.). Ability to create an injured worker's average weekly wage (AWW) based on their wage information (pre-injury, post-injury, and earnings capacity wages) and WSI business rules. Ability to automatically calculate a Weekly Compensation Rate (WCR) based on WSI business rules. Describe the system's ability to automatically calculate a Weekly Compensation Rate (WCR) using WSI business rules. 11 12 13 14 General Claim Management General Claim Management General Claim Management General Claim Management General Claim Management General Claim Management Auto adjudicate Business Business Business Business 15 Business 16 Business 17 Business 18 19 Indemnity Payments Indemnity Payments Business Business AWW 20 Indemnity Payments Business WCR 2 of 57 Injury - Claims 21 22 23 24 25 26 Indemnity Payments Indemnity Payments Indemnity Payments Indemnity Payments Indemnity Payments Indemnity Payments Business Business Business Business Business Business 27 28 29 Indemnity Payments Indemnity Payments Indemnity Payments Business Business Business Ability to manually override a WCR. Automatically calculate appropriate payment amount, based WSI business rules. Ability to specify one or more payees, effective dates, and distribution amount(s) for indemnity payments. Ability to indicate loss of earnings (LOE) and recurrent loss of earning (RLOE) dates. Ability to schedule payments for one or more payment periods. Ability to enter and apply offsets according to WSI business rules (e.g. nursing homes, social security, overpayments, aggravations, suspended benefits ). Ability to recalculate one or more payments in a single interaction and see a history of those changes. Ability to view a summary of all payments related to a claim and/or legal entity and ability to sort by payment parameters. Ability to create and issue lump sum payments such as settlements and Permanent Partial Impairment (PPI), according to WSI business rules. Idemnity payments LOE Offsets 30 31 32 33 Indemnity Payments Indemnity Payments Indemnity Payments Indemnity Payments Business Business Business Business 34 35 Indemnity Payment Business Indemnity Payments/ Business Medical Payments Medical Payments Business Ability to produce a compensation remittance/indemnity payment summary. Provide a rate calculator tool to assist an adjuster in establishing payment Rate Calculator amounts. Ability to automate a schedule or series of schedules of indemnity payments to an injured worker according to WSI business rules. System should be able to issue and track Indemnity Payments automatically and manually as needed. Describe the system's ability to issue and track Indemnity Payments automatically and manually as needed. Ability to generate a discontinuation notice letter linked to the indemnity payment. System should disburse indemnity and medical payments on a daily basis. 36 System should have the ability to sort and filter medical bills by entering search criteria such as date range, bill number, type of service performed/expense code, etc. 3 of 57 Injury - Claims 37 Medical Payments Business Ability to attach narrative text to a specific medical bill. This narrative link should tie in directly to the overall notepadding function on the claim. System should have the capability of automatically attaching the image of the bill to the medical bill record in the system such as CMS1500 and UB92. Ability to transfer bill data and supporting documentation between claims. Ability to update a bill regardless of status based on WSI business rules. Ability to request a medical note from the provider off of a medical bill for a particular date of service through automatic form generation. System should allow for automatic application of travel reimbursement rates according to WSI business rules. Ability to establish and update reserves according to WSI business rules. Reserves Ability to integrate with third party software for reserve predictions. Describe the system's ability to integrate with third party software for reserve predictions. Ability to view indemnity, allocated loss adjustment expense (ALAE) and medical reserve history. Ability to track suspended benefits. Describe how your system handles suspended benefits and how it impacts reserves, such as third party recovery, subrogation and reinsurance. System should have the ability to record and track overpayment activity specific to a claim and/or legal entity. Ability to enter, modify, and track WSI ordered evaluations and services. Such as Independent Medical Evaluations (IME), Functional Capacity Assessments, Chronic Pain Evaluations, etc. 38 Medical Payments Business 39 40 41 42 43 44 Medical Payments Medical Payments Medical Payments Other payments Reserves Reserves Business Business Business Business Business Business 45 46 Reserves Reserves Business Business 47 48 Collections / Overpayments Medical Events Business Business 4 of 57 Injury - Records Number 1 2 3 4 5 6 7 8 9 10 11 12 Subject Matter Area Type (Business or Technical) File Copies Business File Copies Business File Copies Business File Copies File Copies File Copies File Copies File Copies File Copies File Copies Document Management Document Management Document Management Document Management Document Management Records Retention Claim Registration Business Business Business Business Business Business Business Business Business Requirement Glossary Link Capability to bill the customer for file copy requests or services. Track status of file copy request. Ability to track and integrate bar-coding of files according to WSI business rules. Ability to pull, store and export specific imaged file content according to predefined security and business rules. Ability to integrate with a third party software vendor that can deliver an electronic file copy. Ability to integrate with an FTP site for posting electronic files. Ability to produce paper file copies via an image printer. Ability for customer to request a file copy online. Ability to add global and/or individual messages to each file copy request, whether paper or electronic. Ability to establish automatic schedules for file copy updates. Given appropriate security, ability to delete a document that has been scanned incorrectly. Given appropriate security, ability to modify incorrect index values and have automatic workflow event(s) sent according to WSI business rules. Ability to separate a multiple page image into separate documents after indexing. Ability to associate an existing image with multiple electronic files. The system must have the ability to manually or automatically purge imaged records in accordance with WSI business rules. The system must have the ability to purge database records in accordance with WSI business rules. The system must have the ability to register a First Report of Injury (FROI) based on WSI business rules. Describe the system's ability to register a new claim (FROI). 13 14 15 16 17 Business Business Business Business Business 5 of 57 Injury - Records 18 19 20 21 22 23 24 25 26 Claim Registration Claim Registration Claim Registration Bill Entry Bill Entry Bill Entry Bill Entry Verification Document Entry / Indexing Document Entry Document Entry Business Business Business Business Business Business Business Business Business 27 28 Business Ability to register a new claim through an online process and return a claim number to the user immediately. System automatically identifies and flags duplicate claims. Ability to associate multiple claims resulting from a single event. Ability to process medical and non-medical bills based on WSI business rules. Describe this process. Ability to enter duplicate bills in order to accommodate correct records retention needs. Ability to detect, identify and create workflow when a duplicate bill has been entered. Electronically receive medical bills and records and incorporate them into an imaging system. Ability to interface with Optical Character Recognition (OCR). Ability to manage (e.g. scan, view, print, attribute notes, delete, invoke automatic mailing, auto purge) all documentation electronically without a file number in a queue until it can be associated to a file. Ability to interface with FileNet Capture or a third party imaging product. If your product interfaces with a third party imaging product, please explain how your product performs the following tasks: scanning, indexing, committal, retrieval, search/look up, batch management (creation, deletion and interruption of batches), image management (page count, image rotation, text message annotations, printing) and navigation within a batch (include detail on image ID and batch ID). If your product does not interface with a third party imaging product, please explain how it performs the following tasks: scanning, indexing, committal, retrieval, search/look up, batch management (creation, deletion and interruption of batches), image management (page count, image rotation, text message annotations, printing) and navigation within a batch (include detail on image ID and batch ID). Ability to interface with Captaris - FileNet OEM Edition or a third party fax server product. If your product interfaces with a third party fax server, please explain how your product performs the following tasks: batch assembly, document separation, image management (rotation, text message annotations, printing), application of index values, search/look up, and navigation within a batch. 29 Document Entry Business 30 31 Document Entry Document Entry Business Business 6 of 57 Injury - Records 32 Document Entry Business 33 34 35 Fax Fax Server Document Retention Business Business Business If your product does not interface with a third party fax server, please explain how your product performs the following tasks: batch assembly, document separation, image management (rotation, text message annotations, printing), application of index values, search/look up, and navigation within a batch. Describe your system's ability to send and receive faxes and maintain records of all faxing activity. Describe the ability to archive electronic documents directly to the imaging system. Describe your ability to identify and retain, in original format, electronic files and data records for the purpose of document retention. Ability to automatically identify and schedule disposal of electronic records based on WSI's retention schedule. The system should have the ability to manually purge electronic records once the retention schedules have expired. Describe this process. Ability to show what requested information was released and to what outside party. Ability to accept and directly associate electronic information to an electronic file. Ability to automatically identify and notify designated WSI staff of paper records ready for disposal based on WSI's retention schedule. Ability to track the volume of electronic data removed from the system based on WSI retention schedule. 36 37 Document Retention Document Retention Business Business 38 39 40 41 Document Retention Document Retention Document Retention Document Retention Business Business Business Business 7 of 57 Injury - Customer Support Number Subject Matter Area Type (Business or Technical) Requirement Glossary Link 1 General Support Business 2 General Support Business 3 General Support Business Ability to view, on a single summary screen the following claim information: SSN, name, DOB, address, phone number, dependents, date of injury, all injured body parts, ICD-9 codes, primary treating physician, claim history (including claim number, date of injury and body part), employers' name, employers' address, employers' phone number, claim status, adjuster name, adjuster extension, MMI date. MMI Ability to view, on a single summary screen the following benefit information: exact amount of check(s), date check was or will be issued, payee and address check(s) was mailed to, status of check. Ability to view , on a single summary screen the following medical information: authorized physicians, primary physician, designated medical provider, diagnosis and conditions both compensable/denied. Ability to view, on a single summary screen, medical treatment authorizations and requests including past and pending authorizations. Ability to engage in live web chats. Ability to automatically retrieve imaged information when entering a unique identifier. Ability for the customer to access claim/account information through an Interactive Voice Response (IVR) system. Ability to view, on a single summary screen, the following employer information: account number, business name, contact name, phone number, address, minimum and total of premium balance and assessment balance including; due dates, current policy period, status of account, underwriters name and number, status of certificate, payment history, collection information, assessment/deductible information, and payroll report status. Ability to view individuals or businesses with an affidavit of nonemployment on file. Ability to view application for insurance including those pending coverage. 4 General Support 5 General Support 6 General Support 7 General Support Business Business Business Business 8 General Support 9 General Support 10 General Support Business Business Business 8 of 57 Injury - Customer Support 11 General Support Business Ability to support multiple document interface. 9 of 57 Injury - Medical Services Number 1 Subject Matter Area Type (Business or Technical) Pharmacy Services Business Requirement Glossary Link 2 Pharmacy Services Business 3 4 Pharmacy Services Pharmacy Services Business Business 5 6 7 8 9 10 11 12 Pharmacy Services Pharmacy Services Pharmacy Services Pharmacy Services Pharmacy Services Pharmacy Services Pharmacy Services Pharmacy Services Business Business Business Business Business Business Business Business The ability to import pharmacy fill transaction data that follows the National Council on Prescription Drug Program (NCPDP) standard. The ability to export WSI's claimant information as defined by the NCPDP standard. Ability to allow overrides on plan limits based on WSI business rules, such as drugs that require prior authorization, number days supply, number of daily dosages, and maximum dollar amount. Ability to 'lock in'/restrict an injured worker into a specific pharmacy or a specific physician provider. Ability to receive and hold "first fill" information on injured workers that are not in our system (i.e. they have no claim number) until it can be mapped to a claim number. Ability to process/map a held "first fill" charge on injured workers that are not in our system to a claim of any status. Provide an alert notification that would be able to identify potential matches of "first fill" injured workers with data currently in the system. Ability to process and pay administrative fees and unmapped first fill charges. Ability to map administrative charges to specific claims. Ability to apply pharmacy fee schedules to bills that do not come through the Pharmacy Benefit Administrator (PBA). Ability to see individual ingredients in a compound prescription. Capability to import and store data fields related to "captured" pharmacy transactions. Ability to establish limits relative to the override decision of plan limits, such as, if we change the daily dose there needs to be ability to indicate amount changed the new amount would become our new plan limit for that claim. Ability to view the override history of plan limits. Ability to track consultation information in a claim. NCPDP PBA captured pharmacy transactions 13 14 Pharmacy Services Pharmacy Services Business Business 10 of 57 Injury - Medical Services 15 Pharmacy Services Business 16 17 18 Pharmacy Services Bill Processing Bill Processing Business Business Business Ability to identify a rejected pharmacy prescription transaction based on WSI business rules, apply automated approval, and provide an alert if the automated approval fails. Ability to process and track pharmacy rebates. The ability to process fee schedules from submitted medical billing codes. Ability to automatically apply a fee schedule according to WSI's fee schedule methodologies. Existing Fee schedules include: Medical, Durable Medical Equipment (DME), Outpatient/inpatient hospital, Home healthcare, Ambulance, Ambutory Surgical Center, Pharmacy, Maximum DME Allowable Cost (MAC) pricing. Ability to manually audit a medical bill(s). Describe how your system can provide the following: - Ability to change a CPT code - Add/update a modifier - Ability to deny a charge - Ability to approve part of the charge (partial payment) - Ability to review claimant information, prior authorization information, and provider service information - View medical bills - View medical notes - Access to internal generated notes CPT - Ability to change a bill status (audit, pending, released) Ability to automate medical bill payment processing according to WSI business rules. Ability to assign multiple ICD-9 codes to a single bill line item charge. ICD-9 Ability to automatically process medical bills line-by-line, approving or denying charges according to ICD-9 codes. Ability to manually approve medical bills that might have been rejected in the automated process. Ability to adjust and reprocess bills. Ability to manually override assignment of fee schedules. Ability to maintain multiple fee schedules in order to pay old bills according to any of these schedules, where appropriate. 19 20 Bill Processing Bill Processing Business Business 21 22 23 24 25 26 27 Bill Processing Bill Processing Bill Processing Bill Processing Bill Processing Bill Processing Bill Processing Business Business Business Business Business Business Business 11 of 57 Injury - Medical Services 28 Bill Processing Business 29 Bill Processing Business Ability to maintain past as well as add new medical codes such as ICD-9, CPT, Correct Coding Initiative (CCI) rules, HCPCS, conversion factors, modifiers, relative values, etc. Ability to automatically apply edits such as CCI edits, Global Packaging edits and modifiers and produce notification when these edits occur. Ability to process bills by applying alternative fee schedules according to WSI business rules. Ability to automatically apply the appropriate reason codes to each line item charge for all reductions/denials during automated bill processing. Ability to enter notes related to the reasons for the denial or reduced charge of a medical bill. Ability to track on a single, unique identifier all Permanent Partial Impairment (PPI) evaluations/awards to an injured worker with multiple claims. Ability to track all Permanent Partial Impairment (PPI) evaluations/awards for a specific claim. Ability to enter and track Permanent Partial Impairment (PPI) evaluation/awards such as: - % whole body awarded - dollar amount awarded - specific body part(s) evaluated from customizable code list - date award was issued - number of weeks - PPI evaluation date - PPI audit date Ability to enter and track Maximum Medical Improvement (MMI) information such as: - date IW reached MMI status - reviewer's name - date review performed - reviewer's recommendation/results - prior impairment - specific body part(s) to be reviewed CCI Global Packing 30 31 Bill Processing Bill Processing Business Business 32 33 Bill Processing PPI Business Business PPI 34 35 PPI PPI Business Business 36 PPI/MMI Business MMI 12 of 57 Injury - Medical Services 37 Utilization Review Business 38 39 Utilization Review Utilization Review Business Business 40 41 Utilization Review Utilization Review Business Business 42 43 44 45 46 47 48 49 50 Utilization Review Utilization Review Medical Remittances Medical Remittances Medical Remittances Claims / Treatment history Claims / Treatment history Claims / Treatment history Claims / Treatment history Online Services Business Business Business Business Business Business Business Business Business Ability to enter and modify Utilization Review (UR) requests for preauthorization of services such as: patient information, requesting provider information, facility information, specific service details and contact information. Ability to view the UR history both globally and by claim. Ability to enter, modify, and track UR resolution fields such as: reviewer, service approval decision (approved, denied, partial), WSI recommendation, decision reasoning, review status, date of decision and type of review. Ability to send a service request and supporting documentation to an external reviewer in real time. Ability to enter, modify, and track information from an outside reviewer/business which notifies WSI of preauthorization resolutions such as: Chiropractic from OCC, PT, etc. Ability for third parties to electronically review and provide a recommendation directly into our system. Ability to automatically approve a UR request according to WSI business rules. Ability to produce a remittance advice to coincide with a medical bill pay run. Ability to design and incorporate a custom WSI remittance advice template. Ability to insert a customized message on the remittances. Ability to create a treatment entry automatically or manually when a medical bill, medical note, or medical event is received. Ability to view treatment history by a single, unique identifier to an injured worker with multiple claims . Ability to track injured worker satisfaction/success feedback. Describe if/how your system supports tracking of information related to a 'point of service' notification when an injured worker attends a treatment visit. Ability to provide an online service to look up claim information based on WSI business rules. UR OCC 51 Business 13 of 57 Injury - Medical Services 52 Online Services Business Ability to provide an online service to submit UR requests and supporting medical notes from a treating provider for pre-authorization of services. Ability to provide an online service to view WSI's return authorizations/decisions on their UR requests based on WSI business rules. Ability to provide an online service that displays all provider billing information. Ability to provide an online service where providers could access and submit from a library of WSI fillable forms. Ability to enter, modify and track information specific to providers that participate in special programs or meet qualification standards such as: enrollment information, qualifying status, active participation dates, attach imaged documents, type of certifications, certification effective, etc. Ability to automatically auto adjudicate, process, build a custom plan, and pay the medical provider based on data from the system, ODG and CPT codes. 53 Online Services Business 54 55 56 Online Services Online Services Other Business Business Business 57 Other Business 14 of 57 Injury - Return to Work Number 1 2 3 4 5 6 7 8 9 Subject Matter Area Type (Business or Technical) Triage Business Voc Rehab Voc Rehab Voc Rehab Voc Rehab Disability Guidelines Preferred Worker Preferred Worker Preferred Worker Business Business Business Business Business Business Business Business Requirement Glossary Link Ability to automatically triage and generate a customized claims management plan from collected data. Ability to enter, update and track vocational rehabilitation services information by claim number. Ability to enter, update and track case management services information by claim number. Ability to view vocational rehabilitation information by a legal entity. Ability to enter and track return to work statistics based on WSI business rules. Ability to automate workflow events by incorporating WSI business rules and third party disability guidelines. Ability to enter, modify and track Preferred Worker Program (PWP) information. Ability to automatically request a disbursement of PWP payments. Ability to view payment history on all PWP expenses. 15 of 57 Employer - Collections Number Subject Matter Area Type (Business or Technical) Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Collections Process Business Business Business Business Business Business Business Business Business Business Business Business Business Business Requirement Glossary Link 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Ability to record and track employer account collection activity based on WSI business rules. Collection Ability to record and track claims overpayment collection activity based on WSI business rules. Ability to write-off balances of claims overpayments based on WSI business rules. Ability to write-off balances of an employer account based on WSI business rules. Ability to manually or automatically assess and waive penalties and other charges based on WSI business rules. Describe the standard reports and queries available that pertain to collections. Ability to manually or automatically modify the status of an employer account based on WSI business rules. Ability to track multiple collection types for an employer account. Ability to manually or automatically open and close a collection case based on WSI business rules. Ability to record multiple judgments against an employer based on WSI business rules. Provide an amortization schedule for alternative payment arrangements. Ability to automatically manage accounts in bankruptcy based on WSI business rules. Ability to invoice a claims overpayment. Ability to display collection status on a policyholder's certificate of coverage. Amortization schedule Bankruptcy 16 of 57 Employer - Payroll Processing Number 1 2 3 4 5 6 7 8 9 10 11 12 13 Subject Matter Area Type (Business or Technical) Input/Audit Business Input/Audit Input/Audit Input/Audit Input/Audit Input/Audit Input/Audit Input/Audit Input/Audit Input/Audit Input/Audit Input Audit Business Business Business Business Business Business Business Business Business Business Business Business Requirement Glossary Link Capture payroll information on a periodic basis. Notify employers that their payroll information is due. Describe the available methods of notification. Employers can submit their payroll information online using an online form that will automatically integrate the information into the system. Generate custom payroll reports based on employers' legal entity classification. Generate duplicate payroll reports upon request. Barcode payroll reports for tracking and receipt. Track or monitor the status of a payroll report. Identify, track and process employers who are delinquent in filing periodic payroll information. Automatically assess penalties based on WSI business rules. Audit payroll information based on WSI business rules. Automatically identify accounts for a potential field audit based on WSI business rules. Field audit Ability to capture gross and taxable payroll at the employee level based on WSI business rules. Gross Ability to adjust gross and taxable wages at the employee level. wages 17 of 57 Employer - Premium Billing Number Subject Matter Area Type (Business or Technical) Requirement Glossary Link 1 2 Billing Optional Coverage Business Business 3 4 5 6 7 8 9 10 11 12 13 14 Billing Billing Billing Billing Billing Billing Billing Billing Billing Billing Audit Billing Business Business Business Business Business Business Business Business Business Business Business Business 15 16 Billing Experience Modification Business Business Ability to calculate and bill premium for policy periods to include wages, classifications, rates, premium discounts, experience modification, applicable rating plan factors, minimum premium. Premium Ability to bill multiple types of optional coverage based on factors such as rate classification, age and wage cap. Wage cap Ability on a fiscal year basis, to update, apply and maintain history of premium calculation parameters such as manual rates, premium dividend credits, experience modification, loss rates, safety discounts, and wage cap. Dividend Ability to apply different interest rates by fiscal year based on WSI business rules. Ability to provide alternative payment schedules and terms based on WSI business rules. Ability to apply discounts for early payment of premium. Ability to provide electronic billing notification. Ability to present billing statements online or electronically. Ability to generate customized premium statements. Ability to customize messages to premium statements. Ability to attach correspondence to premium statements. Ability to show calculation details on all billing statements including any adjustments. Ability to calculate and generate a revised premium bill. Ability to bill differences in estimated and audited payroll. Ability to complete premium adjustments resulting from changes. Examples of changes include; volunteer roster information, changes in wages, experience modification factor, safety discounts, optional coverage, rate classification. Ability to calculate experience modification factors based on WSI business rules. 18 of 57 Employer - Premium Billing 17 18 19 20 21 22 23 24 25 26 27 Experience Modification Experience Modification Billing Billing Billing Billing Audits Audits Audits Audits Audits Business Business Business Business Business Business Business Business Business Business Business Ability to adjust experience modification factors for multiple policy periods for all policies within a group. Ability to adjust experience modification factors for multiple policy periods resulting from subrogation orders. Ability to establish and maintain retrospective rated policies. Ability to establish and maintain deductible rated policies. Ability to calculate and bill premium, interest, and penalty charges on accounts that are deemed uninsured. Ability to generate premium charges based on alternative units of exposure, such as number per capita, dollar per volunteer, per hour. Ability to maintain historical information of completed premium audits. Ability to query and track premium audits based on WSI business rules. Ability to generate audit work papers on demand. Ability to automatically generate a revised premium billing based on a field audit. Ability to update employer profile information based on WSI business rules. Subrogation 19 of 57 Employer - Payments & Certs Number Subject Matter Area Type (Business or Technical) Cash Receipts Cash Receipts Cash Receipts Cash Receipts Payments Business Business Business Business Business Requirement Glossary Link 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Cash Receipts Cash Receipts Cash Receipts Cash Receipts Certificates Certificates Certificates Certificates Certificates Refunds Refunds Business Business Business Business Business Business Business Business Business Business Business Ability to receive payments by various forms, such as: EFT, check, credit card, cash. Ability to receive payments online. Ability to apply cash receipts based on WSI business rules. Simple view of a specific account's balances, such as: claim loss, deductible, premium, etc. Ability to view notes at a glance pertaining to a specific transaction. Ability to trigger a notification when a payment is applied based on WSI business rules, such as: write-offs, closed accounts, collections, credit balances. Ability to make transaction corrections, such as: credits, refunds, balance transfers, transposition of numbers, voiding a payment. Describe standard reports available that are related to Payments. Ability to process an NSF (Non Sufficient Funds) transaction. Ability to customize a certificate template. Include a copy of the certificate here. Ability to manually generate a certificate on demand. Ability to automatically generate certificates based on WSI business rules. Ability to access and print a certificate online. Ability to generate proof of coverage card in wallet size. Ability to issue and void refunds, individually and in batches, based on WSI business rules. Ability to automatically generate correspondence based on refund type. 20 of 57 Employer - Assesments Number 1 2 Subject Matter Area Type (Business or Technical) Deductible Assessments Business Deductible Assessments Business Deductible Assessments Deductible Assessments Deductible Assessments Deductible Assessments Deductible Assessments Deductible Assessments Deductible Assessments Deductible Assessments Deductible Assessments Deductible Assessments Requirement Glossary Link Ability to automatically assess policyholders for costs associated with each claim based on WSI business rules. Ability to bill premium and claim loss deductibles on a single statement. Ability to automatically adjust claim loss deductible charges based on WSI business rules. Examples include subrogation, transfers, consolidations, denials. Subrogation Ability to manually adjust claim loss deductible charges based on appropriate security levels. Deductible Ability to apply different interest rates by fiscal year based on WSI business rules. Rate Ability to generate customized claim loss deductible statements. Ability to add global and/or individual messages to claim loss deductible statements. Ability to provide electronic billing notification. Ability to attach correspondence to claim loss deductible statements based on WSI business rules. Ability to apply discounts for early payments based on business rules. Ability to establish alternative payment schedules and terms based on WSI business rules. Ability to show detailed calculation on all claim loss deductible statements including any adjustments. Ability for employers to submit an online incident report. Ability to send confirmation to employer once they have submitted their incident report online. 3 4 5 6 7 8 9 10 11 12 13 14 Business Business Business Business Business Business Business Business Business Business Online Incident Report Business Online Incident Report Business 21 of 57 Employer - Underwritting Number Subject Matter Area Type (Business or Technical) 1 Canceling Coverage Business Requirement Glossary Link Ability to underwrite, cancel and reinstate mandatory coverage based on WSI business rules. Ability to underwrite, cancel and reinstate multiple types of optional coverage, such as: owner officers, self employed, family members and type of entity. Mandatory Coverage 2 Optional Coverage Business Ability to generate a customized application for insurance form. Ability to track the underwriting process from the receipt of application to when it is processed for billing. Ability to underwrite using a custom set of rate classification codes. Ability to automatically assign accounts to underwriters based on a set of parameters. Parameters may include alphabetical, size, industry and employer location. Ability for employers to submit their application online and integrate this information into the system automatically. Ability to underwrite uninsured period of exposure for work activity occurring prior to inception of policy based on WSI business rules. Ability to identify and track individuals or businesses who are not required to carry workers' compensation coverage through an issuance of an affidavit of non-employment. Ability to categorize employers, such as: size, industry, Professional Employer Organization (PEO), Preferred worker, Foreign farm worker, NAICS (North American Industrial Classification System). When a new application is received, ability to automatically identify and flag duplicate or similar information, already in the system, based on WSI business rules. Ability to automatically underwrite an application based on WSI business rules. Optional coverage 3 Underwriting Process Business 4 Underwriting Process Business 5 Underwriting Process Business 6 Underwriting Process Business 7 Underwriting Process Business 8 Uninsured Business 9 Underwriting Process Business 10 Underwriting Process Business Affidavit of nonemployment Professional Employer Organization 11 Underwriting Process Business 12 Underwriting Process Business 22 of 57 Employer - Underwritting 13 Rate Classification 14 Canceling Coverage Business Business Ability to assign or change a rate classification sub-class description by employer. Ability to cancel a policy and generate a final payroll report. Ability to flag an account for a potential field audit. Ability to underwrite, cancel and reinstate reciprocal coverage with other states. Ability to calculate an aggregate experience rate for an identified group of policyholders based on WSI business rules. Ability to consolidate policy information based on WSI business rules. Ability to separate a single policy into multiple policies. Ability to barcode applications for tracking and receipt. Ability to provide the employer the ability to establish an account using an online application wizard based on WSI business rules. All states incidental coverage 15 Underwriting Process Business 16 Reciprocal Coverage Business 17 Consolidation 18 Consolidation 19 Consolidation Business Business Business Reciprocal coverage 20 Underwriting Process Business 21 Underwriting Process Business 22 Underwriting Process Business 23 Underwriting Process Business Ability to underwrite, cancel and reinstate all states incidental coverage. Ability to underwrite, cancel and reinstate AG Excess coverage. 23 of 57 Other - Communications Number 1 2 3 4 5 Subject Matter Area Type (Business or Technical) Internet Online Services Business Internet Online Services Business Internet Online Services Business Internet Online Services Business Web Portal Business Requirement Glossary Link Online services should be accessible to the user through WSI's Internet site. WSI should have the ability to control the overall look and feel of online services. Online services provided should have the ability to have the same look and feel as the WSI internet site. Online services provided should be Americans with Disabilities Act (ADA) compliant. Describe the web portal capabilities (if any) of your product. 24 of 57 Other - Executive Staff Number 1 Subject Matter Area Type (Business or Technical) Reports Business Requirement Glossary Link A system reporting tool must be supplied. Describe your system's reporting capabilities including but not limited to; standard reports, automated scheduling capabilities, customizable features to your standard reports, drill down capability through report results, exportable formats, report distribution features (e.g. e-mail scheduled reports to predetermined recipients), report viewing features (e.g. dashboards, scorecards), security structure, capability to design new reports in a user friendly environment, etc. A system query tool must be supplied. Describe your system query capabilities. 2 Query Business 25 of 57 Other - Independent Review Number Subject Matter Area Type (Business or Technical) Dispute Resolution and Constituency 1 Services Business Dispute Resolution , Binding Dispute Resolution, and 2 Constituency Services Business Requirement Glossary Link Ability to view claims and legal information based on appropriate authorization level. Ability to automate the OIR dispute resolution registration process, such as: populating forms, generating letters and sending events. OIR 26 of 57 Other - Legal Number Subject Matter Area Type (Business or Technical) Litigation 1 Management Business Litigation 2 Management Business Litigation Management and Subrogation 3 Processing Business Subrogation 4 Processing Requirement Glossary Link Describe the standard list of reports and queries that pertain to litigation and subrogation. Ability to create, modify, and track history of information throughout the notice of decision process based on WSI business rules. Litigation Business Ability to autopay legal billings based on WSI business rules. Provide a subrogation calculator tool with the ability to perform and save automatic subrogation settlement calculations, with the option to manually override, based on WSI business rules. 27 of 57 Other - Legal Subrogation 28 of 57 Other - Finance Number 1 2 3 4 Subject Matter Area Type (Business or Technical) Tax Tables Business Tax Tables Business 1099 Processing Financial Package Business Business Requirement Glossary Link 5 Financial Package Business Ability to update and maintain history of Federal tax tables. Ability to update and maintain history of the State average weekly wage tables. Ability to issue 1099's to the payee and an electronic file to the IRS as well as maintain history. If a financial package exists in your system, it should process and report on all activity/transactions, on a daily basis, related to workers compensation insurance needs, including General Ledger, Track reserve changes, Losses, Loss payments, Ceded Loss Reserves, Effect of reinsurance on losses, Subrogation, Claim overpayment adjustments, writeoffs and recoveries, Apply cash receipts, Reserves, Claim payments, Premium billing, Premium adjustments, Premium credits, Premium dividends, Premium bad debt/write-offs, Advance premium billings and reconciliations, Customizable account list, Track overpayments, Track subrogation, Accurately record journal entries for all daily transactions (e.g. reserves, premium billing) and activity (e.g. subrogation, overpayments, reinsurance). If your system does not have a financial package included then provide journal (General Ledger) entries for all types of transactions in a summary format and update appropriate General Ledger accounts on a daily basis and upload to our Great Plains financial system. The integration needs would be Payment number, List cleared checks from Great Plains to the new system, Post all daily activities in the new system to Great Plains General Ledger, Maintain its own EFT records in conjunction with its vendor maintenance responsibilities, Administer vendor maintenance for all its claimants, medical providers and policyholders. Ability to issue payments automatically in a batch and individually on demand. Such as Claims Payments, Premium Refunds/Payments, Administrative Payments. Ability to void and reissue payments. 6 Payments Business 7 Payments Business 29 of 57 Other - Finance 8 9 Payments Payments Business Business 10 Payments Business Ability to provide payments via check and EFT. Ability to receive and process a cleared check file from a financial institution and automatically update the status of a check based on WSI business rules. Ability to allow an employee to view the check status (ie: issued, cleared, voided) of a payment, based on WSI business rules. 30 of 57 Other - Global - Legal Entity Number Subject Matter Area Type (Business or Technical) Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Requirement Glossary Link 1 2 3 4 5 Business Business Business Business Business Ability to establish Legal Entities for providers, injured workers, employers, etc. and manage attributes of those entities based on WSI business rules. Legal entity Provide us your list of legal entity attributes for injured worker. Provide us your list of legal entity attributes for providers. Provide us your list of legal entity attributes for employers. Ability to automatically/manually enter and maintain addresses based on United States Postal Service (USPS) information. Ability to view and search all information relating to Legal Entities such as; attribute history, claim history, employment, provider relationship, dependant, beneficiary, etc based on WSI business rules. Ability to link a Legal Entity with one or more other Legal Entities. Describe your system's ability to use Legal Entity attributes in correspondence/payments/billing/etc. Ability to identify the origin of WSI mailings by unique department code to be included in the address block. Describe your ability to manage multiple addresses for a Legal entity such as physical, payment, and mailing/correspondence addresses. Ability to indicate if a vendor is a 1099 recipient. Ability to indicate 1099 payment type. Such as box 6 - medical payments. Ability to record a Doing Business As (DBA) name in addition to a Legal business name, on a legal entity type of provider and employer. Ability to record an alias on a legal entity type of injured worker. 6 7 8 9 10 11 12 13 14 Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Legal entity requirements Business Business Business Business Business Business Business Business 31 of 57 Other - Global - Legal Entity 15 Legal entity requirements Ability to automatically identify duplicate legal entities and allow for manual combination. 32 of 57 Other - Global - Workflow Number Subject Matter Area Type (Business or Technical) Work Flow Work Flow Work Flow Business Business Business Requirement Glossary Link 1 2 3 Work Flow must have specific information required for processing, such as the priority, target completion date, origin of workflow. Work flow Ability to assign workflow activity to one or more users or group of users. Ability for user to add note text to a workflow activity at any point in the workflow process. Ability to manage and/or view any workflow activity and status for, an individual user or defined group at any point in the workflow process, based on WSI business rules. Ability to retain a history of all workflow activity. Ability to search workflow activity history by predefined parameters. Ability to temporarily alter workflow assignment based on WSI business rules. Ability to automatically or manually assign workflow activities based on WSI business rules. Ability to alter workflow, based on WSI business rules. Ability to trigger workflow activity by external applications such as web service. Ability to generate electronic forms by automatically populating information and produce workflow for referrals or procedures. Ability to electronically authorize workflow activity. Ability to provide electronic proof of processing for routing of workflow activity. Describe the ability to select and execute a work task from a master list. Ability for system to interface with state agencies utilizing enterprise service transactions. Ability to send correspondence to multiple recipients utilizing multiple methods such as email, fax, paper. 4 5 6 7 8 9 10 11 12 13 14 15 16 Work Flow Work Flow Work Flow Work Flow Work Flow Work Flow Work Flow Work Flow Work Flow Work Flow Work Flow Work Flow Correspondence Business Business Business Business Business Business Business Business Business Business Business Technical Business 33 of 57 Other - Global - Workflow 17 Correspondence Business Ability for a user to manually trigger the generation of a specific letter to be mailed. 34 of 57 Other - Global - Forms Number 1 Subject Matter Area Type (Business or Technical) Forms Tools Business Requirement Glossary Link 2 3 4 5 Forms Tools Forms Tools Forms Tools Forms Tools Business Business Business Business Describe your forms tools capabilities. Ability to automatically and manually select existing documents, forms and images and attach them to outgoing correspondence based on WSI business rules. Automated capability for attaching images and documents to outgoing correspondence. Ability to create, test, update, maintain and produce forms and envelopes in one system. Ability to auto fill forms and outgoing correspondence with required data. Ability to identify multiple outgoing correspondence to a single recipient and automatically or manually combine correspondence to one mailing based on USPS regulations. Ability to cancel or hold a form at any given time before printing. Ability to override the legal entity address and print alternate addresses for forms and envelopes. Ability to automatically create and store an image of all outgoing correspondence based on WSI business rules. 6 7 8 9 Forms Tools Forms Tools Forms Tools Forms Tools Business Business Business Business 35 of 57 Other - Global - Notes Number Subject Matter Area Type (Business or Technical) Requirement Glossary Link 1 2 3 4 5 6 Notes Notes Notes Notes Notes Notes Business Business Business Business Business Business Ability to create and attach notes to any specific document or any legal entity. Please describe the process by which you will accomplish this. Ability to search, sort and access notes, by category, content, subcategory, header, etc. Describe all the features of your systems notepad functionality such as spell-check, category, captions. Describe your process for displaying notes attached to a specific item such as address, transaction, policyholder, remittance advice. Ability to attach a note to multiple claims or a legal entity. Ability to attach notes to items in an image/content management system. Other - Global - Misc Number 1 Subject Matter Area Type (Business or Technical) General Claim Management Business General Claim Management General Claim Management Global / Voice activation Globals / Visual Indicators GUI Integration GUI Integration Spell Checking Web and mobile access Web and mobile access Field reps Requirement Glossary Link 2 3 4 5 6 7 8 9 10 11 12 13 Business Business Business Business Business Business Business Business Business Business Business Business Ability to link to third party sites to reference their information such as CareMC, Merck, ODG, etc. Ability to enter, modify and track history of approved contacts for the "authorization to release information." This capability should be able to be linked to a specific claim, account and/or legal entity. Ability to use a "calendar assist" to select or input dates or date ranges. Ability to interact with third party voice activation software. Ability to display, a claim or policy status on every page based on WSI business rules. Describe your system error reporting and notification capability. Ability for WSI to customize the look and feel of the application. Ability to maintain user preferences. Describe your ability to integrate with other COTS products. Describe your system's spell checking, grammar checking and content filtering capabilities. Describe all mobile capabilities that your product may offer. Describe all online service capabilities for injured workers, providers and employers. Describe your system's ability to provide off-line data access, usage, and synchronization. 37 of 57 Other - Global - Imaging & Tech Number Subject Matter Area Type (Business or Technical) Imaging Imaging Business Business Requirement Glossary Link 1 2 3 4 5 6 7 8 Imaging (Desktop Imaging (Desktop and Web) Imaging (Desktop and Web) Imaging (Desktop and Web) Imaging (Desktop and Web) Imaging Business Business Business Business Technical Technical Describe your ability to search, sort, view and print by categories and document types. Ability to accept, store, and access imaged documents. Describe the systems' ability to markup an electronic document, such as add annotations, highlight, watermarks, layer of redaction from mail to any appropriate artifact, WITHOUT altering the original artifact. Describe your systems' features and capability for viewing an image. Ability to retrieve electronic records via the desktop. Ability to publish records to the web. Describe your systems' storage options. List all formats that are supported by the content storage system such as audio files, office documents, video files. 38 of 57 Other - Global - Other Number Subject Matter Area Type (Business or Technical) Other Other Other Other Business Business Business Business Requirement Glossary Link 1 2 3 4 Capability to Accept ANSI 837 format for claims aka. Medical Billings transactions. ANSI 835 Remittance compliant. Describe your system's ability to allow WSI to manage its business rules. Describe your procedure for implementing and integrating WSI business rules. 39 of 57 Other - SIU Number 1 Subject Matter Area Type (Business or Technical) Field and Fraud Business Investigation Requirement Glossary Link 2 3 Field and Fraud Investigation Field and Fraud Investigation Field and Fraud Investigation Field and Fraud Investigation Business Business 4 5 Business Technical / Business 6 7 Field and Fraud Investigation Field and Fraud Investigation Business Business Ability to track and reference case assignment and reassignment capability of the following information: name of investigator, internal or external investigator, agency name, address of investigator, e-mail address, contract dates of investigator, phone number of investigator and date investigator was assigned. Ability to provide historical tracking and reporting of all prior investigations/surveillance on claimant, provider, and/or employer. Ability to track and report case activity per each investigator and engagement on a claim, a specific employer, and/or specific provider based on WSI business rules. Ability to track and reference post-investigation activity based on WSI business rules. Ability to interface with outside sources through the use of a quick link to their sites/services. Examples include: state Motor Vehicle office, Outside Corrections offices, ND Job Service, ND Private Investigation Board, sources Secretary of State, etc. Ability to cross reference investigation history with Employer, Injured Worker, and Provider. Ability to integrate bar-coding to track and search all evidence items in a 'library' style system that would keep track of evidence information by using security levels incorporating access to a specific legal entity. Ability to enter, modify and track Hotline information that is accessed according to appropriate security roles for all tips received. Hotline Information 8 Field and Fraud Investigation Business 40 of 57 Technical - SOA Number Subject Matter Area Type (Business or Technical) Requirement Glossary Link 1 SOA Technical Service-Oriented Architecture (SOA) expresses a business-driven approach to software architecture that supports integrating the business as a set of linked, repeatable business tasks, or “services”. Services are selfcontained, reusable software modules with well-defined interfaces and are independent of applications and the computing platforms on which they run. SOA will help WSI innovate its business by ensuring that IT systems can adapt quickly, easily, and economically to support rapidly changing business needs. Please describe how your solution supports SOA, including any architecture diagrams or other documentation that explain your SOA implementation. If the system does not currently support SAO or has limited SOA capability, explain your strategy to transition your system towards SOA. 41 of 57 Technical - Adminstration Number 1 Subject Matter Area Type (Business or Technical) Project Management Technical Requirement Glossary Link Vendor must supply project manager for system implementation as part of this bid. Please describe the credentials and prior experience of this project manager. Activities must abide by the North Dakota State Large Project Oversight Standard. Please see the following websites for these standards: - STD009-05 Standard for the Project Management of Large Information Technology Projects: http://www.nd.gov/ea/standards/standards/approved/std009-05.pdf - ND Century Code: http://www.legis.nd.gov/cencode/T54C35.pdf http://www.legis.nd.gov/cencode/t54c59.pdf Activities must abide by the North Dakota State Project Management Guide Book. Please refer to the following websites: http://www.nd.gov/epm/training/guidebook/index.html Describe the online tutorials and/or help tools that are embedded within your solution. Describe in detail the training plan for train the trainer(s) and end users. The description should include a narrative on the training curriculum and a commitment of the number of days of training that will be provided. Descriptions should include details on training in all the application modules. Describe in detail the training materials given to end users. Describe how you would provide WSI with defined use case scenarios with a prepopulated training database. Training should be held at a WSI approved training facility(s). Describe any training available to WSI IT staff for system customization capabilities. Describe in detail the training plan for administration such as Security administration, System administration, Report administration, Database administration, etc. 2 Project Management Technical 3 4 Project Management Training Technical Technical 5 6 7 8 9 Training Training Training Training Training Business Technical Technical Technical Technical 10 Training Technical 42 of 57 Technical - Adminstration 11 Training Technical 12 Documentation Business 13 Documentation Technical Describe your process of transferring knowledge to WSI leading to selfsufficiency. Ability to have WSI's procedure guides/manuals as an interactive electronic help tool that is fully searchable and contains wizards. These guides/manuals will be updated by WSI. Describe how you would provide the following types of documentation: technical documentation, database documentation, application documentation. 43 of 57 Technical - Post Implementation Number Subject Matter Area Type (Business or Technical) Requirement Glossary Link 1 Maintenance Technical 2 Maintenance 3 Maintenance 4 Maintenance Technical Technical Technical 5 Software Support 6 Software Support Technical Technical 7 Maintenance Technical A maintenance contract is required. Describe both the base maintenance contract and optional maintenance contract. (The percentage of licensing costs for maintenance should be based on the negotiated discount price and not the current list price). Describe software maintenance operations related to corrective maintenance, adaptive maintenance, perfective maintenance, and preventive maintenance. Describe the software "End of Life" version support and notification process. Describe your software release procedures. Include descriptions of frequency, process, and reasons for release. Vendor proposals shall contain a narrative of the proposed service level agreement through which the vendor shall provide on-going support and maintenance after conclusion of the warranty period. The narrative shall include response times and the nature of the response that the contractor shall provide. Describe in detail your warranty and warranty period. Describe your software patch procedures. Include descriptions of frequency, process, and reasons for release, impact of vulnerability, maximum severity rating, etc. 44 of 57 Technical - Post Implementation 8 Transition-Out 9 Transition-Out Technical Technical 10 Transition-Out Technical The vendor should provide to WSI, as part of the Transition-Out Plan: -Technical and functional overviews of the system -System data dictionary -Where applicable, current copies of the application source code. -Documentation as specified in the Documentation Requirements Section. -Detailed documentation of all application modifications, including all changes in progress, in electronic format. -Overviews of all procedures, tools and administrative services provided under the contract. -Listings and details regarding all known system defects. -Entity Relationship Diagrams. Describe how and when vendor staff will transition-out after system implementation. The vendor shall work closely with WSI staff to continue normal maintenance and operations activities until completion of all Transition-Out Plan activities. 45 of 57 Technical - System Number Subject Matter Area Type (Business or Technical) Requirement Glossary Link 1 Licensing Technical 2 Architecture 3 Architecture 4 Architecture 5 Architecture Technical Technical Technical Technical Please describe the software license options that are included with your product. Please state any other software products not included but needed. Using diagrams or other media describe your software solution's architectural blueprint. Describe the frameworks and patterns used by your application. Describe your business rules engine capabilities. Describe your ability to integrate with other software products and services. Describe methods you have for bridging the gap between your solution and WSI application requirements. Describe the capabilities of your product to standardize inputs from any media into a single, uniform format so that they are available to the document management and workflow management components for routing, processing and storing in a manner that is independent of the input media. Describe the web services and application programming interface (API) capabilities your solution provides. The solution shall operate within the existing North Dakota Enterprise Architecture for Web Development Standard (STANDARD EGT003-04.5, STANDARD EGT004-04. STANDARD AST001-04.3 and Best Practice EGT-BP001 ). System data must be housed in an industry standard relational database management system (RDBMS), with Oracle being preferred due to WSI's current investment in Oracle. Data should be available 24 hours a day, 7 days a week. Business rules engine 6 Architecture 7 Web Services Technical Technical 8 Web Services Technical 9 DBMS 10 DBMS Technical Technical 46 of 57 Technical - System The Relational Database Management System (RDBMS) must provide the following -The ability to access the RDBMS for Online or Hot backups (Backups which are taken while data is still accessible to users). -The ability to access the RDBMS for Export of data (A picture of the data which is taken while data is still accessible to users). -The ability to access the RDBMS for an archiving of the entire RDBMS. (Archives are backups of the entire database with the RDBMS inaccessible to users). -The ability to restore the RDBMS using a point-in-time recovery feature which would allow WSI to simply provide a date or time up to which they wish the RDBMS to be restored. Describe methods and/or tools used to guarantee data integrity. Describe the software languages and development skills needed to interface with and maintain application. The solution shall operate within the existing North Dakota Enterprise Architecture Standards for Network Environment 100Base T Ethernet (POLICY N003-96). Refer to Section 2.02 - State of North Dakota Technical Architecture - State Standards. The solution shall operate within the existing North Dakota ITD Standard Inter-LAN Communication Protocol Policy (Policy N001-95). Refer to Section 2.02 - State of North Dakota Technical Architecture - State Standards. The solution shall operate within the existing North Dakota Enterprise Architecture for Operating Systems and Platform Standard (Standard STD001-98). Refer to Section 2.02 - State of North Dakota Technical Architecture - State Standards. The solution shall operate within the existing North Dakota Enterprise Architecture for Desktop Operating Systems Standard (Standard DT00306.1). Refer to Section 2.02 - State of North Dakota Technical Architecture State Standards. 11 Disaster Recovery 12 DBMS 13 Development Tools Technical Technical Technical 14 Hardware Technical 15 Hardware Technical 16 Hardware Technical 17 Hardware Technical 47 of 57 Business Technical - Implement Number Subject Matter Area Type (Business or Technical) Requirement Glossary Link 1 2 Implementation Implementation Technical Technical 3 4 5 Implementation Implementation Implementation Technical Technical Technical The vendor must provide its proposed transition approach for system implementation. The vendor's proposal must provide information that can be used by WSI to evaluate the vendor's knowledge of, and intended approach to, system transition and cutover. This information must include at least the following: Technical Transition Plan (transitioning of hardware, software, networks, data and operations to the new system.) and a Business Transition Plan (transitioning of WSI staff and business processes to the new system). Hardware Requirements--Describe the site-specific hardware requirements necessary to support implementation. Software Requirements--Describe any software required to implement the system (such as, software specifically designed for automating the installation process). Network Requirements--Describe any network requirements required to implement the system. Data Requirements--Describe specific data preparation and conversion requirements that must be available for the system implementation. Facilities Requirements--Describe the site-specific physical facilities and accomodations required during the system implementation period. Team--Describe the composition of the proposed implementation team (including credentials and relevant prior work experience) and the tasks to be performed by each member of the implementation team. Schedule--Provide a detailed transition schedule that clearly defines key milestones, deliverables, tasks, and responsibilities during implementation. Procedures--Describe any operational procedures that are used during implementation such as a checklist, operations guide, etc. Describe vendor(s) experience related to the proposed system implementation. 6 Implementation Technical 7 Implementation Technical 8 9 10 Implementation Implementation Implementation Technical Technical Technical 48 of 57 Business Technical - Implement 11 Implementation Technical Describe the process for assuring that the system implementation was successful. (Please list all relevant references and clients with successful implementations). 49 of 57 Business Technical - Testing Number 1 Subject Matter Area Type (Business or Technical) System support Technical Requirement Glossary Link 2 3 System support System support Technical Technical Describe how, on what schedule, and by whom your product will be tested to assure proper installation has been completed, before any WSI modifications have been incorporated. (get a baseline of the application functionality). Describe how, on what schedule, and by whom your product will be tested after WSI business rule modifications. Describe how your clients have successfully accomplished testing of your product after an upgrade to a new version and applying service upgrades. Describe any tools available or bundled with your product that could be used for testing purposes to include automated functional testing tool scripts. Describe what preprogrammed tests within your test plan are made available to your customers as part of the purchased product price. Describe any support forums you provide for your customers to seek assistance and technical material? Describe features that your product has in order to support/monitor system performance. (e.g.audit logs, error logs, system notifications, etc.). Describe your company’s prior to release: test plan, manual and automated, to include functional, load and regression testing with the priority and pass/fail requirements of individual function points. Describe your load testing procedures. Describe how you communicate any and all unresolved issues to your customers prior to the release of the product? 4 System support Technical 5 6 7 System support System support System Support Technical Technical Technical 8 Product Quality Technical 9 10 Product Quality Product Quality Technical Technical 50 of 57 Business Technical - Security Number Subject Matter Area Type (Business or Technical) Security Security Technical Business Requirement Glossary Link 1 2 Ability for application to provide for secure user authentication. Please describe. Describe how your application administers and applies security in each of its modules/areas. 51 of 57 Safety - Loss Prevention Number 1 2 3 Subject Matter Area Type (Business or Technical) Loss Prevention/Control Business Loss Prevention/Control Business Loss Prevention/Control Business Requirement Glossary Link Ability to integrate WSI's calendar system, such as: Microsoft Outlook. Ability to document customer visits/contacts based on WSI business rules. Ability to automatically or manually assign employer services representatives to an account based on WSI business rules. Ability for the customer to fully manage their account online and receive electronic notices for items such as Loss Runs, request services, experience rate wizard, and safety, grant and/or discount programs. Ability to associate policyholders based on WSI business rules. Ability to administer and track safety, grant and/or discount programs based on WSI business rules. Ability to integrate with WSI's Learning Management System. Ability to identify policyholders eligible for premium discounts based on WSI business rules. 4 5 6 7 8 Online Loss Prevention/Control Loss Prevention/Control Loss Prevention/Control Loss Prevention/Control Business Business Business Business Business 52 of 57 Term "Captured" Pharmacy Transactions Definition Data that are a deviation of the HIPPA norm on patients who do not have an active claim with WSI. The process involved in investigating claims. This process is performed on all disability claims and can be carried out on claims of unusual filing (exposure claims, heart attack, etc...). Upon point of receipt, the adjustor initiates the following: 1. Contact with Injured Worker 2. Contact with Employer 3. Contact with Medical Provider The purpose of the 3 point contact is to gain preliminary info on disability, Return to Work(RTW) and claim details 3pt Contact The processing and managing of claims, making the compensability and claims management decisions on a claim; to review the submitted claim and all pertinent information in the claim file and make a decision as to WSI's liability. Adjudication When an independent contractor and/or owner of a business is applying for a contractor's license, this form is signed to state he or she does not have any employees and is not applying for optional coverage. Provides North Dakota employers with multiple state workers' compensation coverage for employees who work temporarily outside the state. Calculation to determine a regular-interval payment plan to pay principal and interest System is set up so claims are automatically processed (based on pre-defined criteria) without adjuster involvement Average Weekly Wage - The base from which disability payments at WSI are calculated. AWW is the weekly wage the employee was receiving from all employments at the date of first disability. The condition in which a business or individual cannot meet its debt obligations and petitions a federal court either for reorganization of its debts or liquidation of its assets. If a debt is owed for a period before the bankruptcy filing this is a pre-petition debt. If a debt is owed for a period after the bankruptcy filing this is a post-petition debt A Rule Base Engine that allows clients to separate business rules from application code. Correct Coding Initiative - CCI edits identify procedure codes (CPT codes) routinely bundled together. Codes that should be bundled together can not be billed separately. The status of an employer account when default occurs on a premium or medical expense assessment payment or when a required payment is not received on a claims overpayment. Affidavit of Non-employment All State Incidental Coverage Amortization Schedule Auto Adjudication AWW Bankruptcy Business Rules Engine CCI Collections The process of merging two existing claims into one. Consolidation typically occurs when two claims for the same injury are filed in error or a new claim is filed for an injury and it is apparent the current problems stem from an injury on an already existing (prior) claim. Consolidation Consolidations CPT Deductible An active account entity that enters into a merger, acquisition, or purchase of the ownership rights of another account entity. Current Procedural Terminology - Codes used to describe the procedure being performed by the medical provider. A portion of covered loss not paid by the insurer. This is the medical provider that an employer designates for all of their employees to see in the instance of a work related injury. A partial return of premium to the insured based on the insurer's financial performance or the insured's loss experience. Dividends Durable Medical Equipment - This is a term used to indicate any supplies or hardware a person would need i.e brace, cane, guaze, etc. The process by which experience rating data are applied to the premium of the insured. A financial record survey of a person or organization that determines exposures, limits, premium, etc… Global Packaging edits refers to the bundling of CPT codes. An example would be the use of the CPT code for a specific chemistry panel instead of using the CPT codes for each individual test (glucose, potassium, chloride, BUN, etc). The new system must recognize when a bundled code would be the appropriate billing mechanism. An amount of money before deductions, usually associated with salaries and wages. Healthcare Common Procedure Coding System - These codes include supplies and equipment provided as well as procedures being performed. These codes are also used to indicate the nature of an injury (location) as well as track preventative services being provided. Information received regarding possible claimant, employer, or provider fraud. International Classification of Diseases version 9 - These diagnositic codes are used to descripe the injury or illness a person has. These codes establish what is wrong with the individual. A compensation payment including disability payments, permanent partial impairment (PPI) awards, or a lump sum settlement payment. Designated Medical Provider DME Experience Modification Field Audit Global Packaging Gross Wages HCPCS Hotline Information ICD-9 Indemnity Payment Legal Entity Litigation Loss of Earnings(LOE) Mandatory Coverage Minimum Premium MMI Monopolistic State NCPDP Ability to update and track overall demographics specific to an injured worker separate from a claim: such as name, alias, address, address history, phone, SSN, sex, date of birth, marital status, marital history dependant information, overpayments, prior injuries, previous WSI claims,special investigations history, vendor tax ID #, 1099 recipent, employment history, etc… This information should be readily accessible to the adjuster when managing a claim and customizable for additional categories to be added. Disputes pending before WSI or the courts. The date at which the injured worker first lost wages as a result of the work injury. Workers' compensation insurance is mandatory for most employment. This coverage is required by law. The least amount of premium to be charged for providing a particular insurance coverage. Maximum Medical Improvement - Further recovery from, or lasting improvement to, an injury or disease can no longer reasonably be anticipated based upon reasonable medical probability. Workforce Safety & Insurance is the sole provider and administrator of workers' compensation insurance in North Dakota. National Council on Prescription Drug Program - This is the standard transaction data format all pharmacies use when submitting data electronically. National Provider Identification Number - An assigned number a provider must obtain from the government. This number will be the number they will now need to use when providing service to any individual, regardless of payer. There will no longer be different numbers assigned from different insurance carriers, Medicare or Federal agencies. In addition to physicians, all medical providers and facilities will now need to have an assigned number submitted with any billed charge. Orthopedic and Chiropractic Consultants (of North Dakota) - This contracted company reviews all of the chiropractic care being performed that is beyond the established window period. NPIN OCC Provides assistance workers who have filed a claim, which may also include acting on behalf of workers aggrieved by a decision. Provides education to workers regarding the effect of a decision made by the organization. Automatic deductions from an injured worker’s disability payment. When the full disability payment is calculated, the system will deduct the offsets that are set up on a particular claim from that disability amount. The offsets are set up by WSI business rules. Examples of offsets include: Social Security Disability, aggravations(WSI is only liable for a certain percent on the claim), overpayments, Social Security Retirement, etc. Office of Independent Review (OIR) Offsets Optional Coverage Coverage for the owners, partners or corporate officers of a business corporation is optional. An employer may elect to purchase optional coverage for themselves, their spouse, and children under the age of 22. This coverage is not required by law. These are resources or agencies that WSI's Special Investigation Unit (SIU) utilizes in the course of an investigation. Outside sources include, but are not limited to, the Motor Vehicle Department, Job Service, and the Secretary of State's Office. Pharmacy Benefit Administrator - WSI has contracted with a Pharmacy Benefit Administrator to assist in the processing of pharmacy charges in a point-of-sale enviroment. Permanent Partial Impairment - This impariment award is provided to injured workers who have received a permanent impairment due to their injury and met the state requlations for rating impairments. A worker who has incurred a compensible injury that resulted in a disability that poses a substantional obstacle to employment. In addition, employers who apply for and are approved as a preferred worker employer may not be assessed premiums on a preferred worker's salary for 3 years from the date of hiring. The amount of money an insurer charges to provide the coverage described in the policy or bond. A business entity that provides or leases employees or maintains a co-employment relationship with employers in North Dakota. A unit of cost that is multiplied by an exposure base to determine an insurance premium. An insurance rate is the amount of money necessary to cover losses, expenses, and provide a profit to the insurer for a single unit of exposure. A calculating device in which data can be inputed to determine payment information for a given period of time, based on an Average Weekly Wage, a post injury wage, the marital and dependency status, etc... This information does not become a part of the permanent record of the claim Extends to incidental operations lasting fewer than 30 consecutive days in a state where the employer has no other significant contacts with that state and those operations do not require the employer to purchase workers compensation insurance under the laws of that state. This is the date, associated with a reapplication for disability benefits, when an Injured Worker has had a recurrence in losing wages due to the work injury, after an initial period of disability has already been paid. The recurrent loss of earnings is set up when it has been more than one year since WSI last paid disability benefits to the Injured Worker in question, and if the Injured Worker’s current wages at the time of reapplication are greater than the first Loss of Earnings date. Outside Sources PBA PPI Preferred Worker Premium Professional Employer Organization Rate Rate Calculator Reciprocal Coverage Recurrent Loss of Earnings(RLOE) Reserves Dollar amounts set aside for the cost of the claim. Estimating the total probable cost that will be incurred on a claim during its lifetime (See Total Cost Exposure definition). A rating plan that adjusts the premium, subject to a certain minimum and maximum to reflect the current loss experience of the insured. Retrospective rating combines actual losses with the graded expenses to produce a premium which more accurately reflects the current experience of the insured. Adjustments are performed periodically, after the policy has expired. The legal right to recover damages against a third party (someone other than an employee or co-employee) who is at fault for an employee's injury. This right may be brought by the injured employee, the injured employee's dependents or WSI. Retrospective Rating Subrogation A monetary amount suspended on a claim when the injured worker has been successful in a third-party lawsuit. Suspended benefits are the dollar amount over which WSI has expended monies on a claim. Payments on this claim are suspended until the injured worker has absorbed this amount through his own payments. The amount of payroll per employee used to bill premium, which is based on 70% of the state's average annual wage. This is the same as a reserve in which the total probable cost that will be incurred on a claim during its lifetime. These funds are set aside for the total cost of the claim (See Reserves definition). A system designed to prioritize injuries/claims that demand the most attention or pose the greatest potential for a high cost exposures. Utilization Review - Utilzation Review provides for pre-service, concurrent & retro-prosective reviews of services requiring prior authorization from the medical providers in order to be performed. The maximum taxable payroll for each employee calculated by establishing a wage cap of 70% of the state's average annual wage. Weekly Compensation Rate - The rate at which an injured worker is paid disability based on WSI business rules. Activities that include, but are not limited to diary events, system events, calendar tasks, automated form creation, escalation, document events, bill events, and user events. Suspended Benefits Taxable Wages Total Cost Exposures Triage Risk Score UR Wage Cap WCR Work Flow