Injury - Claims Number Subject Matter Area Type Requirement Glossary Link (Business or Technical) 1 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. 2 New /Initiating Claim Business 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. 3 General Claim Business Ability to track and modify information with respect to a claim. Ability to Management 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. 4 General Claim Business Ability to enter 3-point contact triage information and have the system Management prompt adjusters with dynamically (interactive decision tree) appropriate questionnaires based on body part and injury type. 3 point contact 5 General Claim Business Upon completion of the questionnaire response entries, the system Management assigns a triage risk score on the claim according to WSI business rules. Triage risk score 6 General Claim Business Ability to consolidate two matching and or duplicate claims (to include data Management and imaged information). Consolidate 7 General Claim Business Ability to record and modify all parties with a relationship to a claim, and Management the ability to track their role (primary, treating, consultant), effective date, and view their legal entity. 1 of 57 Injury - Claims 8 General Claim Business Ability to create, in whole or part, a claim file copy from the system through Management 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. 9 General Claim Business Ability to create/update multiple locations tied to one employer account. Management 10 General Claim Business Ability to view, update and keep history of Designated Medical Provider Management (DMP), adjuster assignment, and employer contact information on the employer's legal entity for each employer location, based on WSI business Designated rules. Medical Provider 11 General Claim Business Ability to assign a claim to one or more employers and to allocate a certain Management % of costs according to WSI business rules. 12 General Claim Business Ability to update and track all information related to child support Management withholding specific to a claim and/or legal entity. 13 General Claim Business Ability to set up a new claim on a closed, cancelled, uninsured, and open Management policy. 14 General Claim Business Ability to view a claim or search for a claim by entering predefined Management parameters. Parameters such as: policy number, Social Security Number, injury date, etc. 15 General Claim Business Ability to view policyholder's information by entering predefined Management parameters. Parameters such as: employer name, policy number, etc. 16 General Claim Business System should display the current claim number, claimant name, and date Management of injury in the window/page title bar or some obvious location to indicate what claim is currently being worked on. 17 Auto adjudicate Business The ability to auto adjudicate and then auto pay claims according to WSI business rules. Auto adjudicate 18 Indemnity Payments Business Ability to select a benefit type according to WSI business rules (e.g. Temporary Total Disability, Permanent Total Disability, etc.). 19 Indemnity Payments Business 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. AWW 20 Indemnity Payments Business 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. WCR 2 of 57 Injury - Claims 21 Indemnity Payments Business Ability to manually override a WCR. 22 Indemnity Payments Business Automatically calculate appropriate payment amount, based WSI business rules. 23 Indemnity Payments Business Ability to specify one or more payees, effective dates, and distribution Idemnity amount(s) for indemnity payments. payments 24 Indemnity Payments Business Ability to indicate loss of earnings (LOE) and recurrent loss of earning (RLOE) dates. LOE 25 Indemnity Payments Business Ability to schedule payments for one or more payment periods. 26 Indemnity Payments Business Ability to enter and apply offsets according to WSI business rules (e.g. nursing homes, social security, overpayments, aggravations, suspended benefits ). Offsets 27 Indemnity Payments Business Ability to recalculate one or more payments in a single interaction and see a history of those changes. 28 Indemnity Payments Business Ability to view a summary of all payments related to a claim and/or legal entity and ability to sort by payment parameters. 29 Indemnity Payments Business Ability to create and issue lump sum payments such as settlements and Permanent Partial Impairment (PPI), according to WSI business rules. 30 Indemnity Payments Business Ability to produce a compensation remittance/indemnity payment summary. 31 Indemnity Payments Business Provide a rate calculator tool to assist an adjuster in establishing payment amounts. Rate Calculator 32 Indemnity Payments Business Ability to automate a schedule or series of schedules of indemnity payments to an injured worker according to WSI business rules. 33 Indemnity Payments Business 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. 34 Indemnity Payment Business Ability to generate a discontinuation notice letter linked to the indemnity payment. 35 Indemnity Payments/ Business System should disburse indemnity and medical payments on a daily basis. Medical Payments 36 Medical Payments Business 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. 38 Medical Payments Business 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 UB- 92. 39 Medical Payments Business Ability to transfer bill data and supporting documentation between claims. 40 Medical Payments Business Ability to update a bill regardless of status based on WSI business rules. 41 Medical Payments Business Ability to request a medical note from the provider off of a medical bill for a particular date of service through automatic form generation. 42 Other payments Business System should allow for automatic application of travel reimbursement rates according to WSI business rules. 43 Reserves Business Ability to establish and update reserves according to WSI business rules. Reserves 44 Reserves Business Ability to integrate with third party software for reserve predictions. Describe the system's ability to integrate with third party software for reserve predictions. 45 Reserves Business Ability to view indemnity, allocated loss adjustment expense (ALAE) and medical reserve history. 46 Reserves Business 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. 47 Collections / Business System should have the ability to record and track overpayment activity Overpayments specific to a claim and/or legal entity. 48 Medical Events Business Ability to enter, modify, and track WSI ordered evaluations and services. Such as Independent Medical Evaluations (IME), Functional Capacity Assessments, Chronic Pain Evaluations, etc. 4 of 57 Injury - Records Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 File Copies Business Capability to bill the customer for file copy requests or services. 2 File Copies Business Track status of file copy request. 3 File Copies Business Ability to track and integrate bar-coding of files according to WSI business rules. 4 File Copies Business Ability to pull, store and export specific imaged file content according to predefined security and business rules. 5 File Copies Business Ability to integrate with a third party software vendor that can deliver an electronic file copy. 6 File Copies Business Ability to integrate with an FTP site for posting electronic files. 7 File Copies Business Ability to produce paper file copies via an image printer. 8 File Copies Business Ability for customer to request a file copy online. 9 File Copies Business Ability to add global and/or individual messages to each file copy request, whether paper or electronic. 10 File Copies Business Ability to establish automatic schedules for file copy updates. 11 Document Business Given appropriate security, ability to delete a document that has been Management scanned incorrectly. 12 Document Business Given appropriate security, ability to modify incorrect index values and Management have automatic workflow event(s) sent according to WSI business rules. 13 Document Business Ability to separate a multiple page image into separate documents after Management indexing. 14 Document Business Ability to associate an existing image with multiple electronic files. Management 15 Document Business The system must have the ability to manually or automatically purge Management imaged records in accordance with WSI business rules. 16 Records Retention Business The system must have the ability to purge database records in accordance with WSI business rules. 17 Claim Registration Business 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). 5 of 57 Injury - Records 18 Claim Registration Business Ability to register a new claim through an online process and return a claim number to the user immediately. 19 Claim Registration Business System automatically identifies and flags duplicate claims. 20 Claim Registration Business Ability to associate multiple claims resulting from a single event. 21 Bill Entry Business Ability to process medical and non-medical bills based on WSI business rules. Describe this process. 22 Bill Entry Business Ability to enter duplicate bills in order to accommodate correct records retention needs. 23 Bill Entry Business Ability to detect, identify and create workflow when a duplicate bill has been entered. 24 Bill Entry Business Electronically receive medical bills and records and incorporate them into an imaging system. 25 Verification Business Ability to interface with Optical Character Recognition (OCR). 26 Document Entry / Business Ability to manage (e.g. scan, view, print, attribute notes, delete, invoke Indexing automatic mailing, auto purge) all documentation electronically without a file number in a queue until it can be associated to a file. 27 Document Entry Business Ability to interface with FileNet Capture or a third party imaging product. 28 Document Entry 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). 29 Document Entry Business 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). 30 Document Entry Business Ability to interface with Captaris - FileNet OEM Edition or a third party fax server product. 31 Document Entry Business 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. 6 of 57 Injury - Records 32 Document Entry 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. 33 Fax Business Describe your system's ability to send and receive faxes and maintain records of all faxing activity. 34 Fax Server Business Describe the ability to archive electronic documents directly to the imaging system. 35 Document Retention Business Describe your ability to identify and retain, in original format, electronic files and data records for the purpose of document retention. 36 Document Retention Business Ability to automatically identify and schedule disposal of electronic records based on WSI's retention schedule. 37 Document Retention Business The system should have the ability to manually purge electronic records once the retention schedules have expired. Describe this process. 38 Document Retention Business Ability to show what requested information was released and to what outside party. 39 Document Retention Business Ability to accept and directly associate electronic information to an electronic file. 40 Document Retention Business Ability to automatically identify and notify designated WSI staff of paper records ready for disposal based on WSI's retention schedule. 41 Document Retention Business Ability to track the volume of electronic data removed from the system based on WSI retention schedule. 7 of 57 Injury - Customer Support Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 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 1 General Support Business 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, 2 General Support Business 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 3 General Support Business provider, diagnosis and conditions both compensable/denied. Ability to view, on a single summary screen, medical treatment 4 General Support Business authorizations and requests including past and pending authorizations. 5 General Support Business Ability to engage in live web chats. Ability to automatically retrieve imaged information when entering a unique 6 General Support Business identifier. Ability for the customer to access claim/account information through an 7 General Support Business 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 8 General Support Business report status. Ability to view individuals or businesses with an affidavit of non- 9 General Support Business employment on file. 10 General Support Business Ability to view application for insurance including those pending coverage. 8 of 57 Injury - Customer Support 11 General Support Business Ability to support multiple document interface. 9 of 57 Injury - Medical Services Number Subject Matter Area Type Requirement Glossary Link (Business or Technical) 1 Pharmacy Services 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. NCPDP 2 Pharmacy Services Business 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. 3 Pharmacy Services Business Ability to 'lock in'/restrict an injured worker into a specific pharmacy or a specific physician provider. 4 Pharmacy Services Business 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. 5 Pharmacy Services Business Ability to process/map a held "first fill" charge on injured workers that are not in our system to a claim of any status. 6 Pharmacy Services Business Provide an alert notification that would be able to identify potential matches of "first fill" injured workers with data currently in the system. 7 Pharmacy Services Business Ability to process and pay administrative fees and unmapped first fill charges. 8 Pharmacy Services Business Ability to map administrative charges to specific claims. 9 Pharmacy Services Business Ability to apply pharmacy fee schedules to bills that do not come through the Pharmacy Benefit Administrator (PBA). PBA 10 Pharmacy Services Business Ability to see individual ingredients in a compound prescription. 11 Pharmacy Services Business Capability to import and store data fields related to "captured" pharmacy captured pharmacy transactions. transactions 12 Pharmacy Services Business 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. 13 Pharmacy Services Business Ability to view the override history of plan limits. 14 Pharmacy Services Business Ability to track consultation information in a claim. 10 of 57 Injury - Medical Services 15 Pharmacy Services 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. 16 Pharmacy Services Business Ability to process and track pharmacy rebates. 17 Bill Processing Business The ability to process fee schedules from submitted medical billing codes. 18 Bill Processing Business 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 Allowable Cost (MAC) pricing. DME 19 Bill Processing Business Ability to manually audit a medical bill(s). 20 Bill Processing Business 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 - Ability to change a bill status (audit, pending, released) CPT 21 Bill Processing Business Ability to automate medical bill payment processing according to WSI business rules. 22 Bill Processing Business Ability to assign multiple ICD-9 codes to a single bill line item charge. ICD-9 23 Bill Processing Business Ability to automatically process medical bills line-by-line, approving or denying charges according to ICD-9 codes. 24 Bill Processing Business Ability to manually approve medical bills that might have been rejected in the automated process. 25 Bill Processing Business Ability to adjust and reprocess bills. 26 Bill Processing Business Ability to manually override assignment of fee schedules. 27 Bill Processing Business Ability to maintain multiple fee schedules in order to pay old bills according to any of these schedules, where appropriate. 11 of 57 Injury - Medical Services 28 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. CCI 29 Bill Processing Business Ability to automatically apply edits such as CCI edits, Global Packaging edits and modifiers and produce notification when these edits occur. Global Packing 30 Bill Processing Business Ability to process bills by applying alternative fee schedules according to WSI business rules. 31 Bill Processing Business Ability to automatically apply the appropriate reason codes to each line item charge for all reductions/denials during automated bill processing. 32 Bill Processing Business Ability to enter notes related to the reasons for the denial or reduced charge of a medical bill. 33 PPI Business Ability to track on a single, unique identifier all Permanent Partial Impairment (PPI) evaluations/awards to an injured worker with multiple claims. PPI 34 PPI Business Ability to track all Permanent Partial Impairment (PPI) evaluations/awards for a specific claim. 35 PPI Business 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 36 PPI/MMI Business 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 MMI 12 of 57 Injury - Medical Services 37 Utilization Review 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. UR 38 Utilization Review Business Ability to view the UR history both globally and by claim. 39 Utilization Review Business 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. 40 Utilization Review Business Ability to send a service request and supporting documentation to an external reviewer in real time. 41 Utilization Review Business 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. OCC 42 Utilization Review Business Ability for third parties to electronically review and provide a recommendation directly into our system. 43 Utilization Review Business Ability to automatically approve a UR request according to WSI business rules. 44 Medical Remittances Business Ability to produce a remittance advice to coincide with a medical bill pay run. 45 Medical Remittances Business Ability to design and incorporate a custom WSI remittance advice template. 46 Medical Remittances Business Ability to insert a customized message on the remittances. 47 Claims / Treatment Business Ability to create a treatment entry automatically or manually when a history medical bill, medical note, or medical event is received. 48 Claims / Treatment Business Ability to view treatment history by a single, unique identifier to an injured history worker with multiple claims . 49 Claims / Treatment Business Ability to track injured worker satisfaction/success feedback. history 50 Claims / Treatment Business Describe if/how your system supports tracking of information related to a history 'point of service' notification when an injured worker attends a treatment visit. 51 Online Services Business Ability to provide an online service to look up claim information based on WSI business rules. 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. 53 Online Services Business Ability to provide an online service to view WSI's return authorizations/decisions on their UR requests based on WSI business rules. 54 Online Services Business Ability to provide an online service that displays all provider billing information. 55 Online Services Business Ability to provide an online service where providers could access and submit from a library of WSI fillable forms. 56 Other Business 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. 57 Other Business 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. 14 of 57 Injury - Return to Work Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 Triage Business Ability to automatically triage and generate a customized claims management plan from collected data. 2 Voc Rehab Business Ability to enter, update and track vocational rehabilitation services information by claim number. 3 Voc Rehab Business Ability to enter, update and track case management services information by claim number. 4 Voc Rehab Business Ability to view vocational rehabilitation information by a legal entity. 5 Voc Rehab Business Ability to enter and track return to work statistics based on WSI business rules. 6 Disability Guidelines Business Ability to automate workflow events by incorporating WSI business rules and third party disability guidelines. 7 Preferred Worker Business Ability to enter, modify and track Preferred Worker Program (PWP) information. 8 Preferred Worker Business Ability to automatically request a disbursement of PWP payments. 9 Preferred Worker Business Ability to view payment history on all PWP expenses. 15 of 57 Employer - Collections Number Subject Matter Area Type Requirement Glossary Link (Business or Technical) Ability to record and track employer account collection activity based on 1 Collections Process Business WSI business rules. Collection Ability to record and track claims overpayment collection activity based on 2 Collections Process Business WSI business rules. Ability to write-off balances of claims overpayments based on WSI 3 Collections Process Business business rules. Ability to write-off balances of an employer account based on WSI 4 Collections Process Business business rules. Ability to manually or automatically assess and waive penalties and other 5 Collections Process Business charges based on WSI business rules. Describe the standard reports and queries available that pertain to 6 Collections Process Business collections. Ability to manually or automatically modify the status of an employer 7 Collections Process Business account based on WSI business rules. 8 Collections Process Business Ability to track multiple collection types for an employer account. Ability to manually or automatically open and close a collection case based 9 Collections Process Business on WSI business rules. Ability to record multiple judgments against an employer based on WSI 10 Collections Process Business business rules. Amortization 11 Collections Process Business Provide an amortization schedule for alternative payment arrangements. schedule Ability to automatically manage accounts in bankruptcy based on WSI 12 Collections Process Business business rules. Bankruptcy 13 Collections Process Business Ability to invoice a claims overpayment. Ability to display collection status on a policyholder's certificate of 14 Collections Process Business coverage. 16 of 57 Employer - Payroll Processing Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 Input/Audit Business Capture payroll information on a periodic basis. Notify employers that their payroll information is due. Describe the 2 Input/Audit Business available methods of notification. Employers can submit their payroll information online using an online form 3 Input/Audit Business that will automatically integrate the information into the system. Generate custom payroll reports based on employers' legal entity 4 Input/Audit Business classification. 5 Input/Audit Business Generate duplicate payroll reports upon request. 6 Input/Audit Business Barcode payroll reports for tracking and receipt. 7 Input/Audit Business Track or monitor the status of a payroll report. Identify, track and process employers who are delinquent in filing periodic 8 Input/Audit Business payroll information. 9 Input/Audit Business Automatically assess penalties based on WSI business rules. 10 Input/Audit Business Audit payroll information based on WSI business rules. Automatically identify accounts for a potential field audit based on WSI 11 Input/Audit Business business rules. Field audit Ability to capture gross and taxable payroll at the employee level based on 12 Input Business WSI business rules. Gross 13 Audit Business Ability to adjust gross and taxable wages at the employee level. wages 17 of 57 Employer - Premium Billing Number Subject Matter Area Type Requirement Glossary Link (Business or Technical) Ability to calculate and bill premium for policy periods to include wages, classifications, rates, premium discounts, experience modification, 1 Billing Business applicable rating plan factors, minimum premium. Premium Ability to bill multiple types of optional coverage based on factors such as 2 Optional Coverage Business 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 3 Billing Business cap. Dividend Ability to apply different interest rates by fiscal year based on WSI business 4 Billing Business rules. Ability to provide alternative payment schedules and terms based on WSI 5 Billing Business business rules. 6 Billing Business Ability to apply discounts for early payment of premium. 7 Billing Business Ability to provide electronic billing notification. 8 Billing Business Ability to present billing statements online or electronically. 9 Billing Business Ability to generate customized premium statements. 10 Billing Business Ability to customize messages to premium statements. 11 Billing Business Ability to attach correspondence to premium statements. Ability to show calculation details on all billing statements including any 12 Billing Business adjustments. 13 Audit Business Ability to calculate and generate a revised premium bill. 14 Billing Business 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, 15 Billing Business rate classification. Experience Ability to calculate experience modification factors based on WSI business 16 Modification Business rules. 18 of 57 Employer - Premium Billing Experience Ability to adjust experience modification factors for multiple policy periods 17 Modification Business for all policies within a group. Experience Ability to adjust experience modification factors for multiple policy periods 18 Modification Business resulting from subrogation orders. Subrogation 19 Billing Business Ability to establish and maintain retrospective rated policies. 20 Billing Business Ability to establish and maintain deductible rated policies. Ability to calculate and bill premium, interest, and penalty charges on 21 Billing Business accounts that are deemed uninsured. Ability to generate premium charges based on alternative units of 22 Billing Business exposure, such as number per capita, dollar per volunteer, per hour. 23 Audits Business Ability to maintain historical information of completed premium audits. 24 Audits Business Ability to query and track premium audits based on WSI business rules. 25 Audits Business Ability to generate audit work papers on demand. Ability to automatically generate a revised premium billing based on a field 26 Audits Business audit. Ability to update employer profile information based on WSI business 27 Audits Business rules. 19 of 57 Employer - Payments & Certs Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Ability to receive payments by various forms, such as: EFT, check, credit 1 Cash Receipts Business card, cash. 2 Cash Receipts Business Ability to receive payments online. 3 Cash Receipts Business Ability to apply cash receipts based on WSI business rules. Simple view of a specific account's balances, such as: claim loss, 4 Cash Receipts Business deductible, premium, etc. 5 Payments Business 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 6 Cash Receipts Business balances. Ability to make transaction corrections, such as: credits, refunds, balance 7 Cash Receipts Business transfers, transposition of numbers, voiding a payment. 8 Cash Receipts Business Describe standard reports available that are related to Payments. 9 Cash Receipts Business Ability to process an NSF (Non Sufficient Funds) transaction. Ability to customize a certificate template. Include a copy of the certificate 10 Certificates Business here. 11 Certificates Business Ability to manually generate a certificate on demand. 12 Certificates Business Ability to automatically generate certificates based on WSI business rules. 13 Certificates Business Ability to access and print a certificate online. 14 Certificates Business Ability to generate proof of coverage card in wallet size. Ability to issue and void refunds, individually and in batches, based on WSI 15 Refunds Business business rules. 16 Refunds Business Ability to automatically generate correspondence based on refund type. 20 of 57 Employer - Assesments Number Subject Matter Area Type Requirement Glossary Link (Business or Technical) Deductible Ability to automatically assess policyholders for costs associated with each 1 Assessments Business claim based on WSI business rules. Deductible 2 Assessments Business Ability to bill premium and claim loss deductibles on a single statement. Ability to automatically adjust claim loss deductible charges based on WSI Deductible business rules. Examples include subrogation, transfers, consolidations, 3 Assessments Business denials. Subrogation Deductible Ability to manually adjust claim loss deductible charges based on 4 Assessments Business appropriate security levels. Deductible Deductible Ability to apply different interest rates by fiscal year based on WSI 5 Assessments Business business rules. Rate Deductible 6 Assessments Business Ability to generate customized claim loss deductible statements. Deductible Ability to add global and/or individual messages to claim loss deductible 7 Assessments Business statements. Deductible 8 Assessments Business Ability to provide electronic billing notification. Deductible Ability to attach correspondence to claim loss deductible statements based 9 Assessments Business on WSI business rules. Deductible 10 Assessments Business Ability to apply discounts for early payments based on business rules. Deductible Ability to establish alternative payment schedules and terms based on WSI 11 Assessments Business business rules. Deductible Ability to show detailed calculation on all claim loss deductible statements 12 Assessments Business including any adjustments. 13 Online Incident Report Business Ability for employers to submit an online incident report. Ability to send confirmation to employer once they have submitted their 14 Online Incident Report Business incident report online. 21 of 57 Employer - Underwritting Number Subject Matter Area Type Requirement Glossary Link (Business or Technical) Ability to underwrite, cancel and reinstate mandatory coverage based on Mandatory 1 Canceling Coverage Business WSI business rules. Coverage Ability to underwrite, cancel and reinstate multiple types of optional coverage, such as: owner officers, self employed, family members and type of entity. Optional 2 Optional Coverage Business coverage 3 Underwriting Process Business Ability to generate a customized application for insurance form. Ability to track the underwriting process from the receipt of application to 4 Underwriting Process Business when it is processed for billing. 5 Underwriting Process Business 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 6 Underwriting Process Business employer location. Ability for employers to submit their application online and integrate this 7 Underwriting Process Business information into the system automatically. Ability to underwrite uninsured period of exposure for work activity 8 Uninsured Business 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- 9 Underwriting Process Business affidavit of non-employment. employment Ability to categorize employers, such as: size, industry, Professional Professional Employer Organization (PEO), Preferred worker, Foreign farm worker, Employer 10 Underwriting Process Business NAICS (North American Industrial Classification System). Organization When a new application is received, ability to automatically identify and flag duplicate or similar information, already in the system, based on WSI 11 Underwriting Process Business business rules. Ability to automatically underwrite an application based on WSI business 12 Underwriting Process Business rules. 22 of 57 Employer - Underwritting Ability to assign or change a rate classification sub-class description by 13 Rate Classification Business employer. 14 Canceling Coverage Business Ability to cancel a policy and generate a final payroll report. 15 Underwriting Process Business Ability to flag an account for a potential field audit. Ability to underwrite, cancel and reinstate reciprocal coverage with other Reciprocal 16 Reciprocal Coverage Business states. coverage Ability to calculate an aggregate experience rate for an identified group of 17 Consolidation Business policyholders based on WSI business rules. 18 Consolidation Business Ability to consolidate policy information based on WSI business rules. 19 Consolidation Business Ability to separate a single policy into multiple policies. 20 Underwriting Process Business Ability to barcode applications for tracking and receipt. Ability to provide the employer the ability to establish an account using an 21 Underwriting Process Business online application wizard based on WSI business rules. All states incidental 22 Underwriting Process Business Ability to underwrite, cancel and reinstate all states incidental coverage. coverage 23 Underwriting Process Business Ability to underwrite, cancel and reinstate AG Excess coverage. 23 of 57 Other - Communications Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Internet Online Online services should be accessible to the user through WSI's Internet 1 Services Business site. Internet Online WSI should have the ability to control the overall look and feel of online 2 Services Business services. Internet Online Online services provided should have the ability to have the same look and 3 Services Business feel as the WSI internet site. Internet Online Online services provided should be Americans with Disabilities Act (ADA) 4 Services Business compliant. 5 Web Portal Business Describe the web portal capabilities (if any) of your product. 24 of 57 Other - Executive Staff Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 Reports Business 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. 2 Query Business A system query tool must be supplied. Describe your system query capabilities. 25 of 57 Other - Independent Review Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Dispute Resolution and Constituency Ability to view claims and legal information based on appropriate 1 Services Business authorization level. Dispute Resolution , Binding Dispute Resolution, and Ability to automate the OIR dispute resolution registration process, such 2 Constituency Services Business as: populating forms, generating letters and sending events. OIR 26 of 57 Other - Legal Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Litigation Describe the standard list of reports and queries that pertain to litigation 1 Management Business and subrogation. Litigation Litigation Ability to create, modify, and track history of information throughout the 2 Management Business notice of decision process based on WSI business rules. Litigation Management and Subrogation 3 Processing Business Ability to autopay legal billings based on WSI business rules. Provide a subrogation calculator tool with the ability to perform and save Subrogation automatic subrogation settlement calculations, with the option to manually 4 Processing Business override, based on WSI business rules. 27 of 57 Other - Legal Subrogation 28 of 57 Other - Finance Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 Tax Tables Business Ability to update and maintain history of Federal tax tables. 2 Tax Tables Business Ability to update and maintain history of the State average weekly wage tables. 3 1099 Processing Business Ability to issue 1099's to the payee and an electronic file to the IRS as well as maintain history. 4 Financial Package Business 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, write- offs 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). 5 Financial Package Business 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. 6 Payments Business Ability to issue payments automatically in a batch and individually on demand. Such as Claims Payments, Premium Refunds/Payments, Administrative Payments. 7 Payments Business Ability to void and reissue payments. 29 of 57 Other - Finance 8 Payments Business Ability to provide payments via check and EFT. 9 Payments Business 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. 10 Payments Business 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 Requirement Glossary Link (Business or Technical) Legal entity Ability to establish Legal Entities for providers, injured workers, employers, 1 requirements Business etc. and manage attributes of those entities based on WSI business rules. Legal entity Legal entity 2 requirements Business Provide us your list of legal entity attributes for injured worker. Legal entity 3 requirements Business Provide us your list of legal entity attributes for providers. Legal entity 4 requirements Business Provide us your list of legal entity attributes for employers. Legal entity Ability to automatically/manually enter and maintain addresses based on 5 requirements Business United States Postal Service (USPS) information. Ability to view and search all information relating to Legal Entities such as; Legal entity attribute history, claim history, employment, provider relationship, 6 requirements Business dependant, beneficiary, etc based on WSI business rules. Legal entity 7 requirements Business Ability to link a Legal Entity with one or more other Legal Entities. Legal entity Describe your system's ability to use Legal Entity attributes in 8 requirements Business correspondence/payments/billing/etc. Legal entity Ability to identify the origin of WSI mailings by unique department code to 9 requirements Business be included in the address block. Legal entity Describe your ability to manage multiple addresses for a Legal entity such 10 requirements Business as physical, payment, and mailing/correspondence addresses. Legal entity 11 requirements Business Ability to indicate if a vendor is a 1099 recipient. Legal entity 12 requirements Ability to indicate 1099 payment type. Such as box 6 - medical payments. Legal entity Ability to record a Doing Business As (DBA) name in addition to a Legal 13 requirements Business business name, on a legal entity type of provider and employer. Legal entity 14 requirements Business Ability to record an alias on a legal entity type of injured worker. 31 of 57 Other - Global - Legal Entity Legal entity Ability to automatically identify duplicate legal entities and allow for manual 15 requirements combination. 32 of 57 Other - Global - Workflow Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Work Flow must have specific information required for processing, such as 1 Work Flow Business the priority, target completion date, origin of workflow. Work flow 2 Work Flow Business 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 3 Work Flow Business 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, 4 Work Flow Business based on WSI business rules. 5 Work Flow Business Ability to retain a history of all workflow activity. 6 Work Flow Business Ability to search workflow activity history by predefined parameters. Ability to temporarily alter workflow assignment based on WSI business 7 Work Flow Business rules. Ability to automatically or manually assign workflow activities based on 8 Work Flow Business WSI business rules. 9 Work Flow Business Ability to alter workflow, based on WSI business rules. Ability to trigger workflow activity by external applications such as web 10 Work Flow Business service. Ability to generate electronic forms by automatically populating information 11 Work Flow Business and produce workflow for referrals or procedures. 12 Work Flow Business Ability to electronically authorize workflow activity. Ability to provide electronic proof of processing for routing of workflow 13 Work Flow Business activity. 14 Work Flow Business Describe the ability to select and execute a work task from a master list. Ability for system to interface with state agencies utilizing enterprise 15 Work Flow Technical service transactions. Ability to send correspondence to multiple recipients utilizing multiple 16 Correspondence Business methods such as email, fax, paper. 33 of 57 Other - Global - Workflow Ability for a user to manually trigger the generation of a specific letter to be 17 Correspondence Business mailed. 34 of 57 Other - Global - Forms Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 Forms Tools 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 2 Forms Tools Business business rules. Automated capability for attaching images and documents to outgoing 3 Forms Tools Business correspondence. Ability to create, test, update, maintain and produce forms and envelopes 4 Forms Tools Business in one system. 5 Forms Tools Business 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 6 Forms Tools Business based on USPS regulations. 7 Forms Tools Business 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 8 Forms Tools Business forms and envelopes. Ability to automatically create and store an image of all outgoing 9 Forms Tools Business correspondence based on WSI business rules. 35 of 57 Other - Global - Notes Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Ability to create and attach notes to any specific document or any legal 1 Notes Business entity. Please describe the process by which you will accomplish this. Ability to search, sort and access notes, by category, content, sub- 2 Notes Business category, header, etc. Describe all the features of your systems notepad functionality such as 3 Notes Business spell-check, category, captions. Describe your process for displaying notes attached to a specific item such 4 Notes Business as address, transaction, policyholder, remittance advice. 5 Notes Business Ability to attach a note to multiple claims or a legal entity. 6 Notes Business Ability to attach notes to items in an image/content management system. Other - Global - Misc Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) General Claim Ability to link to third party sites to reference their information such as 1 Management Business CareMC, Merck, ODG, etc. Ability to enter, modify and track history of approved contacts for the General Claim "authorization to release information." This capability should be able to be 2 Management Business linked to a specific claim, account and/or legal entity. General Claim 3 Management Business Ability to use a "calendar assist" to select or input dates or date ranges. Global / Voice 4 activation Business Ability to interact with third party voice activation software. Globals / Visual Ability to display, a claim or policy status on every page based on WSI 5 Indicators Business business rules. 6 GUI Business Describe your system error reporting and notification capability. 7 Integration Business Ability for WSI to customize the look and feel of the application. 8 GUI Business Ability to maintain user preferences. 9 Integration Business Describe your ability to integrate with other COTS products. Describe your system's spell checking, grammar checking and content 10 Spell Checking Business filtering capabilities. Web and mobile 11 access Business Describe all mobile capabilities that your product may offer. Web and mobile Describe all online service capabilities for injured workers, providers and 12 access Business employers. Describe your system's ability to provide off-line data access, usage, and 13 Field reps Business synchronization. 37 of 57 Other - Global - Imaging & Tech Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Describe your ability to search, sort, view and print by categories and 1 Imaging Business document types. 2 Imaging Business 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 3 Imaging (Desktop Business appropriate artifact, WITHOUT altering the original artifact. Imaging (Desktop and 4 Web) Business Describe your systems' features and capability for viewing an image. Imaging (Desktop and 5 Web) Business Ability to retrieve electronic records via the desktop. Imaging (Desktop and 6 Web) Business Ability to publish records to the web. Imaging (Desktop and 7 Web) Technical Describe your systems' storage options. List all formats that are supported by the content storage system such as 8 Imaging Technical audio files, office documents, video files. 38 of 57 Other - Global - Other Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Capability to Accept ANSI 837 format for claims aka. Medical Billings 1 Other Business transactions. 2 Other Business ANSI 835 Remittance compliant. 3 Other Business Describe your system's ability to allow WSI to manage its business rules. Describe your procedure for implementing and integrating WSI business 4 Other Business rules. 39 of 57 Other - SIU Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 Field and Fraud Business Ability to track and reference case assignment and reassignment capability Investigation 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. 2 Field and Fraud Business Ability to provide historical tracking and reporting of all prior Investigation investigations/surveillance on claimant, provider, and/or employer. 3 Field and Fraud Business Ability to track and report case activity per each investigator and Investigation engagement on a claim, a specific employer, and/or specific provider based on WSI business rules. 4 Field and Fraud Business Ability to track and reference post-investigation activity based on WSI Investigation business rules. 5 Field and Fraud Technical / Ability to interface with outside sources through the use of a quick link to Investigation Business their sites/services. Examples include: state Motor Vehicle office, Corrections offices, ND Job Service, ND Private Investigation Board, Outside Secretary of State, etc. sources 6 Field and Fraud Business Ability to cross reference investigation history with Employer, Injured Investigation Worker, and Provider. 7 Field and Fraud Business Ability to integrate bar-coding to track and search all evidence items in a Investigation 'library' style system that would keep track of evidence information by using security levels incorporating access to a specific legal entity. 8 Field and Fraud Business Ability to enter, modify and track Hotline information that is accessed Hotline Investigation according to appropriate security roles for all tips received. Information 40 of 57 Technical - SOA Number Subject Matter Area Type Requirement Glossary Link (Business or 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 self- contained, 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 1 SOA Technical towards SOA. 41 of 57 Technical - Adminstration Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 Project Management Technical 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 2 Project Management Technical 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: 3 Project Management Technical http://www.nd.gov/epm/training/guidebook/index.html Describe the online tutorials and/or help tools that are embedded within 4 Training Technical 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 5 Training Business modules. 6 Training Technical Describe in detail the training materials given to end users. Describe how you would provide WSI with defined use case scenarios with 7 Training Technical a prepopulated training database. 8 Training Technical Training should be held at a WSI approved training facility(s). Describe any training available to WSI IT staff for system customization 9 Training Technical capabilities. Describe in detail the training plan for administration such as Security administration, System administration, Report administration, Database 10 Training Technical administration, etc. 42 of 57 Technical - Adminstration Describe your process of transferring knowledge to WSI leading to self- 11 Training Technical sufficiency. Ability to have WSI's procedure guides/manuals as an interactive electronic help tool that is fully searchable and contains wizards. These 12 Documentation Business guides/manuals will be updated by WSI. Describe how you would provide the following types of documentation: technical documentation, database documentation, application 13 Documentation Technical documentation. 43 of 57 Technical - Post Implementation Glossary Number Subject Matter Area Type Requirement Link (Business or 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 1 Maintenance Technical and not the current list price). Describe software maintenance operations related to corrective maintenance, adaptive maintenance, perfective maintenance, and 2 Maintenance Technical preventive maintenance. Describe the software "End of Life" version support and notification 3 Maintenance Technical process. Describe your software release procedures. Include descriptions of 4 Maintenance Technical 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 5 Software Support Technical shall provide. 6 Software Support Technical 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, 7 Maintenance Technical maximum severity rating, etc. 44 of 57 Technical - Post Implementation 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. 8 Transition-Out Technical -Entity Relationship Diagrams. Describe how and when vendor staff will transition-out after system 9 Transition-Out Technical implementation. The vendor shall work closely with WSI staff to continue normal maintenance and operations activities until completion of all Transition-Out 10 Transition-Out Technical Plan activities. 45 of 57 Technical - System Number Subject Matter Area Type Requirement Glossary Link (Business or Technical) Please describe the software license options that are included with your 1 Licensing Technical 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 2 Architecture Technical your application. 3 Architecture Technical Describe your business rules engine capabilities. Business rules engine 4 Architecture Technical Describe your ability to integrate with other software products and services. Describe methods you have for bridging the gap between your solution and 5 Architecture Technical 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 6 Architecture Technical media. Describe the web services and application programming interface (API) 7 Web Services Technical 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 8 Web Services Technical EGT-BP001 ). System data must be housed in an industry standard relational database management system (RDBMS), with Oracle being preferred due to WSI's 9 DBMS Technical current investment in Oracle. 10 DBMS Technical Data should be available 24 hours a day, 7 days a week. 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 11 Disaster Recovery Technical wish the RDBMS to be restored. 12 DBMS Technical Describe methods and/or tools used to guarantee data integrity. Describe the software languages and development skills needed to 13 Development Tools Technical 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 14 Hardware Technical 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 15 Hardware Technical 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 16 Hardware Technical Architecture - State Standards. The solution shall operate within the existing North Dakota Enterprise Architecture for Desktop Operating Systems Standard (Standard DT003- 06.1). Refer to Section 2.02 - State of North Dakota Technical Architecture - 17 Hardware Technical State Standards. 47 of 57 Business Technical - Implement Glossary Number Subject Matter Area Type Requirement Link (Business or 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 1 Implementation Technical processes to the new system). Hardware Requirements--Describe the site-specific hardware 2 Implementation Technical requirements necessary to support implementation. Software Requirements--Describe any software required to implement the system (such as, software specifically designed for automating the 3 Implementation Technical installation process). Network Requirements--Describe any network requirements required to 4 Implementation Technical implement the system. Data Requirements--Describe specific data preparation and conversion 5 Implementation Technical requirements that must be available for the system implementation. Facilities Requirements--Describe the site-specific physical facilities and 6 Implementation Technical 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 7 Implementation Technical be performed by each member of the implementation team. Schedule--Provide a detailed transition schedule that clearly defines key 8 Implementation Technical milestones, deliverables, tasks, and responsibilities during implementation. Procedures--Describe any operational procedures that are used during 9 Implementation Technical implementation such as a checklist, operations guide, etc. Describe vendor(s) experience related to the proposed system 10 Implementation Technical implementation. 48 of 57 Business Technical - Implement Describe the process for assuring that the system implementation was successful. (Please list all relevant references and clients with successful 11 Implementation Technical implementations). 49 of 57 Business Technical - Testing Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) 1 System support 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). 2 System support Technical Describe how, on what schedule, and by whom your product will be tested after WSI business rule modifications. 3 System support Technical Describe how your clients have successfully accomplished testing of your product after an upgrade to a new version and applying service upgrades. 4 System support Technical Describe any tools available or bundled with your product that could be used for testing purposes to include automated functional testing tool scripts. 5 System support Technical Describe what preprogrammed tests within your test plan are made available to your customers as part of the purchased product price. 6 System support Technical Describe any support forums you provide for your customers to seek assistance and technical material? 7 System Support Technical Describe features that your product has in order to support/monitor system performance. (e.g.audit logs, error logs, system notifications, etc.). 8 Product Quality Technical 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. 9 Product Quality Technical Describe your load testing procedures. 10 Product Quality Technical Describe how you communicate any and all unresolved issues to your customers prior to the release of the product? 50 of 57 Business Technical - Security Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Ability for application to provide for secure user authentication. Please 1 Security Technical describe. Describe how your application administers and applies security in each of 2 Security Business its modules/areas. 51 of 57 Safety - Loss Prevention Glossary Number Subject Matter Area Type Requirement Link (Business or Technical) Loss 1 Prevention/Control Business Ability to integrate WSI's calendar system, such as: Microsoft Outlook. Loss 2 Prevention/Control Business Ability to document customer visits/contacts based on WSI business rules. Loss Ability to automatically or manually assign employer services 3 Prevention/Control Business 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, 4 Online Business experience rate wizard, and safety, grant and/or discount programs. Loss 5 Prevention/Control Business Ability to associate policyholders based on WSI business rules. Loss Ability to administer and track safety, grant and/or discount programs 6 Prevention/Control Business based on WSI business rules. Loss 7 Prevention/Control Business Ability to integrate with WSI's Learning Management System. Loss Ability to identify policyholders eligible for premium discounts based on 8 Prevention/Control Business WSI business rules. 52 of 57 Term Definition Data that are a deviation of the HIPPA norm on patients who do "Captured" Pharmacy Transactions 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 Affidavit of Non-employment optional coverage. Provides North Dakota employers with multiple state workers' compensation coverage for employees who work temporarily All State Incidental Coverage outside the state. Calculation to determine a regular-interval payment plan to pay Amortization Schedule principal and interest System is set up so claims are automatically processed (based on pre-defined criteria) without adjuster involvement Auto Adjudication 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 AWW 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 Bankruptcy is a post-petition debt A Rule Base Engine that allows clients to separate business rules Business Rules Engine from application code. Correct Coding Initiative - CCI edits identify procedure codes (CPT codes) routinely bundled together. Codes that should be CCI 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 Collections required payment is not received on a claims overpayment. 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 An active account entity that enters into a merger, acquisition, or Consolidations purchase of the ownership rights of another account entity. Current Procedural Terminology - Codes used to describe the CPT procedure being performed by the medical provider. Deductible 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. Designated Medical Provider 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, DME guaze, etc. The process by which experience rating data are applied to the Experience Modification premium of the insured. A financial record survey of a person or organization that Field Audit 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 Global Packaging appropriate billing mechanism. An amount of money before deductions, usually associated with Gross Wages 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 HCPCS services being provided. Information received regarding possible claimant, employer, or Hotline Information 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 ICD-9 individual. A compensation payment including disability payments, permanent partial impairment (PPI) awards, or a lump sum Indemnity Payment settlement payment. 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 Legal Entity be added. Litigation Disputes pending before WSI or the courts. The date at which the injured worker first lost wages as a result of Loss of Earnings(LOE) the work injury. Workers' compensation insurance is mandatory for most Mandatory Coverage employment. This coverage is required by law. The least amount of premium to be charged for providing a Minimum Premium 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 MMI probability. Workforce Safety & Insurance is the sole provider and administrator of workers' compensation insurance in North Monopolistic State Dakota. National Council on Prescription Drug Program - This is the standard transaction data format all pharmacies use when NCPDP 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. NPIN 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. 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 Office of Independent Review (OIR) 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. Offsets 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 Optional Coverage 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. Outside Sources Pharmacy Benefit Administrator - WSI has contracted with a Pharmacy Benefit Administrator to assist in the processing of PBA 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 PPI 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. Preferred Worker The amount of money an insurer charges to provide the coverage Premium 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. Professional Employer Organization 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 Rate 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 Rate Calculator 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 Reciprocal Coverage 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. Recurrent Loss of Earnings(RLOE) Dollar amounts set aside for the cost of the claim. Estimating the total probable cost that will be incurred on a claim during its Reserves 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. Retrospective Rating 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. 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 Suspended Benefits payments. The amount of payroll per employee used to bill premium, which Taxable Wages 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). Total Cost Exposures A system designed to prioritize injuries/claims that demand the most attention or pose the greatest potential for a high cost Triage Risk Score 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. UR The maximum taxable payroll for each employee calculated by establishing a wage cap of 70% of the state's average annual Wage Cap wage. Weekly Compensation Rate - The rate at which an injured worker WCR 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, Work Flow document events, bill events, and user events.
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