Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
The Functional Requirements (listed in Table 5 of the RFP) are further described below. Each functional requirement is associated
with the users or user groups across HHS agencies who were involved in creating or refining these requirements. Listed
constituents therefore represent potential future users of solution capabilities designed to meet these requirements, and can be
expected to provide SMEs during planning and design phases. Their listing here does not imply any requirement for sequencing of
user access to solution capabilities, nor any requirement for business process integration of solution capabilities.
Each requirement is associated with MITA business processes in which the solution requirement could be reasonably expected to
have potential positive impact on future MITA process. (The listed business processes from the 2.03 framework have identical or
similar representation within the MITA 3.0 framework.)
_____________________________________________________________________________________________________
FR ID
FR001
Functional Requirement:
Map programs and waivers to create a program profile
Stage:
Client, Provider, and Enrollment Visibility
Description:
Many programs and waivers are authorized by federal and/or state legislation. This
will require business-managed reference tables that include enabling legislation and amendments
that authorize Medicaid funding programs. The tables provide a comprehensive view of
requirements for each program.
Potential User Groups:
SDS
System Forecasting
Vendor Drug Program
HHSC Operations Support (Managed Care)
Office of the Medical Director
MITA Business Processes: Develop Agency Goals and Objectives
Develop and Maintain Program Policy
Manage Program Information
Program Management (PG)
Program Management (PG)
Program Management (PG)
_____________________________________________________________________________________________________
FR ID
FR002
Functional Requirement:
Create consistent and readily available per capita program denominators
Stage:
Client, Provider, and Enrollment Visibility
Description:
Programs use program-specific denominators to calculate numbers of people eligible
for services, authorized to receive services, and that actually receive services. There is
significant variation in the way that programs calculate the number of individuals
receiving benefits. For example, a business process may be interested in the total number of
unique individuals receiving Medicaid services for a fiscal year. Another business process may
monitor and report the number of people in service each month. The method for calculating
per capita program participation will maintain flexibility to enable views of program
participation from multiple perspectives.
Potential User Groups:
DADS Budget Analysts
HHSC SDS
HHSC System Forecasting
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
HHSC Actuarial Analysis
LTC Analysts
THSteps
HHSC Rate Analysts
Vendor Drug Program
HHSC Office of the Medical Director
ECI Analysts
MITA Business Processes: Manage Member Grievance and Appeal
Manage Member Information
Perform Population and Member Outreach
Generate Financial and Program Analysis
Maintain Benefits-Reference Information
Member Management (ME)
Member Management (ME)
Member Management (ME)
Program Management (PG)
Program Management (PG)
_________________________________________________________________________________
FR ID
FR014
Functional Requirement:
Create integrated, unduplicated client profile and improve data quality.
Stage:
Client and Provider Data Management
Description:
The EDW will collect client profile data from several source systems and consolidate
this data to create a single, master record for each client.
Business rules will be established by the HHS Enterprise Data Governance (EDG)
project to determine which source system provides the most accurate source for each
data element.
Potential User Groups:
DADS Budget Analysts
LTC Analysts
HHSC Operations Support (Managed Care)
DSHS Center for Health Statistics
Contractors who need clean addresses for mailings
SDS
MH Inpatient Services
THSteps
ECI Analysts
DFPS Analysts
TMHP
HHSC Operations Support (Managed Care)
Office of the Medical Director
MITA Business Processes: Manage Member Information
Member Management (ME)
________________________________________________________________________________
FR ID
FR016
Functional Requirement:
Identify family units (not just households)
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Stage:
Client, Provider, and Enrollment Visibility
Description:
Some programs base eligibility on family units or households. This is not always
visible across programs. The EDW will be able to associate individuals with their
family members. Source systems such as the TIERS eligibility system data will be
used to link parents, children, siblings, and other family members to accurate reflect
family composition.
Potential User Groups:
LTC Analysts
Office of the Medical Director
MITA Business Processes: Determine Eligibility
Manage Member Information
Member Management (ME)
Member Management (ME)
__________________________________________________________________________________
FR ID
FR017
Functional Requirement:
Identify caregivers and track status (e.g., age, health, availability to client, location)
Stage:
Client, Provider, and Enrollment Visibility
Description:
This requirement relates to HHS clients who also serve as caregivers. The intent is to
identify clients who serve as caregivers for others (a child with disabilities, for
example) to enable proactive intervention to support the client's healthcare status.
For example, a parent providing full-time support for a family member with
disabilities may be at risk of stress-related health issues. These individuals may
benefit from periodic respite care services or other supportive services.
Potential User Groups:
LTC Analysts
Office of the Medical Director
People who need clean addresses for mailings
MITA Business Processes: Manage Member Information
Determine Eligibility
Member Management (ME)
Member Management (ME)
__________________________________________________________________________________
FR ID
FR022
Functional Requirement:
Track client eligibility across all programs included in TIERS
Stage:
Client, Provider, and Enrollment Visibility
Description:
The EDW will include information on client eligibility for Medicaid and for the
additional programs included in the TIERS system (Medicaid, CHIP, TANF, SNAP). The
EDW will be able to track periods of eligibility for all programs.
Potential User Groups:
TIERS Users
SDS
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Member Management (ME)
Member Management (ME)
___________________________________________________________________________________
FR ID
FR023
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Functional Requirement:
Provide visibility to client enrollment for all Medicaid programs
Stage:
Client, Provider, and Enrollment Visibility
Description:
Client eligibility for Medicaid is determined by HHSC and documented in the TIERS
system. For some Medicaid clients, an additional step is required to enroll them in
specific programs established to address unique client groups. For example,
Medicaid-eligible clients with disabilities may be enrolled in waiver programs that
allow them to receive services within their communities. The EDW will integrate with
source systems that track client enrollment for these Medicaid programs.
Potential User Groups:
LTC Analysts
HHSC Operations Support (Managed Care)
SDS
Vendor Drug Program
Office of the Medical Director
THSteps
MH Inpatient Services
MITA Business Processes: Enroll Member
Manage Member Information
Member Management (ME)
Member Management (ME)
___________________________________________________________________________________
FR ID
FR024
Functional Requirement:
Trend client enrollment / disenrollment across programs and risk groups.
Stage:
Client, Provider, and Enrollment Visibility
Description:
The EDW will be able to track the net change of client movement in and out of
programs and risk groups. Frequent movement between programs or in and out of
Medicaid-funded services are factors in increasing health risks for clients. Drops in
coverage may lead to limited access to care. Changes in programs may lead to
redundancies in services and agency administrative activities.
Potential User Groups:
SDS
DADS Budget Analysts
LTC Analysts
Office of the Medical Director
MH Inpatient Services
THSteps
Vendor Drug Program
HHSC Operations Support (Managed Care)
DFPS Analysts
System Forecasting
MITA Business Processes: Disenroll Member
Enroll Member
Manage Member Information
Member Management (ME)
Member Management (ME)
Member Management (ME)
_____________________________________________________________________________________
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
FR ID
FR025
Functional Requirement:
Investigate client churn by program or risk group.
Stage:
Client, Provider, and Enrollment Visibility
Description:
Currently, HHS is not able to track churn within or across programs. This is the
measure of unique clients that entered a Medicaid program or risk group and the
number of unique clients that left a program during a time period.
Potential User Groups:
SDS
DADS Budget Analysts
LTC Analysts
Office of the Medical Director
MH Inpatient Services
THSteps
Vendor Drug Program
HHSC Operations Support (Managed Care)
DFPS Analysts
MITA Business Processes: Manage Member Information
Generate Financial and Program Analysis
Member Management (ME)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR026
Functional Requirement:
Classify clients by disenrollment reasons to trigger intervention and/or alternate
program placements
Stage:
Client, Provider, and Enrollment Visibility
Description:
The EDW will include disenrollment reasons captured in eligibility or enrollment source systems
This data is used to determine whether there are additional programs or services that
may be available to a disenrolling client.
Potential User Groups:
DFPS Analysts
Office of the Medical Director
THSteps
LTC Analysts
MITA Business Processes: Disenroll Member
Manage Member Information
Authorize Referral
Member Management (ME)
Member Management (ME)
Operations Management (OM)
___________________________________________________________________________________
FR ID
FR027
Functional Requirement:
Provide visibility to client authorization for Medicaid
Stage:
Client, Provider, and Enrollment Visibility
Description:
Provide visibility into services that are authorized by a payer for a specific service.
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
This will assist to forecast costs in the future because it may indicate future services.
Potential User Groups:
LTC Analysts
System Forecasting
Office of the Medical Director
MITA Business Processes: Disenroll Member
Enroll Member
Manage Member Information
Authorize Referral
Member Management (ME)
Member Management (ME)
Member Management (ME)
Operations Management (OM)
___________________________________________________________________________________
FR ID
FR029
Functional Requirement:
Create an integrated provider profile and cross-reference.
Stage:
Client, Provider, and Enrollment Visibility
Description:
The EDW will integrate provider data from various source systems to create a single,
comprehensive view of the provider. The provider view includes, but is not limited
to, information concerning ownership/affiliation, service offered, locations served,
and HHS programs supported. The EDW will be able to identify all providers enrolled
to provide services under each Medicaid program. This includes a provider view
that identifies all programs for which a provider is enrolled where available in
provider data. This requirement does not involve analysis of service/encounter data.
Potential User Groups:
LTC Analysts
HHSC Operations Support (Managed Care)
People who need clean addresses for mailings
SDS
DADS Budget Analysts
System Forecasting
HHSC Actuarial Analysis
HHSC Rate Analysts
TMHP
Office of the Medical Director
MITA Business Processes: Enroll Provider
Inquire Provider Information
Manage Provider Information
Provider Management (PM)
Provider Management (PM)
Provider Management (PM)
__________________________________________________________________________________
FR ID
FR030
Functional Requirement:
Provide visibility to provider enrollment for all Medicaid clients.
Stage:
Client, Provider, and Enrollment Visibility
Description:
Users will be able to see a listing of all clients served by each provider
where that information is available in eligibility and enrollment systems.
Provider types, specialties, and their relationships within Medicaid managed care
will be described. This requirement is not intended to describe the process or status of
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
operational workflows (currently performed by the Claims Administrator) that credentials
and enrolls Medicaid providers. It is intended to capture the final results of that process,
and to make visible obvious provider relationships to clients (e.g. primary care physician
panel assignments). In early stages, this will not require mining of claims and
encounters events. In later stages, integrating relationship data available within
administrative events will be desirable, especially to understand client relationships
to specialty care, and to provide insight to referral patterns between providers and
provider groups.
Potential User Groups:
SDS
DADS Budget Analysts
THSteps
LTC Analysts
HHSC Actuarial Analysis
HHSC Operations Support (Managed Care)
TMHP
Office of the Medical Director
Vendor Drug Program
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Inquire Provider Information
Manage Provider Information
Member Management (ME)
Member Management (ME)
Provider Management (PM)
Provider Management (PM)
___________________________________________________________________________________
FR ID
FR031
Functional Requirement:
Provide integrated, cleansed provider data to support regulatory changes
Stage:
Description:
The EDW collects provider data from source systems, cleanses data to create
comprehensive provider records in support of regulatory reporting.
Potential User Groups:
HHSC Actuarial Analysis
HHSC Rate Analysts
DADS Budget Analysts
MITA Business Processes: Inquire Provider Information
Manage Provider Information
Provider Management (PM)
Provider Management (PM)
__________________________________________________________________________________
FR ID
FR032
Functional Requirement:
Integrate provider registry data from provider accreditation organizations.
Stage:
Client, Provider, and Enrollment Visibility
Description:
Limited integration to accreditation groups is accomplished through individual
source systems today. This requirement includes integration of licensing and
accreditation groups that are available in source systems and/or external subscriptions.
Potential User Groups:
LTC Analysts
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Office of the Medical Director
MITA Business Processes: Manage Member Information
Manage Provider Information
Member Management (ME)
Provider Management (PM)
___________________________________________________________________________________
FR ID
FR072
Functional Requirement:
Discover duplication based on enrollment in the integrated eligibility systems.
Stage:
Client, Provider, and Enrollment Visibility
Description:
The EDW will include the ability to identify clients who are enrolled in more than
one Medicaid-funded program.
Potential User Groups:
MFADS Users
DADS Budget Analysts
Office of the Medical Director
HHSC Operations Support (Managed Care)
MITA Business Processes: Manage Member Information
Generate Financial and Program Analysis
Identify Candidate Case
Member Management (ME)
Program Management (PG)
Program Integrity Management
___________________________________________________________________________________
FR ID
FR080
Functional Requirement:
Perform geographic and/or demographic analysis of clients.
Stage:
Client, Provider, and Enrollment Visibility
Description:
HHSC areas will be able to identify the characteristics of Medicaid clients receiving services
and their location. This type of analysis enables the HHSC to identify trends in
the types of clients requesting services and their location to ensure that adequate
services are available.
Potential User Groups:
SDS
DADS Budget Analysts
System Forecasting
DSHS Center for Health Statistics
THSteps
LTC Analysts
HHSC Actuarial Analysis
HHSC Rate Analysts
HHSC Operations Support (Managed Care)
TMHP
Vendor Drug Program
Office of the Medical Director
DFPS Analysts
ECI Analysts
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Member Management (ME)
Member Management (ME)
__________________________________________________________________________________
FR ID
FR103
Functional Requirement:
Provide visibility to clients by providers
Stage:
Client, Provider, and Enrollment Visibility
Description:
HHS agencies will be able to see a listing of all clients served by each provider where that
information is available in eligibility and enrollment systems.
Potential User Groups:
HHSC Strategic Decision Support
DADS Budget Analysts
DSHS THSteps
DADS Long Term Care Analysts
HHSC Actuarial Analysis
HHSC Operations Support (Managed Care)
HHSC TMHP
HHSC Office of the Medical Director
HHSC Vendor Drug Program
MITA Business Processes:
Inquire Member Eligibility
Manage Member Information
Inquire Provider Information
Manage Provider Information
Member Management (ME)
Member Management (ME)
Provider Management (PM)
Provider Management (PM)
___________________________________________________________________________________
FR ID
FR105
Functional Requirement:
Map provider and provider parent company relationships
Stage:
Client, Provider, and Enrollment Visibility
Description:
The EDW will support the ability to connect providers to provider parent companies.
The intent is to be able to examine whether and how providers are related so that when trends
or issues are identified, they may be addressed for all providers connected to the parent company.
Provider source systems and/or external subscription data will be used to create and update this
information.
Potential User Groups:
DADS Long Term Care Analysts
HHSC Office of the Medical Director
HHSC Strategic Decision Support
HHSC Actuarial Analysis
MFADS Users
HHSC TMHP
HHSC Operations Support (Managed Care)
DSHS THSteps
HHSC Vendor Drug Program
MITA Business Processes: Manage Provider Information
Provider Management (PM)
___________________________________________________________________________________
FR ID
FR086
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Functional Requirement:
Provide consistent, integrated reference data (e.g., programs/waivers, risk groups,
providers, drugs) to support: MCO oversight, regulatory reporting, and forecasting.
Stage:
All
Description:
Reference data and non-event data (including client profiles, provider profiles, and program
profiles) should be consistent across users. The EDW will provide conformed reference data
needed to describe drugs, DME, supplies, and other services provisioned to Medicaid clients.
Potential User Groups:
Enterprise Data Governance Group
HHSC IT
MITA Business Processes: Develop and Maintain Benefits Package
Develop Agency Goals and Objectives
Develop and Maintain Program Policy
Maintain Benefits-Reference Information
Program Management (PG)
Program Management (PG)
Program Management (PG)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR005
Functional Requirement:
Compare rates & costs for a client cohort within/across programs
Stage:
Service Delivery (Episodes of Care)
Description:
This requirement enables HHSC to make comparisons of costs for services to various
client groups across programs by using established benchmarks. The intent is to
identify disparate costs, investigate the reason for the differences and make policy
and/or rate changes to bring program reimbursements into alignment, if appropriate.
Source data will include both claims and managed care encounter data. The Vendor
will be able to establish a proxy for cost of specific services where the actual
payment is based on a capitated rate (managed care) and compare to other
programs. This requires Episodes of Care.
Potential User Groups:
DADS Budget Analysts
HHSC Rate Analysts
SDS
HHSC Actuarial Analysis
Vendor Drug Program
System Forecasting
LTC Analysts
HHSC Operations Support (Managed Care)
Office of the Medical Director
MITA Business Processes: Price Claim-Value Encounter
Prepare Capitation Premium Payments
Manage Payment Information
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
___________________________________________________________________________________
FR ID
FR007
Functional Requirement:
Monitor service utilization by program, risk group, or cohort.
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Stage:
Service Delivery (Episodes of Care)
Description:
This requirement includes the ability to identify types of service and the amount of
the service used from a program perspective, risk group perspective or cohort
perspective. Risk groups include but are not limited to Aged, Blind & Disabled,
Pregnant Women, Newborns and Infants. This requires Episodes of Care.
Potential User Groups:
SDS
DADS Budget Analysts
System Forecasting
HHSC Operations Support (Managed Care)
Office of the Medical Director
LTC Analysts
HHSC Rate Analysts
HHSC Actuarial Analysis
MITA Business Processes: Manage Provider Grievance and Appeal
Perform Population and Member Outreach
Manage Provider Grievance and Appeal
Manage Payment Information
Develop and Maintain Program Policy
Maintain Benefits-Reference Information
Manage Program Information
Manage Medicaid Population Health
Provider Management (PM)
Member Management (ME)
Provider Management (PM)
Operations Management (OM)
Program Management (PG)
Program Management (PG)
Program Management (PG)
Care Management (CM)
___________________________________________________________________________________
FR ID
FR008
Functional Requirement:
Anticipate future needs for programs by analysis of trends in services
Stage:
Service Delivery (Episodes of Care)
Description:
EDW will provide the ability to analyze service trends. HHS staff will analyze these
trends to identify the need for additional service offerings through Medicaid waivers
or other programs. This analysis may also inform agency biennial Legislative
Appropriations Requests. This will require Episodes of Care.
Potential User Groups:
DADS Budget Analysts
System Forecasting
HHSC Actuarial Analysis
Office of the Medical Director
MITA Business Processes: Develop and Maintain Benefits Package
Develop and Maintain Program Policy
Program Management (PG)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR009
Functional Requirement:
Benchmark Medicaid prices/costs/rates for comparisons within an agency and across
programs with historical data.
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Stage:
Service Delivery (Episodes of Care)
Description:
This requirement involves the collection of prices/costs/rates for all services and
ability to compare these costs across programs to determine benchmarks for services.
Internal data sources include claim and encounter data and rate-setting outputs.
External sources that include cost benchmarks for diagnosis and procedures codes or
for prescription drugs may also be included in the EDW to support comparisons of
Medicaid costs to those paid through private insurance. For capitated programs
external benchmarks will need to be developed. This requires Episodes of Care.
Potential User Groups:
DADS Budget Analysts
HHSC Operations Support (Managed Care)
Office of the Medical Director
SDS
System Forecasting
HHSC Rate Analysts
HHSC Operations Support (Managed Care)
MITA Business Processes: Price Claim-Value Encounter
Prepare Capitation Premium Payments
Manage Payment Information
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
__________________________________________________________________________________
FR ID
FR010
Functional Requirement:
Detect outlier client cohorts and rates that merit new programs/waivers
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will be able to identify client groups with needs that are not met or rates
that represent an outlier. This requires the ability to capture and monitor needs from
program assessment instruments and to identify services that are appropriate to
address these needs but are not available. This requirement does NOT address
geographic differences in the availability of services; rather, it addresses a client
group for whom services either do not exist or are inadequate to respond to their
identified needs. This requires Episodes of Care.
Potential User Groups:
LTC Analysts
Vendor Drug Program
HHSC Operations Support (Managed Care)
Office of the Medical Director
MITA Business Processes: Develop and Maintain Benefits Package
Develop and Maintain Program Policy
Manage Program Information
Program Management (PG)
Program Management (PG)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR011
Functional Requirement:
Improve ability to predict and manage the impact of changes to programs and
service delivery models.
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EDW Detailed Functional Requirements
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will support HHS' ability to "test" program and policy changes prior to
proposing revisions to programs and service delivery models. For example, HHSC will
be able to analyze the impact of a service rate change. This may be tested by
comparing the total cost of a service at the current rate to the cost of the same
services using a proposed rate. Agencies will be able to identify variables for
manipulation to enable testing of new approaches. Predictive analysis may take
place in a "sand box" separate from the operational data in the EDW. For instance, if
the state wanted to add in-patient carve-out program, the agency would want to
predict the pharmacy data for MCOs. This requires Episodes of Care.
Potential User Groups:
SDS
LTC Analysts
System Forecasting
Office of the Medical Director
HHSC Operations Support (Managed Care)
MITA Business Processes: Develop and Maintain Program Policy
Generate Financial and Program Analysis
Manage Program Information
Manage Medicaid Population Health
Manage Member Information
Perform Population and Member Outreach
Establish Case
Manage Registry
Program Management (PG)
Program Management (PG)
Program Management (PG)
Care Management (CM)
Member Management (ME)
Member Management (ME)
Care Management (CM)
Care Management (CM)
______________________________________________________________________________________
FR ID
FR034
Functional Requirement:
Track service delivery to client by provider including parent company.
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will be able to connect claims and encounter service delivery data for
specific clients to providers. The connection will also include the service provider's
parent company. This requires Episodes of Care.
Potential User Groups:
LTC Analysts
Office of the Medical Director
SDS
HHSC Actuarial Analysis
MFADS Users
TMHP
HHSC Operations Support (Managed Care)
THSteps
Vendor Drug Program
MITA Business Processes: Authorize Service
Manage Member Information
Manage Provider Information
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Operations Management (OM)
Member Management (ME)
Provider Management (PM)
Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
___________________________________________________________________________________
FR ID
FR035
Functional Requirement:
Track service delivery across programs by provider including parent company
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will be able to connect claims and encounter service data for specific
programs to providers. The connection will also include the service provider's parent
company. This requires Episodes of Care.
Potential User Groups:
LTC Analysts
Office of the Medical Director
SDS
HHSC Actuarial Analysis
MFADS Users
TMHP
HHSC Operations Support (Managed Care)
THSteps
Vendor Drug Program
MITA Business Processes: Authorize Service
Manage Provider Information
Develop and Maintain Benefits Package
Operations Management (OM)
Provider Management (PM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR036
Functional Requirement:
Compare episodes of care by provider type, specialty, or health plan.
Stage:
Service Delivery (Episodes of Care)
Description:
Agencies need the ability to compare specific services across several dimensions.
Link episodes of care to the providers that provided the services. This requires
Episodes of Care.
Potential User Groups:
Office of the Medical Director
SDS
LTC Analysts
HHSC Operations Support (Managed Care)
Vendor Drug Program
THSteps
MITA Business Processes: Authorize Service
Manage Provider Information
Develop and Maintain Benefits Package
Operations Management (OM)
Provider Management (PM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR037
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EDW Detailed Functional Requirements
Functional Requirement:
Assess quality of service by provider.
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will include a variety of metrics that may be used to assess quality. Where
available, actual quality measurements will be included. However, in most cases,
quality metrics have not yet been developed for various services. In these cases,
existing metrics such as elapsed time between service authorization and service
provision will be used to assess quality of services. This requires Episodes of Care.
Potential User Groups:
LTC Analysts
Office of the Medical Director
DADS Budget Analysts
SDS
TMHP
HHSC Operations Support (Managed Care)
Vendor Drug Program
THSteps
MITA Business Processes: Authorize Service
Manage Provider Information
Develop and Maintain Benefits Package
Operations Management (OM)
Provider Management (PM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR038
Functional Requirement:
Consolidate provider metrics.
Stage:
Service Delivery (Episodes of Care)
Description:
Collect all existing provider-related metrics from various source systems and
consolidate to create a comprehensive list of metrics for providers. This will enable
comparable analysis across provider types for equivalent services.
Potential User Groups:
SDS
DADS Budget Analysts
System Forecasting
THSteps
LTC Analysts
TMHP
Vendor Drug Program
HHSC Actuarial Analysis
Office of the Medical Director
MITA Business Processes: Inquire Provider Information
Manage Provider Information
Provider Management (PM)
Provider Management (PM)
___________________________________________________________________________________
FR ID
FR039
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EDW Detailed Functional Requirements
Functional Requirement:
Support coordination of care between successive care providers or programs
Stage:
Service Delivery (Episodes of Care)
Description:
Potential future enhancement to enable collection of all Episodes of Care by
provider to create a view of services that may be shared with subsequent providers.
This requirement is designed to support continuity of care. (In order to have full
functionality, HIE transactions would need to be integrated in future projects.)
This requires Episodes of Care.
Potential User Groups:
DFPS Analysts
LTC Analysts
HHSC Operations Support (Managed Care)
Office of the Medical Director
THSteps
MITA Business Processes: Authorize Service
Manage Member Information
Manage Provider Information
Develop and Maintain Benefits Package
Operations Management (OM)
Member Management (ME)
Provider Management (PM)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR040
Functional Requirement:
Parse encounters and claims data into Episodes of Care service categories.
Stage:
Service Delivery (Episodes of Care)
Description:
The Vendor will be able to parse encounters and claim data into distinct episodes of
care. Within the episode of care, each service stage (exam, diagnosis, etc.) will be
specifically identifiable to enable comparisons and analysis across episodes. This
requires Episodes of Care.
Potential User Groups:
SDS
DADS Budget Analysts
THSteps
LTC Analysts
HHSC Operations Support (Managed Care)
TMHP
Vendor Drug Program
Office of the Medical Director
MITA Business Processes: Apply Claim Attachment
Price Claim-Value Encounter
Prepare Home and Community Based Services
Payment
Prepare Capitation Premium Payments
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
__________________________________________________________________________________
FR ID
FR042
Functional Requirement:
Track and analyze differences in reimbursement units of service, e.g., time (day,
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hourly, fifteen minutes, encounter, etc.)
Stage:
Service Delivery (Episodes of Care)
Description:
Each program defines a unit of service and these definitions vary from one program
to the next. Units of service may be authorized and paid in time increments or they
may be authorized and paid using some other relevant measure (visit, procedure).
The EDW will be able to track a unit of services using these varying program
Potential User Groups:
MH Inpatient Services
Vendor Drug Program
MEHIS Analysts
LTC Analysts
DADS Budget Analysts
HHSC Rate Analysts
HHSC Actuarial Analysis
HHSC Operations Support (Managed Care)
SDS
Office of the Medical Director
MITA Business Processes: Develop and Maintain Benefits Package
Manage Payment Information
Prepare Capitation Premium Payments
Prepare Home and Community Based Services
Payment
Price Claim-Value Encounter
Authorize Service
Program Management (PG)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
___________________________________________________________________________________
FR ID
FR044
Functional Requirement:
Track cost of care across programs and providers
Stage:
Service Delivery (Episodes of Care)
Description:
The HHSC enterprise needs to ability to analyze costs from several perspectives.
This requirement addresses costs analysis from both a program and provider
perspective. The EDW will be able to access data to establish costs for programs and
providers. This functionality will require documentation of a detailed approach for
identifying costs in capitated care arrangements (managed care). This will require
Potential User Groups:
DADS Budget Analysts
HHSC Rate Analysts
HHSC Actuarial Analysis
SDS
System Forecasting
HHSC Operations Support (Managed Care)
Office of the Medical Director
Vendor Drug Program
MITA Business Processes: Manage Payment Information
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Operations Management (OM)
Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Manage Rate Setting
Develop and Maintain Program Policy
Formulate Budget
Generate Financial and Program Analysis
Manage Program Information
Identify Candidate Case
Program Management (PG)
Program Management (PG)
Program Management (PG)
Program Management (PG)
Program Management (PG)
Program Integrity Management
___________________________________________________________________________________
FR ID
FR045
Functional Requirement:
Identify clients with a specified primary diagnoses over a specific period of time.
Stage:
Service Delivery (Episodes of Care)
Description:
The HHS enterprise seeks the ability to analyze clients and services provided to
individuals with specific diagnoses over time. The intent is to evaluate the
effectiveness and efficacy of the services provided to address the diagnosis and
develop recommendations for improvement such as identification of new disease
management opportunities. This requires Episodes of Care.
Potential User Groups:
SDS
DADS Budget Analysts
System Forecasting
THSteps
LTC Analysts
HHSC Actuarial Analysis
HHSC Rate Analysts
HHSC Operations Support (Managed Care)
Vendor Drug Program
Office of the Medical Director
MITA Business Processes: Manage Member Information
Authorize Service
Authorize Treatment Plan
Manage Case
Manage Medicaid Population Health
Manage Registry
Member Management (ME)
Operations Management (OM)
Operations Management (OM)
Program Integrity Management
Care Management (CM)
Care Management (CM)
___________________________________________________________________________________
FR ID
FR047
Functional Requirement:
Identify clients who have frequent service or provider changes to determine cause.
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will be able to identify changes in services or providers for all clients. Users
need the ability to identify a subset of clients who change services and/or providers
(such as PCP) frequently. The user will be able to specify what constitutes "frequent"
changes for a specific service or provider. This requires Episodes of Care.
Potential User Groups:
SDS
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Texas Health and Human Services Commission
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DADS Budget Analysts
Office of the Medical Director
LTC Analysts
THSteps
MFADS Users
HHSC Operations Support (Managed Care)
MITA Business Processes: Manage Member Information
Inquire Provider Information
Manage Case
Member Management (ME)
Provider Management (PM)
Program Integrity Management
__________________________________________________________________________________
FR ID
FR049
Functional Requirement:
Track health care timeliness, process of service delivery (including disease mgmt).
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will be used to analyze service delivery to determine whether interventions
provided through the Medicaid program are delivered timely. To accomplish this
task, service authorization dates will be compared to service initiation/delivery dates.
The Vendor will define appropriate source systems for each data element as part of
detailed system design. This requires Episodes of Care.
Potential User Groups:
LTC Analysts
Office of the Medical Director
SDS
THSteps
HHSC Operations Support (Managed Care)
MITA Business Processes: Manage Member Information
Enroll Member
Authorize Service
Price Claim-Value Encounter
Develop and Maintain Program Policy
Member Management (ME)
Member Management (ME)
Operations Management (OM)
Operations Management (OM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR054
Functional Requirement:
Identify what ought to be the norms for programs and services.
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW offers the opportunity to establish norms for programs and services. In
some cases, norms or standards for certain services and procedures already exist. In
other cases, longitudinal analysis of EDW will be used to establish norms. These
norms will be used to gauge performance in the future and to identify and evaluate
services that do not conform to the norms. This requires Episodes of Care.
Potential User Groups:
Office of the Medical Director
SDS
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Texas Health and Human Services Commission
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LTC Analysts
HHSC Operations Support (Managed Care)
Vendor Drug Program
MH Inpatient Services
THSteps
MFADS Users
MITA Business Processes: Develop and Maintain Benefits Package
Develop and Maintain Program Policy
Manage Program Information
Program Management (PG)
Program Management (PG)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR062
Functional Requirement:
Monitor duration and continuity of care.
Stage:
Service Delivery (Episodes of Care)
Description:
This functionality requires a longitudinal view of client services. The intent is to be
able to identify the duration of care provided to any client or group of clients. This
requires the identification of episodes of care, the duration of each episode and
alignment of additional episodes or care necessary to determine whether there is
continuity of care for clients and/or client groups. Initially may be limited to
enrollment/eligibility data, but later stages will require Episodes of Care.
Potential User Groups:
LTC Analysts
MITA Business Processes: Manage Member Information
Manage Provider Information
Authorize Service
Authorize Treatment Plan
Price Claim-Value Encounter
Prepare Home and Community Based Services
Payment
Prepare Home and Community Based Services
Payment
Prepare Capitation Premium Payments
Member Management (ME)
Provider Management (PM)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
__________________________________________________________________________________
FR ID
FR063
Functional Requirement:
Integrate Medicaid and Medicare data for dual-eligible population.
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will include both HHSC system data and data from the Medicare program
administered by the Centers for Medicare & Medicaid Services (CMS). The intent is
to match both Medicaid and Medicare data to episodes of care to enable a
comprehensive view of services to dual eligible clients. This requires Episodes of
Potential User Groups:
LTC Analysts
DADS Budget Analysts
SDS
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Texas Health and Human Services Commission
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EDW Detailed Functional Requirements
System Forecasting
HHSC Actuarial Analysis
HHSC Rate Analysts
HHSC Operations Support (Managed Care)
Vendor Drug Program
Office of the Medical Director
MITA Business Processes: Manage Member Information
Inquire Member Eligibility
Price Claim-Value Encounter
Prepare Home & Community Based Services
Prepare Capitation Premium Payments
Member Management (ME)
Member Management (ME)
Operations Management (OM)
Operations Management (OM)
Operations Management (OM)
___________________________________________________________________________________
FR ID
FR065
Functional Requirement:
Measure and evaluate health impact of non-continuous service utilization
Stage:
Service Delivery (Episodes of Care)
Description:
This functionality is designed to enable analysis of the impacts of breaks in service
utilization. For clients who have eligibility and are enrolled in service, the EDW will
be able to identify periods in which authorized services were not utilized. This
requirement also includes data on diagnoses and treatments provided with each
usage that may indicate whether there are changes in health status from one
utilization event to the next. This requires Episodes of Care.
Potential User Groups:
Office of the Medical Director
DADS Budget Analysts
SDS
System Forecasting
LTC Analysts
THSteps
HHSC Actuarial Analysis
HHSC Operations Support (Managed Care)
MITA Business Processes: Manage Member Information
Authorize Service
Inquire Member Eligibility
Enroll Member
Member Management (ME)
Operations Management (OM)
Member Management (ME)
Member Management (ME)
FR ID
FR069
Functional Requirement:
Detect, delineate, and track potential waste and inappropriate use (Services).
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW has the capability to detect potentially inappropriate services. This can
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Texas Health and Human Services Commission
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EDW Detailed Functional Requirements
trigger investigations by the OIG which already has a mature MFADS. This is
accomplished through the analysis of claim and encounter data to detect duplicate
services, aberrant use of service or costs that exceed the norms identified. This will
Potential User Groups:
MFADS Users
Office of the Medical Director
HHSC Operations Support (Managed Care)
TMHP
DADS Budget Analysts
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Inquire Provider Information
Manage Provider Information
Audit Claim-Encounter
Generate Financial and Program Analysis
Member Management (ME)
Member Management (ME)
Provider Management (PM)
Provider Management (PM)
Operations Management (OM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR073
Functional Requirement:
Discover duplication of services based on service utilization.
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will include the ability to identify clients receiving the same service more
than once during a pre-defined period of time. For example, while flu shots are
appropriately provided annually, multiple flu shots in a single year are not
appropriate. This requires Episodes of Care.
Potential User Groups:
MFADS Users
DADS Budget Analysts
HHSC Operations Support (Managed Care)
Office of the Medical Director
MITA Business Processes: Manage Member Grievance and Appeal
Identify Candidate Case
Member Management (ME)
Program Integrity Management
__________________________________________________________________________________
FR ID
FR079
Functional Requirement:
Identify specific services by location.
Stage:
Service Delivery (Episodes of Care)
Description:
HHS agencies need the ability to identify the availability of services across the state.
The EDW will be able to identify the location of all available services. In many
cases, providers offer services in multiple locations and each of these distinct
locations will be identified. HHS will use this data to identify areas with limited
Potential User Groups:
SDS
DADS Budget Analysts
System Forecasting
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DSHS Center for Health Statistics
THSteps
LTC Analysts
HHSC Actuarial Analysis
HHSC Rate Analysts
HHSC Operations Support (Managed Care)
Office of the Medical Director
DFPS Analysts
TMHP
MITA Business Processes: Inquire Provider Information
Manage Provider Information
Perform Provider Outreach
Manage Program Information
Establish Business Relationship
Manage Business Relationship
Provider Management (PM)
Provider Management (PM)
Provider Management (PM)
Program Management (PG)
Business Relationship
Management (BR)
Business Relationship
Management (BR)
__________________________________________________________________________________
FR ID
FR081
Functional Requirement:
Perform geographic and/or demographic analysis of client access to care.
Stage:
Service Delivery (Episodes of Care)
Description:
HHSC agencies will be able to identify the characteristics of clients to determine
whether there are issues with access to care. For example, identify specific types of
clients in a specific location who experience difficulty in accessing services.
Potential User Groups:
SDS
DADS Budget Analysts
LTC Analysts
System Forecasting
DSHS Center for Health Statistics
THSteps
HHSC Actuarial Analysis
HHSC Rate Analysts
HHSC Operations Support (Managed Care)
Vendor Drug Program
Office of the Medical Director
DFPS Analysts
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Inquire Provider Information
Manage Provider Information
Member Management (ME)
Member Management (ME)
Provider Management (PM)
Provider Management (PM)
__________________________________________________________________________________
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EDW Detailed Functional Requirements
FR ID
FR082
Functional Requirement:
Compare services used against services available by client & location.
Stage:
Service Delivery (Episodes of Care)
Description:
To the extent possible with current data sources, HHSC needs the ability to measure provider
capacity by client location. Identify areas where services are available but routinely underused, and
also areas where service capacity is lower than routine client demand (creating possible access-tocare issues for clients).
Potential User Groups:
HHSC Strategic Decision Support
DADS Budget Analysts
DADS Long Term Care Analysts
DSHS Center for Health Statistics
HHSC Operations Support (Managed Care)
HHSC Office of the Medical Director
DSHS THSteps
HHSC Rate Analysts
HHSC Actuarial Analysis
MITA Business Processes: Authorize Service
Inquire Member Eligibility
Manage Member Information
Inquire Provider Information
Manage Provider Information
Operations Management (OM)
Member Management (ME)
Member Management (ME)
Provider Management (PM)
Provider Management (PM)
______________________________________________________________________________
FR ID
FR084
Functional Requirement:
Compare treatments for similar diagnoses by geography or demography
Stage:
Service Delivery (Episodes of Care)
Description:
HHSC will be able to identify the characteristics of clients receiving
treatments for similar diagnoses. This requires Episodes of Care.
Potential User Groups:
SDS
DADS Budget Analysts
DSHS Center for Health Statistics
MH Inpatient Services
THSteps
LTC Analysts
HHSC Actuarial Analysis
HHSC Operations Support (Managed Care)
Vendor Drug Program
Office of the Medical Director
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Authorize Service
Page 24
Member Management (ME)
Member Management (ME)
Operations Management (OM)
Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
__________________________________________________________________________________
FR ID
FR088
Functional Requirement:
Compare Medicare with Medicaid providers
Stage:
Service Delivery (Episodes of Care)
Description:
The EDW will include data regarding types of providers and services for both
Medicaid and Medicare providers. The intent is to enable analysis of these providers
to identify discrepancies in payment/reimbursement for equivalent services, identify
trends in services or identify access issues.
Potential User Groups:
LTC Analysts
SDS
DADS Budget Analysts
THSteps
HHSC Operations Support (Managed Care)
Vendor Drug Program
Office of the Medical Director
HHSC Rate Analysts
MITA Business Processes: Inquire Provider Information
Manage Provider Information
Provider Management (PM)
Provider Management (PM)
__________________________________________________________________________________
FR ID
FR012
Functional Requirement:
Determine when to modify existing programs or design a new waiver based on drug
Stage:
Drug Integration (with Episodes of Care)
Description:
The EDW will enable analysis of drug data to identify trends that may indicate the
need to modify current programs or create new waiver programs. By reviewing
prescribing patterns, HHS will be able to identify when changes (increases/decreases)
in use of certain drugs indicate that other services may be warranted for certain
cohorts of clients. This requires Episodes of Care.
Potential User Groups:
Office of the Medical Director
MEHIS Analysts
Vendor Drug Program
MITA Business Processes: Develop and Maintain Program Policy
Generate Financial and Program Analysis
Program Management (PG)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR055
Functional Requirement:
Map prescription drug stream to episode of care services data.
Stage:
Drug Integration (with Episodes of Care)
Description:
The Vendor will need a method to map prescription drugs to an episode of care. The
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Texas Health and Human Services Commission
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EDW Detailed Functional Requirements
method used to parse drug data will need to identify drug dispensation dates and
type of drug to ascertain which episode of care relates appropriately to the drug
prescribed. This requires Episodes of Care.
Potential User Groups:
Vendor Drug Program
MH Inpatient Services
Office of the Medical Director
HHSC Operations Support (Managed Care)
MEHIS Analysts
MITA Business Processes: Manage Member Information
Authorize Service
Designate Approved Service Drug Formulary
Member Management (ME)
Operations Management (OM)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR056
Functional Requirement:
Collect physician administered drug data.
Stage:
Drug Integration (with Episodes of Care)
Description:
Claim and encounter data will contain information on drugs administered by a
physician during an office visit. These physician administered drugs may be related
to an episode of care or they may represent stand-alone event. For example, a client
may visit a physician for monitoring of diabetes and may also receive a flu shot. In
this example, the flu shot is its own episode of care and not related to the episode of
care for diabetes. This requires Episodes of Care.
Potential User Groups:
MH Inpatient Services
Vendor Drug Program
Office of the Medical Director
THSteps
TMHP
HHSC Operations Support (Managed Care)
MITA Business Processes: Manage Member Grievance and Appeal
Manage Member Information
Perform Population and Member Outreach
Manage Provider Grievance and Appeal
Manage Payment Information
Manage Drug Rebate
Develop and Maintain Program Policy
Generate Financial and Program Analysis
Maintain Benefits-Reference Information
Manage Registry
Member Management (ME)
Member Management (ME)
Member Management (ME)
Provider Management (PM)
Operations Management (OM)
Operations Management (OM)
Program Management (PG)
Program Management (PG)
Program Management (PG)
Care Management (CM)
__________________________________________________________________________________
FR ID
FR057
Functional Requirement:
Monitor drugs prescribed by client, diagnosis, program, service, and provider.
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Texas Health and Human Services Commission
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Stage:
Drug Integration (with Episodes of Care)
Description:
HHSC needs the ability to monitor drugs prescribed from several perspectives. This
includes the ability to see drugs prescribed for individual clients, and for each
diagnosis. A collective view is also required to monitor how drugs are prescribed by
programs, types of service or provider. This requires Episodes of Care.
Potential User Groups:
MH Inpatient Services
Vendor Drug Program
Office of the Medical Director
HHSC Operations Support (Managed Care)
MEHIS Analysts
LTC Analysts
MITA Business Processes: Manage Member Information
Develop and Maintain Program Policy
Generate Financial and Program Analysis
Maintain Benefits-Reference Information
Manage Program Information
Manage Medicaid Population Health
Member Management (ME)
Program Management (PG)
Program Management (PG)
Program Management (PG)
Program Management (PG)
Care Management (CM)
___________________________________________________________________________________
FR ID
FR058
Functional Requirement:
Analyze drug delivery by provider.
Stage:
Drug Integration (with Episodes of Care)
Description:
The EDW will enable analysis of drug delivery by providers by point of sale. Provider
source data that indicate that the provider has delivered a drug to a patient will be
included in the EDW. HHS agencies will analyze this data to identify trends or issues
with delivering drugs to clients. This requires Episodes of Care.
Potential User Groups:
MH Inpatient Services
Vendor Drug Program
Office of the Medical Director
MFADS Users
MEHIS Analysts
HHSC Operations Support (Managed Care)
MITA Business Processes: Inquire Provider Information
Manage Provider Information
Authorize Service
Prepare Capitation Premium Payments
Designate Approved Service Drug Formulary
Provider Management (PM)
Provider Management (PM)
Operations Management (OM)
Operations Management (OM)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR059
Functional Requirement:
Provide integrated visibility of drugs dispensed to Medicaid/Medicare dual eligibles.
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Stage:
Drug Integration (with Episodes of Care)
Description:
Drug data from Medicaid claims and encounter systems and data from Medicare will
be added to the EDW. The purpose is to create a comprehensive view of all drugs
dispensed to individuals receiving both Medicaid and Medicare services (dual
eligibles). This requires Episodes of Care.
Potential User Groups:
LTC Analysts
MH Inpatient Services
Office of the Medical Director
Vendor Drug Program
HHSC Operations Support (Managed Care)
MITA Business Processes: Inquire Member Eligibility
Authorize Service
Prepare Capitation Premium Payments
Designate Approved Service Drug Formulary
Member Management (ME)
Operations Management (OM)
Operations Management (OM)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR060
Functional Requirement:
Identify indicators of aberrant or irregular client use of drugs.
Stage:
Drug Integration (with Episodes of Care)
Description:
The Vendor will work with HHS agencies to identify data in the EDW that may be
used as indicators of aberrant or irregular drug use. For example, a client given a
refillable prescription that is never refilled may indicate irregular use of the drug.
This requires Episodes of Care.
Potential User Groups:
MFADS Users
Office of the Medical Director
MH Inpatient Services
Vendor Drug Program
HHSC Operations Support (Managed Care)
MEHIS Analysts
MITA Business Processes: Manage Member Information
Manage Payment Information
Develop and Maintain Program Policy
Generate Financial and Program Analysis
Manage Program Information
Identify Candidate Case
Manage Medicaid Population Health
Member Management (ME)
Operations Management (OM)
Program Management (PG)
Program Management (PG)
Program Management (PG)
Program Integrity Management
Care Management (CM)
__________________________________________________________________________________
FR ID
FR070
Functional Requirement:
Detect, delineate, and track potential waste and inappropriate use (Drugs and
Stage:
Drug Integration (with Episodes of Care)
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Texas Health and Human Services Commission
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Description:
The EDW will augment the work performed by the Office of the Inspector General
(OIG) and its MFADS systems by enabling early identification of potential fraud,
waste and abuse in prescription drug dispensation and utilization. This is
accomplished through the analysis of claim and encounter data to detect aberrant
use of drugs, contraindicated prescriptions or other indicators of potential waste in
drug dispensation. This will require Episodes of Care.
Potential User Groups:
MFADS Users
Vendor Drug Program
MEHIS Analysts
DADS Budget Analysts
HHSC Operations Support (Managed Care)
Office of the Medical Director
MITA Business Processes: Generate Financial and Program Analysis
Identify Candidate Case
Program Management (PG)
Program Integrity Management
__________________________________________________________________________________
FR ID
FR074
Functional Requirement:
Discover duplication of services based on drug utilization.
Stage:
Drug Integration (with Episodes of Care)
Description:
The EDW will include the ability to identify clients receiving the more than one
prescription for the same drug (or generic equivalent) in the same timeframe for a
single diagnosis. This will require Episodes of Care.
Potential User Groups:
MFADS Users
MEHIS Analysts
Vendor Drug Program
HHSC Operations Support (Managed Care)
Office of the Medical Director
DADS Budget Analysts
MITA Business Processes: Manage Member Information
Manage Provider Information
Authorize Service
Audit Claim-Encounter
Designate Approved Service Drug Formulary
Member Management (ME)
Provider Management (PM)
Operations Management (OM)
Operations Management (OM)
Program Management (PG)
__________________________________________________________________________________
FR ID
FR077
Functional Requirement:
Monitor drug use for clients in concurrent/complex case management programs.
Stage:
Drug Integration (with Episodes of Care)
Description:
The EDW will include the ability to identify clients receiving comprehensive case
management. These clients may be using several medications to address various
complex needs. HHS agencies will be able to monitor the number and types of drugs
utilized by these clients to identify possible complications that may arise for
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EDW Detailed Functional Requirements
concurrent use.
Potential User Groups:
Vendor Drug Program
HHSC Operations Support (Managed Care)
MEHIS Analysts
Office of the Medical Director
DADS Budget Analysts
MH Inpatient Services
DFPS Analysts
THSteps
MITA Business Processes: Manage Member Information
Inquire Member Eligibility
Authorize Service
Audit Claim-Encounter
Designate Approved Service Drug Formulary
Member Management (ME)
Member Management (ME)
Operations Management (OM)
Operations Management (OM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR083
Functional Requirement:
Perform geographic and/or demographic analysis of client drug utilization.
Stage:
Drug Integration (with Episodes of Care)
Description:
HHS agencies need to be able to identify the characteristics of clients utilizing
certain drugs. The EDW will be able to support multi-level analysis to associate client
groups, client locations and drug utilization. This requires Episodes of Care.
Potential User Groups:
Vendor Drug Program
HHSC Operations Support (Managed Care)
MEHIS Analysts
Office of the Medical Director
MH Inpatient Services
SDS
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Authorize Service
Designate Approved Service Drug Formulary
Member Management (ME)
Member Management (ME)
Operations Management (OM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR013
Functional Requirement:
Design more proactive services and programs given wider view of healthcare delivery
over time
Stage:
Client History Information:
Description:
The EDW will support analysis of services and programs to determine whether there
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are unmet client healthcare needs that may indicate the need for new programs and
services. Users will have the ability to draft new service descriptions and test their
impact prior to implementation. This requires Episodes of Care.
Potential User Groups:
SDS
DADS Budget Analysts
System Forecasting
LTC Analysts
HHSC Operations Support (Managed Care)
Vendor Drug Program
Office of the Medical Director
MITA Business Processes: Develop and Maintain Benefits Package
Develop and Maintain Program Policy
Manage Program Information
Perform Population and Member Outreach
Program Management (PG)
Program Management (PG)
Program Management (PG)
Member Management (ME)
___________________________________________________________________________________
FR ID
FR052
Functional Requirement:
Track health outcomes by services and cost.
Stage:
Client History Information:
Description:
Some limited analysis of health outcomes can be derived from the claim and
encounter data within the EDW. However, outcome measures do not exist for many
programs today. The Vendor shall describe its approach to using the EDW to support
identification of data elements that may be used to establish outcomes in the future.
This requires Episodes of Care.
Potential User Groups:
SDS
DADS Budget Analysts
System Forecasting
LTC Analysts
HHSC Operations Support (Managed Care)
Vendor Drug Program
Office of the Medical Director
MITA Business Processes: Enroll Member
Manage Member Information
Inquire Provider Information
Authorize Service
Price Claim-Value Encounter
Manage Case
Member Management (ME)
Member Management (ME)
Provider Management (PM)
Operations Management (OM)
Operations Management (OM)
Program Integrity Management
FR ID
FR064
Functional Requirement:
Identify, measure and evaluate health impact of non-continuous eligibility or
enrollment (Medicaid programs)
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Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
Stage:
Client History Information:
Description:
This functionality is designed to enable analysis of the impacts of breaks in eligibility
and/or service on the health outcomes for individual clients and client groups. This
requires data necessary to determine periods of eligibility and periods of enrollment.
It will also require data on diagnoses and treatments provided in each period of
eligibility/enrollment to identify changes in health care status that may inform the
impact of non-continuous eligibility. This requires Episodes of Care.
Potential User Groups:
Office of the Medical Director
SDS
DADS Budget Analysts
System Forecasting
LTC Analysts
THSteps
HHSC Actuarial Analysis
HHSC Operations Support (Managed Care)
MITA Business Processes: Manage Payment Information
Manage Provider Grievance and Appeal
Generate Financial and Program Analysis
Operations Management (OM)
Provider Management (PM)
Program Management (PG)
___________________________________________________________________________________
FR ID
FR067
Functional Requirement:
Integrate third-party coverage data available within enterprise systems.
Stage:
Client History Information
Description:
This functionality is designed to enable analysis of the impacts of breaks in coverage
on the health outcomes for individual clients and client groups. Information in HHSC systems
including third-party coverage spans should be integrated with Medicaid and CHIP coverage spans
to allow determination of periods of likely uninsurance.
It will also require data on diagnoses and treatments provided in each period of
eligibility/enrollment to identify changes in health care status that may inform the
impact of non-continuous eligibility. This requires Episodes of Care.
Potential User Groups:
Office of the Medical Director
SDS
DADS Budget Analysts
System Forecasting
LTC Analysts
THSteps
HHSC Actuarial Analysis
HHSC Operations Support (Managed Care)
MITA Business Processes: Manage Payment Information
Manage Provider Grievance and Appeal
Generate Financial and Program Analysis
Page 32
Operations Management (OM)
Provider Management (PM)
Program Management (PG)
Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
___________________________________________________________________________________
FR ID
FR071
Functional Requirement:
Detect inappropriate use with respect to “once per lifetime” care episodes.
Stage:
Client History Information:
Description:
The EDW will define the "once per lifetime" care events provided through the
Medicaid program. The EDW will be able to identify clients who have more than
one of these events among their lifetime episodes of care. This will require Episodes
Potential User Groups:
MFADS Users
TMHP
Office of the Medical Director
HHSC Operations Support (Managed Care)
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Audit Claim-Encounter
Member Management (ME)
Member Management (ME)
Operations Management (OM)
__________________________________________________________________________________
FR ID
FR085
Functional Requirement:
Support longitudinal views of clients by geographic and/or demographic groups
Stage:
Client History Information:
Description:
HHS agencies will be able to analyze change in clients’ characteristics including
demographic and location changes over time. This requires Episodes of Care.
Potential User Groups:
SDS
LTC Analysts
HHSC Operations Support (Managed Care)
Office of the Medical Director
THSteps
MITA Business Processes: Inquire Member Eligibility
Manage Member Information
Member Management (ME)
Member Management (ME)
__________________________________________________________________________________
FR ID
FR099
Functional Requirement:
Provide history in accordance with retention requirements
Stage:
TIERS Data Mart Replacement (TDM)
Vision21 Replacement (V21)
Description:
Provide historical records in accordance with retention requirements.
Potential User Groups:
HHSC IT
Enterprise Data Governance Group
Page 33
Texas Health and Human Services Commission
EDW/BI Solution - RFP No. 529-16-0001
EDW Detailed Functional Requirements
MITA Business Processes: Manage Member Information
Manage Provider Information
Develop and Maintain Program Policy
Member Management (ME)
Provider Management (PM)
Program Management (PG)
_________________________________________________________________________________
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