Job Description
STATE OF SOUTH DAKOTA DEPARTMENT OF SOCIAL SERVICES DIVISION OF MEDICAL SERVICES Interoperability and Patient Access 1. Scope of Work DSS is seeking a qualified individual with a cost-effective solution that can implement and support the health plan’s requirements described in the CMS Interoperability and Patient Access Final Rule (CMS-9115-F) and 2024 CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). The Final Rules require health plans serving Medicaid, Medicare Advantage, and the Federally Facilitated Exchanges to implement extensive mandates to share health information at the direction and approval of enrolled members, with third party SMART on FHIR applications in a more accessible and timely manner. The solution must be flexible enough to support future business requirements and regulatory changes, specifically regarding patient data access and interoperability outlined in CMS-9115-F and CMS-0057-F and associated CMS released guidance, FAQs, and Companion Guides. Minimum Functional Requirements Patient Access API · Solution is compliant with the Patient Access API described in CMS Interoperability and Patient Access Final Rule. · FHIR API System Requirements o Cloud-hosted FHIR API server supporting FHIR version 4.0.1 or greater protocol. · Façade data model served to each client via the FHIR protocol and data model. · Makes available source data for claims, encounters, clinical data (based on USCD1 v1+) and drug formulary data using publicly available implementation guides such as (CARIN IG for Blue Button IG, US Core IG, Da Vinci IG) · Data Maintenance Timeframes o Drug formularies are updated monthly no later than thirty calendar days. o Data for claims, encounters, and clinical data are available no later than one business day after receipt. o Drug benefit data, no later than one business day after the effective date of any such information or updates to such information. o Applicable to recipients with a date of service on or after January 1, 2016 and are active members. · 99.9% Systems Availability · A fully documented API · A documented plan for ongoing maintenance and operations Provider Access API · Solution is compliant with the Provider Access API described in CMS Interoperability and Prior Authorization Final Rule. · FHIR API System Requirements o Cloud-hosted FHIR API server supporting FHIR version 4.0.1 or greater protocol. · Façade data model served to each client via the FHIR protocol and data model. · Makes available source data for claims, encounters, clinical data (based on USCD1 v1+) and drug formulary data using publicly available implementation guides such as (CARIN IG for Blue Button IG, US Core IG, Da Vinci IG) · Data Maintenance Timeframes o Data for claims, encounters, and clinical data are available no later than one business day after receipt. o Applicable to recipients with a date of service on or after January 1, 2016 and are active members. · 99.9% Systems Availability · A fully documented API · A documented plan for ongoing maintenance and operations Payer-to-Payer API · Solution is compliant with the Payer-to-Payer API described in CMS Interoperability and Prior Authorization Final Rule. · FHIR API System Requirements o Cloud-hosted FHIR API server supporting FHIR version 4.0.1 or greater protocol. · Façade data model served to each client via the FHIR protocol and data model. · Makes available source data for claims, encounters, clinical data (based on USCD1 v1+) and drug formulary data using publicly available implementation guides such as (CARIN IG for Blue Button IG, US Core IG, Da Vinci IG) · Data Maintenance Timeframes o Data for claims, encounters, and clinical data are available no later than one business day after receipt. o Impacted payers are only required to share patient data with a date of service within five years of the request for data. · 99.9% Systems Availability · A fully documented API · A documented plan for ongoing maintenance and operations Consent and Identity Management · Obtain member consent of third-party SMART on FHIR applications and ability for each member to view, track, and modify their consent. · Ability to integrate with existing Medical Services portal and data warehouse. · Ability to support identity verification and authentication via OAuth 2+ and OpenID Connect 1+ incorporating errata set 1. · Support SMART on FHIR authorization process (Application Launch Framework Implementation Guide Release 1.0.0) for secure authorization of third-party application access to the Patient Access API, Provider Access API, and Payer-to-Payer API. · Customer service support for member questions and troubleshooting. T