John W Beck, PhD

American Healthcare Requirements

Recent Legislation

Congressional Report Card

Minimum System Requirements

Coverage and Eligibility:

• Support universal eligibility determination and enrollment pathways (auto-enroll where legally permissible)
• Reduce churn (continuous eligibility policies, simplified renewals)
• Support special populations (children, seniors, disability, veterans, undocumented per program rules).

Benefits and Access:

• Standardized essential benefits baseline; configurable state supplements (if allowed)
• Network adequacy and access monitoring
• Transparent member materials and digital self-service.

Provider and Payment:

• Provider enrollment and credentialing workflow
• Payment models support (fee-for-service + value-based arrangements)
• Claims processing with clear adjudication rules and explanations of benefits (EOB)
• Provider dispute resolution and appeals.

Prescription and Medical Necessity Controls:

• Formulary governance support
• Prior authorization minimization strategies
• Evidence-based policy updates with traceable change control.

Member Support and Appeals:

• Omnichannel contact center support (phone, chat, secure messaging)
• Appeals and grievances workflows with SLA tracking and reporting
• Language access and disability accommodations.

Data and Interoperability:

• Interoperability with providers, pharmacies, labs, and state systems
• Robust master data management (member, provider, plan, service)
• Standards-based exchange (Offeror to propose standards approach).

Fraud, Waste, and Abuse (FWA):

• Pre- and post-payment controls
• Anomaly detection, audit trails, case management
• Recovery workflow and reporting.

Non-Functional Requirements

Security and Privacy:

• Compliance with applicable federal requirements (Offeror to enumerate)
• Role-based access control, MFA, encryption at rest/in transit
• Logging, monitoring, SIEM integration
• Privacy-by-design and data minimization
• Security incident response playbooks and testing.

Resilience and Availability:

• High availability and disaster recovery (RTO/RPO targets proposed)
• Continuity of operations planning
• Stress testing and capacity planning.

Performance:

• Eligibility and enrollment response times
• Claims throughput and latency requirements
• Contact center SLA support.

Auditability:

• Traceability from policy --> requirement --> implementation --> test --> KPI
• Evidence generation for audits (immutable logs where appropriate).