Health, Education & Government
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Government & Public Sector
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Public Health & Human Services
Medicaid Systems
Multi-agency, multi-stakeholder programs where procurement, compliance, and mission alignment determine success.
Example organizations in this space:
Gainwell Technologies
DXC Technology
Conduent
Deloitte
This interactive experience is the shipped product itself — the same application code customers run in production, mounted read-only in your browser over a real sample journey. Not a video, not a mockup: because the demo and the product are one codebase, it can never drift from the real thing.
Inside this journey
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Pre-Sales
Qualify and diagnose before investing in a full evaluation cycle.
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Qualification
Confirm budget window, decision-makers, procurement timeline, and high-level risks before committing to a full discovery cycle.
Qualification Questions
Certification and transition risk
- What is your current CMS certification status for the claims processing system?
- Will protected health information (PHI) be processed or stored by the replacement system?
- Briefly list the top 1–3 high-level risks you see for a vendor transition (certification, provider payments, data conversion, stakeholder readiness, etc.).
Operational fit: claims volume and accuracy
- Roughly how many claims does your program process per year?
- Do you have a minimum claims accuracy or error-rate threshold we should know for acceptance testing?
Budget and procurement timing
- Is there an allocated budget range for this modernization or replacement?
- What is your target procurement timeline or fixed go-live date that would drive prioritization?
Decision authority and external dependencies
- Who must sign final approval for a project like this? Select all that apply.
- Which external dependencies must be confirmed before a full discovery (CMS approvals, MCO coordination, PBM integrations, provider readiness, access to incumbent data, test environments)? Select all that apply.
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Outcome Discovery
Map desired outcomes, current-state constraints, stakeholder roles, and CMS certification and transition risks.
Discovery Questions
Starting point, quickly — why this matters now
- Tell me in one sentence why you began exploring a new claims or MMIS solution now
- Which one timeline describes your target decision window
- How fixed is the budget window you expect to use for this work
- Who on your leadership team will need to sign contract and certification acceptance
- If a decision had to be made in the next 30 days, how ready would your team be to proceed
Where the system actually breaks and what that costs
- If you had to pick the recurring system failure that most puts provider payments at risk, which one would it be
- How often does that failure occur in a typical month
- Walk me through the last time that failure disrupted payments or reporting, and what immediate action your team took
- Estimate the financial or operational consequence when that issue happens, choose the closest range
- Who finds out first internally when this happens and what do they do next
- Which downstream function suffers most when the failure continues beyond 2 weeks
Outcomes that will make this effort a success for you
- Which measurable outcome, if unmet after 12 months, would make you view the project as a failure
- Choose the minimum acceptable claims accuracy and throughput targets you need to see
- How important is enabling value based payment and modular modernization within the first 24 months
- If a single performance metric could accelerate your approval, which would it be
- Describe how meeting your primary outcome would change daily life for your operations team
Who will make the calls and how decisions get made
- Which person or role owns final sign-off for CMS certification and production acceptance
- List the stakeholders who must approve technical integration, and which of them can block the schedule
- How many named owners do you have assigned to data conversion, integration, and testing respectively
- When requirements change during a project, which forum decides scope tradeoffs
- If a single stakeholder withheld approval at a go/no-go gate, which stakeholder would most likely do it
Transition risks and certification pitfalls we should call out now
- Which certification step do you believe is most likely to delay your go-live
- Do you currently have unresolved findings or corrective action plans from CMS or external auditors
- Describe any mandated reporting deadlines or federal funding milestones that cannot be moved
- Which contingency would you accept if a certification milestone slipped by one quarter
- Which single unresolved regulatory or audit issue would force you to stop the project immediately
The other options you are weighing
- Which alternatives to selecting a new vendor are you actively considering
- If you stayed with the current system, which condition would have to be true for you to feel comfortable keeping it
- Has anyone on your team proposed solving key gaps internally without an outside partner
- Which vendors or approaches have you already ruled out and why
- What single condition would make you abandon vendor selection and commit to an internal build instead
Practical readiness, integrations, and data constraints
- Which external systems must be live with validated interfaces before cutover
- For those interfaces, which are already available as APIs or standard feeds
- Who within your organization owns the APIs and permission to connect external vendors
- How clean and accessible is your source claims and provider data for conversion
- How many historic claim transactions would you expect to convert or use for parallel testing
- If a crucial integration were unavailable at cutover, which option could you accept instead
- Do you have named technical resources available full time for testing and cutover
Governance, procurement, and timeline levers
- If a successful pilot met your target metrics, what nontechnical barrier would most delay signature
- How long does typical legal and contract review take for projects of this scale
- Which procurement constraint would be impossible to change before award
- What acceptance criteria do you require for go-live approval, select all that apply
- Who holds budget authority to reallocate funds if a critical integration requires additional spend
Pilot and early validation that changes the decision
- Name the pilot outcome that would make you willing to sign within seven days
- Which subset of claims or modules are highest priority for a pilot
- How long of a parallel run would you consider minimally convincing
- Who will sign off on pilot success and what evidence do they require
- If the pilot uncovers significant data gaps, which response would you accept
Operational impact and ongoing support expectations
- How much executive time can you commit to governance meetings during implementation
- Which level of post-go-live support would you require from a vendor
- Estimate the number of state staff who will need role-based training before cutover
- Which operational metric would cause you to reopen acceptance if it missed targets after 90 days
- If ongoing federal matching funds were at risk due to a certification issue, who on your team would manage that escalation
Immediate commitments and next steps to accelerate progress
- If we left this conversation with one commitment from your side to keep momentum, what must it be
- Which documents or artifacts can you provide in the next 2 weeks to validate constraints
- Who should our team contact to arrange a technical kickoff and integration discovery
- How soon can your team make available a sandbox or sample data set for parallel-run planning
- What single unresolved risk would you like us to prioritize resolving first
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Solution Experience
Walk through how the solution will meet certification requirements, improve claims accuracy and throughput, and support modular modernization using the buyer's real scenarios.
Solution Experience
- Solution Experience: Certification, Claims Accuracy, Modernization
- Confirm the current state and its cost
- You confirm that the demonstrated flow resolves the specific adjudication failures and manual rework described in Discovery.
- Provide three representative claim scenarios, including at least one known rejection case and expected correct outcome.
- You accept the measured accuracy and throughput evidence as a credible basis for acceptance criteria in a parallel run.
- Walk a real failing claim scenario through the current flow
- Confirm the list of external dependencies and current points of contact for CMS, MCOs, and PBMs.
- Prove the future state with the same scenario
- Run the sample parallel-run using the provided scenarios and deliver a comparative accuracy and throughput report before the next session.
- You agree on the modular cutover checkpoints and the external dependencies that must be confirmed before deployment.
- Demonstrate throughput and scaled batch handling
- You commit to providing representative claim scenarios and a list of external dependency contacts to enable the parallel-run deliverable.
- Draft measurable acceptance criteria for parallel-run success, including accuracy threshold, throughput target, and provider payment continuity checks.
- Map modular modernization and transition risk mitigations
- Validate the demonstrated outcomes
- Agree next evidence and acceptance criteria
- Solution Experience: Certification, Claims Accuracy, Modernization
- Solution Experience Deck
- Solution Brief
- meeting
- slides
- document
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Solution Scope
Define included modules, responsibilities, data conversion scope, parallel-run testing, and measurable acceptance criteria.
Scope Configuration
- Deploy claims adjudication engine and payment rules
- Migrate historical claims, member, and payment data
- Migrate and deduplicate provider enrollment records
- Implement provider enrollment and directory management
- Configure EDI/X12 transaction interfaces (837/835/834)
- Deploy member eligibility verification and real-time services
- Implement pharmacy benefit processing and PBM interface
- Deploy managed care encounter adjudication and submission
- Implement third-party liability recovery and COB coordination
- Generate federally-required reporting files and exports
- Perform parallel processing and claims reconciliation
- Execute cutover and go-live with payment continuity
- Operate and monitor MMIS claims processing (managed service)
- Train providers and agency staff on system workflows
Scope Questions
Deploy claims adjudication engine and payment rules
- Which fee schedules and line-level pricing sources must be encoded (e.g., state fee schedule, encounter rates, managed care capitation adjustments)?
- How many distinct benefit packages or program types (e.g., Fee-For-Service, Managed Care, Dental, Behavioral Health) must the adjudicator support at go-live?
- Do you require implementation of custom medical necessity or utilization edits tied to state rules or CMS guidance (list specific rule IDs or references)?
- Specify the throughput and latency targets for claims adjudication tied to your certification needs (e.g., claims per minute, end-to-end adjudication time for an 837 batch).
- What acceptance criteria will confirm the adjudication engine meets production standards for accuracy and throughput (for example, post-parallel claims accuracy >= 99.5% and sustain X claims/min)?
Migrate historical claims, member, and payment data
- Which historical time window must be migrated for adjudicated claims and EOBs (for example, last 36 months, 10 years for audit trails)?
- List the specific source extracts you will provide for migration (claims header/detail, payments, remittance advices, member eligibility history, provider NPIs).
- Indicate the required data quality thresholds for migrated records (for example, completeness of key fields like member ID, NPI, procedure codes), and any mandatory reconciliation targets.
- Are there PHI handling or encryption-at-rest/transit requirements for the migration extracts (refer to your state security standard or SOC/HIPAA controls)?
- What acceptance evidence will validate migrated claims and payment data are complete and accurate (for example, sample reconciliation percentages, checksum counts, and end-to-end adjudication of X sample claims)?
Migrate and deduplicate provider enrollment records
- Which provider identifier sources must be reconciled during migration (for example, National Provider Identifier (NPI), state provider ID, taxonomy codes)?
- How should duplicate provider records be detected and resolved (rules based on NPI + Taxonomy, NPI + address, manual review thresholds)?
- Describe any provider enrollment lifecycle states you need preserved (for example: enrolled, suspended, terminated, pending revalidation) and their effective date handling.
- Do you require linkage of provider records to internal payer IDs used by MCOs or PBMs, and are mapping tables available?
- Which authority will sign off on provider deduplication and authoritative provider directory records before go-live?
Implement provider enrollment and directory management
- Which enrollment workflows must be implemented (initial enrollment, revalidation, reassignments, adverse actions) and which forms/attachments are required per workflow?
- Will providers use a web portal for enrollment submission and credential uploads and which authentication method is required (SAML, OAuth, state identity provider)?
- Which directory outputs must be produced (public provider directory, API endpoint for MCOs, Encounters mapping) and what refresh cadence is required?
- Identify any state-specific credentialing or licensing verifications we must integrate (for example, board license lookup, DEA validation).
- Specify the acceptance evidence for a populated provider directory (for example, X% of active providers present, API responses within Y ms).
Configure EDI/X12 transaction interfaces (837/835/834)
- Which X12 transaction types and versions must be supported at go-live (for example, 837 Professional/Institutional 005010X222, 835 005010X221)?
- Which trading partners require secure transport and which protocols do they mandate (for example, AS2, SFTP, SOAP over TLS)?
- Provide your expected daily transaction volumes by type (837 claims batches, 834 eligibility feeds, 835 remits) to size interface throughput.
- Are there custom ASC X12 segment edits or state-specific loop requirements we must implement for payers or MCOs?
- Which partner will validate EDI 837/835/834 test cases and who provides test cert scenarios (state EDI team, MCO, PBM)?
Deploy member eligibility verification and real-time services
- Which eligibility sources must be consolidated (MMIS eligibility table, Medicaid Management Information System feed, client portal updates) and what is the required freshness for real-time checks?
- Which external verification services must be integrated (federal data services hub, Social Security Administration, state workforce systems)?
- Describe required response SLA for real-time eligibility queries from provider portals or clearinghouses (for example, <2 seconds per lookup).
- Indicate membership data elements that must be authoritative at cutover (for example, benefit tier, managed care assignment, effective/termination dates).
- Who is the named owner in your agency for signing off on eligibility reference data and real-time endpoint acceptance?
Implement pharmacy benefit processing and PBM interface
- Which PBM interfaces and standards must be supported (for example, NCPDP real-time adjudication, batch paid claims feeds, TRR)?
- Which formulary objects and drug code systems will you rely on (for example, NDC lists, state preferred drug list, clinical edits)?
- Do you require coordination of pharmacy COB with medical claims (third-party liability for Rx) and which payers must be included?
- Specify throughput expectations for PBM real-time transactions (transactions per second or average response time) and any peak-day multipliers.
- Who will approve PBM interface test scenarios and provide test files (your PBM contacts or state pharmacy team)?
Deploy managed care encounter adjudication and submission
- Which encounter formats and standards must be produced for MCO submission (for example, 837I/E encounter extract, CSV encounter templates, CMS encounter reporting regs)?
- How should encounter attribution be handled for dual-enrolled members or split-eligibility periods?
- Are there managed care value-based payment calculations that must be replicated in encounter processing (for example, risk adjustment factors, encounter aggregation windows)?
- Provide expected monthly encounter volumes and late-submission tolerance windows for reconciliation with MCOs.
- Which MCOs will participate in test and who will sign off on encounter file acceptance?
Implement third-party liability recovery and COB coordination
- Which external payer sources must be matched for third-party liability (Medicare crossover files, commercial EDI feeds, auto subrogation feeds)?
- Describe the coordination-of-benefits rule set you require (policy precedence, recovery windows, deductible coordination).
- Indicate the minimum recoverable amount threshold for TPL actions and whether automated recovery versus manual review applies.
- Which evidence or file formats will you provide for payer matches (e.g., COB match reports, Medicare crossover EOBs)?
- Who is accountable at the agency for authorizing TPL offsets and accepting recovery reports?
Generate federally-required reporting files and exports
- Which federal reports must be produced from day one (for example, CMS-64 expenditure reports, T-MSIS extracts, Medicaid Statistical Information System submissions)?
- What is the required extraction cadence and file format for each federal export (monthly CMS-64, quarterly T-MSIS CSV, etc.)?
- Do you require automated reconciliation for federally-required reports against financial systems or your state accounting extracts?
- Specify any state-level reporting that must be generated in addition to federal reports and the owner who will certify them.
- Which archival retention rules apply to export files (for example, 7 years per state policy) and do you require searchable audit logs?
Perform parallel processing and claims reconciliation
- Which claims windows and sample criteria will be used for parallel runs (for example, all claims for a 30-day window, or stratified sample across high-volume providers)?
- Describe the reconciliation metrics you need during parallel (for example, claim-level match rate, paid amount variance thresholds, denial rate delta).
- Are any external parties required to participate in parallel validations (MCOs, PBMs, clearinghouses), and who will coordinate their test artifacts?
- Indicate how differences will be triaged and tracked (issue tracker, severity levels, owner assignments) during parallel testing.
- What defines successful parallel processing for go/no-go (for example, reconciliation within X% and defect backlog <= Y items)?
Execute cutover and go-live with payment continuity
- Which cutover model do you prefer: big-bang, phased by module, or hybrid (for example eligibility then claims)?
- Identify blackout windows or blackout days when cutover cannot occur due to state fiscal obligations or federal reporting deadlines.
- Which contingency plans must be in place to preserve provider payment continuity (for example, temporary manual pay process, accelerated remittance runs)?
- Who will be the named signatory for the go/no-go gate and which acceptance evidence must be presented at that gate?
- Describe the rollback criteria and triggers that would require reverting to the incumbent system during cutover.
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Mutual Commit
Finalize commercial and legal terms, confirm dependencies (CMS, MCOs, PBMs, providers), and lock acceptance and governance obligations.
Agreement Modules
- Master Services Agreement (MSA)
- Statement of Work (SOW)
- Software Subscription and Licensing Agreement
- Order Form and Pricing Schedule
- Service Level Agreement (SLA)
- Acceptance Criteria and Go-Live Sign-Off
- Third-Party Dependency Acknowledgement
- Governance and Escalation Framework
- Compliance and Procurement Rider (HIPAA BAA + Public Sector Procurement Rider)
- Transition Services and Continuity Agreement (TSA)
- Change Order Agreement
- Termination, Exit and Data Return Addendum
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Deployment
Operationalize rollout with readiness checks, execution, and outcome validation.
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Pre-Deployment Readiness
Capture concrete readiness facts — data sources, test environments, named owners, cutover windows, and external dependencies that must be confirmed before execution.
Pre-Deployment Questions
Environment and access
- Are the production, pre-production, and integration/test environments provisioned and accessible to the seller's deployment team? If not, indicate expected availability date (so we can schedule environment-based testing).
- Has the buyer provided a complete inventory of integration endpoints and a named technical owner for each (so interface test owners are clear)?
- Are representative test datasets from the incumbent systems available for conversion and parallel testing, and are refresh schedules confirmed? (so we can plan conversion runs and parallel validation)
Data and configuration
- Is the authoritative source and named owner identified for each dataset category: members, providers, claims? (so data cutover responsibilities are clear)
- Has the field-mapping and transformation approach been decided (buyer-delivered mappings, seller-delivered, or joint)? (so mapping workshops and timelines can be set)
- Are data acceptance criteria for conversion and parallel testing defined (measurable thresholds for record counts, claims accuracy, and reconciliation)? (so go/no-go criteria are unambiguous)
People and ownership
- Has the buyer appointed a single named deployment owner with authority to approve go/no-go decisions during cutover? (we capture the role here; exact contact details go into the deployment config)
- Which external stakeholder groups have a named owner committed to support interface and parallel testing? (select all that apply — we use this to schedule cross-party test windows)
Timing and constraints
- List any known blackout or high-risk windows (payment cycles, fiscal close, holidays or provider billing cycles) when testing or cutover cannot occur. (so we avoid interrupting payments)
- Is a tentative cutover window agreed and will the buyer provide a 48-hour go/no-go approver during that window? (we need a committed approver to lock the execution calendar)
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Configuration Details
Lock exact configuration values the deployment team will use — field mappings, interface endpoints, credentials, throughput thresholds, and reporting mappings.
Configuration Details
Environments & Endpoints
- Enter the Production instance name to be created/used (format: single token, e.g. 'prod-mmps-01') — this exact value will be used in DNS, monitoring, and deployment manifests.
- Enter the Production API endpoint URL (format: https://api.your-domain.gov/; include protocol and trailing slash). This value is consumed verbatim by the API gateway and integration configs.
Authentication & Integrations
- Select the type of identity provider (IdP) the buyer will use for admin SSO (this config drives the product's SSO connector selection).
- Enter the IdP connector / client identifier (do NOT paste secrets). Example format: 'client-12345' or 'urn:entity:abc'. This identifier is consumed by the SSO connector settings.
Field Mappings & Data Conversion
- Provide the canonical field-mapping document location (format: https://... or file-share path). The deployment build will pull mappings from this location; include a single URL or path.
- List the source system identifier used as the single source-of-truth for member IDs (enter the source field name exactly as in the legacy extract; e.g., 'MEM_ID' or 'member_identifier').
Throughput, Reporting & Acceptance
- Required claims throughput threshold (numeric — claims processed per hour). Default is 10000 per hour — confirm or specify another integer value.
- Enter the reporting endpoint URL where acceptance-test results and daily operational reports should be posted (format: https://.../ingest). This endpoint is used by the runbook and monitoring jobs.
- Enter the batch SFTP integration username used for inbound legacy extracts (format: alphanumeric username; do NOT provide the password). This username will be created or validated during deployment.
- Who owns the SFTP credential and by which secure channel will its secret be exchanged? Enter as 'Team/Owner; secrets manager name' (example: 'State-ITS; your secrets manager'). Never paste the secret itself.
- Go-live acceptance claims accuracy threshold (numeric percent). Default is 99.5 — confirm or specify another value (enter as a decimal or percent, e.g., '99.5' for 99.5%).
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Deployment
Execute the rollout plan with sequenced tasks, parallel processing, testing, cutover steps, and clear owners for each milestone.
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Go-Live Acceptance
Formal go/no-go gate: verify parallel-run results, claims accuracy, provider payment continuity, and CMS certification milestones with named sign-offs before cutover.
Checklist items
- Receive parallel-run results report
- Confirm claims accuracy meets agreed acceptance criteria
- Verify provider payment continuity during parallel run
- Obtain CMS certification milestone documentation
- Collect written confirmations from external dependencies
- Validate rollback plan and recovery point
- Confirm final cutover runbook and sequencing
- Validate production interface connectivity and configuration
- Confirm monitoring, alerting, and escalation procedures are in place
- Obtain formal Go/No-Go decision with named sign-offs
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Success
Validate outcomes against success criteria, run recurring operational reviews, and maintain a shared channel for issues and enhancement requests.
Success Reviews
- Go-Live Health Check (weeks 1-4)
- First Measurement and Incumbent Wind-down (weeks 4-10)
- 90-Day Operational Stability Review
- Quarterly Operational Review (ongoing)
- Annual Success Review
Issues & Enhancements
- Publish the prioritized quarterly enhancement backlog with expected delivery quarters for each item.
- Close or set firm completion dates for all high-severity incidents that threaten payment continuity or CMS certification.
- Document outstanding external dependencies and the concrete actions required to mitigate each risk.
- Produce and share the 90-day performance report with metric trends and unresolved exceptions.
- Deliver root-cause analysis documents for each remaining Sev 1/2 incident with recommended permanent fixes.
- Update the dependency tracker with committed dates from CMS, MCOs, and PBMs and circulate for confirmation.
- Trend review of key metrics
- Maintain or improve claims throughput and on-time payment rate toward the Solution Scope targets for the quarter.
- Agree a prioritized enhancement backlog and scheduled delivery windows for the next quarter.
- Ensure no unresolved regulatory items are at risk of missing required cycles or filings.
- Re-confirm Solution Scope acceptance criteria and owners
- Assign due dates for closure of the top 5 operational issues and publish the burn-down plan.
- Circulate the regulatory watch list with required actions and deadlines for stakeholder confirmation.
- Yearly performance against Solution Scope targets
- Validate whether annual outcomes meet the Solution Scope targets for claims accuracy and provider payment continuity, and document any persistent gaps.
- Agree the annual governance calendar and the format/frequency of recurring operational reviews for the next year.
- Confirm the enhancement pipeline and schedule the top-priority operational improvements for delivery in the coming year.
- Publish the annual performance report with metric trends, exception analysis, and recommended next-year priorities.
- Deliver the agreed governance calendar and document the owners for each recurring review.
- Create a delivery plan for the top three operational enhancements to start in Q1 of the next year.
- Deployment passes initial health checks and no blocker prevents normal claims processing during hypercare.
- Named owners confirmed for each Solution Scope acceptance criterion and for all open high-severity defects.
- Immediate remediation tasks prioritized with committed completion windows.
- Publish the go-live health checklist and defect log to the shared channel within 24 hours.
- Record owners and target dates for all high-severity issues identified in the session.
- Circulate a short adoption summary (training completions, active users) for async review before the next meeting.
- Present first-period data for key metrics
- Determine whether claims accuracy, throughput, and on-time payment rate are tracking toward the Solution Scope targets and document any shortfalls.
- Confirm the incumbent system is either decommissioned or formally retained-read-only with archival completed and no active fallback.
- Agree a prioritized remediation plan with task-level actions and due dates to address gaps identified in metric performance.
- Publish the metric export and variance report versus Solution Scope targets for asynchronous review.
- Document and publish the incumbent wind-down checklist showing archive completion, contract/renewal handling, and read-only status.
- Create a short remediation task list with owners and due dates for closure before the 90-day stability review.
- Aggregate 90-day performance vs Solution Scope targets
- Confirm whether 90-day performance meets the trajectory toward Solution Scope targets for claims accuracy and CMS certification milestones.
- Deployment and migration validation
- Diagnose gaps and root causes
- Governance and operational cadence effectiveness
- Parallel-run and reconciliation outcomes
- Enhancement request backlog review
- Open high-severity incidents and RCA
- Enhancements delivered versus requested
- Incumbent system wind-down status
- Open issues burn-down
- Early adoption signals and user onboarding
- External dependency status
- Open defects and blockers
- Long-term operational risks and compliance posture
- Agree remediation actions and timelines
- Regulatory and certification watch items
- Finalize stability remediation plan
- Agree immediate remediation actions
- Confirm next quarter objectives
- Confirm timeline to stabilized operations