DHCS is directly responsible for enrolling and re-enrolling all eligible fee-for-service Providers in the Medi-Cal program. DHCS also manages other Medi-Cal Providers and services, such as dental, specialty mental health, nursing facilities, pharmacy, adult day care, and specialized family services.  

DHCS currently utilizes Provider Application and Validation for Enrollment solution (PAVE), the Software-as-a-Service (SaaS) cloud solution which is based on the "Know Your Provider" (KYP) proprietary SaaS offering. PAVE is based on the configuration, customization, deployment, and operations of KYP to meet the DHCS-specific program needs. The PAVE solution provides a secure web portal to on-board, enroll, and monitor Providers in the Medi-Cal program and maintain accurate up-to-date information.  The PAVE solution also interfaces with integration systems such as CD-MMIS and CA-MMIS mainframe for two-way data transmission and synchronization. PAVE is primarily used by multiple Programs and Divisions within DHCS to manage their Provider community.  However, other Programs within DHCS access PAVE to perform auditing, legal, and application review functions. PAVE consists of four configured and customized modules.

1. Portal - The portal component provides and offers a secure web-based platform through which the Providers can submit their applications and initiate the enrollment process into the Medi-Cal program. Providers can create profiles and use that information across multiple applications. Provider online applications are generated based on the type and scope of the application. Providers can connect their application information with documents and communications within the portal and submit in real-time to DHCS. E-signature capability is also available for the Providers to digitally sign and submit the applications. PAVE also allow for multiple types of roles and administrative rights to be created by the users in Portal and allows for sharing of the application.
2. Enrollment - The enrollment component contains a comprehensive workflow, document management, and decision support features.  The component captures unified information about practices, credentials, organizational relationships and affiliated parties and uses this information to verify and validate the enrollment process. It improves access to enrollment services, facilitates ease of use, and adds efficiencies to enrollment processes that are critical to supporting the timely enrollment of Providers that provide critical health services to California’s Medi-Cal member population.
3. Screening– The screening component executes an automated workflow in real-time against multiple data sources to create a comprehensive risk profile to assist the enrollment analyst in identifying the most high-risk Providers to maintain program integrity.  Screening must fulfill federal screening requirements by checking all state and federal-mandated databases and providing comprehensive results, allowing DHCS to be able to verify results and include documentation within the application. 
4. Monitoring—The monitoring component uses a platform to automatically match all enrolled entities (Providers and affiliated parties) against dozens of negative “lists.” It generates alerts for potential changes in the status of current enrollees and allows DHCS to take immediate action, including notifying the Provider. 

PAVE Screening and Monitoring component is used by the DHCS to ensure on-going compliance of Providers. PAVE provides significant and immediate benefits to the DHCS, including fraud prevention through enhanced screening and monitoring. Screening is completed every time an application is submitted (such as new enrollment, change of location, change of ownership, etc.) and monitoring of enrolled Providers is completed on a monthly basis. PAVE screens the applicant and the reported owners, officers, managing employees, and those with controlling interest against federal and state exclusionary boards, namely, Office of Inspector General (OIG), Medicaid and Children's Health Insurance Program State Information Sharing System (MCSIS), currently known as CMS Data Exchange System (DEX), System for Award Management (SAM), and the Suspended & Ineligible list (S&I). Additionally, PAVE screens and monitors the Provider’s licenses and permits, Social Security Administration Death Master File (SSA DMF), and National Plan and Provider Enumeration System (NPPES). PAVE Monitoring generates monthly alerts using mandatory compliance and risk data sources (at a minimum, based on PPACA compliance) to indicate potential risk of fraud, program vulnerability or non-compliance issues for the Provider and all parties associated with the Provider.

The Provider-related data is maintained in the Provider Master File (PMF) databases, part of the California Medi-Cal Management Information System (CA-MMIS). The dental provider data is California Dental Medicaid Management Information Systems (CD-MMIS), which is maintained by the current Fiscal Intermediary, Gainwell Technologies (GWT). The functions of DHCS are critical to the front-end program integrity efforts to curtail the potential for fraud, waste, or abuse to preserve Medicaid funds.  The PMF and CD-MMIS are essential subsystems that integrate with PAVE for data exchange. The PMF and CD-MMIS function as a data repository of Providers that are eligible to provide Medi-Cal related services to program beneficiaries and ensures that medical professionals submitting bills to Medi-Cal are approved Providers. 

PAVE facilitates the DHCS' compliance with Provider integrity mandates under the Patient Protection and Affordable Care Act (PPACA) of 2010 and provides the following functionality: enrollment of ordering, referring, and prescribing Providers; mandatory screening; initial and on-going monthly checks against exclusionary databases for Providers. PAVE also checks on those with ownership, control interests, agents or managing employees; and functionality to manage the revalidation of Providers every five (5) years. In addition, PAVE allows Providers to manage their own network of enrolled Providers.   

As of April 1, 2021, the Centers for Medicare and Medicaid Services (CMS) certified PAVE to receive enhanced federal funding. The system serves as an enterprise-wide provider management solution based on the Medicaid Information Technology Architecture (MITA) standards and improves efficiency, accuracy, interoperability, business results, and cross-organizational program integration. PAVE lays the foundation to incorporate other Provider Enrollment Programs within the Medicaid Enterprise System (MES).

Currently, there are approximately 313,900 active Medi-Cal Providers consisting of more than 56 different Provider types, and approximately 20,500 enrolled Medi-Cal Dental providers with approximately 65,000 applications per year processed, including physicians, nurses, pharmacists, medical suppliers, hospitals, and other medical facilities serving program beneficiaries. Furthermore, the Provider Enrollment Division  is responsible for developing and enforcing Medi-Cal Provider enrollment policies, which potentially affect approximately 906,000 active and inactive health care Providers whose records are maintained on the PMF, CD-MMIS, and PAVE. 

DHCS receives approximately 5000 – 8000 applications per month via PAVE. These applications include requests to enroll or re-enroll in the program, along with thousands of miscellaneous documents that require significant analytical research. Among the applications received, approximately 40 percent are deemed deficient for various reasons, including incomplete application packages and missing documentation and/or attachments. Those applications deemed deficient are subsequently returned to the Provider for additional information. 
 

CMS introduced MITA, which DHCS adopted. MITA is both an initiative and a framework aimed at improving program administration through integrated business, information, and technology transformation. CMS has issued new standards and conditions that it expects States to adhere to in order for Medicaid technology investments to be eligible for enhanced federal matching funds. Thus, one of the Department’s goals is to implement an enterprise-wide Provider Management solution aligned with the MITA standards, introduced by CMS.

The solution must comply with the accessibility requirements of Sections 7405 and 11135 of the California Government Code, Section 508 of the Rehabilitation Act of 1973 as amended (29 U.S.C. § 794d), regulations implementing the Rehabilitation Act of 1973 as set forth in Title 36 Part 1194 of the Code of Federal Regulations, and the Americans with Disabilities Act of 1990 (42 U.S.C. § 12101 et seq.).  In 1998, Congress amended the Rehabilitation Act of 1973 to require Federal agencies to make their electronic and information technology (EIT) accessible to people with disabilities.  California Government Code Sections 7405 and 11135 codifies Section 508 of the Rehabilitation Act of 1973 requiring accessibility of EIT. This must be validated against WCAG 2.1 Standard, and a report must be sent to the DHCS according to A Voluntary Product Accessibility Template (VPAT).

The solution must be compliant with the Provider integrity mandates under the Patient Protection and Affordable Care Act, 42 CFR 455.410, 455.414, and 455.436. The proposed solution will lay the foundation to incorporate other DHCS Provider Enrollment Programs to align and increase the Department’s MITA maturity to a level three (3) for Provider Management at full deployment.

The Department aims to implement a complete web-based solution where Providers can submit their applications and maintain accurate up-to-date information via an online portal. Screening and Monitoring components assist and validate fraud prevention on applications and active enrollments ensure on-going compliance. Enrollment components must improve access to enrollment services, facilitate ease of use, and add efficiencies to enrollment processes that are critical to supporting the timely enrollment of providers that provide critical health services to California’s Medi-Cal member population and messaging capabilities to assist with effective correspondence between the Providers and DHCS.

The solution must be compatible to integrate with the CA-MMIS and CD-MMIS systems, and any future systems that are added as required for the DHCS provider management activities. The performance must not be impacted as it expands to include new Providers and all provider management activities. The solution must be able to scale horizontally, diagonally, and vertically to ensure satisfactory user experience and response times with future growth. The vendor must use these scaling techniques to add new nodes, server space, storage, and networking resources for improving performance and expand system capacity to handle more load of concurrent requests and process significant amounts of data simultaneously while accommodating additional provider types, increasing individual user roles with unique role-based permissions, and integration with other systems. The scalability must be measured with the system response time, throughput, CPU usage, Memory usage, and network usage. The solution must be tightly secured behind a Web Application Firewall (WAF) that leverages the application layer protection for the Open Web Application Security Project (OWASP) security standards. The solution must not have a direct internet routing. 

DHCS is looking for a broad set of solution options available in the market. DHCS is open to SaaS, COTS, MOTS, custom development, and any other hybrid solution that meets DHCS’ needs.  The solution must be cost effective to implement and maintain for the life of the contract.  In general, DHCS is looking for an integrated enterprise-wide Provider Management and Monitoring solution that:  

• Has the ability to submit and e-sign Provider applications through the internet that are received electronically in real-time to DHCS during enrollment.
• Reviews and processes applications including full auditing capabilities from application submission, enrollment, and monitoring.
• Allows for different user roles, queues, and work streams in enrollment and monitoring. 
• Allows for multiple actions to be taken on applications and Provider accounts. 
• Meets State and Federal security requirements.
• Provides two-way communication between the Provider and the enrollment analyst.
• Links applications from account data, attached documentation, and communications into a unified case.
• Creates case management from shared affiliations, ownerships, and demographics.
• Generates a comprehensive view of the risk associated with the Provider.
• Monitors and alerts enrollment analyst when there is a change in Provider status. 
• Enables users to pull canned and ad hoc reports on all data elements.
• Generates actionable dashboards for risk management reporting.
• Allows DHCS to set and disable moratoriums in real-time.
• Identifies and allows for the re-validation and re-certification of enrolled Providers.
• Maintains a state database that can be updated in real-time by DHCS and is included in screening results for submitted applications.
• Exchanges data with the CA-MMIS and CD-MMIS.
• Will be the system of record for DHCS’ Provider management. 
• Is capable of data warehousing and data mining.
• Adapts to business process changes with minimal reconfiguration and cost to DHCS.
• Can integrate with various sub-systems.
• Allows Providers to submit tickets to resolve any technical issues.