• Data Mining Solution Functionalities: The Quoter selected for this engagement must provide a data mining solution that will: ο Handle second pass for all claims submitted to CareOregon for payment. ο Integrate seamlessly into the existing CareOregon claims processing system with minimal effort, time, and cost, and assure no disruption in the regulatory processing of claims. ο Integrate into multiple points in the claim processing flow from submission through adjudication for the identification of high-risk and suspect claims. ο Provide a rapid solution with the ability to assess the risk of providers and target specific provider types as well as those requested by CareOregon. ο Limit and facilitate the amount of manual effort and review time of flagged high-risk and suspect claims. ο Utilize statistically sound, empirically derived data mining technologies including link analytics, geospatial capabilities including but not limited to analysis of third party sources designed to identify high-risk and suspect claims and identify suspect relationships, patterns, trends, utilization, and billing behavior. ο Process historical transaction data and information from external databases. ο Be linked to third party systems and data sources, such as the MFCU Investigation Database, List of Excluded Individuals/Entities (LEIE), vital statistics, land records, and criminal history data.
