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SAS Provider Network & Accreditation Module — Software Requirements Specification (SRS)

Table of Contents​

1 Document Information​

FieldValue
Project NameSAS Provider Network & Accreditation Module
Version1.0
Date2025-10-17
Project ManagerTBD
Tech LeadTBD
Qa LeadTBD
Platforms['Web']
Document StatusComprehensive Draft
Module CodePROVIDER
Parent ProjectSAS - Smart Assemble System

2 Project Overview​

2.1 What Are We Building​

2.1.1 System Function​

Comprehensive provider network management system handling provider registration, accreditation, contract management, credential verification, fee schedule management, capitation, network categorization, provider portals, claims authorization, provider performance tracking, and provider payments

2.1.2 Users​

  • Provider Relations Officers (onboarding and accreditation)
  • Network Managers (network strategy and optimization)
  • Contracting Officers (contract negotiation and management)
  • Finance Officers (fee schedules and capitation)
  • Medical Directors (clinical quality oversight)
  • Provider Relations Managers (provider performance)
  • Providers (hospitals, clinics, doctors, pharmacies)
  • Provider Portal Users (service delivery and claims)

2.1.3 Problem Solved​

Manual provider onboarding, no credential verification, inconsistent fee schedules, delayed provider payments, lack of provider performance tracking, no self-service provider portal, manual authorization processes, limited network analytics

2.1.4 Key Success Metric​

100% digital provider onboarding, automated credential verification, 95% provider satisfaction score, real-time authorization responses, automated capitation calculations, 50% provider portal adoption within 6 months, comprehensive provider performance dashboards

2.2 Scope​

2.2.1 In Scope​

  • Provider registration and profiling (hospitals, clinics, doctors, pharmacies, labs, imaging centers)
  • Accreditation workflow with document verification
  • Contract management (negotiation, approval, renewal, termination)
  • Credential verification (licensing, certifications, specializations)
  • Network categorization (Tier 1/2/3, specialty networks)
  • Fee schedule management (fee-for-service rates)
  • Capitation management (per-member-per-month rates)
  • Provider portal for service delivery and claims submission
  • Authorization management (referrals, pre-authorizations)
  • Provider performance tracking (utilization, quality, member satisfaction)
  • Provider payment processing and reconciliation
  • Geographic coverage mapping
  • Panel management (assigned members per provider)
  • Multi-currency support for cross-border providers
  • Provider training and certification tracking
  • Provider communication (notifications, bulletins)
  • Audit trail for all provider interactions

2.2.2 Out Of Scope​

  • Provider clinical systems integration (EMR/EHR)
  • Provider inventory management
  • Provider HR and payroll systems
  • Telemedicine platform (future phase)
  • International provider networks outside East Africa
  • Provider financing and loans

3 User Requirements​

3.1 Provider Registration​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-REGISTRATIONRegister new providers with comprehensive profile informationBuild a complete provider network databaseMustProvider types: Hospital, Clinic, Doctor, Pharmacy, Lab, Imaging Center. Profile includes: name, type, contact, address, services offered, operating hours, capacity.
FT-PROV-CREDENTIAL-VERIFICATIONVerify provider credentials (licenses, certifications)Ensure provider quality and complianceMustVerification of medical licenses, board certifications, DEA numbers, malpractice insurance. Integration with regulatory bodies (TMC, NCK).
FT-PROV-SPECIALIZATIONCapture provider specializations and sub-specialtiesMatch members with appropriate specialistsMustSpecialty taxonomy: primary care, cardiology, oncology, pediatrics, etc. Sub-specialty tracking. Board certification dates.
FT-PROV-SERVICE-CATALOGDefine service catalog per providerKnow what services each provider offersMustService catalog: outpatient, inpatient, emergency, lab, imaging, pharmacy, dental, optical. Service availability hours.
FT-PROV-FACILITY-INFOCapture facility information (beds, equipment, accreditation)Assess provider capacity and capabilityMustFacility details: bed capacity, ICU beds, emergency dept, operating theaters, medical equipment, facility accreditation (JCI, COHSASA).

3.2 Accreditation​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-ACCREDITATION-WORKFLOWManage provider accreditation workflowSystematically approve providers for networkMustWorkflow stages: Application submitted -> Document review -> Site inspection -> Medical director review -> Contract negotiation -> Approved. Rejection workflow with reasons.
FT-PROV-DOCUMENT-UPLOADCollect and verify provider documentsMaintain compliance documentationMustDocument types: business license, medical license, insurance certificates, tax clearance, bank details. Document expiry tracking.
FT-PROV-SITE-INSPECTIONSchedule and record site inspection resultsVerify provider facilities meet standardsMustInspection checklist: cleanliness, equipment, staff qualifications, emergency preparedness. Inspection report with photos. Pass/fail scoring.
FT-PROV-REACCREDITATIONManage periodic provider reaccreditationEnsure ongoing compliance with standardsMustReaccreditation cycle: every 2-3 years. Automated reminders 90 days before expiry. Simplified reaccreditation for good performers.
FT-PROV-SUSPENSION-TERMINATIONSuspend or terminate provider contractsRemove non-compliant providers from networkMustSuspension reasons: quality issues, fraud, non-compliance. Termination workflow with notice period. Impact on active members and claims.

3.3 Contract Management​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-CONTRACT-NEGOTIATIONManage contract negotiation processAgree on terms with providersMustContract terms: payment model (FFS, capitation, hybrid), fee schedules, service scope, performance targets, termination clauses.
FT-PROV-CONTRACT-APPROVALImplement contract approval workflowEnsure proper authorization of contractsMustApproval hierarchy: Provider relations officer -> Network manager -> Finance manager -> Medical director -> CEO. Approval limits by contract value.
FT-PROV-CONTRACT-TEMPLATESUse contract templates for different provider typesStandardize contract termsMustTemplates: Hospital contract, Clinic contract, Doctor contract, Pharmacy contract. Customizable clauses. Version control.
FT-PROV-CONTRACT-RENEWALManage contract renewal processMaintain provider relationshipsMustRenewal reminders 90 days before expiry. Renewal negotiation workflow. Rate adjustments. Auto-renewal option with notice.
FT-PROV-CONTRACT-AMENDMENTSProcess contract amendments and addendumsUpdate contract terms as neededMustAmendment types: rate changes, service additions, term extensions. Amendment approval workflow. Amendment history tracking.
FT-PROV-CONTRACT-REPOSITORYMaintain digital contract repositoryAccess contracts easilyMustDocument management: signed contracts, amendments, correspondence. Search by provider, date, contract type. Expiry alerts.

3.4 Network Management​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-NETWORK-TIERSCategorize providers into network tiersImplement tiered benefit structuresMustTiers: Tier 1 (preferred, lowest cost-share), Tier 2 (standard), Tier 3 (out-of-network). Tier assignment criteria: cost, quality, location.
FT-PROV-SPECIALTY-NETWORKSCreate specialty networks (e.g., oncology, cardiology)Manage specialized care deliveryShouldSpecialty networks: Center of Excellence designation. Minimum volume/quality requirements. Enhanced reimbursement for COEs.
FT-PROV-GEOGRAPHIC-COVERAGEMap provider geographic coverageEnsure adequate network accessMustGeographic mapping: providers by region, city, district. Coverage gap analysis. Distance/time to care metrics. Service area definitions.
FT-PROV-PANEL-MANAGEMENTManage provider panels (assigned members)Control provider capacity and accessShouldPanel capacity: max members per provider. Panel assignment rules. Panel open/closed status. Panel utilization tracking.
FT-PROV-NETWORK-ADEQUACYAnalyze network adequacyIdentify and fill coverage gapsMustAdequacy metrics: provider-to-member ratios, geographic access, specialty availability. Regulatory compliance reporting (TIRA requirements).

3.5 Fee Schedules​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-FEE-SCHEDULE-SETUPCreate and manage fee schedulesDefine reimbursement rates for servicesMustFee schedule types: procedure codes (ICD-10, CPT), drug pricing (NLEM), lab tests, imaging. Multiple fee schedules per provider type.
FT-PROV-NEGOTIATED-RATESSet negotiated rates per providerCustomize reimbursement by providerMustRate types: percentage of charges, fixed fee, discounted fee schedule. Rate effective dates. Rate comparison reports.
FT-PROV-RATE-UPDATESManage fee schedule updatesKeep rates currentMustRate update workflow: proposal -> approval -> effective date. Bulk rate updates. Historical rate tracking. Provider notification.
FT-PROV-BILLING-RULESConfigure billing rules and limitsControl reimbursement appropriatelyMustBilling rules: maximum allowable charge, bundling rules, frequency limits (1x per year), age/gender edits. Automated claims adjudication.

3.6 Capitation​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-CAPITATION-RATESSet capitation rates (PMPM) per providerImplement capitation payment modelMustCapitation rates: per member per month (PMPM). Rate stratification by age, gender, product. Risk adjustment. Effective dates.
FT-PROV-CAPITATION-ROSTERMaintain capitation rostersTrack which members are assigned to which providersMustRoster management: member assignments, effective dates, terminations. Monthly roster reconciliation. Roster changes mid-month handling.
FT-PROV-CAPITATION-CALCULATIONCalculate monthly capitation paymentsPay providers accuratelyMustCalculation: member count × PMPM rate. Adjustments for mid-month changes. Capitation voucher generation. Integration with finance module.
FT-PROV-CAPITATION-WITHHOLDSManage capitation withholds and incentivesIncentivize quality and utilization managementShouldWithholds: percentage held back for performance. Incentive criteria: quality metrics, utilization targets. Annual reconciliation and payout.

3.7 Provider Portal​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-PORTAL-DASHBOARDProvide provider dashboardGive providers overview of their activityMustDashboard: active members, claims status, payments, authorizations pending, performance metrics. Real-time updates.
FT-PROV-MEMBER-VERIFICATIONEnable real-time member eligibility verificationHelp providers verify coverage before serviceMustVerification: member ID, policy status, benefit coverage, co-pay amounts, authorization requirements. QR code scanning. Biometric verification.
FT-PROV-CLAIMS-SUBMISSIONAllow providers to submit claims electronicallyStreamline claims processingMustClaims submission: diagnosis codes, procedure codes, charges. Attachment upload (invoices, prescriptions). Real-time validation. Submission confirmation.
FT-PROV-AUTHORIZATION-REQUESTEnable providers to request authorizationsFacilitate pre-authorization processMustAuthorization request: service details, diagnosis, estimated cost, medical justification. Attachment support. Real-time approval/denial.
FT-PROV-PAYMENT-TRACKINGShow provider payment history and remittanceGive providers transparency on paymentsMustPayment tracking: payment date, amount, claim details, deductions. Remittance advice download. Payment reconciliation tools.
FT-PROV-COMMUNICATIONEnable provider communication with insurerFacilitate information exchangeMustCommunication: messaging system, claim inquiries, member issues, policy updates. Notification center. Bulletins and announcements.

3.8 Authorization​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-PREAUTH-WORKFLOWManage pre-authorization workflowControl utilization of high-cost servicesMustPre-auth required for: hospitalizations, surgeries, imaging, specialty care. Workflow: Request -> Medical review -> Approve/Deny. Turnaround time: 24-48 hours.
FT-PROV-AUTO-AUTHORIZATIONImplement automated authorization rulesExpedite routine authorizationsMustAuto-approval rules: routine procedures, in-network providers, within benefit limits. Auto-denial rules: excluded services, benefit exhausted.
FT-PROV-REFERRAL-MANAGEMENTManage referrals between providersTrack care coordinationMustReferral workflow: PCP creates referral -> Member visits specialist -> Referral closed. Referral validity period. Specialist network restrictions.
FT-PROV-EMERGENCY-AUTHHandle emergency authorizationsEnsure timely emergency careMustEmergency services: auto-approved, notification within 24 hours. Retrospective review. Emergency definition criteria.

3.9 Provider Performance​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-UTILIZATION-TRACKINGTrack provider utilization patternsIdentify high/low utilizersMustUtilization metrics: visits per member, cost per visit, admission rates, length of stay, referral rates. Benchmarking against network averages.
FT-PROV-QUALITY-METRICSMeasure provider quality metricsAssess provider qualityMustQuality metrics: readmission rates, patient satisfaction scores, clinical outcomes, adherence to protocols. HEDIS measures.
FT-PROV-MEMBER-SATISFACTIONCollect member satisfaction feedback on providersMonitor member experienceMustSatisfaction surveys: post-visit surveys, ratings (1-5 stars), comments. Complaint tracking. Provider response to feedback.
FT-PROV-PERFORMANCE-SCORECARDSGenerate provider performance scorecardsProvide feedback to providersMustScorecard: utilization, quality, satisfaction, compliance. Quarterly reports. Performance tiers (top, average, needs improvement). Incentive linkage.
FT-PROV-OUTLIER-DETECTIONDetect provider outliersIdentify potential fraud or quality issuesMustOutlier detection: statistical analysis of utilization and cost patterns. Alerts for investigation. Provider education and corrective action plans.

3.10 Provider Reporting​

Feature CodeI Want ToSo That I CanPriorityNotes
FT-PROV-NETWORK-REPORTSGenerate network composition reportsUnderstand network makeupMustReports: provider count by type, specialty, region. Network growth trends. Provider turnover. Contract expiration pipeline.
FT-PROV-UTILIZATION-REPORTSGenerate provider utilization reportsAnalyze service utilization patternsMustReports: claims volume by provider, service mix, cost trends. Top 10 providers by volume/cost. Utilization by specialty.
FT-PROV-PAYMENT-REPORTSGenerate provider payment reportsTrack provider reimbursementMustReports: payments by provider, payment method (FFS vs capitation), payment timeliness. Outstanding payables. Payment accuracy.
FT-PROV-CREDENTIALING-REPORTSGenerate credentialing status reportsMonitor credential expirationMustReports: providers with expiring credentials, pending reaccreditation, suspended providers. Compliance dashboard.

4 Detailed Feature Requirements​

4.1 Ft Prov Registration​

4.1.1 Priority​

Must Have

4.1.2 User Story​

As a provider relations officer, I want to register new providers with comprehensive profile information so that I can build a complete provider network database

4.1.3 Preconditions​

Provider relations officer permissions granted, provider information available

4.1.4 Postconditions​

Provider registered with complete profile, provider ID assigned, ready for accreditation workflow

4.1.5 Test Cases​

IdDescriptionWeight
REGISTRATION-TC-001Verify provider can be registered with all required fieldsHigh
REGISTRATION-TC-002Verify provider type selection (Hospital, Clinic, Doctor, Pharmacy, Lab, Imaging)High
REGISTRATION-TC-003Verify contact information captured (phone, email, address)High
REGISTRATION-TC-004Verify services offered can be selectedHigh
REGISTRATION-TC-005Verify operating hours capturedMedium
REGISTRATION-TC-006Verify facility capacity information capturedHigh
REGISTRATION-TC-007Verify unique provider ID generatedHigh

4.2 Ft Prov Credential Verification​

4.2.1 Priority​

Must Have

4.2.2 User Story​

As a provider relations officer, I want to verify provider credentials so that I can ensure provider quality and compliance

4.2.3 Preconditions​

Provider registered, credential documents uploaded

4.2.4 Postconditions​

Credentials verified, verification status updated, expiry dates tracked

4.2.5 Test Cases​

IdDescriptionWeight
CREDENTIAL-VERIFICATION-TC-001Verify medical license validationHigh
CREDENTIAL-VERIFICATION-TC-002Verify board certification validationHigh
CREDENTIAL-VERIFICATION-TC-003Verify malpractice insurance validationHigh
CREDENTIAL-VERIFICATION-TC-004Verify integration with regulatory bodies (TMC, NCK)High
CREDENTIAL-VERIFICATION-TC-005Verify credential expiry trackingHigh
CREDENTIAL-VERIFICATION-TC-006Verify alerts for expiring credentials (90 days)High
CREDENTIAL-VERIFICATION-TC-007Verify credential verification history maintainedMedium

4.3 Ft Prov Specialization​

4.3.1 Priority​

Must Have

4.3.2 User Story​

As a provider relations officer, I want to capture provider specializations so that I can match members with appropriate specialists

4.3.3 Preconditions​

Provider registered, specialty taxonomy configured

4.3.4 Postconditions​

Specializations and sub-specialties captured, board certification dates recorded

4.3.5 Test Cases​

IdDescriptionWeight
SPECIALIZATION-TC-001Verify primary specialty selectionHigh
SPECIALIZATION-TC-002Verify sub-specialty selectionHigh
SPECIALIZATION-TC-003Verify multiple specialties supportedHigh
SPECIALIZATION-TC-004Verify board certification date capturedHigh
SPECIALIZATION-TC-005Verify specialty taxonomy comprehensive (primary care, cardiology, oncology, etc.)High
SPECIALIZATION-TC-006Verify specialty search functionalityMedium

4.4 Ft Prov Service Catalog​

4.4.1 Priority​

Must Have

4.4.2 User Story​

As a provider relations officer, I want to define service catalog per provider so that I can know what services each provider offers

4.4.3 Preconditions​

Provider registered, service taxonomy configured

4.4.4 Postconditions​

Service catalog defined, service availability hours set

4.4.5 Test Cases​

IdDescriptionWeight
SERVICE-CATALOG-TC-001Verify outpatient services can be addedHigh
SERVICE-CATALOG-TC-002Verify inpatient services can be addedHigh
SERVICE-CATALOG-TC-003Verify emergency services can be addedHigh
SERVICE-CATALOG-TC-004Verify lab/imaging/pharmacy services can be addedHigh
SERVICE-CATALOG-TC-005Verify service availability hours capturedMedium
SERVICE-CATALOG-TC-006Verify service catalog searchableMedium

4.5 Ft Prov Facility Info​

4.5.1 Priority​

Must Have

4.5.2 User Story​

As a provider relations officer, I want to capture facility information so that I can assess provider capacity and capability

4.5.3 Preconditions​

Provider registered as facility (Hospital or Clinic)

4.5.4 Postconditions​

Facility details captured including bed capacity, equipment, accreditation

4.5.5 Test Cases​

IdDescriptionWeight
FACILITY-INFO-TC-001Verify bed capacity captured (total, ICU, maternity)High
FACILITY-INFO-TC-002Verify emergency department information capturedHigh
FACILITY-INFO-TC-003Verify operating theater count capturedHigh
FACILITY-INFO-TC-004Verify medical equipment inventory capturedMedium
FACILITY-INFO-TC-005Verify facility accreditation (JCI, COHSASA) capturedHigh
FACILITY-INFO-TC-006Verify facility accreditation expiry dates trackedHigh

4.6 Ft Prov Accreditation Workflow​

4.6.1 Priority​

Must Have

4.6.2 User Story​

As a provider relations officer, I want to manage provider accreditation workflow so that I can systematically approve providers for network

4.6.3 Preconditions​

Provider registered with complete profile

4.6.4 Postconditions​

Provider progresses through accreditation stages, final approval or rejection recorded

4.6.5 Test Cases​

IdDescriptionWeight
ACCREDITATION-WORKFLOW-TC-001Verify workflow stages defined (Application -> Document review -> Site inspection -> Medical review -> Contract -> Approved)High
ACCREDITATION-WORKFLOW-TC-002Verify stage transitions tracked with datesHigh
ACCREDITATION-WORKFLOW-TC-003Verify rejection workflow with reasonsHigh
ACCREDITATION-WORKFLOW-TC-004Verify resubmission after rejection allowedMedium
ACCREDITATION-WORKFLOW-TC-005Verify workflow status visible to providerHigh
ACCREDITATION-WORKFLOW-TC-006Verify notifications sent at each stageHigh
ACCREDITATION-WORKFLOW-TC-007Verify audit trail maintainedHigh

4.7 Ft Prov Document Upload​

4.7.1 Priority​

Must Have

4.7.2 User Story​

As a provider relations officer, I want to collect and verify provider documents so that I can maintain compliance documentation

4.7.3 Preconditions​

Provider in accreditation workflow

4.7.4 Postconditions​

Documents uploaded, verified, expiry dates tracked

4.7.5 Test Cases​

IdDescriptionWeight
DOCUMENT-UPLOAD-TC-001Verify business license can be uploadedHigh
DOCUMENT-UPLOAD-TC-002Verify medical license can be uploadedHigh
DOCUMENT-UPLOAD-TC-003Verify insurance certificates can be uploadedHigh
DOCUMENT-UPLOAD-TC-004Verify tax clearance can be uploadedHigh
DOCUMENT-UPLOAD-TC-005Verify bank details can be uploadedHigh
DOCUMENT-UPLOAD-TC-006Verify document expiry dates trackedHigh
DOCUMENT-UPLOAD-TC-007Verify alerts for expiring documentsHigh
DOCUMENT-UPLOAD-TC-008Verify document versioning maintainedMedium

4.8 Ft Prov Site Inspection​

4.8.1 Priority​

Must Have

4.8.2 User Story​

As a provider relations officer, I want to schedule and record site inspection results so that I can verify provider facilities meet standards

4.8.3 Preconditions​

Provider documents verified, site inspection scheduled

4.8.4 Postconditions​

Inspection completed, results recorded, pass/fail determination made

4.8.5 Test Cases​

IdDescriptionWeight
SITE-INSPECTION-TC-001Verify site inspection can be scheduledHigh
SITE-INSPECTION-TC-002Verify inspection checklist available (cleanliness, equipment, staff, emergency prep)High
SITE-INSPECTION-TC-003Verify inspection findings can be recordedHigh
SITE-INSPECTION-TC-004Verify photos can be uploadedMedium
SITE-INSPECTION-TC-005Verify pass/fail scoring calculatedHigh
SITE-INSPECTION-TC-006Verify inspection report generatedHigh
SITE-INSPECTION-TC-007Verify re-inspection can be scheduled if failedHigh

4.9 Ft Prov Reaccreditation​

4.9.1 Priority​

Must Have

4.9.2 User Story​

As a provider relations officer, I want to manage periodic provider reaccreditation so that I can ensure ongoing compliance with standards

4.9.3 Preconditions​

Provider accredited, reaccreditation due

4.9.4 Postconditions​

Reaccreditation process completed, provider status updated

4.9.5 Test Cases​

IdDescriptionWeight
REACCREDITATION-TC-001Verify reaccreditation cycle configured (every 2-3 years)High
REACCREDITATION-TC-002Verify automated reminders sent 90 days before expiryHigh
REACCREDITATION-TC-003Verify simplified reaccreditation for good performersMedium
REACCREDITATION-TC-004Verify full reaccreditation for poor performersHigh
REACCREDITATION-TC-005Verify reaccreditation status trackedHigh
REACCREDITATION-TC-006Verify expired accreditation suspends providerHigh

4.10 Ft Prov Suspension Termination​

4.10.1 Priority​

Must Have

4.10.2 User Story​

As a network manager, I want to suspend or terminate provider contracts so that I can remove non-compliant providers from network

4.10.3 Preconditions​

Provider in network, suspension/termination reasons documented

4.10.4 Postconditions​

Provider suspended or terminated, member notifications sent, claims processing adjusted

4.10.5 Test Cases​

IdDescriptionWeight
SUSPENSION-TERMINATION-TC-001Verify suspension reasons captured (quality issues, fraud, non-compliance)High
SUSPENSION-TERMINATION-TC-002Verify suspension workflow with approvalHigh
SUSPENSION-TERMINATION-TC-003Verify termination workflow with notice periodHigh
SUSPENSION-TERMINATION-TC-004Verify impact on active members assessedHigh
SUSPENSION-TERMINATION-TC-005Verify claims in process handled appropriatelyHigh
SUSPENSION-TERMINATION-TC-006Verify member notifications sentHigh
SUSPENSION-TERMINATION-TC-007Verify reinstatement process available for suspensionsMedium

4.11 Ft Prov Contract Negotiation​

4.11.1 Priority​

Must Have

4.11.2 User Story​

As a contracting officer, I want to manage contract negotiation process so that I can agree on terms with providers

4.11.3 Preconditions​

Provider accredited, ready for contracting

4.11.4 Postconditions​

Contract terms negotiated, documented, ready for approval

4.11.5 Test Cases​

IdDescriptionWeight
CONTRACT-NEGOTIATION-TC-001Verify payment model selection (FFS, capitation, hybrid)High
CONTRACT-NEGOTIATION-TC-002Verify fee schedules attached to contractHigh
CONTRACT-NEGOTIATION-TC-003Verify service scope definedHigh
CONTRACT-NEGOTIATION-TC-004Verify performance targets setHigh
CONTRACT-NEGOTIATION-TC-005Verify termination clauses includedHigh
CONTRACT-NEGOTIATION-TC-006Verify negotiation history trackedMedium

4.12 Ft Prov Contract Approval​

4.12.1 Priority​

Must Have

4.12.2 User Story​

As a network manager, I want to implement contract approval workflow so that I can ensure proper authorization of contracts

4.12.3 Preconditions​

Contract negotiation completed

4.12.4 Postconditions​

Contract approved through hierarchy, ready for execution

4.12.5 Test Cases​

IdDescriptionWeight
CONTRACT-APPROVAL-TC-001Verify approval hierarchy enforced (Officer -> Manager -> Finance -> Medical Director -> CEO)High
CONTRACT-APPROVAL-TC-002Verify approval limits by contract valueHigh
CONTRACT-APPROVAL-TC-003Verify rejection with reasons supportedHigh
CONTRACT-APPROVAL-TC-004Verify renegotiation after rejectionMedium
CONTRACT-APPROVAL-TC-005Verify approval notifications sentHigh
CONTRACT-APPROVAL-TC-006Verify audit trail maintainedHigh

4.13 Ft Prov Contract Templates​

4.13.1 Priority​

Must Have

4.13.2 User Story​

As a contracting officer, I want to use contract templates so that I can standardize contract terms

4.13.3 Preconditions​

Contract templates configured in system

4.13.4 Postconditions​

Contract generated from template, customized clauses added

4.13.5 Test Cases​

IdDescriptionWeight
CONTRACT-TEMPLATES-TC-001Verify hospital contract template availableHigh
CONTRACT-TEMPLATES-TC-002Verify clinic contract template availableHigh
CONTRACT-TEMPLATES-TC-003Verify doctor contract template availableHigh
CONTRACT-TEMPLATES-TC-004Verify pharmacy contract template availableHigh
CONTRACT-TEMPLATES-TC-005Verify customizable clauses supportedHigh
CONTRACT-TEMPLATES-TC-006Verify template version control maintainedMedium

4.14 Ft Prov Contract Renewal​

4.14.1 Priority​

Must Have

4.14.2 User Story​

As a contracting officer, I want to manage contract renewal process so that I can maintain provider relationships

4.14.3 Preconditions​

Contract approaching expiry

4.14.4 Postconditions​

Contract renewed with updated terms or allowed to expire

4.14.5 Test Cases​

IdDescriptionWeight
CONTRACT-RENEWAL-TC-001Verify renewal reminders sent 90 days before expiryHigh
CONTRACT-RENEWAL-TC-002Verify renewal negotiation workflow initiatedHigh
CONTRACT-RENEWAL-TC-003Verify rate adjustments proposedHigh
CONTRACT-RENEWAL-TC-004Verify auto-renewal option with notice periodMedium
CONTRACT-RENEWAL-TC-005Verify renewal approval workflowHigh
CONTRACT-RENEWAL-TC-006Verify expired contract handlingHigh

4.15 Ft Prov Contract Amendments​

4.15.1 Priority​

Must Have

4.15.2 User Story​

As a contracting officer, I want to process contract amendments so that I can update contract terms as needed

4.15.3 Preconditions​

Active contract in place, amendment requested

4.15.4 Postconditions​

Amendment approved, contract updated, history maintained

4.15.5 Test Cases​

IdDescriptionWeight
CONTRACT-AMENDMENTS-TC-001Verify rate change amendments supportedHigh
CONTRACT-AMENDMENTS-TC-002Verify service addition amendments supportedHigh
CONTRACT-AMENDMENTS-TC-003Verify term extension amendments supportedHigh
CONTRACT-AMENDMENTS-TC-004Verify amendment approval workflowHigh
CONTRACT-AMENDMENTS-TC-005Verify amendment history trackedHigh
CONTRACT-AMENDMENTS-TC-006Verify amendment effective dates managedHigh

4.16 Ft Prov Contract Repository​

4.16.1 Priority​

Must Have

4.16.2 User Story​

As a contracting officer, I want to maintain digital contract repository so that I can access contracts easily

4.16.3 Preconditions​

Contracts executed and signed

4.16.4 Postconditions​

Contracts stored digitally, searchable, accessible

4.16.5 Test Cases​

IdDescriptionWeight
CONTRACT-REPOSITORY-TC-001Verify signed contracts uploadedHigh
CONTRACT-REPOSITORY-TC-002Verify amendments stored with contractHigh
CONTRACT-REPOSITORY-TC-003Verify correspondence storedMedium
CONTRACT-REPOSITORY-TC-004Verify search by provider nameHigh
CONTRACT-REPOSITORY-TC-005Verify search by contract dateHigh
CONTRACT-REPOSITORY-TC-006Verify expiry alerts generatedHigh

4.17 Ft Prov Network Tiers​

4.17.1 Priority​

Must Have

4.17.2 User Story​

As a network manager, I want to categorize providers into network tiers so that I can implement tiered benefit structures

4.17.3 Preconditions​

Providers in network, tier criteria defined

4.17.4 Postconditions​

Providers assigned to tiers, tier displayed in provider directory

4.17.5 Test Cases​

IdDescriptionWeight
NETWORK-TIERS-TC-001Verify Tier 1 (preferred, lowest cost-share) definedHigh
NETWORK-TIERS-TC-002Verify Tier 2 (standard) definedHigh
NETWORK-TIERS-TC-003Verify Tier 3 (out-of-network) definedHigh
NETWORK-TIERS-TC-004Verify tier assignment criteria (cost, quality, location)High
NETWORK-TIERS-TC-005Verify tier changes tracked with effective datesHigh
NETWORK-TIERS-TC-006Verify tier displayed in provider searchHigh

4.18 Ft Prov Specialty Networks​

4.18.1 Priority​

Should Have

4.18.2 User Story​

As a network manager, I want to create specialty networks so that I can manage specialized care delivery

4.18.3 Preconditions​

Specialty network criteria defined

4.18.4 Postconditions​

Specialty networks created, Centers of Excellence designated

4.18.5 Test Cases​

IdDescriptionWeight
SPECIALTY-NETWORKS-TC-001Verify specialty network types defined (oncology, cardiology, etc.)High
SPECIALTY-NETWORKS-TC-002Verify Center of Excellence designation supportedHigh
SPECIALTY-NETWORKS-TC-003Verify minimum volume requirements enforcedHigh
SPECIALTY-NETWORKS-TC-004Verify quality requirements enforcedHigh
SPECIALTY-NETWORKS-TC-005Verify enhanced reimbursement for COEsHigh

4.19 Ft Prov Geographic Coverage​

4.19.1 Priority​

Must Have

4.19.2 User Story​

As a network manager, I want to map provider geographic coverage so that I can ensure adequate network access

4.19.3 Preconditions​

Provider locations captured

4.19.4 Postconditions​

Geographic coverage mapped, gaps identified

4.19.5 Test Cases​

IdDescriptionWeight
GEOGRAPHIC-COVERAGE-TC-001Verify providers mapped by regionHigh
GEOGRAPHIC-COVERAGE-TC-002Verify providers mapped by cityHigh
GEOGRAPHIC-COVERAGE-TC-003Verify providers mapped by districtHigh
GEOGRAPHIC-COVERAGE-TC-004Verify coverage gap analysis performedHigh
GEOGRAPHIC-COVERAGE-TC-005Verify distance/time to care metrics calculatedHigh
GEOGRAPHIC-COVERAGE-TC-006Verify service area definitions maintainedMedium

4.20 Ft Prov Panel Management​

4.20.1 Priority​

Should Have

4.20.2 User Story​

As a network manager, I want to manage provider panels so that I can control provider capacity and access

4.20.3 Preconditions​

Panel capacity defined per provider

4.20.4 Postconditions​

Member assignments managed, panel status tracked

4.20.5 Test Cases​

IdDescriptionWeight
PANEL-MANAGEMENT-TC-001Verify max members per provider configuredHigh
PANEL-MANAGEMENT-TC-002Verify panel assignment rules definedHigh
PANEL-MANAGEMENT-TC-003Verify panel open/closed status maintainedHigh
PANEL-MANAGEMENT-TC-004Verify panel utilization trackedHigh
PANEL-MANAGEMENT-TC-005Verify members cannot be assigned to closed panelsHigh

4.21 Ft Prov Network Adequacy​

4.21.1 Priority​

Must Have

4.21.2 User Story​

As a network manager, I want to analyze network adequacy so that I can identify and fill coverage gaps

4.21.3 Preconditions​

Provider network data available, member distribution known

4.21.4 Postconditions​

Network adequacy analyzed, compliance reports generated

4.21.5 Test Cases​

IdDescriptionWeight
NETWORK-ADEQUACY-TC-001Verify provider-to-member ratios calculatedHigh
NETWORK-ADEQUACY-TC-002Verify geographic access analyzedHigh
NETWORK-ADEQUACY-TC-003Verify specialty availability analyzedHigh
NETWORK-ADEQUACY-TC-004Verify regulatory compliance reporting (TIRA)High
NETWORK-ADEQUACY-TC-005Verify gap analysis reports generatedHigh
NETWORK-ADEQUACY-TC-006Verify recruitment recommendations providedMedium

4.22 Ft Prov Fee Schedule Setup​

4.22.1 Priority​

Must Have

4.22.2 User Story​

As a finance officer, I want to create and manage fee schedules so that I can define reimbursement rates for services

4.22.3 Preconditions​

Service codes configured (ICD-10, CPT, NLEM)

4.22.4 Postconditions​

Fee schedules created, rates assigned to services

4.22.5 Test Cases​

IdDescriptionWeight
FEE-SCHEDULE-SETUP-TC-001Verify procedure code fee schedules (CPT)High
FEE-SCHEDULE-SETUP-TC-002Verify drug pricing (NLEM)High
FEE-SCHEDULE-SETUP-TC-003Verify lab test fee schedulesHigh
FEE-SCHEDULE-SETUP-TC-004Verify imaging fee schedulesHigh
FEE-SCHEDULE-SETUP-TC-005Verify multiple fee schedules per provider typeHigh
FEE-SCHEDULE-SETUP-TC-006Verify fee schedule versioningMedium

4.23 Ft Prov Negotiated Rates​

4.23.1 Priority​

Must Have

4.23.2 User Story​

As a contracting officer, I want to set negotiated rates per provider so that I can customize reimbursement by provider

4.23.3 Preconditions​

Fee schedules configured, provider contracts in place

4.23.4 Postconditions​

Negotiated rates assigned to providers, effective dates set

4.23.5 Test Cases​

IdDescriptionWeight
NEGOTIATED-RATES-TC-001Verify percentage of charges rate typeHigh
NEGOTIATED-RATES-TC-002Verify fixed fee rate typeHigh
NEGOTIATED-RATES-TC-003Verify discounted fee schedule rate typeHigh
NEGOTIATED-RATES-TC-004Verify rate effective dates managedHigh
NEGOTIATED-RATES-TC-005Verify rate comparison reports availableMedium
NEGOTIATED-RATES-TC-006Verify provider-specific rates override default ratesHigh

4.24 Ft Prov Rate Updates​

4.24.1 Priority​

Must Have

4.24.2 User Story​

As a finance officer, I want to manage fee schedule updates so that I can keep rates current

4.24.3 Preconditions​

Fee schedules in use, rate changes approved

4.24.4 Postconditions​

Rates updated, effective dates applied, providers notified

4.24.5 Test Cases​

IdDescriptionWeight
RATE-UPDATES-TC-001Verify rate update proposal workflowHigh
RATE-UPDATES-TC-002Verify rate update approval workflowHigh
RATE-UPDATES-TC-003Verify effective dates for rate changesHigh
RATE-UPDATES-TC-004Verify bulk rate updates supportedHigh
RATE-UPDATES-TC-005Verify historical rates trackedHigh
RATE-UPDATES-TC-006Verify provider notification of rate changesHigh

4.25 Ft Prov Billing Rules​

4.25.1 Priority​

Must Have

4.25.2 User Story​

As a finance officer, I want to configure billing rules so that I can control reimbursement appropriately

4.25.3 Preconditions​

Fee schedules configured

4.25.4 Postconditions​

Billing rules applied during claims adjudication

4.25.5 Test Cases​

IdDescriptionWeight
BILLING-RULES-TC-001Verify maximum allowable charge rulesHigh
BILLING-RULES-TC-002Verify bundling rules (procedure bundling)High
BILLING-RULES-TC-003Verify frequency limits (1x per year)High
BILLING-RULES-TC-004Verify age/gender editsHigh
BILLING-RULES-TC-005Verify automated claims adjudication applies rulesHigh
BILLING-RULES-TC-006Verify rule violations flagged for reviewHigh

4.26 Ft Prov Capitation Rates​

4.26.1 Priority​

Must Have

4.26.2 User Story​

As a finance officer, I want to set capitation rates so that I can implement capitation payment model

4.26.3 Preconditions​

Capitation model configured

4.26.4 Postconditions​

PMPM rates set per provider, stratification applied

4.26.5 Test Cases​

IdDescriptionWeight
CAPITATION-RATES-TC-001Verify PMPM rates can be setHigh
CAPITATION-RATES-TC-002Verify rate stratification by ageHigh
CAPITATION-RATES-TC-003Verify rate stratification by genderHigh
CAPITATION-RATES-TC-004Verify rate stratification by productHigh
CAPITATION-RATES-TC-005Verify risk adjustment factors appliedMedium
CAPITATION-RATES-TC-006Verify effective dates managedHigh

4.27 Ft Prov Capitation Roster​

4.27.1 Priority​

Must Have

4.27.2 User Story​

As a finance officer, I want to maintain capitation rosters so that I can track which members are assigned to which providers

4.27.3 Preconditions​

Members assigned to capitated providers

4.27.4 Postconditions​

Rosters maintained, changes tracked, monthly reconciliation completed

4.27.5 Test Cases​

IdDescriptionWeight
CAPITATION-ROSTER-TC-001Verify member assignments to providers trackedHigh
CAPITATION-ROSTER-TC-002Verify effective dates for assignmentsHigh
CAPITATION-ROSTER-TC-003Verify termination dates trackedHigh
CAPITATION-ROSTER-TC-004Verify monthly roster reconciliation processHigh
CAPITATION-ROSTER-TC-005Verify mid-month changes handled pro-rataHigh
CAPITATION-ROSTER-TC-006Verify roster reports generatedHigh

4.28 Ft Prov Capitation Calculation​

4.28.1 Priority​

Must Have

4.28.2 User Story​

As a finance officer, I want to calculate monthly capitation payments so that I can pay providers accurately

4.28.3 Preconditions​

Capitation rosters finalized, PMPM rates configured

4.28.4 Postconditions​

Capitation payments calculated, vouchers generated, integrated with finance

4.28.5 Test Cases​

IdDescriptionWeight
CAPITATION-CALCULATION-TC-001Verify calculation formula (member count × PMPM rate)High
CAPITATION-CALCULATION-TC-002Verify adjustments for mid-month changesHigh
CAPITATION-CALCULATION-TC-003Verify capitation voucher generationHigh
CAPITATION-CALCULATION-TC-004Verify integration with finance moduleHigh
CAPITATION-CALCULATION-TC-005Verify calculation audit trailHigh
CAPITATION-CALCULATION-TC-006Verify provider notification of paymentHigh

4.29 Ft Prov Capitation Withholds​

4.29.1 Priority​

Should Have

4.29.2 User Story​

As a finance officer, I want to manage capitation withholds so that I can incentivize quality and utilization management

4.29.3 Preconditions​

Capitation model in use, withhold percentages defined

4.29.4 Postconditions​

Withholds applied, performance tracked, annual reconciliation completed

4.29.5 Test Cases​

IdDescriptionWeight
CAPITATION-WITHHOLDS-TC-001Verify withhold percentage configuredHigh
CAPITATION-WITHHOLDS-TC-002Verify withhold applied to monthly paymentsHigh
CAPITATION-WITHHOLDS-TC-003Verify incentive criteria defined (quality, utilization)High
CAPITATION-WITHHOLDS-TC-004Verify annual reconciliation processHigh
CAPITATION-WITHHOLDS-TC-005Verify payout calculation based on performanceHigh

4.30 Ft Prov Portal Dashboard​

4.30.1 Priority​

Must Have

4.30.2 User Story​

As a provider, I want to view a dashboard so that I have an overview of my activity

4.30.3 Preconditions​

Provider portal access granted

4.30.4 Postconditions​

Dashboard displays key metrics in real-time

4.30.5 Test Cases​

IdDescriptionWeight
PORTAL-DASHBOARD-TC-001Verify active members count displayedHigh
PORTAL-DASHBOARD-TC-002Verify claims status summary displayedHigh
PORTAL-DASHBOARD-TC-003Verify payments summary displayedHigh
PORTAL-DASHBOARD-TC-004Verify authorizations pending displayedHigh
PORTAL-DASHBOARD-TC-005Verify performance metrics displayedHigh
PORTAL-DASHBOARD-TC-006Verify real-time updatesMedium

4.31 Ft Prov Member Verification​

4.31.1 Priority​

Must Have

4.31.2 User Story​

As a provider, I want to verify member eligibility in real-time so that I can confirm coverage before service

4.31.3 Preconditions​

Member registered, provider portal access

4.31.4 Postconditions​

Eligibility verified, coverage details displayed

4.31.5 Test Cases​

IdDescriptionWeight
MEMBER-VERIFICATION-TC-001Verify member ID lookupHigh
MEMBER-VERIFICATION-TC-002Verify policy status displayed (active/inactive)High
MEMBER-VERIFICATION-TC-003Verify benefit coverage displayedHigh
MEMBER-VERIFICATION-TC-004Verify co-pay amounts displayedHigh
MEMBER-VERIFICATION-TC-005Verify authorization requirements displayedHigh
MEMBER-VERIFICATION-TC-006Verify QR code scanning supportedHigh
MEMBER-VERIFICATION-TC-007Verify biometric verification (fingerprint, facial recognition)High

4.32 Ft Prov Claims Submission​

4.32.1 Priority​

Must Have

4.32.2 User Story​

As a provider, I want to submit claims electronically so that I can streamline claims processing

4.32.3 Preconditions​

Service delivered to member, provider portal access

4.32.4 Postconditions​

Claim submitted, validation completed, confirmation received

4.32.5 Test Cases​

IdDescriptionWeight
CLAIMS-SUBMISSION-TC-001Verify diagnosis codes (ICD-10) can be enteredHigh
CLAIMS-SUBMISSION-TC-002Verify procedure codes (CPT) can be enteredHigh
CLAIMS-SUBMISSION-TC-003Verify charges can be enteredHigh
CLAIMS-SUBMISSION-TC-004Verify attachments can be uploaded (invoices, prescriptions)High
CLAIMS-SUBMISSION-TC-005Verify real-time validation performedHigh
CLAIMS-SUBMISSION-TC-006Verify submission confirmation providedHigh
CLAIMS-SUBMISSION-TC-007Verify claim tracking number assignedHigh

4.33 Ft Prov Authorization Request​

4.33.1 Priority​

Must Have

4.33.2 User Story​

As a provider, I want to request authorizations electronically so that I can facilitate pre-authorization process

4.33.3 Preconditions​

Service requires authorization, provider portal access

4.33.4 Postconditions​

Authorization request submitted, response received

4.33.5 Test Cases​

IdDescriptionWeight
AUTHORIZATION-REQUEST-TC-001Verify service details can be enteredHigh
AUTHORIZATION-REQUEST-TC-002Verify diagnosis can be enteredHigh
AUTHORIZATION-REQUEST-TC-003Verify estimated cost can be enteredHigh
AUTHORIZATION-REQUEST-TC-004Verify medical justification can be enteredHigh
AUTHORIZATION-REQUEST-TC-005Verify attachments supportedHigh
AUTHORIZATION-REQUEST-TC-006Verify real-time approval/denial responseHigh
AUTHORIZATION-REQUEST-TC-007Verify authorization number provided upon approvalHigh

4.34 Ft Prov Payment Tracking​

4.34.1 Priority​

Must Have

4.34.2 User Story​

As a provider, I want to view payment history so that I have transparency on payments

4.34.3 Preconditions​

Claims processed and paid, provider portal access

4.34.4 Postconditions​

Payment history displayed, remittance advice available

4.34.5 Test Cases​

IdDescriptionWeight
PAYMENT-TRACKING-TC-001Verify payment date displayedHigh
PAYMENT-TRACKING-TC-002Verify payment amount displayedHigh
PAYMENT-TRACKING-TC-003Verify claim details displayedHigh
PAYMENT-TRACKING-TC-004Verify deductions displayed (withholds, adjustments)High
PAYMENT-TRACKING-TC-005Verify remittance advice downloadableHigh
PAYMENT-TRACKING-TC-006Verify payment reconciliation tools availableMedium

4.35 Ft Prov Communication​

4.35.1 Priority​

Must Have

4.35.2 User Story​

As a provider, I want to communicate with the insurer so that I can exchange information efficiently

4.35.3 Preconditions​

Provider portal access

4.35.4 Postconditions​

Messages exchanged, notifications received

4.35.5 Test Cases​

IdDescriptionWeight
COMMUNICATION-TC-001Verify messaging system availableHigh
COMMUNICATION-TC-002Verify claim inquiries can be sentHigh
COMMUNICATION-TC-003Verify member issues can be reportedHigh
COMMUNICATION-TC-004Verify policy updates receivedHigh
COMMUNICATION-TC-005Verify notification center availableHigh
COMMUNICATION-TC-006Verify bulletins and announcements displayedMedium

4.36 Ft Prov Preauth Workflow​

4.36.1 Priority​

Must Have

4.36.2 User Story​

As a medical director, I want to manage pre-authorization workflow so that I can control utilization of high-cost services

4.36.3 Preconditions​

Pre-auth rules configured, request received

4.36.4 Postconditions​

Pre-auth reviewed, approved or denied, provider notified

4.36.5 Test Cases​

IdDescriptionWeight
PREAUTH-WORKFLOW-TC-001Verify services requiring pre-auth configured (hospitalizations, surgeries, imaging, specialty care)High
PREAUTH-WORKFLOW-TC-002Verify workflow stages (Request -> Medical review -> Decision)High
PREAUTH-WORKFLOW-TC-003Verify turnaround time tracked (24-48 hours)High
PREAUTH-WORKFLOW-TC-004Verify medical review criteria appliedHigh
PREAUTH-WORKFLOW-TC-005Verify approval/denial with reasonsHigh
PREAUTH-WORKFLOW-TC-006Verify provider notificationHigh
PREAUTH-WORKFLOW-TC-007Verify appeal process availableHigh

4.37 Ft Prov Auto Authorization​

4.37.1 Priority​

Must Have

4.37.2 User Story​

As a medical director, I want to implement automated authorization rules so that I can expedite routine authorizations

4.37.3 Preconditions​

Auto-approval rules configured

4.37.4 Postconditions​

Routine authorizations auto-approved, exceptions flagged for review

4.37.5 Test Cases​

IdDescriptionWeight
AUTO-AUTHORIZATION-TC-001Verify auto-approval rules for routine proceduresHigh
AUTO-AUTHORIZATION-TC-002Verify auto-approval for in-network providersHigh
AUTO-AUTHORIZATION-TC-003Verify auto-approval for services within benefit limitsHigh
AUTO-AUTHORIZATION-TC-004Verify auto-denial rules for excluded servicesHigh
AUTO-AUTHORIZATION-TC-005Verify auto-denial for benefit exhaustedHigh
AUTO-AUTHORIZATION-TC-006Verify exceptions flagged for manual reviewHigh

4.38 Ft Prov Referral Management​

4.38.1 Priority​

Must Have

4.38.2 User Story​

As a provider, I want to manage referrals so that I can track care coordination

4.38.3 Preconditions​

Referral network configured

4.38.4 Postconditions​

Referrals tracked, care coordination documented

4.38.5 Test Cases​

IdDescriptionWeight
REFERRAL-MANAGEMENT-TC-001Verify PCP can create referralHigh
REFERRAL-MANAGEMENT-TC-002Verify member notified of referralHigh
REFERRAL-MANAGEMENT-TC-003Verify specialist visit trackedHigh
REFERRAL-MANAGEMENT-TC-004Verify referral closed after visitHigh
REFERRAL-MANAGEMENT-TC-005Verify referral validity period enforcedHigh
REFERRAL-MANAGEMENT-TC-006Verify specialist network restrictions appliedHigh

4.39 Ft Prov Emergency Auth​

4.39.1 Priority​

Must Have

4.39.2 User Story​

As a claims processor, I want to handle emergency authorizations so that I can ensure timely emergency care

4.39.3 Preconditions​

Emergency service definition configured

4.39.4 Postconditions​

Emergency services auto-approved, retrospective review completed

4.39.5 Test Cases​

IdDescriptionWeight
EMERGENCY-AUTH-TC-001Verify emergency services auto-approvedHigh
EMERGENCY-AUTH-TC-002Verify notification within 24 hours requiredHigh
EMERGENCY-AUTH-TC-003Verify retrospective review processHigh
EMERGENCY-AUTH-TC-004Verify emergency definition criteria appliedHigh
EMERGENCY-AUTH-TC-005Verify inappropriate emergency use flaggedMedium

4.40 Ft Prov Utilization Tracking​

4.40.1 Priority​

Must Have

4.40.2 User Story​

As a network manager, I want to track provider utilization patterns so that I can identify high/low utilizers

4.40.3 Preconditions​

Claims data available

4.40.4 Postconditions​

Utilization patterns analyzed, outliers identified

4.40.5 Test Cases​

IdDescriptionWeight
UTILIZATION-TRACKING-TC-001Verify visits per member trackedHigh
UTILIZATION-TRACKING-TC-002Verify cost per visit trackedHigh
UTILIZATION-TRACKING-TC-003Verify admission rates trackedHigh
UTILIZATION-TRACKING-TC-004Verify length of stay trackedHigh
UTILIZATION-TRACKING-TC-005Verify referral rates trackedHigh
UTILIZATION-TRACKING-TC-006Verify benchmarking against network averagesHigh

4.41 Ft Prov Quality Metrics​

4.41.1 Priority​

Must Have

4.41.2 User Story​

As a medical director, I want to measure provider quality metrics so that I can assess provider quality

4.41.3 Preconditions​

Quality data collected

4.41.4 Postconditions​

Quality metrics calculated, providers scored

4.41.5 Test Cases​

IdDescriptionWeight
QUALITY-METRICS-TC-001Verify readmission rates trackedHigh
QUALITY-METRICS-TC-002Verify patient satisfaction scores trackedHigh
QUALITY-METRICS-TC-003Verify clinical outcomes trackedHigh
QUALITY-METRICS-TC-004Verify adherence to protocols trackedHigh
QUALITY-METRICS-TC-005Verify HEDIS measures calculatedMedium

4.42 Ft Prov Member Satisfaction​

4.42.1 Priority​

Must Have

4.42.2 User Story​

As a provider relations officer, I want to collect member satisfaction feedback so that I can monitor member experience

4.42.3 Preconditions​

Member visited provider

4.42.4 Postconditions​

Satisfaction feedback collected, aggregated by provider

4.42.5 Test Cases​

IdDescriptionWeight
MEMBER-SATISFACTION-TC-001Verify post-visit surveys sentHigh
MEMBER-SATISFACTION-TC-002Verify ratings (1-5 stars) collectedHigh
MEMBER-SATISFACTION-TC-003Verify comments capturedHigh
MEMBER-SATISFACTION-TC-004Verify complaint trackingHigh
MEMBER-SATISFACTION-TC-005Verify provider response to feedback trackedMedium
MEMBER-SATISFACTION-TC-006Verify satisfaction scores aggregatedHigh

4.43 Ft Prov Performance Scorecards​

4.43.1 Priority​

Must Have

4.43.2 User Story​

As a network manager, I want to generate provider performance scorecards so that I can provide feedback to providers

4.43.3 Preconditions​

Performance data collected (utilization, quality, satisfaction)

4.43.4 Postconditions​

Scorecards generated, providers notified

4.43.5 Test Cases​

IdDescriptionWeight
PERFORMANCE-SCORECARDS-TC-001Verify scorecard includes utilization metricsHigh
PERFORMANCE-SCORECARDS-TC-002Verify scorecard includes quality metricsHigh
PERFORMANCE-SCORECARDS-TC-003Verify scorecard includes satisfaction metricsHigh
PERFORMANCE-SCORECARDS-TC-004Verify scorecard includes compliance metricsHigh
PERFORMANCE-SCORECARDS-TC-005Verify quarterly reports generatedHigh
PERFORMANCE-SCORECARDS-TC-006Verify performance tiers (top, average, needs improvement)High
PERFORMANCE-SCORECARDS-TC-007Verify incentive linkageMedium

4.44 Ft Prov Outlier Detection​

4.44.1 Priority​

Must Have

4.44.2 User Story​

As a network manager, I want to detect provider outliers so that I can identify potential fraud or quality issues

4.44.3 Preconditions​

Utilization and cost data available

4.44.4 Postconditions​

Outliers detected, flagged for investigation

4.44.5 Test Cases​

IdDescriptionWeight
OUTLIER-DETECTION-TC-001Verify statistical analysis of utilization patternsHigh
OUTLIER-DETECTION-TC-002Verify statistical analysis of cost patternsHigh
OUTLIER-DETECTION-TC-003Verify alerts generated for investigationHigh
OUTLIER-DETECTION-TC-004Verify investigation workflowHigh
OUTLIER-DETECTION-TC-005Verify provider education initiatedMedium
OUTLIER-DETECTION-TC-006Verify corrective action plans trackedHigh

4.45 Ft Prov Network Reports​

4.45.1 Priority​

Must Have

4.45.2 User Story​

As a network manager, I want to generate network composition reports so that I can understand network makeup

4.45.3 Preconditions​

Provider network data available

4.45.4 Postconditions​

Network reports generated showing composition and trends

4.45.5 Test Cases​

IdDescriptionWeight
NETWORK-REPORTS-TC-001Verify provider count by typeHigh
NETWORK-REPORTS-TC-002Verify provider count by specialtyHigh
NETWORK-REPORTS-TC-003Verify provider count by regionHigh
NETWORK-REPORTS-TC-004Verify network growth trendsHigh
NETWORK-REPORTS-TC-005Verify provider turnover trackedMedium
NETWORK-REPORTS-TC-006Verify contract expiration pipelineHigh

4.46 Ft Prov Utilization Reports​

4.46.1 Priority​

Must Have

4.46.2 User Story​

As a network manager, I want to generate provider utilization reports so that I can analyze service utilization patterns

4.46.3 Preconditions​

Claims data available

4.46.4 Postconditions​

Utilization reports generated showing patterns and trends

4.46.5 Test Cases​

IdDescriptionWeight
UTILIZATION-REPORTS-TC-001Verify claims volume by providerHigh
UTILIZATION-REPORTS-TC-002Verify service mix by providerHigh
UTILIZATION-REPORTS-TC-003Verify cost trendsHigh
UTILIZATION-REPORTS-TC-004Verify top 10 providers by volumeHigh
UTILIZATION-REPORTS-TC-005Verify top 10 providers by costHigh
UTILIZATION-REPORTS-TC-006Verify utilization by specialtyHigh

4.47 Ft Prov Payment Reports​

4.47.1 Priority​

Must Have

4.47.2 User Story​

As a finance officer, I want to generate provider payment reports so that I can track provider reimbursement

4.47.3 Preconditions​

Payment data available

4.47.4 Postconditions​

Payment reports generated showing payment patterns

4.47.5 Test Cases​

IdDescriptionWeight
PAYMENT-REPORTS-TC-001Verify payments by providerHigh
PAYMENT-REPORTS-TC-002Verify payment method breakdown (FFS vs capitation)High
PAYMENT-REPORTS-TC-003Verify payment timeliness trackedHigh
PAYMENT-REPORTS-TC-004Verify outstanding payables shownHigh
PAYMENT-REPORTS-TC-005Verify payment accuracy metricsMedium

4.48 Ft Prov Credentialing Reports​

4.48.1 Priority​

Must Have

4.48.2 User Story​

As a provider relations officer, I want to generate credentialing status reports so that I can monitor credential expiration

4.48.3 Preconditions​

Credential data maintained

4.48.4 Postconditions​

Credentialing reports generated showing status and expirations

4.48.5 Test Cases​

IdDescriptionWeight
CREDENTIALING-REPORTS-TC-001Verify providers with expiring credentials listedHigh
CREDENTIALING-REPORTS-TC-002Verify pending reaccreditation listedHigh
CREDENTIALING-REPORTS-TC-003Verify suspended providers listedHigh
CREDENTIALING-REPORTS-TC-004Verify compliance dashboard availableHigh
CREDENTIALING-REPORTS-TC-005Verify regulatory reporting supportedMedium