DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services (CMS) 

[CMS-2382-N] 

Medicaid Program; Announcement of Requirements and Registration for CMS Provider 

Screening Innovator Challenge 

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: The Centers for Medicare & Medicaid Services (CMS), is announcing the launch 

of the “CMS Provider Screening Innovator Challenge.” This Challenge is sponsored by CMS 

and is presented as part of the Partnership for Program Integrity Innovation program, and will be 

administered by the National Aeronautic and Space Administration’s (NASA) Federal Center of 

Excellence for Collaborative Innovation. This Challenge addresses our goals of improving our 

abilities to streamline operations, screen providers, and reduce fraud and abuse. Specifically, the 

challenge is an innovation competition to develop a multi-State, multi-program provider 

screening software application which would be capable of risk scoring, credentialing validation, 

identity authentication, and sanction checks, while lowering burden on providers and reducing 

administrative and infrastructure expenses for States and Federal programs. More information 

pertaining to the Medicaid and CHIP programs can be found at www.medicaid.gov. 

DATES: Important dates concerning the Challenge include the following: 

Challenge Competition Begin: 6:00 pm, e.d.t., May 30, 2012. 

Challenge Competition End: To be determined, but expected to be completed by 

October/November 2012 timeframe. 

FOR FURTHER INFORMATION CONTACT: John “Chip” Garner, 410-786-3012. 

SUPPLEMENTARY INFORMATION: 
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Subject of Challenge Competition: 

Entrants are asked to develop artifacts and components of software applications that can be 

integrated into an open source solution that can deliver a reliable, scalable, and cost-effective 

provider-screening capability for multiple States (or for the nation). 

We expect the winning entry to exhibit the following characteristics: 

1. Reduced processing and transaction time for submitting and receiving queries to 

authoritative data sources regarding provider credentials and sanctions. 

2. Reductions in time needed by providers to submit information and resolve discrepancies. 

3. Administrative/infrastructure savings from a multi-tenant provider screening solution. 

4. Improved availability of key provider data relevant for program participation and 

oversight. 

5. Improved timeliness and accuracy in provider participation, oversight, and enrollment 

decisions. 

6. Improved ability to implement sections 1902(a)(39) and 1902(a)(77) of the Social 

Security Act, as amended by the Patient Protection and Affordable Care Act (P.L. 111-148 and 

111-152) subsections 6401(b) and (c) (Provider Screening and Other Enrollment Requirements 

Under Medicare, Medicaid, and CHIP), and section 6501 (Termination of Provider Participation 

Under Medicaid if Terminated by Medicare or Other State Plan). 

7. Assist in better driving alignment of the Medicaid Information Technology Architecture 

(MITA) 3.0 framework to the Information and Technology Architecture levels. More information 

pertaining to MITA can be found at the following Web site: www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Data-and-Systems/Medicaid-Information-TechnologyArchitecture-MITA.html . 
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General Eligibility Rules for Participating in the Competition:

To be eligible to win a prize under this Challenge, an individual or entity must comply 

with all the requirements under this section. 

An individual or entity shall not be deemed ineligible solely because the individual or 

entity used Federal facilities or consulted with Federal employees during a competition if such 

facilities and employees are made available to all individuals and entities participating in the 

competition on an equitable basis. 

A Federal entity or Federal employee acting within the scope of his or her employment is 

not eligible to participate. A Federal employee seeking to participate in this competition outside 

the scope of his/her employment should consult his/her ethics official prior to developing the 

submission. Employees of CMS, the Challenge judges, and employees of any other company or 

individual involved with the design, production, execution, or distribution of the Challenge, along 

with such employees’ or judges’ immediate families (spouse, parents and step-parents, siblings 

and step-siblings, and children and step-children) and household members (people who share the 

same residence at least three (3) months out of the year) are not eligible to participate. 

Regarding Registration Process for Participants, interested persons should read the Official 

Rules and register at the Center of Excellence for Collaborative Innovation Challenge portal: 

http://community.topcoder.com/coeci/. Registration is free and can be completed at any time 

before an entry is submitted in response to a particular competition. 

Amount of the Prize:

Based on our current assumptions, we estimate that the total prize amount for the 

competitions conducted as part of this Challenge will fall between $500,000 and $600,000. 

Basis Upon Which Winner Will Be Selected:

Challenge competition entries will be judged by an expert panel composed of CMS 
CMS-2382-N 4 

program staff. Judges shall be named after commencement of the Challenge. Competitions will 

be judged based upon both subjective and objective criteria. Should the highest-scoring 

submitted solution be missing requirements or otherwise need modification, it will enter a 

remediation/fix phase. Projects are posted and administered through a personalized, web-based 

administration tool. All projects progress, with some variance, through a sequence of phases 

from Registration to Submission to Screening to Review to Final Fixes. Submissions will be 

screened to ensure they meet minimum requirements for the project and do not include 

forbidden material. Competition submissions with subjectively-evaluated components (for 

example, graphical design, workflow, GUI layout, etc.) are anonymized and evaluated by the 

Judges. Submissions with objectively-scored components, such as projects (for example, 

architecture, development, etc.) are scored by the Judges by their fidelity to exact, enumerated 

requirements. 

Overall, the solution must, at a minimum, meet the following criteria: 

1. Capability to Conduct Identity Verification. 

a. Capability to link individuals to their organizations and vice versa. 

b. Capability to match on multiple variations of an individual’s or organization’s name to 

ensure that the correct entity is verified. 

c. Ability to apply a range of screening rules to cross check data elements within the 

enrollment application. 

d. Ability to apply a range of screening rules to cross check data elements against 

authoritative external sources for consistency. 

e. Capability to establish and employ a graded screening methodology that escalates the 

intensity of screening for providers that are flagged as higher risk (that is, Report Card 

Methodology). 
CMS-2382-N 5 

2. Capability to Build Provider Profiles 

a. Capability to retain screening and enrollment information and results, and compare 

against past and future screening results. 

b. Capability to create a watch list to ensure that providers that are suspected or known to 

be fraudulent are flagged at the time of screening. 

c. Capability to track re-enrollment attempts to ensure that slight changes to provider 

information are not considered a new enrollment. 

d. Capability to revalidate periodically to ensure that changes in provider profiles are 

updated on a regular basis. 

e. Capability to leverage public Web sites to conduct link analysis through which provider 

associations could be explored, and alerts posted on similar Web sites could be considered. 

f. Capability to capture critical attributes 

● Collection of application fees status. 

● Exception waiver approved status. 

● Incorporating enhanced screening data, including the results of site visits, criminal 

background checks, and finger printing. 

● Capturing licensing information, financial data, and any other data attributes which could 

impact a risk lever. 

● Other critical attributes. 

g. Capability to achieve real time screening, scoring, and system outputs (queries/reports). 

3. Capability to Evaluate and Maintain the Integrity of the Results. 

a. Capability to persist data sources scores to determine the most reliable source for each 

data element. 

b. Capability to evaluate data sources for reliability and accuracy. 
CMS-2382-N 6 

c. Capability to create a learning system to ensure that observed negative trends factor back 

into screening rules so as to flag suspicious enrollments early in the screening process, ensuring the 

ability to detect and reduce/eliminate the incidence of false positives. 

d. Capability to create system outputs to assign reasons/explanations to each code or score 

used. 

e. Capability to build processes to allow for appropriate interpretation and action on 

screening and scoring results. 

f. Capability to ensure that each rule is tested and its impact is evaluated prior to 

implementing. 

4. Improves Efficiency. 

a. Capability to allow searches to find specific provider information with minimal search 

attempts. 

b. Capability to identify applicants, including individual providers and owners of 

institutional providers. 

c. Capability to verify identity and prior history of problems with Medicaid/CHIP or 

Medicare programs. 

d. Capability to identify and schedule revalidation process. 

5. Meets Architectural Guidelines. 

a. Adheres to the Architectural Guidance and meets the seven conditions and standards 

detailed in the Guidance for Exchange and Medicaid IT Systems, Version 2.0, located at: 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-andSystems/Downloads/exchangemedicaiditguidance.pdf .

b. Integrates into the MITA Framework – Is MITA Compliant. Information regarding 

MITA can be found at: http://www.cms.gov/MedicaidInfoTechArch/. 
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6. Accurate, Cost Effective, and Timely. 

a. Turnaround time for performing automated checks typical for a web-based system. 

b. Comprehensive verification of all data fields for all providers enrolled. 

c. Efficiency of the Screening Solution in terms of cost and schedule to actually 

implement: Potential extra costs (for example, licenses, etc.) are documented. 

d. Effectiveness of the risk-screening model in detecting fraud based issues. 

e. Technical soundness of risk-scoring in flagging potential fraudulent patterns and 

tendencies. 

Additional Information: 

CMS is one of the principal agencies dedicated to protecting the health of citizens by 

making our world healthier, safer, and better for all Americans. For more information, see 

www.cms.gov. 

General Conditions: 

CMS reserves the right to cancel, suspend, and/or modify the Competition, or any part of 

it, for any reason, at CMS’ sole discretion.
CMS-2382-N 

Authority: This competition is administrated by the Federal Center of Excellence for 

Collaborative Innovation through a partnership between CMS and NASA. The partnership is in 

accordance with the National Aeronautics and Space Act (51 U.S.C. 20113(e)) and The Economy 

Act (31 U.S.C. 1535). 

Dated: May 4, 2012

 _____________________________ 

 Marilyn Tavenner 

 Acting Administrator

 Centers for Medicare & Medicaid Services.

BILLING CODE 4120-01-P 

[FR Doc. 2012-12633 Filed 05/25/2012 at 8:45 

am; Publication Date: 05/29/2012]