DEMO MODE

Implementation & Architecture Reference

MMIS-adjacent ingestion. Analyst risk signals.

Reference architectureNot a production deployment

Reference Deployment Architecture

Four-tier reference architecture for reference state deployment scenarios. Each tier independently deployable. Data flows through documented interfaces only.

Reference Deployment Architecture
Tier 01State Source Systems
MMIS/Claims
Provider Enrollment
Eligibility
Pharmacy POS
Tier 02Ingestion & Adapter Layer
REST API
Batch SFTP
X12/NCPDP Parser
State Adapter Profile
Tier 03Operational Analytics Layer
Rule Library
Risk Prioritization
Threshold Governance
Explainability Layer
Tier 04Analyst Oversight Layer
Analyst Workbench
Supervisor Approval
Audit Trail
Program Integrity Review

Technical Architecture View

Five-layer operational intelligence framework showing data flow from state source systems through ingestion, analytics, analyst oversight, and governance controls.

TECHNICAL ARCHITECTURE VIEW · CONCEPTUAL MODEL

LAYER 01Ingestion & Adapter
REST API
Batch SFTP
Event Stream
LAYER 02Transformation Layer
Schema Mapping
Data Normalization
State Adapter Profile
LAYER 03Operational Analytics
Operational Rule Library
Risk Prioritization
Threshold Governance
Explainability Layer
LAYER 04Governance & Security
Role-Based Access
Data Quality Checks
Auditability
Privacy Safeguards
LAYER 05Analyst Oversight
Analyst Review Queue
Supervisor Review
Disposition Routing
Immutable Audit Log

This architecture view is a conceptual demonstration model. It is not a CMS production system, does not represent CMS TRA certification, and does not imply agency deployment, endorsement, or ATO approval.

API and Batch Ingestion Pathways

REST API · Real-time

Sub-second

OAuth2-secured endpoints for per-claim risk prioritization at submission. Used by conceptual MMIS-adjacent integration pattern for pre-adjudication signal retrieval concept to retrieve a risk signal before state payment-routing review.

Auth
OAuth2 · mTLS
Throughput
1.2K req/s illustrative target
P95 latency
180ms P95 illustrative target
Uptime
99.9% illustrative uptime target

Batch SFTP · Nightly

24h cycle

Encrypted batch transfer of daily claim extracts, eligibility deltas, and provider enrollment updates. Supports states without real-time integration capacity.

Transport
SFTP · PGP
Format
X12 837 · CSV
Window
00:00–04:00 ET

Event Stream · Optional

Continuous

For states with event-driven claims platforms, MedIntegrity OS subscribes to a documented event topic and ingests change events as they occur. Enables sub-minute signal refresh.

Transport
Kafka · TLS
Schema
Avro · registry
Backfill
7-day replay

Performance figures are illustrative targets. Not measured against production infrastructure.

Interoperability Workflow

  1. Step 01
    Source Extraction

    Source systems may publish claim records through approved interfaces via API, batch, or event stream.

    State-owned
  2. Step 02
    Adapter Mapping

    Declarative state adapter profile maps source fields into the MedIntegrity OS canonical schema.

    Framework
  3. Step 03
    Rule Evaluation

    Versioned rule library evaluates each claim. Risk prioritization output and feature attribution recorded.

    Framework
  4. Step 04
    Signal Return

    Risk signal returned to state via the same channel. State retains adjudication and payment-routing authority.

    Bidirectional
  5. Step 05
    Analyst Oversight

    Flagged cases routed to analyst workbench. Determinations recorded to the audit trail.

    Framework

Modular Configuration Layers

Each layer configurable per jurisdiction. Updates to one layer do not require redeployment of others.

Operational Rule Library

Scope
Active rules, severity, thresholds, domain bindings.
Configured By
State PI office
Change Window
Weekly · governed
Versioning
Semver · audit logged

Risk Prioritization Weights

Scope
Component weights and tier cutoffs for risk prioritization output.
Configured By
State PI office + framework administrator
Change Window
Quarterly
Versioning
Profile snapshot

Workflow & SLA

Scope
Queue priority, SLA windows, supervisor approval thresholds.
Configured By
State operations
Change Window
On request
Versioning
Profile snapshot

Data Adapter Profile

Scope
Source to canonical schema mapping, value normalization, lookups.
Configured By
State IT + framework administrator
Change Window
Per release
Versioning
Semver · CI-validated

Access & Roles

Scope
Analyst, supervisor, auditor, and read only roles. SSO bindings.
Configured By
State IAM
Change Window
Continuous
Versioning
IdP-managed

Adaptable Schema Mapping

MMIS source fields mapped to canonical schema via state adapter profile. Supports X12 837/835, NCPDP, state extracts. No source schema changes required.

claim_id

Required
Type
string
Source Standard
X12 837 · CLM01
Example Mapping
MMIS.CLAIM_HDR.CLM_ID

provider_npi

Required
Type
string(10)
Source Standard
X12 837 · NM109
Example Mapping
PROV.NPI

beneficiary_id

Required
Type
string
Source Standard
State eligibility extract
Example Mapping
ELIG.MEMBER_ID

service_date

Required
Type
date
Source Standard
X12 837 · DTP*472
Example Mapping
MMIS.SVC_DT

procedure_code

Required
Type
string
Source Standard
HCPCS / CPT
Example Mapping
MMIS.PROC_CD

ndc_code

Optional
Type
string(11)
Source Standard
NCPDP D.0 · 407-D7
Example Mapping
PHARM.NDC

billed_amount

Required
Type
decimal(10,2)
Source Standard
X12 837 · CLM02
Example Mapping
MMIS.BILL_AMT

place_of_service

Optional
Type
string(2)
Source Standard
CMS POS code
Example Mapping
MMIS.POS_CD

Governance Configuration Profiles

Governance profiles bundle threshold posture, supervisor approval requirements, and analyst routing defaults. Editable per jurisdiction.

Profile
Conservative

Higher thresholds, supervisor signoff required for all prepayment escalations, no automated escalation. Favors minimizing provider abrasion.

Risk threshold
85
Supervisor signoff
All prepayment escalations
Prepayment escalation automation
Disabled
SLA · P1
8 hours
Profile
Balanced

Default posture. Supervisor signoff for P1 only, analyst discretion at P2/P3. Recommended for most states.

Risk threshold
75
Supervisor signoff
P1 only
Prepayment escalation automation
Disabled
SLA · P1
4 hours
Profile
Vigilant

Lower thresholds, expanded rule activation. Higher review volume; appropriate for states with mature PI capacity.

Risk threshold
65
Supervisor signoff
P1 only
Prepayment escalation automation
Optional · documented
SLA · P1
2 hours

State Onboarding Lifecycle

  1. Step 01

    Engagement & Scoping

    2–3 weeks

    Procurement intake, scope confirmation with state Medicaid agency and CIO office, baseline integrity metrics review.

    Statement of workData-use agreementScope memo
  2. Step 02

    Data Discovery

    3–4 weeks

    Source system inventory, extract format review, sample data exchange under DUA. Adapter profile draft.

    Source inventorySample extractsAdapter draft
  3. Step 03

    Integration Build

    4–6 weeks

    Adapter profile finalized, API/batch endpoints stood up in state environment, encrypted transport modeled.

    Adapter profile v1Connectivity test report
  4. Step 04

    Calibration

    3–4 weeks

    Threshold and profile tuning against historical claims. False positive baseline established with state PI office.

    Calibration reportGovernance profile v1
  5. Step 05

    Pilot · Shadow Mode

    6–8 weeks

    Signals generated but not surfaced to operational queues. Analyst review against historical dispositions.

    Pilot evaluationVariance report
  6. Step 06

    Operational readiness transition

    2 weeks

    Phased rollout by domain or region. Analyst training complete, audit trail active, supervisor routing modeled.

    Readiness checklistRunbookTraining attestation
  7. Step 07

    Conceptual steady-state model

    Continuous

    Quarterly governance review, rule recalibration, performance reporting to state reporting interface concepts as required.

    Quarterly governance report

Implementation Readiness Checklist

Executed data-use agreement

Signed DUA covering scope, retention, breach notification, and inspector general access.

Source system access

Network path, authentication, and extract cadence confirmed with state IT.

Adapter profile modeled

Source to canonical mapping reviewed by state subject matter expert and passes CI checks.

Governance profile selected

Conservative / Balanced / Vigilant chosen and approved by program integrity leadership.

Analyst roster & roles

Named analysts and supervisors mapped to MedIntegrity OS IAM roles via state SSO.

Training attestation

Analyst and supervisor training completed; attestations filed in operational runbook.

Audit trail destination

WORM storage location and retention window confirmed with state records officer.

Runbook & escalation

Operational runbook published; on-call and escalation paths documented.

Phased Implementation Model

Phase 1
Foundation
Months 1–2

Conceptual agreement, data-use framework, IAM planning, and source connectivity modeling. No signals generated.

Exit criteria
Connectivity modeled; sample data flowing.
Phase 2
Shadow
Months 3–4

Signals generated and reviewed by state PI office against historical dispositions. No analyst queue impact (shadow mode).

Exit criteria
False positive rate within target band.
Phase 3
Pilot-readiness
Months 5–6

Signals routed to analyst queue for a bounded domain (e.g., pharmacy only). Audit trail active (illustrative scenario).

Exit criteria
Operational metrics meet governance targets.
Phase 4
Expanded Domain Coverage Scenario
Month 7+

Full domain coverage. Quarterly governance cadence established with state reporting interface concepts.

Exit criteria
Conceptual steady-state model.

Does not modify existing state claims systems. States retain adjudication authority. Framework produces risk signals; review recommendations remain with program integrity staff.