1. Program Manager for a Medicare Administrative Contractor’s Provider Portal
Overview
My team’sclientwas aMedicare Administrative Contractor(MAC) that providedspecified claims
administration servicesforMedicare PartA and Part B, includingclaims processing,paymentservices,
and providereducationforamulti-state Medicare jurisdiction.The servicesprovidedwerebasedon
operationsconductedin5geographicareas.
We designed,developed andimplementedasecured,custom Internetportal solution forMedicare Part
B providers, anddelivered post-implementation application support.
Business Challenge
The portal solution wasrequiredtomeetvariouscompliancestandards,includingCMSmandated J2EE
(Technical Reference Architecture- TRA),andLevel 2 applicationsecurity compliance. The application
provided the followingfunctionality:
A. SupportMedicare Part B electronicclaimsubmission:
i.Individual claimsubmissionviadirectdataentry
ii.Batch submissionviaX12version5010 compliantfiles
B. BenefitsandEligibility queryability,viaCMSHETS 270/271 transaction,utilizingthe
HETS UI lookand feel,withasingle sign-on.
C. Part B claimstatus query.
D. MailboxingcapabilityforElectronicStandardProviderRemittances(eSPR) forPartB
claims.
E. eSPRand paperSPRviewing forPartB claims.
F. CapabilityforproviderstoresubmitcorrectedPartB claims.
G. Achieved508 compliance.
How We Helped
We establishedateamof systemsandbusinessanalystsalongwithsoftware engineersand
programmers whoworkedwiththe clienttocreate a customsoftware solution thatmetinternal and
CMS requirements.Theireffortswere orchestratedbyaPMP certifiedprojectmanagerwhouseda
Waterfall methodologyforthe Software DevelopmentLifeCycle (SDLC). The projectcovered six SDLC
phasesthatincluded:
 Requirements Gathering;
 Design/Architecture;
 Development/Coding;
 QA/Testing/Acceptance Testing;
 Implementation/Deployment;
 Maintenance/Support.
The requirementsgatheringandsystemdesignleveragedRational tools,while the software
developmentutilizedEclipse inaJ2EE/Websphere platform. Use Caseswere developedusingUnified
Markup Language (UML) andreviewedwiththe enduserstoensure thatnotonlywere the

2. requirementsmet,butthe intentbehindthe requirementswerealsomet.Indoingthisearlyinthe
designstage,we were able tomake adjustmentsthatmore closelyalignedwithwhatourclient
intended.
We designedasystemthatwas efficienttomaintain byensuringthatthe majorityof businessrules
were table drivenandcouldbe modifiedasCMS regulations,orbusinessneedsdictated.The goal was
to touch the code as minimallyaspossible duringongoingmaintenanceof the software.
We alsoused a Service OrientedArchitecture (SOA) toprovide seamlessintegrationwithexternal and
internal components,toprovide extensibilityforthe future,andtoenable reusabilityof business
objects.
Other design aspects utilized included:
Role-Based Data Security to ensure that internal andexternal users,aswell asCMS onlysaw what they
were supposedtosee,andwere restrictedtotheirpredefinedfunctionalcapabilities.Role-basedsecurity
instructions were incorporated into the data model, but were also enforced with an external LDAP;
System security – Application Server, Web servers and Database servers were secured by seamless
integration with built-in security of various servers to protect them from any external threat;
Error handling – We designed a fault-tolerant system so that errors were escalatedto the end users as
minimally as possible;
Efficiency – We focused on designing the system that could handle a high volume of users, had high
availabilityandscalability.We designedthesecure portalasthinaspossible(i.e.,stateless)sothatitcould
accommodate a high number of public users without putting a large toll on system resources.
Results
The team implemented aMedicare ProviderPortal whichbecame one of the firstCMS-approvedsecure
portalsofferingPartB claimssubmissionandcorrectionfunctionality.Duringthe course of the project,
several technical hurdleshadtobe overcome thatincludedCMSregulationchanges,aCMS-mandated
data centermove,anda change inthe client’sthird-partyservice vendor.
The projectwas completedwithin the projected18monthtimeframe,andwithinthe agreedbudget.