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pdfEQR PROTOCOL 1 – ASSESSING MCO COMPLIANCE WITH MEDICAID AND CHIP
MANAGED CARE REGULATIONS
Attachment A: Compliance Review Worksheet
Subpart C--Enrollee Rights and Protections
Federal Regulation
State Regulation Source(s)
Source(s)
438.100(b)(2)(i)
Enrollee right to receive
information
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
1) The language(s) that the State
has determined are prevalent in
the MCO’s geographic service
area.
2) Any requirements the State has
issued to the MCO specifying a
standard for the reading level of
written materials prepared for
enrollees.
3) The State’s decision about
whether or not the MCO is to
notify all enrollees at least once a
year of their right to request and
obtain the information listed in
paragraphs (f)(6) and (g) of
§438.10.
4) The State’s decision about
whether the MCO is to furnish to
each of its Medicaid/CHIP
enrollees the information listed in
paragraphs (f)(6) and (g) within a
reasonable time after the MCO
receives, from the State or its
contracted representative, notice
Applicable MCO
Documents
Medicaid/CHIP and other enrollee
survey results (AM)
Provider Contracts (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Statement of enrollee rights (ES)
Medicaid/CHIP enrollee
marketing materials (ES)
Medicaid/CHIP marketing plans,
policies and procedures (ES)
Medicaid/CHIP enrollment and
disenrollment policies and
procedures (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee
grievance and appeals policies
and procedures (ES)
Staff Handbooks (SP)
Staff Orientation and Training
Curriculum (SP)
Other:
Reviewer
Determination
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
1
Federal Regulation
State Regulation Source(s)
Source(s)
Applicable MCO
Documents
Reviewer
Determination
of the recipient’s enrollment.
5) Information on how the State has
defined a “significant change” in
the information MCOs are
required to give enrollees
pursuant to §438.10(f) and (g).
6) Whether or not the MCO is part of
a State managed care initiative
that employs mandatory
enrollment of beneficiaries in the
MCO under section 1932(a)(1)(A)
of the Act. If the MCO is part of
such an initiative, obtain
information from the State on the
State’s decision about whether
the State or the MCO is to provide
potential enrollees with the
information contained in
§438.10(h).
7) If the MCO is part of a mandatory
managed care initiative AND IF
the State has directed the MCO to
provide comparative information
on disenrollment as part of a
chart-like comparison of MCOs
obtain the State agency’s
definition of “disenrollment rate”.
8) Whether or not the State agency
has chosen to give providers the
right to challenge the failure of an
MCO to cover a contracted
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
2
Federal Regulation
State Regulation Source(s)
Source(s)
Applicable MCO
Documents
Reviewer
Determination
service.
9) Any applicable State laws on
enrollee rights.
438.100(b)(2)(iii)
Enrollee right to receive
information on available
treatment options and
alternatives . . . including
requirements of
§438.102: Providerenrollee communications
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Information on whether or not the
MCO has documented to the State
any moral or religious objection to
providing, reimbursing for, or
providing coverage of, a counseling
or referral service for a particular
Medicaid/CHIP service or services.
Medicaid/CHIP and other enrollee
survey results (AM)
Provider Contracts (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Statement of enrollee rights (ES)
Medicaid/CHIP enrollee
marketing materials (ES)
Medicaid/CHIP marketing plans,
policies and procedures (ES)
Medicaid/CHIP enrollment and
disenrollment policies and
procedures (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee
grievance and appeals policies
and procedures (ES)
Staff Handbooks (SP)
Staff Orientation and Training
Curriculum (SP)
Other:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
3
Federal Regulation
State Regulation Source(s)
Source(s)
438.100(b)(2)(iv)
and (v): Enrollee right
to:
- participate in decisions
regarding his or her care,
including the right to
refuse treatment;
- Be free from any form of
restraint . . . as specified
in other Federal
regulations.
And related:
438.6(i) Advance
directives
1) A written description of any State
law(s) concerning advance
directives. The written description
may include information from
State statutes on advance
directives, regulations that
implement the statutory
provisions, opinions rendered by
State courts and other States
administrative directives. [Note to
reviewers: Each State
Medicaid/CHIP agency is required
under Federal regulations at 42
CFR 431.20 to develop such a
description of State laws and to
distribute it to all MCOs.
Revisions to this description as a
result of changes in State law are
to be sent to MCOs no later than
60 days from the effective date of
the change in State law.]
2) Information on whether or not the
MCO has documented to the State
any moral or religious objection to
fulfilling the regulatory provisions
pertaining to advance directives.
438.100(d):
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Obtain from the State
Applicable MCO
Documents
Medicaid/CHIP and other enrollee
survey results (AM)
Provider Contracts (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Statement of enrollee rights (ES)
Medicaid/CHIP enrollee
marketing materials (ES)
Medicaid/CHIP marketing plans,
policies and procedures (ES)
Medicaid/CHIP enrollment and
disenrollment policies and
procedures (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee
grievance and appeals policies
and procedures (ES)
Staff Handbooks (SP)
Staff Orientation and Training
Curriculum (SP)
Other:
Reviewer
Determination
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
Medicaid/CHIP and other enrollee
Fully Met
4
Federal Regulation
State Regulation Source(s)
Source(s)
Compliance with other
Federal and State laws
Medicaid/CHIP agency the
identification of all State laws that
pertain to enrollee rights and with
which the State Medicaid/CHIP
Agency requires its MCOs to
comply.
Applicable MCO
Documents
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
survey results (AM)
Provider Contracts (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Statement of enrollee rights (ES)
Medicaid/CHIP enrollee
marketing materials (ES)
Medicaid/CHIP marketing plans,
policies and procedures (ES)
Medicaid/CHIP enrollment and
disenrollment policies and
procedures (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee
grievance and appeals policies
and procedures (ES)
Staff Handbooks (SP)
Staff Orientation and Training
Curriculum (SP)
Other:
Reviewer
Determination
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
5
Subpart D:--Quality Assessment and Performance Improvement
Federal
Regulation
Source(s)
438.206:
Availability of
services
State Regulation Source(s)
Information on whether or not:
1) The State agency has required the
MCO to adhere to any explicit standards
for provider network adequacy, such as
prescribed primary physician/enrollee
ratios or specialist/enrollee ratios
2) The State agency has in place any
time or distance standards for
beneficiary travel to access covered
services in Medicaid/CHIP fee-forservice
3) There are any State laws requiring
MCOs to make specific types of
providers available for the provision of
certain services
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer
Determination
Applicable MCO Documents
Service planning documents and
provider network planning
documents (e.g., geographic
assessments, provider network
assessments, enrollee
demographic studies, population
needs assessments)(AM)
Service availability and
accessibility expectations and
standards (AM)
Other performance standards and
quality indicators established by
the MCO (AM)
Any measurement or analysis
reports on service availability and
accessibility (AM)
List of all care and service
providers in the MCO’s network
(may be the same as the provider
directory) (AM)
Organization strategic plans (AM)
Administrative policies and
procedures (AM)
Medicaid/CHIP and other enrollee
survey results (AM)
Utilization management policies
and procedures (UM)
Service authorization policies and
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
6
Federal
Regulation
Source(s)
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
procedures (UM)
Provider Contracts (PS)
Provider/Contractor procedure
manuals (PS)
Provider/Contractor oversight and
evaluation policies and
procedures, audit tools (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Statement of enrollee rights (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Medicaid/CHIP provider directory
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
438.206(c)(1):
Furnishing of
services and timely
access
Obtain a copy of the State
Medicaid/CHIP agency’s standards for
timely enrollee access to care and
services required of Medicaid/CHIP and
MCOs.
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Service planning documents and
provider network planning
documents (e.g., geographic
assessments, provider network
assessments, enrollee
demographic studies, population
needs assessments)(AM)
Service availability and
accessibility expectations and
standards (AM)
Other performance standards and
quality indicators established by
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
7
Federal
Regulation
Source(s)
State Regulation Source(s)
Applicable MCO Documents
the MCO (AM)
Any measurement or analysis
reports
on service availability
and accessibility (AM)
List of all care and service
providers in the MCO’s network
(may be the same as the provider
directory) (AM)
Organization strategic plans (AM)
Administrative policies and
procedures (AM)
Medicaid/CHIP and other enrollee
survey results (AM)
Utilization management policies
and procedures (UM)
Service authorization policies and
procedures (UM)
Provider Contracts (PS)
Provider/Contractor procedure
manuals (PS)
Provider/Contractor oversight and
evaluation policies and
procedures, audit tools (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Statement of enrollee rights (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Medicaid/CHIP provider directory
Medicaid/CHIP Enrollee
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer
Determination
Reviewer Notes:
8
Federal
Regulation
Source(s)
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
Orientation Curriculum (ES)
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Other:
438.206(c)(2):
Furnishing of
services and cultural
considerations.
1) Descriptive information on the State’s
efforts to promote the delivery of
services in a culturally competent
manner to all enrollees, including those
with limited English proficiency and
diverse cultural and ethnic backgrounds.
2) The requirements the State has
communicated to the MCO with respect
to how the MCO is expected to
participate in the State’s efforts to
promote the delivery of services in a
culturally competent manner.
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Service planning documents and
provider network planning
documents (e.g., geographic
assessments, provider network
assessments, enrollee
demographic studies, population
needs assessments)(AM)
Service availability and
accessibility expectations and
standards (AM)
Other performance standards and
quality indicators established by
the MCO (AM)
Any measurement or analysis
reports on service availability and
accessibility (AM)
List of all care and service
providers in the MCO’s network
(may be the same as the provider
directory) (AM)
Organization strategic plans (AM)
Administrative policies and
procedures (AM)
Medicaid/CHIP and other enrollee
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
9
Federal
Regulation
Source(s)
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
survey results (AM)
Utilization management policies
and procedures (UM)
Service authorization policies and
procedures (UM)
Provider Contracts (PS)
Provider/Contractor procedure
manuals (PS)
Provider/Contractor oversight and
evaluation policies and
procedures, audit tools (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Statement of enrollee rights (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Medicaid/CHIP provider directory
(ES)
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
438.208:
Coordination and
continuity of care
1) Definition/specifications used by State
to identify individuals with special health
care needs (SHCNs).
2) Methods used by the State to identify
to the MCO new enrollees with SHCNs.
3) Whether the MCO is required to
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Practice guidelines adopted by
the MCO (AM)
Provider/Contractor Services
policies and procedures manuals
(PS)
Provider Contracts (PS)
Provider/Contractor procedure
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
10
Federal
Regulation
Source(s)
State Regulation Source(s)
Applicable MCO Documents
screen to identify and/or assess persons
with SHCNs using the State’s definition
of SHCNs.
manuals (PS)
Medicaid/CHIP enrollee services
policies and procedures (ES)
Medicaid/CHIP enrollment and
disenrollment policies and
procedures (ES)
Medicaid/CHIP Enrollee
Handbooks (ES)
Care coordination policies and
procedures, and enrollee records
(ES)
Sample of Medicaid/CHIP
enrollee records (ES)
Other:
4) State requirements for MCO care
coordination programs.
5) If the organization to be reviewed is a
MCO, whether the MCO is required to
ensure each enrollee has: A) an ongoing
source of primary care appropriate to
his/her needs, and B) a person/entity
formally and primarily responsible for
coordinating the health care services
furnished to the enrollee.
Reviewer
Determination
Not Applicable
Reviewer Notes:
6) If the organization is an MCO serving
enrollees also enrolled in a Medicare
Advantage plan and receiving Medicare
benefits, information about the extent to
which the MCO is required to implement:
- for enrollees determined to have
ongoing special conditions that require a
course of treatment or regular care
monitoring, a mechanism to ensure that:
(1) the enrollee may directly access a
specialist (e.g., through a standing
referral or approved number of visits) as
appropriate for the enrollee’s condition
and identified needs; and (2) a treatment
plan that, if required by the MCO is
developed by the specialist in
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
11
Federal
Regulation
Source(s)
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
consultation with the enrollee’s primary
care provider, and is
(i) developed with enrollee
participation;
(ii) approved by the MCO in a timely
manner, if this approval is required; and
iii) In accord with the State’s quality
assurance and utilization review
standards.
- a primary care and coordination
program that meets State requirements
and ensures each enrollee has: 1) an
ongoing source of primary care
appropriate to his/her needs; and 2) a
person or entity formally and primarily
responsible for coordinating health care
services furnished to the enrollee.
7) The State’s quality assurance and
utilization review standards.
438.210(b-e):
Coverage and
authorization of
services, including
Obtain from the State Medicaid/CHIP
agency the State-established standards
for MCO processing of standard
authorization decisions.
438.114, emergency
and postEQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Contracts or written agreements
with organizational subcontractors
(AM)
Other:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
12
Federal
Regulation
Source(s)
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
stabilization services
Not Applicable
Reviewer Notes:
438.210(b-e):
Coverage and
authorization of
services, including
Obtain from the State Medicaid/CHIP
agency the State-established standards
for MCO processing of standard
authorization decisions.
438.114, emergency
and poststabilization services
438.214:
Provider selection
Obtain from the State information on any
credentialing, recredentialing, or other
provider selection and retention
requirements established by the State.
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Completed evaluations of entities
conducted before delegation is
granted (AM)
Medicaid/CHIP and other enrollee
grievance and appeals data (AM)
(AM)
Utilization management policies
and procedures (UM)
Coverage rules and payment
policies (UM)
Data on claims denials (UM)
Service authorization policies and
procedures (UM)
Policies and procedures for
notifying providers and enrollees
of denials of service (UM)
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Service planning documents and
provider network planning
documents (e.g., geographic
assessments, provider network
assessments, enrollee
demographic studies, population
needs assessments) (AM)
Contracts or written agreements
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
13
Federal
Regulation
Source(s)
State Regulation Source(s)
438.226:
Enrollment and
disenrollment,
including section
438.56:
Information on:
1) Whether or not the State
Medicaid/CHIP agency allows the MCO
to process enrollee requests for
disenrollment for cause and, if so,
whether or not the State requires
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer
Determination
Applicable MCO Documents
with organizational subcontractors
(AM)
Procedures and methodology for
oversight, monitoring, and review
of delegated activities (AM)
Contracts or written agreements
with organizational subcontractors
(AM)
Completed evaluations of entities
conducted before delegation is
granted (AM)
Provider/Contractor files, 15-20
individual health care professional
files, and 15-20 institutional
provider files (PS)
Credentialing committee or other
provider review mechanism
meeting minutes (PS)
Sample of files of practitioners
who have not been appointed or
reappointed (PS)
Other:
Medicaid/CHIP enrollment and
disenrollment policies and
procedures (ES)
Other:
Reviewer Notes:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
14
Federal
Regulation
Source(s)
Enrollment and
disenrollment:
Requirements and
limitations
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
enrollees to seek redress through the
MCO’s grievance system before the
State makes a determination on the
enrollee’s request.
Not Applicable
Reviewer Notes:
2) A copy of the State-MCO contract
provisions, which specify the methods by
which the MCO assures the State
Medicaid/CHIP agency that it does not
request disenrollment for reasons other
than those permitted under the contract.
438.228:
Grievance systems
438.230:
Sub contractual
relationships and
delegation
Obtain information on whether or not the
State delegates responsibility to the
MCO for providing each Medicaid/CHIP
enrollee (who has received an adverse
decision with respect to a request for a
covered service) notice that he or she
has the right to a State fair hearing to
reconsider their request for the covered
service.
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Medicaid/CHIP enrollee grievance
and appeal tracking reports (ES)
Other:
Obtain from the State the “periodic
schedule” established by the State
according to which the MCO is to
monitor and formally review on an
ongoing basis all subcontractors’
performance of any delegated activities.
Procedures and methodology for
oversight, monitoring, and review
of delegated activities (AM)
Contracts or written agreements
with organizational subcontractors
(AM)
Completed evaluations of entities
conducted before delegation is
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
15
Federal
Regulation
Source(s)
438.240:
Quality assessment
and performance
improvement
program
(a) General rules
(b) Basic elements
of MCO quality
assessment and
performance
improvement
programs
(d) Performance
improvement
projects
State Regulation Source(s)
Obtain from the State Medicaid/CHIP
agency:
1) Information on whether or not the
State Medicaid/CHIP agency has
required the MCO’s performance
improvement projects to address a
specific topic(s), or address a specific
topic(s) and also use specific quality
indicators identified by the State
Medicaid/CHIP agency
2) The State’s requirements with respect
to MCO reporting of the status and
results of each performance
improvement project to the State
Medicaid/CHIP agency
3) Any reports on the status and results
of the performance improvement
projects submitted by the MCO in
response to State requirements for
reporting the status and results of each
performance improvement project to the
State Medicaid/CHIP agency
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer
Determination
Applicable MCO Documents
granted (AM)
Ongoing evaluations of entities
performing delegated activities
Other:
Reviewer Notes:
QAPI program evaluation (AM)
QAPI project descriptions,
including data sources and data
audit results (AM)
QAPI project quality indicators,
the selection or development
criteria, and processes for
selection or development (AM)
QAPI program evaluation (AM)
QAPI data analysis and reports
(AM)
Performance measures produced
by the MCO (AM)
Policies and procedures related to
data collection and data quality
checks for QAPI projects (AM)
Utilization management policies
and procedures (UM)
Other:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
QAPI program evaluation (AM)
Reviewer Notes:
Fully Met
16
Federal
Regulation
Source(s)
438.240(c):
Performance
measurement and
improvement
State Regulation Source(s)
Obtain from the State Medicaid/CHIP
agency:
1) A list of all performance measures
required of the MCO by the State for the
year or years for which the review is
being conducted
2) The actual performance measures
submitted by the MCO to the State for
the year or years for which the review is
being conducted
3) Instructions from the State on whether
or not the State wishes the EQRO to
validate the MCO’s submitted
performance measures.
438.240(e):
Program review by
the State.
Determine from the State Medicaid/CHIP
agency whether or not the State has
required the MCO to have in effect a
process for its own evaluation of the
impact and effectiveness of its quality
assessment and performance
improvement (QAPI) program and, if so,
how frequently the MCO is to make such
an evaluation.
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer
Determination
Applicable MCO Documents
QAPI project descriptions,
including data sources and data
audit results (AM)
QAPI project quality indicators,
the selection or development
criteria, and processes for
selection or development (AM)
QAPI program evaluation (AM)
QAPI data analysis and reports
(AM)
Performance measures produced
by the MCO (AM)
Policies and procedures related to
data collection and data quality
checks for QAPI projects (AM)
Utilization management policies
and procedures (UM)
Other:
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
QAPI program evaluation (AM)
QAPI project descriptions,
including data sources and data
audit results (AM)
QAPI project quality indicators,
the selection or development
criteria, and processes for
selection or development (AM)
QAPI program evaluation (AM)
QAPI data analysis and reports
(AM)
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
Reviewer Notes:
17
Federal
Regulation
Source(s)
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
Performance measures produced
by the MCO (AM)
Policies and procedures related to
data collection and data quality
checks for QAPI projects (AM)
Utilization management policies
and procedures (UM)
Other:
438.242:
Health information
systems
QAPI project descriptions,
including data sources and data
audit results (AM)
Medicaid/CHIP and other enrollee
grievance and appeals data (AM)
Analytic reports of service
utilization (UM)
Information systems capability
assessment reports (IS)
Policies and procedures for
auditing data or descriptions of
other mechanisms used to check
the accuracy and completeness of
data (internally generated and
2) State specifications for data on
externally generated data)
enrollee and provider characteristics that
information system
must be collected by the MCO.
Completed audits of data or other
evidence of data monitoring for
3) State specifications for how MCOs are
accuracy and completeness both
to collect data on services furnished to
for MCO data and information
enrollees (i.e., whether or not the MCO
system
must collect encounter data or may use
1) Information on whether or not the
State has required the MCO to undergo,
or has otherwise received, a recent
assessment of the MCO’s health
information system. If the State has
required or received such an
assessment, obtain a copy of the
information system Assessment from the
State or the MCO. Also obtain contact
information about the person or entity
that conducted the assessment and to
whom follow-up questions may be
addressed.
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
18
Federal
Regulation
Source(s)
State Regulation Source(s)
Applicable MCO Documents
Reviewer
Determination
other methods). If the State allows the
Provider/Contractor Services
MCO to use other methods, what are the
policies and procedures manuals
State’s requirements with respect to
(PS)
these “other methods?” If the State
Provider Contracts (PS)
requires MCOs to collect encounter data Other:
and report it to the State, does the State
validate this data or require it to be
validated? If the data is validated, obtain
a copy of the most recent validation
report.
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
19
Subpart F:--Grievance System
Federal
Regulation
Source(s)
438.402:
General
requirements
State Regulation Source(s)
QAPI project descriptions,
including data sources and data
1) The time frame during which enrollees
audit results (AM)
and providers are allowed to file an
Medicaid/CHIP and other enrollee
appeal;
grievance and appeals data (AM)
Analytic reports of service
2) Whether or not the State requires
utilization (UM)
enrollees to exhaust MCO level appeals
Information systems capability
prior to requesting a State fair hearing;
assessment reports (information
and
systems)
3) Whether enrollees are required or
Policies and procedures for
permitted to file a grievance with either
auditing data or descriptions of
the State or the MCO or both.
other mechanisms used to check
the accuracy and completeness of
both internally generated and
externally generated data
(Information systems)
Completed audits of data or other
evidence of data monitoring for
accuracy and completeness both
for MCO data and contractor
(delegate) data (information
systems)
Provider/Contractor Services
policies and procedures manuals
(PS)
Provider Contracts (PS)
Ot
Obtain from the State information on:
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer
Determination
Applicable MCO Documents
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
20
Federal
Regulation
Source(s)
438.404:
Notice of Action
438.408:
Resolution and
notification:
Grievances and
appeals
State Regulation Source(s)
Applicable MCO Documents
Obtain from the State Medicaid/CHIP
Agency information on the time frames
within which it requires MCOs to make
standard (initial) coverage and
authorization decisions and provide
written notice to requesting enrollees.
These time frames will be the required
period within which MCOs must provide
Medicaid/CHIP enrollees written notice
of any intent to deny or limit a service
(for which previous authorization has not
been given by the MCO) and the
enrollee’s right to file an MCO appeal (or
request a State fair hearing if the State
does not require the enrollee to exhaust
MCO level appeals prior to requesting a
State fair hearing).
Data on claims denials (UM)
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Other:
Obtain from the State Medicaid/CHIP
Agency:
1) The State-established standard time
frames during which the State requires
MCOs to:
- dispose of a grievance and notify the
affected parties of the result;
- resolve appeals and notify affected
parties of the decision; and
- expedite and resolve appeals and
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Medicaid/CHIP enrollee grievance
and appeal tracking reports (ES)
Other:
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer
Determination
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
21
Federal
Regulation
Source(s)
State Regulation Source(s)
Reviewer
Determination
Applicable MCO Documents
notify affected parties of the decision.
2) The methods prescribed by the State
that the MCO must follow to notify an
enrollee of the disposition of a grievance.
3) Information on whether or not the
State requires Medicaid/CHIP enrollees
to exhaust MCO level appeals before
receiving a State fair hearing.
438.414:
Information about
the grievance
system to providers
and subcontractors
438.420:
Continuation of
Obtain from the State Medicaid/CHIP
Agency information on:
1) Whether the State develops or
approves the MCO’s description of its
grievance system that the MCO is
required to provide to all Medicaid/CHIP
enrollees [Note that under regulations at
§438.10(g)(1) the State must either
develop a description for use by the
MCO or approve a description
developed by the MCO]
2) If the States approves, rather than
develops, the description of the MCO’s
grievance system, information on
whether or not the State has already
approved the MCO’s description
3) The State-specified time frames for
disposition of grievances
Contracts or written agreements
with organizational subcontractors
(AM)
Completed evaluations of entities
conducted before delegation is
granted (AM)
Provider Contracts (PS)
Provider/Contractor procedure
manuals (PS)
Other:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Obtain from the State Medicaid/CHIP
Agency information on any time limits
Medicaid/CHIP enrollee grievance
and appeals policies and
Fully Met
Substantially Met
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
Reviewer Notes:
22
Federal
Regulation
Source(s)
State Regulation Source(s)
benefits while the
MCO appeal and the
State Fair Hearing
are pending
specified by the State that must be met
by Medicaid/CHIP enrollees who wish to
file an appeal, request for expedited
appeal, or State fair hearing
Reviewer
Determination
Applicable MCO Documents
procedures (ES)
Other:
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
438.424:
Effectuation of
reversed appeal
resolutions
Obtain from the State Medicaid/CHIP
Agency information on whether the State
or the MCO is required to pay for
services in situation in which the MCO,
or the State fair hearing officer reversed
a decision to deny authorization of
services, and the enrollee received the
disputed services while the appeal was
pending
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Other:
Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable
Reviewer Notes:
[1] MCO documents are identified using generic names, except in instances where the regulatory provisions refer to and require a specific
document be present and reviewed for content.
The subject matter of each example MCO document is indicated in parenthesis as follows:
Administrative/ Managerial (AM)
Provider/Contractor Services
Utilization Management (UM)
Enrollee Services (ES)
Information Systems
Staff Planning, Education, Development and Evaluation (SP)
Note: The subject matter designation does not imply that the document cannot be used as a data source for addressing other provision
issues, or that it should be the sole source of data in evaluating compliance with the provisions noted.
EQR Protocol 1 Attachment A
Compliance Review Worksheet
December 2011
23
| File Type | application/pdf |
| Author | Maria Goebert |
| File Modified | 2012-01-24 |
| File Created | 2012-01-24 |