(Private Sector) External Quality Review of Medicaid MCOs and Supporting Regulations in 42 CFR 438.360, 438.362, and 438.364

EQR 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
Source(s)

438.100(b)(2)(i)
Enrollee right to
receive information

State Regulation Source(s)
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 their rights to request and
obtain the information listed in
paragraphs (f)(6) and (g) of
§438.10.

Reviewer
Determination

Applicable MCO Documents
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•
•
•
•
•

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
Medicaid/CHIP marketing plans,
policies and procedures (ES)

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number
for this information collection is 0938-0786. The time required to complete this information collection is estimated to average 1,591 hours per response for all activities, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

1

Federal
Regulation
Source(s)

438.100(b)(2)(i)
Enrollee right to
receive information

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

State Regulation Source(s)
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
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

Applicable MCO Documents
•
•
•
•
•
•
•

Reviewer
Determination

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

2

Federal
Regulation
Source(s)

State Regulation Source(s)

Reviewer
Determination

Applicable MCO Documents

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 service.
9) Any applicable State laws on enrollee
rights.
Information on whether or not the MCO
has documented to the State any moral
Enrollee right to
receive information on or religious objection to providing,
reimbursing for, or providing coverage
available treatment
of, a counseling or referral service for a
options and
particular Medicaid/CHIP service or
alternatives . . .
services.
including
requirements of
§438.102: Providerenrollee
communications

438.100(b)(2)(iii)

•
•
•
•
•
•
•
•
•
•

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

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

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

3

Federal
Regulation
Source(s)

State Regulation 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

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Applicable MCO Documents

•
•
•
•
•
•
•
•
•
•

and procedures (ES)
Staff Handbooks (SP)
Staff Orientation and Training
Curriculum (SP)
Other:

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)

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

4

Federal
Regulation
Source(s)

State Regulation Source(s)
MCO has documented to the State any
moral or religious objection to fulfilling
the regulatory provisions pertaining to
advance directives.

Obtain from the State Medicaid/CHIP
Compliance with other agency the identification of all State
laws that pertain to enrollee rights and
Federal and State
with which the State Medicaid/CHIP
laws

438.100(d):

Agency requires its MCOs to comply.

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•
•

•
•
•
•
•
•
•
•
•
•
•
•

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Applicable MCO Documents
Staff Handbooks (SP)
Staff Orientation and Training
Curriculum (SP)
Other:

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)

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

5

Federal
Regulation
Source(s)

State Regulation Source(s)

Applicable MCO Documents
•

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Other:

6

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
September 2012

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)

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

7

Federal
Regulation
Source(s)

State Regulation Source(s)
•
•
•
•
•
•
•
•
•
•

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
September 2012

Reviewer
Determination

Applicable MCO Documents
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
Orientation Curriculum (ES)
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
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

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

8

Federal
Regulation
Source(s)

State Regulation Source(s)

Applicable MCO Documents

•
•

•
•
•
•
•
•
•
•
•
•
•
•
EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

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
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

Reviewer
Determination

Reviewer Notes:

9

Federal
Regulation
Source(s)

State Regulation Source(s)
•
•
•

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
September 2012

Reviewer
Determination

Applicable MCO Documents
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Other:
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)

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

10

Federal
Regulation
Source(s)

State Regulation Source(s)
•
•
•
•
•
•
•
•
•
•
•
•

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.

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Applicable MCO Documents

•
•
•

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
(ES)
Medicaid/CHIP Enrollee
Orientation Curriculum (ES)
Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Practice guidelines adopted by
the MCO (AM)
Provider/Contractor Services
policies and procedures manuals
(PS)
Provider Contracts (PS)

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met
11

Federal
Regulation
Source(s)

State Regulation Source(s)
3) Whether the MCO is required to
screen to identify and/or assess persons
with SHCNs using the State’s definition
of SHCNs.
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

Applicable MCO Documents
•
•
•
•
•
•
•

Provider/Contractor procedure
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:

•

Not Met

•

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
EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

12

Federal
Regulation
Source(s)

State Regulation Source(s)

Reviewer
Determination

Applicable MCO Documents

developed by the specialist in
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
September 2012

•
•

Contracts or written agreements
with organizational subcontractors
(AM)
Other:

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met
13

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
September 2012

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

Reviewer Notes:

14

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
enrollees to seek redress through the

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

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:

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

Not Applicable

Reviewer Notes:

15

Federal
Regulation
Source(s)

State Regulation Source(s)

Enrollment and
disenrollment:
Requirements and
limitations

MCO’s grievance system before the
State makes a determination on the
enrollee’s request.

438.228:

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.

Grievance systems

Reviewer
Determination

Applicable MCO Documents
•

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.
•
•
•

Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Medicaid/CHIP enrollee grievance
and appeal tracking reports (ES)
Other:

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

438.230:
Sub contractual
relationships and
delegation

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.

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

•
•
•

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)

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable
16

Federal
Regulation
Source(s)

State Regulation Source(s)
•

Ongoing evaluations of entities
performing delegated activities
Other:

Reviewer Notes:

•

Fully Met

•

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)
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:

•
•

QAPI program evaluation (AM)
QAPI project descriptions,

•

Fully Met

•

Substantially Met

•

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

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

438.240(c):
Performance

Obtain from the State Medicaid/CHIP
agency:

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Applicable MCO Documents

•
•
•

•
•
•
•
•

Reviewer Notes:

17

Federal
Regulation
Source(s)
measurement and
improvement

State Regulation Source(s)
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
September 2012

Reviewer
Determination

Applicable MCO Documents
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:

•

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)
Performance measures produced

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

Reviewer Notes:

18

Federal
Regulation
Source(s)

State Regulation Source(s)
•
•
•

438.242:
Health information
systems

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.
2) State specifications for data on
enrollee and provider characteristics that
must be collected by the MCO.

•
•
•
•
•

•

3) State specifications for how MCOs are
to collect data on services furnished to
enrollees (i.e., whether or not the MCO
must collect encounter data or may use
other methods). If the State allows the
•
EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Applicable MCO Documents
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:
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
externally generated data)
information system
Completed audits of data or other
evidence of data monitoring for
accuracy and completeness both
for MCO data and information
system
Provider/Contractor Services

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

Reviewer Notes:

19

Federal
Regulation
Source(s)

State Regulation Source(s)

Reviewer
Determination

Applicable MCO Documents

MCO to use other methods, what are the
State’s requirements with respect to
these “other methods?” If the State
•
requires MCOs to collect encounter data •
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.

policies and procedures manuals
(PS)
Provider Contracts (PS)
Other:

Subpart F:--Grievance System
Federal
Regulation
Source(s)

State Regulation Source(s)
•

438.402:

Obtain from the State information on:

General
requirements

1) The time frame during which enrollees
and providers are allowed to file an
•
appeal;
•
2) Whether or not the State requires
enrollees to exhaust MCO level appeals
•
prior to requesting a State fair hearing;
and

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Applicable MCO Documents
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 (information

•

Fully Met

•

Substantially Met

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable
20

Federal
Regulation
Source(s)

State Regulation Source(s)
3) Whether enrollees are required or
permitted to file a grievance with either
the State or the MCO or both.

•

•

•
•
•

438.404:
Notice of Action

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

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

Reviewer
Determination

Applicable MCO Documents

•
•
•

systems)
Reviewer Notes:
Policies and procedures for
auditing data or descriptions of
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
Data on claims denials (UM)
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:
21

Federal
Regulation
Source(s)

State Regulation Source(s)

Reviewer
Determination

Applicable MCO Documents

(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).

438.408:
Resolution and
notification:
Grievances and
appeals

438.414:
Information about
the grievance

•

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
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.
Obtain from the State Medicaid/CHIP
Agency information on:
1) Whether the State develops or

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

•
•

•

Medicaid/CHIP enrollee
grievance and appeals policies
and procedures (ES)
Medicaid/CHIP enrollee
grievance and appeal tracking
reports (ES)
Other:

Contracts or written agreements
with organizational subcontractors
(AM)

•
•
•
•
•
•

Fully Met
Substantially Met
Partially Met
Minimally Met
Not Met
Not Applicable

Reviewer Notes:

•

Fully Met

•

Substantially Met

22

Federal
Regulation
Source(s)

State Regulation Source(s)
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

•

Obtain from the State Medicaid/CHIP
Agency information on any time limits
Continuation of
specified by the State that must be met
benefits while the
MCO appeal and the by Medicaid/CHIP enrollees who wish to
file an appeal, request for expedited
State Fair Hearing
appeal, or State fair hearing
are pending

•

system to providers
and subcontractors

438.420:

Reviewer
Determination

Applicable MCO Documents

•
•
•

•

Completed evaluations of entities
conducted before delegation is
granted (AM)
Provider Contracts (PS)
Provider/Contractor procedure
manuals (PS)
Other:

•

Partially Met

•

Minimally Met

•

Not Met

•

Not Applicable

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:

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,

EQR Protocol 1 Attachment A
Compliance Review Worksheet
September 2012

•
•

Medicaid/CHIP enrollee grievance
and appeals policies and
procedures (ES)
Other:

•

Fully Met

•

Substantially Met

•

Partially Met
23

Federal
Regulation
Source(s)

State Regulation Source(s)
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

Reviewer
Determination

Applicable MCO Documents
•

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
September 2012

24