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pdfAPPENDIX V – Information Systems Capabilities Assessment
Attachment A: Tools for Assessing MCO Information Systems
INFORMATION SYSTEM CAPABILITIES ASSESSMENT (ISCA) TOOL
This tool was developed in 2001 for inclusion in the original EQR Protocol package. This tool
will be replaced with an updated tool after CMS completes a business intelligence analysis
currently underway. The purpose of the tool remains the validation of information systems,
processes, and data from providers and MCOs.
The ISCA is an information collection tool provided to the MCO by the State or its EQRO. The
State or EQRO will define a time frame in which the MCO is expected to complete and return
the tool. The MCO will record data on the provided tool. Documents from the MCO are
requested throughout the tool and are summarized on the checklist at the end of this
assessment tool. These documents should be attached to the tool and be identified as
applicable to the numbered item on the tool (e.g., II.B.3 or IV.6). The tool itself is based on that
produced by MEDSTAT Group, Inc., with some additional elements included to address the
multiple purposes of performing assessments of information systems.
Note: The information requested below pertains to the collection and processing of data for an
MCO’s Medicaid line of business. In many situations, if not most, this may be no different than
how an MCO collects and processes commercial or Medicare data. However, for questions
which may address areas where Medicaid data is managed differently than commercial or other
data, please provide the answers to the questions as they relate to Medicaid enrollees and
Medicaid data.
A. Contact Information
Please insert (or verify the accuracy of) the MCO identification information below, including
the MCO name, MCO contact name and title, mailing address, telephone and fax numbers,
and E-mail address, if applicable.
MCO Name:
Contact Name and Title:
Mailing address:
Phone number:
Fax number:
E-mail address:
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
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B.
Managed Care Model Type (Please circle one, or specify other.)
MCO-staff model
MCO-group model
MCO-IPA model
MCO-mixed model
PIHP
Other - specify:__________________
C.
Year Incorporated ______________
D.
Member Enrollment for the Last Three Years.
INSURER
Year 1:____________
Year 2 ___________
Year 3:____________
Privately Insured
Medicare
Medicaid
Other
E.
Has your organization ever undergone a formal information system capability
assessment?
Circle a response:
Yes
No
If yes, who performed the assessment?
When was the assessment completed?
NOTE: If your MCO’s information has been formally assessed in the recent past (2 years or
less), please attach a copy of the assessment report. Complete only those sections of the ISCA
that are not covered by or have changed since the formal assessment was conducted.
INFORMATION SYSTEMS: DATA PROCESSING PROCEDURES & PERSONNEL
1.
What data base management system(s) (DBMS) do/does your organization use to
store Medicaid claims and encounter data?
2.
How would you characterize this/these DBMSs? (Circle all that apply.)
A. Relational
B. Network
C. Hierarchical
D. Flat File
E. Indexed
F. Proprietary
G. Other
H. Don’t Know
3.
Into what DBMS(s), if any, do you extract relevant Medicaid
encounter/claim/enrollment detail for analytic reporting purposes?
4.
How would you characterize this/these DBMS(s)? (Circle all that apply.)
A. Relational
B. Network
C. Hierarchical
D. Flat File
E. Indexed
F. Proprietary
G. Other
H. Don’t Know
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5.
What programming language(s) do your programmers use to create Medicaid data
extracts or analytic reports? How many programmers are trained and capable of
modifying these programs?
6.
Do you calculate defect rates for programs?
Circle your response.
Yes
No
If yes, what methods do you use to calculate the defect rate?
What was the most recent time period?
What were the results?
7.
Do you rely on any quantitative measures of programmer performance? If so, what
method(s) do you use to measure the effectiveness of the programmer?
8.
Approximately what percentage of your organization’s programming work is
outsourced? _______%
9.
What is the average experience, in years, of programmers in your organization?
10.
Approximately how many resources (time, money, etc.) are spent on training per
programmer per year? What type of standard training for programmers is provided?
What type of additional training is provided?
11.
What is the programmer turnover rate for each of the last 3 years (new programmers
per year/total programmers)?
Year 1 (20xx): _____ %
Year 2 (20xx): _____ %
Year 3 (20xx): _____ %
12.
Outline the steps of the maintenance cycle for your State’s mandated Medicaid
reporting requirement(s). Include any tasks related to documentation, debugging,
roll out, training, etc. The level of detail should result in 10-25 steps in the outline.
13.
What is the process for version control when code is revised?
14.
How does your organization know if changes to the claims/encounter/enrollment
tracking system affect required reporting to the State Medicaid program? What
prompts your organization to change these systems?
15.
Who is responsible for your organization meeting the State Medicaid reporting
requirements (e.g., CEO, CFO, and COO)?
16.
Staffing
16a. Describe the Medicaid data processing organization in terms of staffing and
their expected productivity goals. What is the overall daily, monthly, and annual
productivity of overall department and by processor?
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16b. Describe processor training from new hire to refresher courses for seasoned
processors.
16c. What is the average tenure of the staff? What is annual turnover?
17.
Security
17a. Describe how loss of Medicaid claim and encounter and other related data is
prevented when systems fail? How frequently are system back-ups
performed? Where is back-up data stored? How and how often are the
backups tested to make sure that the back-up is functional?
17b. How is Medicaid data corruption prevented due to system failure or program
error?
17c. Describe the controls used to assure all Medicaid claims data entered into the
system is fully accounted for (e.g., batch control sheets).
17d. Describe the provisions in place for physical security of the computer system
and manual files:
• Premises
• Documents
• Computer facilities
• Terminal access and levels of security
17e. What other individuals have access to the computer system? Customers?
Providers? Describe their access and the security that is maintained restricting
or controlling such access.
DATA ACQUISITION CAPABILITIES
The purpose of this section is to obtain a high-level understanding of how you collect and
maintain claims/encounters, enrollment information, and data on ancillary services such as
prescription drugs.
A. Administrative Data (Claims and Encounter Data)
This section requests information on input data sources (e.g., paper and electronic claims)
and on the transaction system(s) you use.
1. Do you use standard claims or encounter forms for the following? If yes, please
specify (e.g., CMS1500, UB 92).
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DATA
SOURCE
NO
YES
IF YES, PLEASE SPECIFY
Hospital
Physician
Drug
Nursing
Home
Home Health
Mental Health
Dental
2.
We would like to understand how claims or encounters are submitted to your plan.
We are also interested in an estimate of what percentage (if any) of services
provided to your enrollees by all providers serving your Medicaid enrollees are NOT
submitted as claims or encounters, and therefore, are not represented in your
administrative data. Please fill in the following table with the appropriate
percentages:
CLAIMS OR ENCOUNTER TYPES
MEDIUM
Hospital
PCP
Specialist
Physician
100%
100%
100%
Dental
Mental
health/
Substance
abuse
Drug
Other
100%
100%
100%
100%
Claims/encounters
submitted
electronically
Claims/encounters
submitted on paper
Services not submitted
as claims or
encounters
TOTAL
3.
Please document whether the following data elements (data fields) are required by
you for providers, for each of the types of Medicaid claims/encounters identified
below. If required, enter an “R” in the appropriate box.
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CLAIMS/ENCOUNTER TYPES
DATA
ELEMENTS
Hospital
Primary Care
Physician
Specialist
Physician
Mental
Health/
Substance
Abuse
Dental
Drug
Other
Patient Gender
Patient DOB/Age
Diagnosis
Procedure
First Date of
Service
Last Date of
Service
Revenue Code
Provider Specialty
4.
How many diagnoses and procedures are captured on each claim? On each encounter?
Claim
Institutional Data
Provider/Provider Group Data
5.
Diagnoses
Encounter
Procedures
Diagnoses
Procedures
Can you distinguish between principal and secondary diagnoses?
Circle your response.
Yes
No
5a.
If “Yes” to 5a, above, how do you distinguish between principal and secondary
diagnoses?
6.
Please explain what happens if a Medicaid claim/encounter is submitted and one or
more required fields are missing, incomplete, or invalid. For example, if diagnosis is
not coded, is the claims examiner required by the system to use an on-line software
product like AutoCoder to determine the correct ICD-9/10 code?
Institutional Data:
Professional Data:
7.
What steps do you take to verify the accuracy of submitted information (e.g.,
procedure code- diagnosis edits, gender-diagnosis edits, gender-procedure code
edits)?
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Institutional Data:
Professional Data:
8.
Under what circumstances can claims processors change Medicaid claims/encounter
information?
9.
Identify any instance where the content of a field is intentionally different from the
description or intended use of the field. For example, if the dependent’s SSN is
unknown, do you enter the member’s SSN instead?
10a. How are Medicaid claims/encounters received?
SOURCE
Received
Directly from
Provider
Submitted through an
Intermediary
Hospital
Physician
Pharmacy
Nursing Home
Home Health
Mental health
Dental
Other
10b. If the data are received through an intermediary, what changes, if any, are made to
the data?
11.
Please estimate the percentage of Medicaid claims/encounters that are coded using
the following coding schemes:
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CODING SCHEME
Inpatient
Diagnosis
Inpatient
Procedure
Ambulatory/
Outpatient
Diagnosis
100%
100%
Ambulatory/
Outpatient
Procedure
Drug
ICD-9/10 CM
CPT-4
HCPCS
DSM-IV
National Drug
Code
Internally
Developed
Other (specify)
Not required
TOTAL
100%
100%
100%
12.
Please identify all information systems through which service and utilization data for
the Medicaid population is processed.
13.
Please describe any major systems changes/updates that have taken place in the
last three years in your Medicaid claims or encounter system (be sure to provide
specific dates on which changes were implemented).
•
New system purchased and installed to replace old system.
•
New system purchased and installed to replace most of old system; old system
still used.
•
Major enhancements to old system (what kinds of enhancements?).
•
New product line adjudicated on old system.
•
Conversion of a product line from one system to another.
14.
In your opinion, have any of these changes influenced, even temporarily, the quality
and/or completeness of the Medicaid data that are collected? If so, how and when?
15.
How many years of Medicaid data are retained on-line? How is historical Medicaid
data accessed when needed?
16.
How much Medicaid data is processed on-line vs. batch? If batch, how often are
they run?
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17.
How complete are the Medicaid data three months after the close of the reporting
period? How is completeness estimated? How is completeness defined?
18.
What is your policy regarding Medicaid claim/encounter audits? Are Medicaid
encounters audited regularly? Randomly? What are the standards regarding
timeliness of processing?
19.
Please provide detail on system edits that are targeted to field content and
consistency. Are diagnostic and procedure codes edited for validity?
20.
Please complete the following table for Medicaid claims and encounter data and
other Medicaid administrative data. Provide any documentation that should be
reviewed to explain the data that is being submitted.
Claims
Encounters
Other
Administrative
Data
Percent of total service
volume
Percent complete
How are the above statistics
quantified?
Incentives for data
submission
21.
Describe the Medicaid claims/encounter suspend (“pend”) process including
timeliness of reconciling pended services.
22.
Describe how Medicaid claims are suspended/pended for medical review, for nonapproval due to missing authorization code(s) or for other reasons. What triggers a
processor to follow up on “pended” claims? How frequent are these triggers?
23.
If any Medicaid services/providers are capitated, have you performed studies on the
completeness of the information collected on capitated services? If yes, what were
the results?
24a.
Identify the claim/encounter system(s) for each product line offered to Medicaid
enrollees. (Note: Typically, there is just one product line offered to Medicaid
enrollees, but there may be some circumstances in which a MCO offers additional
product lines to the State (e.g., CHIP, partial risk products).
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Systems
Used to
Process
Product Line:_______
Product Line: ________
Product Line:_____
Fee-for-service
(indemnity) claims
Capitated service
encounters
Clinic patient
registrations
Pharmacy claims
Other (describe)
24b.
If multiple systems are used to process claims for the Medicaid product line,
document how claims/encounters are ultimately merged into Medicaid-specific files-and on which platform?
Note which merges or data transfers or downloads are automated and which rely on
manual processes.
Are these merges and/or transfers performed in batch? With what frequency?
24c.
Beginning with receipt of a Medicaid claim in-house, describe the claim handling,
logging, and processes that precede adjudication. When are Medicaid claims
assigned a document control number and logged or scanned into the system? When
are Medicaid claims microfilmed? If there is a delay in microfilming, how do
processors access a claim that is logged into the system, but is not yet filmed?
24d.
Please provide a detailed description of each system or process that is involved in
adjudicating:
•
•
A professional encounter(s) for a capitated service (e.g., child immunizations that
arrive separately from the office visit.)
A hospital claim for a delivery or for a newborn that exceeds its mother’s stay.
24e.
Discuss which decisions in processing a Medicaid claim/encounter are automated,
which are prompted by automated messages appearing on the screen, and which
are manual. Document the opportunities a processor has for overriding the system
manually. Is there a report documenting over-rides or “exceptions” generated on
each processor and reviewed by the claim supervisor? If so, please describe this
report.
24f.
Are there any outside parties or contractors used to complete adjudication, including
but not limited to:
•
Bill auditors (hospital claims, claims over a certain dollar amount)
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•
Peer or medical reviewers
•
Sources for additional charge data (usual & customary)
•
Bill “re-pricing” for carved out benefits (mental health, substance abuse)
How is this data incorporated into your organization’s data?
24g.
Describe the system’s editing capabilities that assure that Medicaid claims are
correctly adjudicated
- Provide a list of the specific edits that are performed on claims as they are
adjudicated, and note: 1) whether the edits are performed pre or post-payment,
and 2) which are manual and which are automated functions.
24h.
Discuss the routine and non-routine (ad hoc or special) audits that are performed on
claims/encounters to assure the quality and accuracy and timeliness of processing.
Note which audits are performed per processor, which rely on targeted samples, and
which use random sampling techniques. What is the total percentage of claims onhand that are audited through these QA processes? How frequently?
24i.
Please describe how Medicaid eligibility files are updated, how frequently and who
has “change” authority. How and when does Medicaid eligibility verification take
place?
24j.
How are encounters for capitated services handled by payment functions? What
message appears to notify processors that they are handling a capitated service?
24k.
Describe how your systems and procedures handle validation and payment of
Medicaid claims when procedure codes are not provided.
24l.
Where does the system-generated output (EOBs, letters, etc.) reside? In-house? In
a separate facility? If located elsewhere, how is such work tracked and accounted
for?
25a.
Describe all performance monitoring standards for Medicaid claims/encounters
processing and recent actual performance results.
25b.
Describe processor-specific performance goals and supervision of actual vs. target
performance. Do processors have to meet goals for processing speed? Do they
have to meet goals for accuracy?
25c.
How is performance against targets figured into the official performance appraisal
process? Into processor and supervisor compensation?
B. Enrollment System
1. Please describe any major changes/updates that have taken place in the last three
years in your Medicaid enrollment data system (be sure to identify specific dates on
which changes were implemented). For example:
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•
New enrollment system purchased and installed to replace old system
•
New enrollment system purchased and installed to replace most of old system is old system still used
•
Major enhancements to old system (what kinds of enhancements?)
•
New product line members stored on old system
2. In your opinion, have any of these changes influenced, even temporarily, the quality
and/or completeness of the Medicaid data that are collected? If so, how and when?
3. How does your plan uniquely identify enrollees?
4. How do you handle enrollee disenrollment and re-enrollment in the Medicaid product
line? Does the member retain the same ID?
5. Can your systems track enrollees who switch from one product line (e.g., Medicaid,
commercial plan, Medicare) to another? Circle your response.
Yes
No
5a. Can you track an enrollee’s initial enrollment date with your MCO or is a new enrollment
date assigned when a member enrolls in a new product line?
5b. Can you track previous claim/encounter data or are you unable to link previous
claim/encounter data across product lines?
6. Under what circumstances, if any, can a Medicaid member exist under more than one
identification number within your MCO’s information management systems? Under what
circumstances, if any, can a member’s identification number change?
7. How does your MCO enroll and track newborns born to an existing Medicaid enrollee?
7a. If your MCO has a Medicare product line, describe how your enrollment systems link
individuals simultaneously enrolled in both your Medicare product line and the Medicaid
plan product line.
8a. Is claim/encounter data linked for Medicare/Medicaid dual eligibles so that all encounter
data can be identified for the purposes of performance measure reporting?
Circle your response.
Yes
No
8b. Is claim/encounter data linked for individuals enrolled in both a Medicare and Medicaid
plan so that all encounter data can be identified for the purposes of performance
measure reporting? Circle your response.
Yes
No
9. How often is Medicaid enrollment information updated?
10. How is Medicaid continuous enrollment being defined? In particular, does your system
have any limitations that preclude you from fully implementing continuous enrollment
requirements exactly as specified in the State performance measure requirements?
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11. Please attach a copy of the source code that you use to calculate Medicaid continuous
enrollment.
12. How do you handle breaks in Medicaid enrollment--e.g., situations where a Medicaid
enrollee is disenrolled one day and re-enrolled the next simply for administrative
reasons? Does this affect your continuous enrollment calculations?
13. Do you have restrictions on when Medicaid enrollees can enroll or disenroll? Please
describe.
14. How do you identify and count Medicaid member months? Medicaid member years?
15. Please identify all data from which claims/encounters for the Medicaid product line are
verified.
16. Does the plan offer vision or pharmacy benefits to its Medicaid members that are
different from the vision or pharmacy benefits offered to its commercial enrollees (within
a given contract or market area)? Circle your response. Yes
No
If yes,
explain:
16a. If vision benefits vary by benefit package, outline the different options available. How
are enrollees tracked?
16b. If pharmacy benefits vary by benefit package, outline the different options available.
How are enrollees tracked?
C. Ancillary Systems
Use this section to record information on stand-alone systems or benefits provided through
subcontracts, such as pharmacy or mental health/substance abuse.
1. Does your MCO incorporate data from vendors to calculate any of the following Medicaid
quality measures? If so, which measures require vendor data?
NOTE: The measures listed in the following table are examples of measures that can be
calculated with administrative data and align with CMS quality measurement initiatives as of
2011. The State and EQRO should tailor this table to list those measures that the State requires
its MCO contractors to produce and any other measures in which the State is interested.
Measures denoted with an asterisk are part of either the CHIPRA or Medicaid adult core
measure sets.
Appendix V Attachment A
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MEASURE
VENDOR NAME
Childhood and Adolescent Immunization
Rate(s)*
Well Child Visits*
Adolescent Well-Care Visits*
Initiation of Prenatal Care
Prenatal and Postpartum Care: Timeliness of
Prenatal Care*
Frequency of Ongoing Prenatal Care*
Developmental Screening In the First Three
Years of Life*
Cervical Cancer Screening
Chlamydia Screening in Women*
Child and Adolescent Access to Primary Care
Practitioners*
Percentage of Eligibles Who Received
Preventive Dental Services*
Weight Assessment and Counseling for
Nutrition and Physical Activity for Children/
Adolescents: Body Mass Index Assessment
for Children/ Adolescents*
Breast Cancer Screening (Mammography
Glycohemoglobin Monitoring
Annual Pediatric Hemoglobin A1C Testing*
Provider Certification
Appropriate Testing for Children with
Pharyngitis*
Otitis Media with Effusion (OME) – Avoidance
of Inappropriate Use of Systemic
Antimicrobials in Children*
Percentage of Eligibles who Received Dental
Treatment Services*
Ambulatory Care: Emergency Department
Visits*
Annual Percentage of Asthma Patients 2
Through 20 Years Old with One or More
Asthma-Related Emergency Room Visits*
Follow-Up Care for Children Prescribed
Attention Deficit Hyperactivity Disorder
(ADHD) Medication*
Follow-up After Hospitalization for Mental
Illness*
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2. Discuss any concerns you may have about the quality or completeness of any vendor
data.
3. Please list subcontracted Medicaid benefits that are adjudicated through a separate
system that belongs to a vendor.
4. Describe the kinds of information sources available to the MCO from the vendor (e.g.,
monthly hard copy reports, full claims data).
5. Do you evaluate the quality of this information? If so, how?
6. Did you incorporate these vendor data into the creation of Medicaid-related studies? If
not, why not?
D. Integration and Control of Data for Performance Measure Reporting
This section requests information on how your MCO integrates Medicaid claims, encounter,
membership, provider, vendor, and other data to calculate performance rates. All questions
relate to your current systems and processes, unless indicated otherwise.
1. Please attach a flowchart outlining the structure of your management information
systems, indicating data integration (i.e., claims files, encounter files, etc.). For an
example of the minimum level of detail requested, please refer to the example on page
38. Label the attachment II.D.1.
2. In consolidating data for Medicaid performance measurement, how are the data sets for
each measure collected:
•
By querying the processing system online?
•
By using extract files created for analytical purposes? If so, how frequently are the
files updated? How do they account for claim and encounter submission and
processing lags? How is the file creation process checked for accuracy?
•
By using a separate relational database or data warehouse (i.e., a performance
measure repository)? If so, is this the same system from which all other reporting is
produced?
3. Describe the procedure for consolidating Medicaid claims/encounter, member, and
provider data for performance measure reporting (whether it is into a relational database
or file extracts on a measure-by-measure basis).
3a. How many different sources of data are merged together to create reports?
3b. What control processes are in place to ensure data merges are accurate and
complete?
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3c. What control processes are in place to ensure that no extraneous data are captured
(e.g., lack of specificity in patient identifiers may lead to inclusion of non-eligible
members or to double counting)?
3d. Do you compare samples of data in the repository to transaction files to verify if all
the required data are captured (e.g., were any members, providers, or services lost
in the process)?
3e. Describe your process(es) to monitor that the required level of coding detail is
maintained (e.g., all significant digits, primary and secondary diagnoses remain)?
4.
Describe both the files accessed to create Medicaid performance measures and the
fields from those files used for linking or analysis. Use either a schematic or text to
respond.
5. Are any algorithms used to check the reasonableness of data integrated to report
Medicaid performance measures?
6. Are Medicaid reports created from a vendor software product? If so, how frequently are
the files updated? How are reports checked for accuracy?
7. Are data files used to report Medicaid performance measures archived and labeled with
the performance period in question?
Appendix V Attachment A
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Performance Measure Data: Flowchart of Information System Structure
Paper
Claims/
Encounter
Electronic
Claims/
Encounter
EHRs
Claims/Encounter
Transaction System
• System Edits
• Pricing files
• Diagnosis
procedure
files
• Provider files
Medical
Records
Claims
History
File
Enrollment
File
Provider
File
Plan-Level
Measures
Performance
Vendor
Data
Vendor Data Integration
7. Information on several types of external encounter sources is requested. In the table on
the following page, for each type of delegated service, please indicate the following:
•
Second column: Indicate the number of vendors contracted (or subcontracted) to
provide the Medicaid service. Include vendors that offer all or some of the
service.
•
Third column: Indicate whether your MCO receives member-level data for any
Medicaid performance measure reporting from the vendor(s). Only answer “Yes”
if all data received from contracted vendor(s) are at the member level. If any
encounter-related data is received in aggregate form, you should answer “No”. If
type of service is not a covered benefit, indicate “N/A”.
•
Fourth column: Indicate whether all data needed for Medicaid performance
measure reporting are integrated, at the member-level, with MCO administrative
data.
•
Fifth and sixth columns: rank the completeness and quality of the Medicaid data
provided by the vendor(s). Consider data received from all sources when using
the following data quality grades:
A. Data are complete or of high quality
B. Data are generally complete or of good quality
C. Data are incomplete or of poor quality
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•
In the seventh column, describe any concerns you have in ensuring
completeness and quality of Medicaid data received from contracted vendors. If
measure is not being calculated because of any eligible members, please
indicate “N/A”.
Medicaid Claim/Encounter Data from Vendors
Type of
Delegated
Service
Number of
Contracted
Vendors
Always
receive
member-level
data from all
vendor(s)?
(Yes or No)
Integrate
vendor data
with MCO
administrative
data?
(Yes or No)
Completen
ess of Data
(A, B, or C)
Quality of
Data
(A, B, or C)
Behavioral
Health
Family
Planning
Home
Health Care
Hospital
Laboratory
Pharmacy
Primary
Care
Radiology
Specialty
Care
Vision Care
Dental for
Children
Performance Measure Repository Structure
If your MCO uses a performance measure repository, please answer the following question.
Otherwise, skip to the Report Production section.
9. If your MCO uses a performance measure repository for Medicaid performance
measures, review the repository structure. Does it contain all the key information
necessary for Medicaid performance measure reporting?
Report Production
10. Please describe your Medicaid report production logs and run controls. Please describe
your Medicaid performance measure report generation process.
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Rationale
for
Rating/
Concerns
with Data
Collection
11. How are Medicaid report generation programs documented? Is there a type of version
control in place?
12. How does your MCO test the process used to create Medicaid performance measure
reports?
13. Are Medicaid performance measure reporting programs reviewed by supervisory staff?
14. Do you have internal back-ups for performance measure programmers (i.e., do others
know the programming language and the structure of the actual programs)? Is there
documentation?
15. How are revisions to Medicaid claims, encounters, membership, and provider data
systems managed?
PROVIDER DATA
Compensation Structure
The purpose of this section is to evaluate the Medicaid provider compensation structure, as this
may influence the quality and completeness of data. Please identify the percentage of member
months in your plan contributed by Medicaid members whose primary care providers and
specialists are compensated through each of the following payment mechanisms.
PAYMENT MECHANISM
1.
Salaried
2.
Fee-for-Service, no withhold or
bonus
3.
Fee-for-Service, with withhold
Please specify % withhold:
4.
Fee-for-Service with bonus
Bonus range:
5.
Capitated - no withhold or bonus
6.
Capitated with withhold
Please specify % withhold:
7.
Capitated with bonus
Bonus range:
8.
Other
TOTAL
9.
Primary Care
Physician
100%
Specialist
Physician
100%
Please describe how Medicaid provider directories are updated, how frequently, and
who has “change” authority.
Appendix V Attachment A
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9a. Does your MCO maintain provider profiles in its information system?
Please circle response:
YES
NO
9b. If yes to “a,” what provider information is maintained in the provider profile database
(e.g., languages spoken, special accessibility for individuals with special health care
needs). Other? Please describe:
10.
How are Medicaid fee schedules and provider compensation rules maintained? Who
has updating authority?
11.
Are Medicaid fee schedules and contractual payment terms automated? Is payment
against the schedules automated for all types of participating providers?
Summary of Requested Documentation
The documentation requested in the previous questions is summarized in the table below.
Please label all attached documentation as described in the table, and when applicable by the
item number from the ISCA (e.g., III.B.10). Remember, you are not limited to providing only the
documentation listed below; you are encouraged to provide any additional documentation that
helps clarify an answer or eliminates the need for a lengthy response.
Requested Document
Details
Previous Medicaid Performance
Measure Audit Reports
Please attach final reports from any previous Medicaid
performance measure audits in which your MCO
participated during the past two years.
Organizational Chart
Please attach an organizational chart for your MCO. The
chart should make clear the relationship among key
Individuals/departments responsible for information
management, including performance measure reporting.
Data Integration Flow Chart
Please provide a flowchart that gives an overview of the
structure of your management information system. See
the example provided in Section II-D. “Integration and
Control of Data for Performance Measure Reporting.”
Be sure to show how all claims, encounter, membership,
provider, EHR, and vendor data are integrated for
performance measure reporting.
Performance Measure Repository File
Structure (if applicable)
Provide a complete file structure, file format, and field
definitions for the performance measure repository.
Program/Query Language for
Performance Measure Repository
Reporting (if applicable)
Provide full documentation on the software programs or
codes used to convert performance measure repository
data to performance measures.
Continuous Enrollment Source Code
Attach a copy of the source code/computer programs
that you use to calculate continuous enrollment for
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Requested Document
Details
Medicaid enrollees.
Medicaid Member Months Source
Code
Attach a copy of the source code/computer programs
that you use to calculate member months, member
years for Medicaid enrollees.
Medicaid Claims Edits
List of specific edits performed on claims as they are
adjudicated with notation of performance timing (pre or
post-payment) and whether they are manual or
automated functions.
Statistics on Medicaid
claims/encounters and other
administrative data
Documentation that explains statistics reported in the
ISCA.
Appendix V Attachment A
Information Systems Capabilities Assessment (ISCA) Tool
September 2012
21
| File Type | application/pdf |
| File Title | Appendix V - Attachment A - Tools for assessing MCO information Systems |
| Subject | 2012 EQR Protocol |
| Author | CMS |
| File Modified | 2012-10-11 |
| File Created | 2012-10-11 |