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

EQR APPENDIX V – Information Systems Capabilities Assessment
Attachment B: Information System Review Worksheet and Interview Guide
MANAGED CARE ORGANIZATION INFORMATION SYSTEM REVIEW WORKSHEET
AND INTERVIEW GUIDE
The EQRO can use the Managed Care Organization Information System Review: Worksheet &
Interview Guide (Worksheet) in Attachment A to conduct interviews with MCO staff who
completed the ISCA, as well as other necessary MCO staff. The worksheet is an annotated
version of the ISCA tool, with examples of the types of answers a reviewer should expect to
receive, along with additional notes relative to the issues being pursued. During an onsite visit,
EQRO staff may explore in more detail the responses to the Worksheet submitted by the MCO.
The space to record answers may be used by the reviewers to write interview notes, or
document specific issues identified during pre-visit analysis that need to be pursued with the
MCO during the onsite visit.
Reviewer Worksheet and Interview Guide
This annotated version of the Information System Capabilities Assessment for Managed Care
Organizations / Prepaid Health Plans (ISCA) is provided for EQRO personnel to: 1) record their
findings from the review of ISCA forms completed by each MCO, 2) note issues to be
addressed in follow-up interviews with MCO personnel, and 3) to record their findings from
those interviews. EQRO staff may need to revise this form to provide additional space under
each question to record issues and findings.
GENERAL INFORMATION
Interviewee(s) names and titles:
Interviewer(s) names and tiles:
Date of interview:
Please provide the following general information:
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.

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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MCO Information System Review Worksheet and Interview Guide
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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:
B.

Managed Care Model Type (Please circle one, or specify “other.”)
MCO-staff model

MCO-group model

MCO-IPA

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?

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NOTE:

If your MCO’s information system 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
Interviewee(s) names and titles:
Interviewer(s) names and tiles:
Date of interview:
The State and the MCO should be certain that data being reported are not only accurate today,
but also have a reasonable chance of being accurate for future reporting periods. Future
accuracy can be predicted by assessing the MCO’s systems development cycle and supporting
environment. Plans that lack development checkpoints and controls are much more likely to
introduce errors as systems change. The following criteria can be used to subjectively assess
the likelihood of future reporting anomalies. States should be informed that very few
programming shops in the world really meet all the desirable criteria. The EQRO will consider
the status of checkpoints and controls in its overall assessment of findings.
1.

What data base management system(s) (DBMS(s) 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. Hierarchical
C. Indexed
D. Other

E. Network
F. Flat File
G. Proprietary
H. Don’t Know

[Knowing the DBMS provides an indication of the organization’s overall level of
sophistication typical responses would include Oracle, DB2, VTAM, Paradox, dBase,
R:Base, Sybase, Informix, SAS, Rdb, etc.]
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
E. Network
B. Hierarchical
F. Flat File
C. Indexed
G. Proprietary
D. Other
H. Don’t Know
[Answers to these questions will provide an indicator of how the process works.
Note that it is possible that reports are generated directly from the incidence
database without any intermediate extraction.]

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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?

[For example, many more Cobol programmers are available on the market than for
Smalltalk.]
6.

Do you calculate defect rates for programs?
Circle your response.

Yes

No

If yes, what methods do you use?
7.

Do you rely on any quantitative measures of programmer performance? If so, what
method(s) do you use?
[Methods to calculate defect rates and productivity measures are indicators of the
information system organization’s level of sophistication. Very few firms calculate
either of these very well today, if at all. Typical methods would include Lines of Code
(LoC), Pages of code, ratio of severe bugs to all bugs found, or Function Points
(FP).]

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) 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 (200x): _____ %
Year 2 (200x): _____ %
Year 3 (200x): _____ %
[These questions attempt to determine the stability and expertise of the information
system department. Answers to these questions can provide additional insight into
the development cycle responses. Outsourcing means using non-employees to get
the work done, sometimes off-site, in which case project specification, management,
coordination and acceptance become key success factors. Ask for a guess if the
turnover rate is unknown. However, not knowing the rate is an indicator of higherthan-usual turnover.]

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?

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[The information system department should follow a standardized process when
updating and revising code. This process should include safeguards which ensure
that the correct version of a program is in use.]
14.

How does your organization know if changes to the claims/encounter/enrollment
tracking system impact required reporting to the State Medicaid program? What
motivates you to update the program?
[A specific individual within the organization should be responsible for determining
the impact of any changes made to the plan’s claims/encounter/enrollment tracking
systems. The plan should have in place a system for triggering information system
staff to update the programs.]

15.

Who is responsible for your organization meeting the State Medicaid reporting
requirements (e.g., CEO, CFO, and COO)?

16.

Staffing
16a. Describe the 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?
[Unusually high productivity goals can affect the accuracy and quality of a
processor’s work.]
16b. Describe processor training from new hire to refresher courses for seasoned
processors.
[New hires should be provided with on-the-job training and supervision. Supervisors
should closely audit the work of new hires before suspending the training process.
Seasoned processors should be given occasional refresher courses and training
concerning any system modifications.]
16c. What is the average tenure of the staff? What is annual turnover?
[A larger number of new employees or high turn-over of experienced staff could
result in decreased accuracy and processing speed.]

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 when are the back-ups tested?
[System back-ups should be performed daily (at a minimum) to prevent against data
loss. Back-up data should be stored on separate systems or tape, diskettes or DAT,
and stored in a separate location in case of fire, flood, etc.]
17b. How is Medicaid data corruption prevented due to system failure or to program
error?

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[A back-up procedure will protect the data from destruction due to system failure and
program error. Plans can also institute additional safeguards to protect data from
being written over during these processes.]
17c. Describe the controls used to assure all Medicaid claims data entered into the
system is fully accounted for (e.g., batch control sheets).
[The plan should have a process in place that ensures that all claims/encounters
which have been logged as received are entered into the system and processed.]
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
[The system should be protected from both unauthorized usage and accidental
damage. Paper based claims/encounters should be in locked storage facilities when
not in use. The computer system and terminals should be protected from
unauthorized access using a password system and security screens. Passwords
should be changed frequently and should be re-set whenever an employee
terminates.]
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.
[Both customers and providers should have their access limited to read-only so that
they cannot alter any files. They should be given access to only those files
containing their own patients or members. Customers should be prevented from
accessing highly confidential patient information by being given “blinded” patient
names and “scrambled” ID numbers, or restricted access to particular files.]

DATA ACQUISITION CAPABILITIES
Interviewee(s) names and titles:
Interviewer(s) names and tiles:
Date of interview:
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)

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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)

DATA SOURCE

NO

YES

IF YES, PLEASE SPECIFY

Hospital
Physician
Drug
Dental
Other
(Plans that do not use either CMS 1500 or UB 92 forms may be using forms they
developed themselves. If a plan is using its own forms, these forms should be
reviewed to ensure they are capturing the following key data elements: patient
identification information [SSN, name, date of birth, gender], provider identifying
information [Tax ID, name], date of service, place of service and diagnoses and
procedure codes. An evaluation of their forms to ascertain adequacy and
completeness of data collection may be necessary.
2.

We would like to understand the means by which 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

Dental

Mental
Health
/Substance
Abuse

Drug

Other

100%

100%

100%

100%

100%

100%

100%

Claims/encounters submitted
electronically
Claims/encounters submitted on
paper
Services not submitted as claims
or encounters
TOTAL

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(Since paper forms need to be entered into a plan’s system, processing paper forms
is prone to error. If a plan is receiving more that 50 percent of its data on paper
forms, verify the data checks the plan uses to test processor accuracy. Electronic
data submission should also undergo data edits and validity checks. Plans with a
high percentage of unavailable data for a particular category will have difficulty
reporting measures that use that category. For example, a plan receiving no drug
data from its vendor would not be able to report the HEDIS measures for Outpatient
Drug Utilization.)
3.

Please document whether the following data elements are required for each of the
types of Medicaid claims/encounters identified below. If required, enter an “R” in the
appropriate box.
CLAIMS/ENCOUNTER TYPES

DATA ELEMENTS

Hospital

Primary
Care
Physician

Specialist
Physician

Dental

Mental
Health /
Substance
Abuse

Drug

Patient Gender
Patient DOB/Age
Diagnosis
Procedure
First Date of Service
Last Date of Service
Revenue Code
Provider Specialty
(Standard measures of plan performance such as Medicaid HEDIS are dependent
upon the availability of the fields listed above. If procedure codes or diagnosis codes
are not available, the data will not include the necessary level of detail to report
performance measures.)
4.

How many diagnoses and procedures are captured on each claim? On each
encounter?
Claim
Diagnoses

Encounter
Procedures

Diagnoses

Procedures

Institutional Data
Professional Data

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Other

(A minimum of two diagnosis codes and two procedure codes should be available. If
only one diagnosis is available, it may be difficult to identify patients with chronic
conditions such as diabetes or asthma.)
5a.

Can you distinguish between principal and secondary diagnoses?
Circle your response.
Yes
No
(Some plans will consider the first diagnosis on the claim to be principal. Other plans
determine the principal diagnosis by selecting the most expensive condition
represented.)

5b.

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 Auto-Coder to determine the correct ICD-9/10 code?
(The use of an automated coding product such as GMIS’ AutoCoder can result in
more consistent coding of missing information. Plans that do not use such a product
may allow processors to make their own decisions on appropriate coding. Processor
judgment could result in less accurate coding.)

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)?
(For example, plans will often verify that the information in procedure code and
diagnosis code fields is valid codes. Plans may also verify that diagnosis and
procedure codes are appropriate for age and gender. For example, a claim with a
procedure of hysterectomy should be for a female patient.)

Institutional Data:
Professional Data:
8.

Under what circumstances can claims processors change Medicaid claims/encounter
information?
(If processors are given the ability to modify claims/encounter information, the
accuracy of that information could be affected either negatively or positively.
Processors may simply correct data that was submitted incorrectly, which would
increase the quality of the data. However, processors may also change diagnosis
and procedure codes which could result in a loss of coding specificity. Does the plan
check processed data against paper claims?)

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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?
(Changing the content of a field can create data processing issues. For example, if
the enrollee’s SSN is used as an ID for a number of dependents, the claim may be
given the age and sex of the member rather than the actual patient. The use of the
enrollee’s SSN would make it difficult to track the dependent’s experience over time.)

10a. How are Medicaid claims/encounters received?
SOURCE

Received directly from provider

Submitted through an
Intermediary

Hospital
Physician
Pharmacy
Dental
Other
10b. If the data are received through an intermediary, what changes, if any, are made to
the data?
(Intermediaries that are processing the data, such as a pharmacy benefit firm, could
modify the data, creating a data set that is inconsistent with the plan’s data. The
intermediary may define field content differently or may not be using the same fields
as the plan, making it difficult to integrate the intermediary’s data into the plan’s
systems. All data submitted through an intermediary should be monitored for quality
by the plan.)
11.

Please estimate the percentage of Medicaid claims/encounters that are coded using
the following coding schemes:

CODING SCHEME

Inpatient
Diagnosis

Inpatient
Procedure

Ambulatory/
Outpatient
Diagnosis

Ambulatory/
Outpatient
Procedure

Drug

ICD-9/10 CM
CPT-4
HCPCS
DSM-IV
National Drug Code
Internally Developed

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Other (specify)
Not required
TOTAL

100%

100%

100%

100%

100%

(If a plan is using internally-developed coding schemes, the State should verify
whether this coding can be mapped to standard coding such as ICD-9/10 or CPT-4.
If the coding can be translated for reporting purposes [Medicaid HEDIS requires
diagnosis and procedure codes], the plan should provide information on the level of
specificity with which the coding maps to standard coding [e.g., three-digit specificity
or five-digit specificity]. If the mapping has a low level of specificity, information on
co-morbidities and complications may not be retained during translation.)
12.

Please identify all systems through which service and utilization data for the
Medicaid population are processed.
(Each upgrade or consolidation of the plan’s information system has the potential to
damage the quality of the data. For example, data could be lost or corrupted during
a system conversion, or a new system could limit a plan’s access to historical data.
Changes in data quality and access will affect the plan’s ability to report performance
measures and utilization. The plan should have a fallback option, such as parallel
operations.)

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.

[When a plan undertakes any major system changes such as conversion to a new
system, the system changes could affect data quality. Data quality problems include
corruption of data, loss of data, and loss of the level of detail within the data. The
implementation of a new system can also affect the accessibility of historical data.]
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?
[System conversions could affect the quality or completeness of encounter data the
plan submits to the State, or the accuracy of performance measures. A temporary
decrease in data quality could be a sign of a more serious undiscovered problem.]

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15.

How many years of Medicaid data are retained on-line? How is historical Medicaid
data accessed when needed?
[Due to system constraints, a plan may remove historical data and place it in off-line
storage. The MCO’s ability to report on experience spanning several years of data
could be affected by the accessibility of the data stored off-line.]

16.

How much Medicaid data is processed on-line vs. batch? If batch, how often are
they run?
[Data which are processed on-line will be incorporated into the system on a real-time
basis. If batch processing is not conducted frequently, it can result in data
processing lags which affect data completeness.]

17.

How complete are the Medicaid data three months after the close of the reporting
period? How is completeness estimated? How is completeness defined?
[The completeness of data three months after the close of the reporting period can
vary greatly by plan. A plan’s contracting arrangements with providers can affect
data completeness. Plans that delegate provider payment or data collection to
medical groups or IPAs are less likely to have complete data three months after the
reporting period ends.]

18.

What is your policy regarding Medicaid claim/encounter audits? Are Medicaid
encounters audited regularly? Randomly? What are the standards regarding
timeliness of processing?
[Plans should be performing random periodic audits of their encounter data to
determine the quality of data processing. Plans that do not perform audits at least
annually are not closely monitoring the quality of data processing. Plan standards
regarding timeliness of processing will influence the lag time for encounter data
processing.]

19.

Please provide detail on system edits that are targeted to field content, consistency.
Are diagnostic and procedure codes edited for validity?
[MCOs should have an established, standard set of edits that verify field content and
consistency. For example, a field content data edit would verify that a valid date is
entered into the date of service field. Key fields which should be edited include
patient identifying information (SSN, name, date of birth, sex), provider identifying
information (name, tax ID, type), date and place of service, and diagnosis and
procedure codes. The quality of diagnosis and procedure coding will affect the
validity of reports and performance measures submitted by the MCO/PIHP.]

20.

Please complete the following table for Medicaid claim and encounter data and other
Medicaid Administrative data. Provide any documentation that should be reviewed
to explain the data that is being submitted.

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Claims

Certified
EHR

Encounters

Other
Administrative
Data

Percent of total service volume
Percent complete
How are the above statistics
quantified?

Incentives for data submission

[MCOs with claims data comprising more than 50 percent of their total service
volume are likely to have a more complete representation of total MCO experience
than MCOs that rely heavily on encounter data. While providers have an incentive to
submit claims in order to receive payment for services, they do not always have
incentives to submit encounter information. If an MCO does not offer providers an
incentive, or does not require the submission of encounter data, the MCO may not
receive data for every encounter. Other administrative data collected by an MCO
could include data from pharmacy or laboratory vendors.]
21.

Describe the Medicaid claims/encounter suspend (“pend”) process including timeliness
of reconciling pended services.
[Pended claims/encounters are those claims/encounters that have been suspended
during processing because they failed data quality edits or violated provider payment
parameters. Information on these claims and encounters will not be available for
reporting until they have been reconciled and processed into the system. What
percentage of claims are suspended or pended?]

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?
[Review and processing should not be handled by the same employee. A system
should be in place which encourages the processor to follow-up on the status of
claims in review that have not yet been approved to ensure they are resolved?]

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?
[Because provider payment for capitated services is not determined by the encounter
data submitted, providers do not have an incentive to submit complete and accurate
information on every service provided. Data on capitated services often does not

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include the same level of detail as fee-for-service claims information. Plans should
be aware that capitated data is less complete and should audit the data at least
annually to monitor its quality.]
24a.

Identify the claim/encounter system(s) for each product line offered to Medicaid
enrollees:

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.
[When data are merged across multiple systems, records or data elements can be
altered or lost during the conversion and integration processes. Multiple conversions,
integrations, and the use of manual processes will increase the probability of an error
occurring.]
Are these merges and/or transfers performed in batch? With what frequency?
[Batch processes that are not timely can result in data processing lags which affect
the completeness of data after the close of the reporting period.]

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:

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[Professional encounters arriving separately from an office visit may not be
processed as quickly as the actual office visits. If these encounters are treated as
“non-standard” events, the plan may not be able to easily link these encounters with
the related office visit. For example, newborns exceeding a mother’s stay may have
their hospital stay split into two parts. The part of the stay which coincides with the
mother’s hospitalization may be processed on the mother’s claim and the remainder
of the stay could be processed separately. Processing the newborn’s stay as two
separate claims could affect the plan’s ability to report accurately on newborn
hospital utilization.]

24e.

•

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.

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 overrides or “exceptions” generated on each
processor and reviewed by the claim supervisor? Please describe this report.
[If processors have the ability to override the system manually they may be able to
force claims/encounters with missing information through the system. For example, a
processor may be able to fill in missing diagnosis or procedures codes. Processors
could also use override codes such as “99999" or “00000" to fill in for missing codes.
If the system does not “kick-out” these override codes during processing, the
services will be retained in the system without diagnosis or procedure detail.
Processors may also be able to substitute “000000000" for a missing SSN, which
can lead to services for unidentified members existing on the system.]

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)
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?
[If outside parties are used, the plan should be incorporating data generated by
those parties into the system. The data should first be run through the plan’s data
quality checks to verify its accuracy and completeness.]
24g.

Describe the system’s editing capabilities that assure that Medicaid claims are
adjudicated correctly. 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 postpayment, and 2) which are manual and which are automated functions.

Appendix V Attachment B
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[When reviewing plan adjudication edits, the State should concentrate on edits which
affect the data fields that are used to generate plan performance measures and
reports. Are outliers for length of stay and charges edited? Utilizing an automated
editing process provides more consistent results that do not require processor
judgment. Edits that are performed pre-payment can prevent invalid data from being
incorporated into the system.]
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?
[Note: This item is not relevant in instances where the EQRO is performing
encounter data validation. When reviewing edits that are used to determine
processor accuracy, consider that these edits will not provide information on the
quality of the initial provider data submission. The audit plan should include random
sampling techniques to provide an overall picture of quality. Plans will often
concentrate on auditing complicated or aberrant claims/encounters rather than using
a random sample. The plan should have instituted a process for sharing audit results
with the processor to facilitate quality improvement.]

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?
[The plan should add new enrollees to the system within a reasonable amount of
time after they have enrolled. Enrollees should not be experiencing delays in access
to care due to plan enrollment processes. The plan may be using a different
enrollment process for Medicaid enrollees than for enrollees with commercial
coverage.]

24j.

How are encounters for capitated services handled by payment functions? What
message appears to notify processors that they are handling a capitated service?
[If no message appears to notify processors that they are handling a capitated
service, these services could be processed incorrectly. Payment functions can be
suspended or modified to handle capitated services. The plan should explain how
capitated services are processed and how processing affects data quality.]

24k.

Describe how your systems and procedures handle validation and payment of
Medicaid claims when procedure codes are not provided.
[Plans requiring valid procedure coding for all claims/encounters will have more
detailed data available for reporting and analysis. However, these plans may allow
processors to supply missing codes using a code book or override the system using
an unspecified code. A number of plans use programs such as the GMIS AutoCoder
product to fill in missing codes. When a plan supplies missing codes, the coding can
be less accurate than codes supplied directly by the provider of service.]

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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?
[Plans that have delegated the production of EOBs, letters and other output should
monitor the accuracy and timeliness of those activities.]

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):
•

New enrollment system purchased and installed to replace old system

•

New enrollment 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 members stored on old system.

[Changes to a plan’s enrollment system requiring data conversion and data
integration can create data quality problems. Implementing a new enrollment system
could lead to a loss of access to data on the old system, or the assignment of new
member numbers for all enrollees. Data conversion and integration can also limit a
plan’s ability to track an enrollee’s enrollment history. When a new product line is
added to an existing system, a plan may need to make the new data fit the older
process, therefore modifying the system to “handle” new information. Implementing
such modifications can be difficult for a plan that has been using the same system for
a number of years. The level of enrollment detail retained can be affected by such
modifications.]
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?
[Consider whether changes in data quality will affect the validity of the data submitted
to the State].
3. How does your plan uniquely identify enrollees?

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(Major changes to a MCO’s enrollment system could involve the conversion of
membership data to a new system. When MCOs convert members, they may
change the enrollee’s ID number, making it difficult to track the enrollee’s enrollment
pattern across time. Changes to the enrollment system could also lead to a loss of
data for specific patients.)
4. How do you handle enrollee disenrollment and re-enrollment in the Medicaid product
line? Does the member retain the same ID?
(Enrollees should have a single ID number to facilitate tracking their experience.
However, some plans change an enrollee’s ID number when the enrollee re-enrolls.
Experience for enrollees who have switched ID numbers will be more difficult to
track. Dependents using an enrollee’s ID are also difficult to identify for reporting
purposes. For example, children without a unique ID could affect the ability of the
plan to report on low birth-weight babies, childhood immunizations, and asthma
inpatient admissions. This is an important point. EQROs should give higher “grades”
to plans which have good methods of identifying enrollees.)
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 an enrollee 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 MCO enrollee?
8. If your MCO has a Medicare product line, describe how your enrollment systems link
individuals simultaneously enrolled in both your Medicare product and the Medicaid
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?
[Enrollment information should be updated real-time, daily, or weekly.]

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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?
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 reenrolled 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.
[Eligibility of the patient should be verified before claims and encounters are
processed. Dates of enrollment and disenrollment are key reporting fields for
Medicaid HEDIS measures. Eligibility status is dynamic for Medicaid beneficiaries
and should be updated frequently. Eligibility status should also be verified before
data is submitted to the State].
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
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.
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.
1. Does your plan incorporate data from vendors to calculate any of the following Medicaid
quality measures? If so, which measures require vendor data?

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MEASURE

VENDOR NAME

Prenatal and Postpartum Care: Timeliness of
Prenatal Care
Frequency of Ongoing Prenatal Care
Percentage of Live Births Weighing Less Than
2,500 Grams
Cesarean Rate for Nulliparous Singleton Vertex
Childhood Immunization Status
Immunizations for Adolescents
Weight Assessment and Counseling for Nutrition
and Physical Activity for Children/ Adolescents:
Body Mass Index Assessment for Children/
Adolescents
Developmental Screening In the First Three Years
of Life
Chlamydia Screening
Well-Child Visits in the First 15 Months of Life
rd

th

th

th

Well-Child Visits in the 3 , 4 , 5 , and 6 Years of
Life
Adolescent Well-Care Visit
Percentage of Eligibles Who Received Preventive
Dental Services
Child and Adolescent Access to Primary Care
Practitioners
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
Pediatric Central-line Associated Blood Stream
Infections – Neonatal Intensive Care Unit and
Pediatric Intensive Care Unit
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
Annual Pediatric Hemoglobin A1C Testing
Follow-up After Hospitalization for Mental Illness

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MEASURE

VENDOR NAME

CAHPS® 4.0 (Child Version Including Medicaid and
Children with Chronic Conditions Supplemental
Items)
Flu Shots for Adults Ages 50-64 (Collected as part
of HEDIS CAHPS Supplemental Survey)
Adult BMI Assessment
Breast Cancer Screening
Cervical Cancer Screening
Medical Assistance With Smoking and Tobacco
Use Cessation (Collected as part of HEDIS CAHPS
Supplemental Survey)
Screening for Clinical Depression and Follow-Up
Plan
Plan All-Cause Readmission
PQI 01: Diabetes, Short-term Complications
Admission Rate
PQI 05: Chronic Obstructive Pulmonary Disease
(COPD) Admission Rate
PQI 08: Congestive Heart Failure Admission Rate
PQI 15: Adult Asthma Admission Rate
Chlamydia Screening in Women age 21-24
Follow-Up After Hospitalization for Mental Illness
PC-01: Elective Delivery
PC-03 Antenatal Steroids
Controlling High Blood Pressure
Comprehensive Diabetes Care: LDL-C Screening
Annual HIV/AIDS medical visit
Comprehensive Diabetes Care: Hemoglobin A1c
Testing
Antidepressant Medication Management
Adherence to Antipsychotics for Individuals with
Schizophrenia
Annual Monitoring for Patients on Persistent
Medications
CAHPS Health Plan Survey v 4.0 - Adult
Questionnaire with CAHPS Health Plan Survey v
4.0H - NCQA Supplemental
Care Transition – Transition Record Transmitted to
Health care Professional

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MEASURE

VENDOR NAME

Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment
Prenatal and Postpartum Care: Postpartum Care
Rate

(If a plan is using vendor data, the plan should have a formal process in place to validate
that data before incorporating it into their information system. The plan needs to check
the vendor data for reliability, completeness and timeliness of submission.)
2. Discuss any concerns you may have about the quality or completeness of any vendor
data.
(The plan should have staff who is experienced with the vendor’s data. Furthermore,
most plans will answer this question by saying “we have no concerns”. Probe on this
issue. The EQRO should “award points” for answers demonstrating understanding of
potential problems with vendor data.)
3. Please itemize subcontracted Medicaid benefits that are adjudicated through a separate
system that belongs to a vendor.
[Many plans contract-out services for pharmacy benefits management, mental
health/substance abuse, laboratory and radiology services. If the data are processed on
the vendor’s system, it may not be forwarded to the plan in a complete form or on a
timely basis. Vendors may also use a different method of processing resulting in data
that will not merge with or complement plan data.]
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?
[All of the vendor information should be verified for accuracy before a plan loads it into
their information system. The plan and the vendor may not define variables consistently
or use the same reporting format.]
6. Did you incorporate these 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.
File Consolidation
1. Please attach a flowchart outlining the structure of your management information
system, indicating data integration (i.e., claims files, encounter files, etc.). For an

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example of the minimum level of detail requested, please refer to the example on page
92. Label the attachment II.D.1.
2. In consolidating data for Medicaid performance measurement, how are the data sets for
each Medicaid 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 claims/encounter, member, and provider data
for Medicaid performance measure reporting (whether it be 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?
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?

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Performance Measure Data: Flowchart of Information System Structure
Paper
Claims/
Encounter

EHRs

Medical
Records

Claims/Encounter
Transaction System
Electronic
Claims/
Encounter

•
•
•
•

System edits
Pricing files
Diagnosis
procedure files
Provider files

Enrollment
File
Provider
File

Plan-Level
Performance
Measures

Claims
History
File

Vendor
Data

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Vendor Data Integration
8. 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

•

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”.

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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)

Completeness of
Data
(A, B, or C)

Behavioral Health
Family Planning
Home Health Care
Hospital
Laboratory
Pharmacy
Primary Care
Radiology
Specialty Care
Dental Care
Vision Care

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Quality of Data
(A, B, or C)

Rationale for
Rating/
Concerns with
Data Collection

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.

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?

E. Meaningful Use of Electronic Health Records
This section requests information on how the MCO and its contracted providers utilize electronic health
records (EHRs). All questions relate to your current systems and processes, unless indicated otherwise.
1. Describe any planning and/or development efforts the MCO has taken toward certified EHR
adoption and use.
2. How many providers in your network currently utilize EHRs?
3. In cases where providers are utilizing EHRs, has there been any outreach or assessment by the
MCO to determine whether the technology has been certified by an Office of the National
Coordinator (ONC) Authorized Testing and Certification Body (ATCB)?
4. Describe any training, education, or outreach the MCO has directed to network providers on the
meaningful use of certified EHR technology?
5. Does the MCO utilize data from EHRs as part of its quality improvement program (e.g., does the
MCO use EHR data to improve the quality of services delivered or to develop performance
improvement projects)?
6. What strategies or policies has the MCO developed to encourage the adoption of EHR for those
providers that are not eligible for the Medicaid Incentive Program?
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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 % of withhold:

4.

Fee-for-Service with bonus
Bonus range:

5.

Capitated - no withhold or bonus

6.

Capitated with withhold - Please
specify % of withhold:

7.

Capitated with bonus
Bonus range:

8.

Other

Primary Care Physician

TOTAL

100%

Specialist Physician

100%

[Timeliness and completeness of provider data submissions often varies by contracting
arrangement. Salaried providers work directly for the MCO and will submit data on a timely
basis if data submission is a parameter in their contract with the MCO. Fee-for-service
providers have the largest incentive to submit accurate and complete data since their
payment depends upon it. Capitated providers will need incentives to submit accurate and
complete data. Their compensation should be linked to data submission, which can be done
through the use of bonuses and withholds. For example, lag times may differ by
compensation arrangement as follows: Capitation/Salaried-no lag, Fee-for-Service - 60 day
lag, Hospital - 45 day lag.]

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9.

Please describe how Medicaid provider directories are updated, how frequently, and who has
“change” authority.
[Provider directories should be updated to reflect changes in provider status to prevent
members from selecting providers no longer under contract with the plan. The plan should
have adequate security procedures in place to restrict the number of individuals who can
access confidential provider information and institute changes in status.]

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 and 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?
[Since providers consider fee schedule and compensation information to be confidential,
access to this information should be restricted by the MCO. The MCO should have
standardized process for updating and maintaining this information.]

11.

Are Medicaid fee schedules and contractual payment terms automated? Is payment against
the schedules automated for all types of participating providers?
[Manual payment processes are more prone to error and reduce processing speed.]

Requested Documentation
The documentation requested previously 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.
Details

Requested Document
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, certified EHR technology and

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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 Medicaid enrollees

Medicaid Member Months Source
Code

Attach a copy of the source code/computer programs that you use
to calculate member months and 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

END OF DOCUMENT

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