Medicaid Contract Purchasing SpecificationsPart 9Data Collection and ReportingTable of Contents §901. In General
K§901. In General (a) Information Systems —Contractor shall maintain an information system that meets the requirements of §914. (b) Medicaid-Related Data (1) EPSDT Data —Contractor shall comply with the requirements of §902 relating to collection and reporting of datarelating to the provision of EPSDT services covered under Part 1 to enrolled children. (2) Access Data —Contractor shall comply with the requirements of §904 relating to collection and reporting of data relating to access to items and services covered under Part 1 by enrolled children. (3) Quality Data —Contractor shall comply with the requirements of §905 relating to collection and reporting of data relating to the quality of items and services covered under Part 1 furnished to enrolled children. (4) Utilization Data —Contractor shall comply with the requirements of §906 relating to collection and reporting of data relating to the utilization of items and services covered under Part 1 by enrolled children. (5) Encounter Data — Contractor shall comply with the requirements of §907 relating to collection and reporting of data relating to encounter data. (6) Complaint and Grievance Data — Contractor shall comply with the requirements of §908 relating to collection and reporting of data relating to complaints and grievances by or on behalf of enrolled children. (7) Expenditure and Claims Data —Contractor shall comply with the requirements of §909 relating to collection and reporting of data relating to Contractor's expenditures for covered items and services and claims submitted to Contractor by providers furnishing such services. (8) Data Relating to Practitioners —Contractor shall comply with the requirements of §910 relating to collection and reporting of data relating to practitioners. (c) Public Health Data (1) Access to Data — Subject to subsection (d), Contractor shall ensure that Contractor and each provider participating in Contractor's provider network provides upon request to [drafter insert name of state or local public health agency with responsibility for surveillance, prevention, and control activities in the area served by Contractor] access (including on-line access where applicable) to: (A) any public health data enumerated in subsection (b); and (B) any written or electronic records, medical charts, data files, or other documentation relating to data under subparagraph (A). (2) Collection and Reporting —Contractor shall comply with the requirements of §903 relating to collection and reporting of data relating to public health. (d) Data Disclosure — In disclosing data under this Part to Purchaser or [drafter insert name of public health agency identified in subsection (c)], Contractor shall comply with the applicable provisions of: (1) §1002 of Part 10 (relating to confidentiality protections); (2) 42 C.F.R. §§435.940 - 435.960 (relating to exchanges of income and eligibility information); and (3) 42 C.F.R. Part 2 (pertaining to the confidentiality of data related to alcohol or substance abuse). (e) Responsible Individual — Contractor shall designate an individual with the responsibility and authority for responding to requests for data under this Part and shall inform Purchaser and [drafter insert name of public health agency identified in subsection (c)] of the name and work phone number of the individual and any successor to such individual. (f) Purchaser Access to Data — Contractor shall comply with the requirements of §915 relating to access to data by Purchaser. (g) Responsibility of Participating Providers — Contractor shall, through the written agreement under §501(b) of Part 5, require each provider participating in Contractor's provider network to agree to submit accurate and complete data necessary to satisfy the duties of Contractor under this Part. (h) Data Defined —As used in this Part and in [drafter insert name of purchasing document], data includes information.
§902. EPSDT Data L(a) Annual Participation Report —Contractor shall collect and report, in such form and manner as Purchaser specifies, the data required to enable Purchaser to comply with the requirements of §1902(a)(43)(D) of the Social Security Act, 42 U.S.C. §1396a(a)(43)(D), as implemented by State Medicaid Manual, HCFA Pub. 45-2, Transmittal No. 86 (May, 1996) (HCFA-416 Annual Report), relating to participation by enrolled children in early and periodic screening, diagnostic, and treatment (EPSDT) services. K(b) Compliance with EPSDT Requirements — Contractor shall collect and report, in such form and manner as Purchaser specifies, data relating to Contractor's compliance with the requirements of §102 of Part 1 relating to the furnishing of EPSDT services to enrolled children.
K§903. Public Health Data2 (a) In General — Contractor shall comply, and shall ensure that each provider participating in Contractor's provider network complies, with the reporting requirements of §702 of Part 7 relating to reportable conditions or diseases. (b) Immunizations [To be supplied upon completion of data collection and reporting provisions in sample purchasing specifications for immunizations] (c) Pediatric HIV [To be supplied upon completion of data collection and reporting provisions in sample purchasing specifications for pediatric HIV] (d) STDs [To be supplied upon completion of data collection and reporting provisions in sample purchasing specifications for STDs] (e) TB [To be supplied upon completion of data collection and reporting provisions in sample purchasing specifications for TB] (f) Childhood Lead Poisoning [To be supplied upon completion of data collection and reporting provisions in sample purchasing specifications for childhood lead poisoning] (g) Family Planning — Contractor shall collect and report, in such form and manner as Purchaser specifies, data necessary to document each encounter by an enrolled child (including an adolescent) with a provider of family planning services (whether participating in Contractor's provider network or being reimbursed on the basis of a self-referral under §005(f)(1) of the Overview).
K§904. Access Data (a) In General — Contractor shall collect and report, in such form and manner as Purchaser specifies, the data necessary to enable Purchaser to determine whether enrolled children have access to items and services covered under Part 1. (b) Provider Network-Related Data — Contractor shall collect and report, in such form and manner as Purchaser specifies, the data necessary to enable Purchaser to determine Contractor's compliance withthe requirements of §502 (relating to primary care providers) and §503 (relating to pediatric specialists) of Part 5. (c) Access Standards — Contractor shall collect and report, in such form and manner as Purchaser specifies, the data necessary to enable Purchaser to determine Contractor's compliance with the requirements of: (1) §602 of Part 6 (relating to travel time); (2) §603 of Part 6 (relating to service waiting times); and (3) §604 of Part 6 (relating to services for enrolled adolescents).
§905. Quality Data K(a) HEDIS — Contractor shall report to Purchaser all outcomes of care measurements included in [drafter insert name of most current version of the Health Employer Data Information Set (HEDIS)] at such time as Purchaser specifies. K(b) Results of Clinical Studies — Contractor shall report the results of all clinical studies conducted under §803 of Part 8 to Purchaser in such form and manner as Purchaser specifies. K(c) Results of Drug Formulary Assessments — Contractor shall report the results of drug formulary assessments conducted under §804 of Part 8 to Purchaser in such form and manner as Purchaser specifies. K(d) External Quality Review Organizations —Contractor shall comply with the requirement of §806(a) of Part 8 that Contractor and each provider participating in Contractor's provider network collect and report the data and information required by an external quality review organization to carry out its responsibilities under 1902(a)(30)(C) and §1932(c)(2) of the Social Security Act, 42 U.S.C. §1396a(a)(30)(C) and 42 U.S.C. §1396u-2(c)(2). K(e) Results of Periodic Medical Audits — Contractor shall report the results of any medical audits performed by Contractor under Purchaser's system of periodic medical audit under §807 of Part 8. L(f) Substandard Providers (1) Quality — As required by the Health Care Quality Improvement Act of 1986, 42 U.S.C. §11133, Contractor shall report to the Board of Medical Examiners any professional review action taken by Contractor or provider participating in Contractor's provider network relating to the clinical privileges of a physician or other health care practitioner. (2) Fraud and Abuse — As required under §1128E of the Social Security Act, 42 U.S.C. §1320a-7e, Contractor shall report to the National Health Care Fraud and Abuse Data Collection Program established by the Secretary of HHS any final adverse action taken against a health care provider, supplier, or practitioner.
§906. Aggregate Utilization Data K(a) In General —Contractor shall collect and report, on a [ ] basis, the data relating to aggregate utilization of items and services covered under Part 1 by enrolled children required under §805 of Part 8 using the minimum data elements and format specified by Purchaser for the purpose of: (1) detecting under-utilization of covered items or services by enrolled children; (2) ensuring the actuarial soundness of the capitation rates under [drafter insert name of purchasing document]; (3) validating the encounter data collected and reported under §907 of Part 9; and (4) [drafter insert any other purpose]. L(b) MMIS — Contractor shall collect and report to Purchaser, in such form and manner as Purchaser specifies, the aggregate utilization data necessary to enable Purchaser to comply with the requirements of §1903(r) of the Social Security Act, 42 U.S.C. §1396b(r), relating to the operation of a Medicaid Management Information System.
§907. Encounter Data K(a) In General —Contractor shall collect and report, on a [ ] basis, encounter data relating to utilization of each item or service covered under Part 1 by each enrolled child using the minimum data elements and format specified by Purchaser for the purpose of: (1) detecting under-utilization of covered items or services by enrolled children as required under §805(b) of Part 8; (2) measuring compliance with the coverage requirements under §§101A -103A of Part 1A as required under §805(a) of Part 8; (3) establishing or adjusting the capitation rates under [drafter insert name of purchasing document] to take into account the health status of enrolled children; (4) assessing the quality of the covered items and services furnished to enrolled children by Contractor under [drafter insert name of purchasing document]; and (5) [drafter insert any other purpose]. L(b) MMIS —Contractor shall collect and report to Purchaser, in such form and manner as Purchaser specifies, the encounter data necessary to enable Purchaser to comply with the requirements of §1903(r)(1)(F) and (r)(2)(A) of the Social Security Act, 42 U.S.C. §1396b(r)(1)(F) and (r)(2)(A), relating to the requirements for Purchaser's Medicaid Management Information System relating to detailed individual enrollee encounter data and provider, physician, and patient profiles. L(c) Identification of Treating Physician — Contractor shall collect and report to Purchaser, in such form and manner as Purchaser specifies, the encounter data necessary to enable Purchaser to comply with the requirements of §1903(m)(2)(A)(xi) of the Social Security Act, 42 U.S.C. §1396b(m)(2)(A)(xi), relating to the identification of the physician who furnishes an item or service covered under Part 1 to an enrolled child. §908. Complaint and Grievance Data — [RESERVED]
§909. Expenditure and Claims Data K(a) Expenditures — Contractor shall collect and report to Purchaser on a [ ] basis, in such form and manner as Purchaser specifies, data on expenditures made by Contractor under [drafter insert name of purchasing document ] for items and services covered under Part 1 furnished to enrolled children. K(b) Claims — Contractor shall collect and report to Purchaser on a [ ] basis, in such form and manner as Purchaser specifies, the following data on claims in connection with items and services covered under Part 1 furnished to enrolled children: (1) claims pended; (2) claims denied; (3) claims paid; and (4) estimated claims incurred but not reported. L(c) MMIS — Contractor shall collect and report to Purchaser the data relating to expenditures and claims under [drafter insert name of purchasing document] necessary to enable Purchaser to comply with the requirements of §1903(r) of the Social Security Act, 42 U.S.C. §1396b(r), relating to the operation of a Medicaid Management Information System.
K§910. Data Relating to Practitioners (a) In General — Contractor shall collect and maintain the data enumerated in subsection (b) with respect to each practitioner participating in Contractor's provider network. (b) Data Elements (1) name; (2) area of practice; (3) provider number; (4) address (including zip code) at which the practitioner offers services; (5) current practice site telephone numbers; (6) office hours at each practice site; (7) capacity to accept additional patients at each practice site; (8) licensure status; (9) hospital privileges; (10) education and training; (11) board certification and specialization; (12) age, sex, and race or ethnicity; and (13) languages in which the practitioner is fluent.
K§911. Confidentiality of Data Contractor shall comply with the requirements of §1002 of Part 10 relating to confidentiality protections in the collection and reporting of data under this Part.
§912. Public Access to Data K(a) Access to Reported Data and Information — Contractor agrees that all data and information reported by Contractor to Purchaser or to the Health Care Financing Administration under [drafter insert name of purchasing document] is: (1) subject to disclosure under the Freedom of Information Act, 5 U.S.C. §552, and under [drafter insert reference to applicable state or local freedom of information act]; and (2) not a trade secret or commercial or financial information that is privileged or confidential. (b) Access to External Quality Review Results — [RESERVED] L(c) Access to Survey Findings — Contractor agrees that all findings from surveys of Contractor (or of health care facilities, laboratories, agencies, clinics, or organizations participating in Contractor's provider network) conducted by [drafter insert name of State Survey Agency] shall, as required by §1902(a)(36) of the Social Security Act, 42 U.S.C. §1396a(a)(36) and 42 C.F.R. §431.115: (1) be available to the public; and (2) be made available to the public by [drafter insert name of State Survey Agency].
K§913. Ownership of Data (a) Agreement — Contractor agrees that: (1) any data collected or prepared by Contractor or by a provider participating in Contractor's provider network in connection with [drafter insert name of purchasing document] shall be the property of Purchaser and the U.S. Department of Health and Human Services; and (2) all data and information reported by Contractor to Purchaser or to the Health Care Financing Administration under this [drafter insert name of purchasing document] is: (A) subject to disclosure under the Freedom of Information Act, 5 U.S.C. §552, and under [drafter insert reference to applicable state or local freedom of information act]; and (B) not a trade secret or commercial or financial information that is privileged or confidential. (b) Consideration — The agreement referred to in subsection (a) is made by Contractor in consideration of the use of federal and state Medicaid funds in collecting and preparing data under [drafter insert name of purchasing document].
K§914. Information System Commentary: The following illustrative provision would require Contractor to maintain an information system meeting certain standards. The provision would not limit the Contractor to one information system, nor would it require that Contractor's other information systems meet any of the specified standards. (a) Basic Duty —Contractor shall maintain an information system that meets the requirements of this section. (b) Compliance Capability — The information system shall enable Contractor to comply with the requirements of this Part relating to the collection, reporting, and confidentiality of, and public and Purchaser access to, data. (c) Elements — The information system shall have the capacity to: (1) collect and maintain all data in electronic record; (2) verify the accuracy of the data collected and reported; (3) screen the data collected and reported for completeness; (4) integrate data collected from enrolled children, from providers participating in Contractor's provider network, and from Purchaser and [if applicable, drafter insert name of Purchaser's enrollment broker]; (5) receive data from, and transmit data to, Purchaser's Medicaid Management Information System; (6) provide Purchaser with direct, on-line access to Contractor's data under [drafter insert name of purchasing document] in such manner and format as Purchaser specifies; and (7) update data and upgrade software as necessary to comply with the requirements of this Part.
K§915. Purchaser Access to Data (a) Basic Duty — Contractor shall ensure that Contractor and each provider participating in Contractor's provider network provides upon request to the entities enumerated under subsection (b) access (including on-line access where applicable) to: (1) any Medicaid-related data enumerated in §901(b); (2) any other data required by Purchaser to comply with §1902(a)(27) of the Social Security Act, 42 U.S.C.§1396a(a)(27), 42 C.F.R. §431.107; and (3) any written or electronic records, medical charts, data files, or other documentation relating to data under paragraphs (1) or (2). (b) Accessibility of Data — Contractor agrees to provide the data enumerated in subsection (a) upon request to the following: (1) Purchaser; (2) [drafter insert name of State Medicaid Fraud Control Unit]; (3) the Health Care Financing Administration, U.S. Department of Health and Human Services; (4) the Office of the Inspector General, U.S. Department of Health and Human Services; and (5) the General Accounting Office. (c) Independent Audit — Contractor agrees that Purchaser has the right to conduct (directly or by contract) an independent audit of any data collected or reported by Contractor under this Part, and agrees to cooperate with such audit.
K§916. Remedies for Noncompliance Contractor shall comply with §1205 of Part 12 relating to remedies for noncompliance with the requirements of this Part. KCompliance measure: Contractor shall make available to Purchaser on request copies of: (1) Contractor's provider manual and any other directives, guidelines, protocols, or forms relating to Contractor's information system or to data transmitted in writing or electronically by Contractor to providers participating in Contractor's provider network; (2) the subcontract or other written agreement between Contractor and each provider participating in Contractor's provider network; and (3) Contractor's operations manual and any other directive, guidelines, protocols, or forms, whether in written or electronic format, relating to Contractor's information system, to data, or to Contractor's duties under this Part. Endnotes
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Reflected in this Part are provisions from the Balanced Budget Act of 1997 (BBA), P.L. 105-33 under §1932(c)(1)(A)(iii) of the Social Security Act, 42 U.S.C. §1396u-2(c)(1)(A)(iii) relating to data and reporting by Medicaid MCOs. In particular, this provision requires States that contract with Medicaid MCOs on a risk basis to develop and implement a "quality assessment and improvement strategy" which includes "the provision of quality assurance data to the state using the data and information set that the Secretary has specified for use under Part C of Title XVIII or such alternative data as the Secretary approves, in consultation with the State."
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), P.L. 104-191, contains requirements for the adoption by the Secretary of Health and Human Services of standards for information transactions and data elements applicable to, among others, MCOs contracting with State Medicaid Agencies, §1172 of the Social Security Act, 42 U.S.C. §1320d-1. Regulations implementing these provisions have not been issued to date. When they are promulgated, conforming changes in this language may be required.
CHSRP is also developing sample purchasing specifications relating to data and information collection and reporting and a number of public health issues.1 Upon completion of these sample purchasing specifications, the relevant sections relating to data requirements will be incorporated into this Part.
If, as a purchaser, you are interested in purchasing pediatric care for Medicaid-eligible children from managed care organizations on a risk basis, the following language on data and reporting requirements is for your consideration. Purchasers may also find it useful to review Negotiating the New Health System (3rd Ed.) which provides other options relating to data reporting used by state agency purchasers in contracting with Medicaid MCOs. These options may be found at Table 5.2, Vol. 2, Part 4, pages 5-216 through 5-440 , Table 5.4, Vol. 2, Part 4, pages 5-492 through 5-517 (www.gwu.edu/~chsrp).