A. The MCO shall operate the MIS capable of maintaining, providing, documenting, and retaining information sufficient to substantiate and report MCO’s compliance with the n contract requirements. The MCOs must maintain current International Classification of Diseases (ICD) and Electronic Data Interchange (EDI) compliance as defined by CMS regulation and policy and no funding will be provided for the MCO’s requirement

B. The MCO shall have an MIS capable of documenting administrative and clinical procedures while maintaining the privacy and confidentiality requirements pursuant to HIPAA. The MCO shall provide the DHCFP with aggregate performance and outcome data, as well as its policies for transmission of data from network providers. The MCO shall submit its work plan or readiness survey assessing its ability to comply with HIPAA mandates in preparation for the standards and regulations.

C. The MCO shall have internal procedures to ensure that data reported to the DHCFP are valid and to test validity and consistency on a regular basis.

D. Eligibility Data

  1. The MCO enrollment system shall be capable of linking records for the same enrollee that are associated with different Medicaid and/or NCU identification
    numbers; e.g., recipients who are re-enrolled and assigned new numbers.
  2. At the time of service, the MCO or its subcontractors shall verify every enrollee’s eligibility through the current electronic verification system (EVS).
  3. The MCO shall update its eligibility database whenever enrollees change names, phone numbers, and/or addresses, and shall notify the DHCFP of such changes.
  4. The MCO shall notify the DHCFP of any enrollees for whom accurate addresses or current locations cannot be determined and shall document the action that has been
    taken to locate the enrollees. The MCO shall immediately notify the DHCFP of the births and known deaths of all enrollees.

E. Encounter and Claims Records

  1. The encounter data reporting system should be designed to assure aggregated,
    unduplicated service counts provided across service categories, provider types, and
    treatment facilities. The MCO shall use a standardized methodology capable of
    supporting CMS reporting categories for collecting service event data and costs
    associated with each category of service.
  2. The MCO shall collect and submit service specific encounter data in the appropriate CMS 1500, UB04 and the appropriate ADA Dental Claim format or an alternative format if prior approved by the DHCFP. The data shall be submitted in accordance with the requirements set forth by the American National Standards Institute (ANSI), Accredited Standards Committee (ASC), Electronic Data Interchange (EDI) standards in current use and in the Forms and Reporting Guide of the current DHCFP Managed Care Contract. The data shall include all services reimbursed by Medicaid.

F. EPSDT Tracking System

The MCO shall operate a system that tracks EPSDT activities for each enrolled Medicaid eligible child by name and Medicaid identification number. The system shall allow the MCO to report annually on the CMS 416 reporting form. This system shall be enhanced, if needed, to meet any other reporting requirements instituted by CMS or the DHCFP.


Adequate data reporting capabilities are critical to the ability of CMS and the DHCFP to effectively evaluate the DHCFP’s Managed Care Programs. The success of the Managed Care Program is based on the belief that recipients will have better access to care, including preventive services, and will experience improved health status, outcomes, and satisfaction with the health care delivery system. To measure the program’s accomplishments in each of these areas, the MCO mustprovide the DHCFP and/or its contractors with uniform utilization, cost, quality assurance, and recipient satisfaction and grievance/appeal data on a regular basis. It must also cooperate with the DHCFP in carrying out data validation steps.

The MCO is required to certify the data including, but not limited to, all documents specified by the State as required in the Reporting Guide of the current DHCFP Managed Care Contract, enrollment information, encounter data, and other information contained in contract proposals, as provided in 42 CFR §438.606. The data must be certified by the MCO’s Chief Executive Officer (CEO), the MCO’s Chief Financial Officer (CFO) or an individual who has delegated authority to sign for, and who reports directly to, the MCO’s CEO or CFO. The certification must attest, based on best knowledge, information, and belief as to the accuracy, completeness and truthfulness of the documents and data.

The MCO must meet all reporting requirements and timeframes as required in the Reporting Guide of the current DHCFP Managed Care Contract unless otherwise agreed to in writing by both parties. Failure to meet all reporting requirements and timeframes as contractually required and all attachments thereto may be considered to be in default or breach of said contract.

A. Encounter Reporting
Contracted MCOs must submit encounter data for all recipients and all claims paid and denied in accordance with current ANSI, ASC, EDI standards and requirements in the Reporting Guide of the current DHCFP Managed Care Contract, to include any revisions or additions which contain information regarding encounter data, including the DHCFP’s media and file format requirements, liquidated damages and submittal timeframes. The MCO must assist the DHCFP in its validation of encounter data.

B. Summary Utilization Reporting

The contracted MCO shall produce reports using the Healthcare Effectiveness Data and Information Set (HEDIS), as specified in the current DHCFP Managed Care Contract. The MCO must submit these reports to the DHCFP in a timely manner pursuant to contract requirements in addition to the other reports required by this contract.

C. Dispute Resolution Reporting

Contracted MCOs must provide the DHCFP with monthly reports documenting the number and types of provider disputes, enrollee grievances, appeals and fair hearing request received. Reports must be submitted within 45 business days after close of the quarter to which they apply.

These reports are to include, but not be limited to, the total number of enrollee grievances, the total number of notices provided to enrollees, the total number of enrollee and appeals requests, and provider disputes filed, including reporting of all subcontractor’s enrollee grievances, notices, appeals and provider disputes. The reports must identify the enrollee grievance or appeal issue, or provider dispute received; and verify the resolution timeframe for enrollee grievances and appeals and provider disputes.

Comprehensive enrollee grievance and appeal information, fair hearing requests, and provider dispute information, including, but not limited to, specific outcomes, shall beretained for each occurrence for review by the DHCFP.

D. Quality Assurance Reporting

Studies will be performed by the MCOs pursuant to guidelines established jointly by the MCOs, the DHCFP, and the External Quality Review Organization (EQRO) as well as those identified in the current DHCFP Managed Care Contract. In addition, the MCO must provide outcome-based clinical reports and management reports as may be requested by the DHCFP. Should the MCO fail to provide such reports in a timely manner, the DHCFP may require the MCO to submit a Plan of Correction (POC) to address contractual requirements regarding timely reporting submissions.

E. Enrollee Satisfaction Reporting

Each MCO must collect and submit to the DHCFP a statistically valid uniform data set measuring enrollee satisfaction prior to the third quarter of each contract year, unless the requirement is waived by the DHCFP due to an EQRO performed survey. This may be done in conjunction with the MCO’s own satisfaction survey. The DHCFP may request a specific sample, and/or survey tool, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. Survey results must be disclosed to the State, and, upon State’s or enrollee’s request, disclosed to enrollees.