CMS Certification Library

The ReadyCert team turns compliance frameworks into data. Since some of this data is published by the government, and therefore subject to the public domain, we showcase this data in a more digestible format than PDF. Of course, this handy tool pales in comparison to the tool that does the work for you - ReadyCert.

5 Core Checklists

These 5 checklists are part of every CMS Certification unless CMS grants an exception. Click on the name of the checklist item to view the guidance and other data related to the System Review Criteria (SRC) you're researching.

TA.BI.10

The system of interest collects and stores data needed to produce reports consistent with data collection plan to assess quality and appropriateness of care furnished to participants of the waiver program.

TA.BI.2

The system of interest supports a range of analysis actions. (These include benefit modeling, utilization management, provider-member-MCO profiling, program planning, forecasting, program assessment, provider or contractor performance, quality assurance, fraud detection, comparison of fee-for-service and managed care, statistical analysis, comparative analysis, financial trends, case-mix adjustments within time ranges specified in the APD and/or RFP, and other functions as described in the APD and/or RFP.)

TA.BI.4

The system of interest collects and summarizes data for specific user communities (e.g. data marts or cubes) such as program analysis staff, research group, financial management unit, agency executives (e.g. dashboard).

TA.BI.5

The system of interest provides reports that allow users to drill down from summarized data to detailed data.

TA.BI.7

The system of interest's business intelligence information is consistent and reliable with full automation.

TA.BI.9

The system of interest limits access to authorized group of stakeholders.

IA.CDM.1

The SMA demonstrates adoption of a conceptual data model (CDM) that depicts the business area high-level data and general relationships for intrastate exchange.

IA.CDM.2

The system of interest identifies relationships between key entities in the Medicaid enterprise.

IA.DMS.2

The SMA demonstrates adoption of an intrastate metadata repository where the agency defines the data entities, attributes, data models, and relationships sufficiently to convey the overall meaning and use of Medicaid data and information.

IA.DMS.4

The SMA demonstrates adoption of statewide standard data definitions, data semantics, and harmonization strategies.

IA.DMS.5

The system of interest updates all historical claim data, recipient enrollment, provider enrollment, and other primary reference data on a scheduled basis.

IA.DS.1

The system of interest supports system transmission and receipt of all current version x12N and NCPDP eligibility verification transactions.

TA.BPM.1

The system of interest uses Enterprise Content Management (ECM) services to allow entry of different forms of information content in a variety of ways.

TA.BPM.4

The system of interest uses a mix of manual and automated business processes.

TA.DC.1

The system receives and processes member eligibility information from external sources.

TA.DC.10

The system of interest securely conducts electronic information exchange within the agency and with multiple intrastate agencies via an information hub.

TA.DC.7

The system of interest performs advanced information monitoring and routes system alerts and alarms to communities of interest when the system detects unusual conditions.

TA.DC.9

The system of interest uses standards (e.g. XML or JSON in a RESTful environment) for message format to ensure interoperability.

TA.CM.4

The system of interest uses technology-neutral interfaces that localize and minimize impact of new technology insertion.

TA.DAM.1

The system of interest maintains online access to at least four years of selected management reports and five years of annual reports.

TA.DAM.2

The system of interest conducts information exchange (internally and externally) using MITA Framework, industry standards, and other nationally recognized standards.

TA.DAM.3

The system of interest develops data models that include mapping of information exchange with external organizations.

TA.DAM.7

The system of interest applies single source of information methodologies.

TA.DM.1

The system of interest uses standardized business rules definitions that reside in a separate application or rules engine.

S&C.BRC.5

The system of interest accommodates customer preferences for communications by email, text, mobile devices, or phones.

S&C.IC.2

SMA uses a medical code set for coding diseases, signs and symptoms, abnormal findings, and external causes of injuries/diseases, as stipulated in 45 CFR Part 162.1002.

S&C.IC.6

The architecture adopted preserves the ability to efficiently, effectively, and appropriately exchange data with other participants in the health and human services enterprise.

S&C.ISC.6

The system of interest complies with standards and protocols adopted by the Secretary under sections 1104 and 1561 of the Affordable Care Act.

S&C.LC.11

SMA has identified and adopted transition and retirement plans.

S&C.MS.10

The SMA uses regionally standardized business rule definitions in both human and machine-readable formats.

S&C.MS.14

The SMA defines system of interest modules that can be interchanged without major system design.

S&C.MS.16

The state uses an intrastate rules engine separate from core programming with established interstate standardized business rules definitions.

S&C.MS.18

The system of interest design documents utilize a widely supported modeling language (e.g., UML, BPMN).

S&C.MS.2

Open standards between key interfaces have been considered for all and chosen where feasible.

MMIS Certification Checklists

MMIS Checklists - These checklist items come from each specialized area of the Medicaid Enterprise Certification Toolkit. Some checklist items have guidance, others have forthcoming guidance. Click on the name of the checklist item to view the guidance and other data related to the System Review Criteria (SRC) you're researching.

CM.CM23.1

The system receives and processes PCP registry data from MCOs.

CM.CM27.1

The system stores the plan of care and makes it available for viewing.

CM.CM27.2

The system provides monitoring reports to determine if services approved in the plan of care are provided.

CM.CM27.3

The system identifies the date a participant�s plan of care (POC) assessment is completed and the date of the next POC re-evaluation, if applicable.

CM.CM29.1

The system generates reports to monitor PCCM referrals to specialty care.

CM.CM7.1

SMA detects under-underutilization of PIHP enrollees using encounter data.

FM.DSS1.1

The system provides information to assist management in fiscal planning and control.

FM.DSS1.11

The system supports online real time summary information such as, but not limited to, number and type of providers, members and services.

FM.DSS1.12

The system tracks claims processing financial activities and provides reports on current status of payments.

FM.DSS1.13

The system provides the capability to produce unduplicated counts within a type of service and in total by month.

FM.DSS1.14

The system reports the utilization and cost of services against benefit limitations.

FM.DSS1.16

The system produces an annual hospice report showing a comparison of hospice days versus inpatient days for each enrolled hospice member and for all hospice providers.

CM.CL3.1

The system provides the ability to allow approved service (e.g. private duty nursing) on one prior authorization to be used by multiple providers during overlapping dates of service based on State rules.

CM.CL7.1

The system processes and retains prior authorization request data.

CM.CL7.10

The system captures and maintains both the requested and authorized amount on the prior authorization record.

CM.CL7.11

The system provides and maintains the capability to change the services authorized and to extend or limit the effective dates of the authorization. Maintains the original and the change data in the prior authorization record.

CM.CL7.12

The system provides the capability to accept updates from claims processing that �draw down� or decrement authorized services.

CM.CL7.13

The system uses imaging equipment to capture, store, and retrieve hard copy of prior authorization requests and associated documents.

CM.ME1.1

If the EPSDT reporting process is performed by the MMIS, provides Member data to support case identification, tracking, and reporting for the EPSDT services covered under Medicaid (optional).

CM.ME1.2

The system maintains clinical, utilization and other indicators for special population, special needs status on programs such as lock-in, disease management, outcomes, and high dollar case management files.

EE.ME3.1

The system provides eligibility status for the date(s) queried in response to the eligibility inquiry made and shall track and monitor the responses to the queries

EE.ME3.2

In response to an eligibility inquiry made through the MMIS, SMA provides notice of participation in a managed care program (SMM 11281.1B).

EE.ME3.3

In response to an eligibility inquiry made through the MMIS, SMA provides notification of program and service restrictions, such as lock-in or lock-out (SMM 11281.1B).

EE.ME3.4

The system maintains record/audit trail of responses to eligibility inquiries.

CM.PH3.1

SMA ensures that edits are performed on a prior authorization when required.

FM.PH5.2

SMA identifies claims appropriate for pay and chase function. If the drug is designated as �pay and chase�, processes and pays the claim (if it meets all other criteria), and reports the claim for follow up activities.

FM.PH6.1

The system flags claims for drug rebate processing.

FM.PH6.3

The system provides data to support the state in case of a drug manufacturer dispute over the rebate invoice.

ME.PH1.1

The system provides real-time access to member eligibility. Note: Depends on the timing of the updates maintained in the individual state. See state-specific requirements.

OM.PH1.1

The system ensures that all claims are assigned a unique identification number upon entering the system.

EE.PR1.1

The system produces notices to applicants of pending status, approval, or rejection of their applications.

PL.PR2.1

The system maintains multiple provider specific reimbursement rates with begin and end dates, consistent with state policy. Examples include: per diems, level-of-care per diems, case mix, percentage-of-charge rates, rates based on level of care, preferred provider agreements, managed care agreements, volume purchase contracts, or other cost-containment initiatives with begin and end effective dates.

PM.PR1.1

SMA supports provider outreach through evaluation of provider networks and tracking of performance measures to ensure correct mix of providers within state.

PM.PR1.10

The system produces responses to requests/inquiries on the adequacy of the Medicaid provider network based on provider/beneficiary ratios by geographic region, provider type, etc.

PM.PR1.11

The system uses consistent provider naming conventions to differentiate between first names, last names, and business or corporate names and to allow flexible searches based on the provider name.

PM.PR1.2

The system routes provider applications, and collects and processes provider enrollment and status information.

OM.RDM1.1

The system NCCI - All five Medicaid NCCI methodologies must be incorporated into MMIS. The MCDNCCI methodology files are located on the Medicaid Integrity Institutes (MII) secure web site. These files are updated on a quarterly basis.

PL.RDM1.1

The agency must use medical code set ICD-10 for coding diseases, signs and symptoms, abnormal findings, and external causes of injuries/disease, as stipulated in 45 CFR Part 162.1002.

PL.RDM1.10

The system generates a summary of history file transfers.

PL.RDM1.11

The system maintains online access to all reference tables with an option for inquiry by the appropriate code.

PL.RDM1.12

The system maintains an audit trail of all information changes, including errors in changes and suspended changes.

PL.RDM1.14

The system maintains date sensitive parameters for all Reference Data Management data.

CM.R1.10

The system supports change to periodicity schedules for vaccinations (e.g. capability to add/delete vaccines as new vaccinations are added to the recommended schedule and others are removed).

CM.R1.11

SMA provides a mechanism for providers to submit Member-specific vaccination information to the registry; validates that information received within one month of vaccine administration; flags late notices for staff action.

CM.R1.12

The system receives and processes vaccination reports from service providers in an electronic format using the HL-7 defined code set for exchanging information.

CM.R1.13

The system collects and maintains claims history for vaccinations at the member-specific level until the member is 18 years of age.

CM.R1.15

The system edits data for data validity, duplicate records and performs quality checks; sends error message if appropriate.

CM.R1.3

SMA establishes a registry record for children no later than six weeks after birth or six weeks after they have been otherwise entered into the State�s Information management system and maintains record until child reaches the age of 18.

EE.TPL2.1

SMA identifies Members for referral to the Lock-in program.

FM.TPL1.10

The system provides the State with the capability to update member TPL Resource by batch interface or online real-time.

FM.TPL1.10

The system provides the State with the capability to update member TPL Resource by batch interface or online real-time.

FM.TPL1.11

The system allows online entry of TPL and COB rules by the State staff or contractor staff as defined by the State.

FM.TPL1.11

The system allows online entry of TPL and COB rules by the State staff or contractor staff as defined by the State.

FM.TPL1.12

The system generates alerts to the State recovery units and others designated by the State when retroactive third party coverage has been identified.

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