Common use of Health Information System Requirements Clause in Contracts

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM therefore requires MCPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the MCP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the MCP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the MCP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, screening the data for completeness, logic, and consistency, and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3), the MCP must make all collected data available upon request by ODM or CMS. v. Acceptance testing of any data that is electronically submitted to ODM is required: a. Before the MCP may submit production files; b. Whenever the MCP changes the method or preparer of the electronic media; and/or c. When ODM determines that the MCP’s data submissions have an unacceptably high error rate. When the MCP changes or modifies information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is required to submit to ODM for review and approval a transition plan that includes the submission of test files in the ODM-specified formats. Once an acceptable test file is submitted to ODM, as determined solely by ODM, the MCP can return to submitting production files. XXX will inform the MCP in writing when a test file is acceptable. Once the MCP’s new or modified information system is operational, that MCP will have up to ninety (90) days to submit an acceptable test file and an acceptable production file. Submission of test files can start before the new or modified information system is in production. ODM reserves the right to verify any MCP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties for noncompliance with this requirement are specified in Appendix N of this Agreement, Compliance Assessment System. b. Electronic Data Interchange, Claims Adjudication and Payment Processing Requirements

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM therefore requires MCPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the MCP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the MCP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the MCP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, screening the data for completeness, logic, and consistency, and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3), the MCP must make all collected data available upon request by ODM or CMS. v. Acceptance testing of any data that is electronically submitted to ODM is required: a. Before the MCP may submit production files; b. Whenever the MCP changes the method or preparer of the electronic media; and/or c. When ODM determines that the MCP’s data submissions have an unacceptably high error rate. When the MCP changes or modifies information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is required to submit to ODM for review and approval a transition plan that includes the submission of test files in the ODM-specified formats. Once an acceptable test file is submitted to ODM, as determined solely by ODM, the MCP can return to submitting production files. XXX ODM will inform the MCP in writing when a test file is acceptable. Once the MCP’s new or modified information system is operational, that MCP will have up to ninety (90) days to submit an acceptable test file and an acceptable production file. Submission of test files can start before the new or modified information system is in production. ODM reserves the right to verify any MCP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties for noncompliance with this requirement are specified in Appendix N of this Agreement, Compliance Assessment System. b. Electronic Data Interchange, Claims Adjudication and Payment Processing Requirements

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM therefore requires MCPs MCOPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the MCP MCOP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP MCOP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the MCP MCOP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the MCP MCOP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, screening the data for completeness, logic, and consistency, and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3438.242(b)(4), the MCP MCOP must make all collected data available upon request by ODM or CMS. v. Acceptance testing of any data that is electronically submitted to ODM is required: a. 1. Before the MCP MCOP may submit production files; b. 2. Whenever the MCP MCOP changes the method or preparer of the electronic media; and/or c. 3. When ODM determines that the MCPMCOP’s data submissions have an unacceptably high error rate. vi. When the MCP MCOP changes or modifies information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is required to submit to ODM for review and approval a transition plan that includes the submission of test files in the ODM-specified formats. Once an acceptable test file is submitted to ODM, as determined solely by ODM, the MCP MCOP can return to submitting production files. XXX ODM will inform the MCP MCOP in writing when a test file is acceptable. Once the MCPMCOP’s new or modified information system is operational, that MCP MCOP will have up to ninety (90) 90 days to submit an acceptable test file and an acceptable production file. vii. Submission of test files can start before the new or modified information system is in production. ODM reserves the right to verify any MCPMCOP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties Sanctions for noncompliance with this requirement are specified in Appendix N of this Agreement, the Compliance Assessment SystemMethodology document. b. Electronic Data Interchange, Claims Adjudication and Payment Processing Requirements

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM ODJFS therefore requires MCPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the each MCP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the each MCP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the each MCP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, ; screening the data for completeness, logic, and consistency, ; and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3), the each MCP must make all collected data available upon request by ODM ODJFS or the Center for Medicare and Medicaid Services (CMS). v. Acceptance testing of any data that is electronically submitted to ODM ODJFS is required: a. Before the an MCP may submit production files;files ODJFS-specified formats; and/or b. Whenever the an MCP changes the method or preparer of the electronic media; and/or c. When ODM the ODJFS determines that the an MCP’s data submissions have an unacceptably high error rate. When the MCP changes MCPs that change or modifies modify information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is are required to submit to ODM ODJFS for review and approval a transition plan that includes including the submission of test files in the ODMODJFS-specified formats. Once an acceptable test file is submitted to ODMODJFS, as determined solely by ODMODJFS, the MCP can return to submitting production files. XXX ODJFS will inform the MCP MCPs in writing when a test file is acceptable. Once the an MCP’s new or modified information system is operational, that MCP will have up to ninety (90) days to submit an acceptable test file and an acceptable production file. Submission of test files can start before the new or modified information system is in production. ODM ODJFS reserves the right to verify any MCP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties for noncompliance with this requirement are specified in Appendix N of this AgreementN, Compliance Assessment SystemSystem of the Provider Agreement. b. Electronic Data Interchange, Interchange and Claims Adjudication and Payment Processing Requirements

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM therefore requires MCPs MCOPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the MCP MCOP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP MCOP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the MCP MCOP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the MCP MCOP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, screening the data for completeness, logic, and consistency, and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3), the MCP MCOP must make all collected data available upon request by ODM or CMS. v. Acceptance testing of any data that is electronically submitted to ODM is required: a. Before the MCP MCOP may submit production files; b. Whenever the MCP MCOP changes the method or preparer of the electronic media; and/or c. When ODM determines that the MCPMCOP’s data submissions have an unacceptably high error rate. When the MCP MCOP changes or modifies information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is required to submit to ODM for review and approval a transition plan that includes the submission of test files in the ODM-specified formats. Once an acceptable test file is submitted to ODM, as determined solely by ODM, the MCP MCOP can return to submitting production files. XXX ODM will inform the MCP MCOP in writing when a test file is acceptable. Once the MCPMCOP’s new or modified information system is operational, that MCP MCOP will have up to ninety (90) days to submit an acceptable test file and an acceptable production file. Submission of test files can start before the new or modified information system is in production. ODM reserves the right to verify any MCPMCOP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties Sanctions for noncompliance with this requirement are specified in Appendix N of this Agreement, the Compliance Assessment SystemMethodology document. b. Electronic Data Interchange, Claims Adjudication and Payment Processing Requirements i. Claims Adjudication The MCOP must have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures must be provided to non-contracting providers within thirty (30) days of a request. The MCOP must inform providers of its ability to electronically process and adjudicate claims and the process for submission. Such information must be initiated by the MCOP and not only in response to provider requests. The MCOP must notify providers who have submitted claims of claims status [paid, denied, pended (suspended)] within one month of receipt by the MCOP or its designee. Such notification may be in the form of a claim payment/remittance advice produced on a routine monthly, or more frequent, basis. ii. The MCOP is prohibited from recovering back or adjusting any payments that are beyond two years from the date of payment of the claim due to the MCOP member’s retroactive termination of coverage from the MCOP, unless the MCOP is directed to do so by CMS, ODM, or applicable state or federal law and regulation. However, the preceding sentence does not prohibit the MCOP or ODM from initiating a recovery or adjustment more than two years after the payment of a claim in the event of fraud, abuse, or as otherwise provided by applicable state or federal law and regulation. iii. The MCOP must have policies providing that, upon discovery of claims payment systemic errors that resulted in incorrectly underpaying or denying claims, the MCOP is required to reprocess and correctly pay such claims, from the date of identification of the error retroactively through the period specified in the contract between the MCOP and the provider for claims payment corrective activity. A claims payment systemic error is defined as involving more than five providers, or involving a significant number of payment errors if five or fewer providers are affected. If a claims payment systemic error occurs, the MCOP shall notify ODM of the error and shall specify its process and timeline for corrective action, unless the MCOP corrects the payments within 60 days from the date of identification of the error. The MCOP’s policies must include how corrective action will be taken on behalf of all affected providers, regardless of whether the claims payment systemic error is identified by the MCOP or by any provider. If the error is not a claims payment systemic error, the MCOP shall correct the payments within 60 days from the date of identification of the error. iv. The MCOP is prohibited from engaging in practices that unfairly or unnecessarily delay the processing or payment of any claim for MCOP members.

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM therefore requires MCPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the MCP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the MCP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the MCP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, screening the data for completeness, logic, and consistency, and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3), the MCP must make all collected data available upon request by ODM or CMS. v. Acceptance testing of any data that is electronically submitted to ODM is required: a. Before the MCP may submit production files; b. Whenever the MCP changes the method or preparer of the electronic media; and/or c. When ODM determines that the MCP’s data submissions have an unacceptably high error rate. When the MCP changes or modifies information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is required to submit to ODM for review and approval a transition plan that includes the submission of test files in the ODM-specified formats. Once an acceptable test file is submitted to ODM, as determined solely by ODM, the MCP can return to submitting production files. XXX ODM will inform the MCP in writing when a test file is acceptable. Once the MCP’s new or modified information system is operational, that MCP will have up to ninety (90) days to submit an acceptable test file and an acceptable production file. Submission of test files can start before the new or modified information system is in production. ODM reserves the right to verify any MCP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties for noncompliance with this requirement are specified in Appendix N of this Agreement, Compliance Assessment System. b. Electronic Data Interchange, Claims Adjudication and Payment Processing Requirements

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM therefore requires MCPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the MCP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the MCP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the MCP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, screening the data for completeness, logic, and consistency, and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3), the MCP must make all collected data available upon request by ODM or CMS. v. Acceptance testing of any data that is electronically submitted to ODM is required: a. Before the MCP may submit production files; b. Whenever the MCP changes the method or preparer of the electronic media; and/or c. When ODM determines that the MCP’s data submissions have an unacceptably high error rate. When the MCP changes or modifies information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is required to submit to ODM for review and approval a transition plan that includes the submission of test files in the ODM-specified formats. Once an acceptable test file is submitted to ODM, as determined solely by ODM, the MCP can return to submitting production files. XXX will inform the MCP in writing when a test file is acceptable. Once the MCP’s new or modified information system is operational, that MCP will have up to ninety (90) days to submit an acceptable test file and an acceptable production file. Submission of test files can start before the new or modified information system is in production. ODM reserves the right to verify any MCP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties for noncompliance with this requirement are specified in Appendix N of this Agreement, Compliance Assessment System. b. Electronic Data Interchange, Claims Adjudication and Payment Processing Requirements

Health Information System Requirements. The ability to develop and maintain information management systems capacity is crucial to successful plan performance. ODM therefore requires MCPs MCOPs to demonstrate their ongoing capacity in this area by meeting several related specifications. a. Health Information System i. As required by 42 CFR 438.242(a), the MCP MCOP must maintain a health information system that collects, analyzes, integrates, and reports data. The system must provide information on areas including, but not limited to, utilization, grievances and appeals, and MCP MCOP membership terminations for other than loss of Medicaid eligibility. ii. As required by 42 CFR 438.242(b)(1), the MCP MCOP must collect data on member and provider characteristics and on services furnished to its members. iii. As required by 42 CFR 438.242(b)(2), the MCP MCOP must ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data, screening the data for completeness, logic, and consistency, and collecting service information in standardized formats to the extent feasible and appropriate. iv. As required by 42 CFR 438.242(b)(3438.242(b)(4), the MCP MCOP must make all collected data available upon request by ODM or CMS. v. Acceptance testing of any data that is electronically submitted to ODM is required: a. 1. Before the MCP MCOP may submit production files; b. 2. Whenever the MCP MCOP changes the method or preparer of the electronic media; and/or c. 3. When ODM determines that the MCPMCOP’s data submissions have an unacceptably high error rate. vi. When the MCP MCOP changes or modifies information systems that are involved in producing any type of electronically submitted files, either internally or by changing vendors, it is required to submit to ODM for review and approval a transition plan that includes the submission of test files in the ODM-specified ODM‐specified formats. Once an acceptable test file is submitted to ODM, as determined solely by ODM, the MCP MCOP can return to submitting production files. XXX ODM will inform the MCP MCOP in writing when a test file is acceptable. Once the MCPMCOP’s new or modified information system is operational, that MCP MCOP will have up to ninety (90) 90 days to submit an acceptable test file and an acceptable production file. vii. Submission of test files can start before the new or modified information system is in production. ODM reserves the right to verify any MCPMCOP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties Sanctions for noncompliance with this requirement are specified in Appendix N of this Agreement, the Compliance Assessment SystemMethodology document. b. Electronic Data Interchange, Claims Adjudication and Payment Processing Requirements