Management Information System (MIS) Capability. Contractor shall have and maintain an MIS that provides, at a minimum:
A. All Medi-Cal eligibility data,
B. Members enrolled in Contractor's plan,
C. Provider claims status and payment data,
D. Encounter-level health care services delivery data,
E. Provider network information, and
F. Financial information as specified in Section 6.2.5(E), Administrative Duties/Responsibilities.
Management Information System (MIS) Capability. A. Contractor’s Management and Information System (MIS) shall be fully compliant with 42 CFR section 438.242 requirements and shall have the capability to capture, edit, and utilize various data elements for both internal management use as well as to meet the data quality and timeliness requirements of DHCS’s Encounter Data submission. All data related to this Contract shall be available to DHCS and to the Centers for Medicare and Medicaid Services (CMS) upon request. Contractor shall have and maintain a MIS that provides, at a minimum:
1) All Medi-Cal eligibility data,
2) Information of Members enrolled in Contractor's plan,
3) Provider claims status and payment data,
4) Health care services delivery Encounter Data,
5) Provider Network information,
6) Program Data,
7) Financial information as specified in Exhibit A, Attachment 1, Provision 8. Administrative Duties/Responsibilities, and
8) Member and Member’s authorized representative Alternative Format Selection(s) (AFS).
B. Contractor’s MIS shall have processes that support the interactions between Financial, Member/Eligibility; Provider; Encounter Claims; Quality Management/Quality Improvement/Utilization; and Report Generation subsystems. The interactions of the subsystems must be compatible, efficient and successful.
C. Contractor shall implement and maintain a publicly accessible, standards- based Patient Access Application Programming Interface (API), and a provider directory API, as described in 42 CFR sections 431.60 and 431.70, and in APL 22-026. Contractor must operate the API in the manner specified in 45 CFR section 170.215 and include information per 42 CFR section 438.242(b)(5) and (6).
Management Information System (MIS) Capability. A. Contractor shall implement and maintain an MIS system that can process and provide all Medi-Cal eligibility, membership enrolled with Contractor, provider claims payment and status. Encounter-level health care services delivery, provider network, financial, and any other data necessary to carry out all processes and procedures needed by Contractor to perform and administer all of the functions required under this Contract. All data shall be available to DHCS and to the Centers for Medicare and Medicaid Services (CMS) upon request. Request for data shall be in writing and specify the timeframe, format, and method required for submission.
B. Contractor shall implement policies and procedures for ensuring the complete, accurate, and timely submission of data for all services for which Contractor incurred any financial liability whether directly or through Subcontracts or other arrangements. The MIS shall be able to collect, process, edit, and submit:
1) Utilization and Statistical Data
a) Utilization of services or encounters by and benefits to Members;
b) Cost of health care;
c) Administrative expenses;
d) Quality of care rendered compliant with Exhibit A, Attachment 4, Quality Improvement System; and
e) Other utilization Encounter and financial information required for auditing purposes or calculations of capitation rates.
Management Information System (MIS) Capability. A. Contractor’s Management and Information System (MIS) shall have the capability to capture, edit, and utilize various data elements for both internal management use as well as to meet the data quality and timeliness requirements of DHCS’ Encounter Data submission. All data related to this Contract shall be available to DHCS and to the Centers for Medicare and Medicaid Services (CMS) upon request. Contractor shall have and maintain a MIS that provides, at a minimum:
1) All Medi-Cal eligibility data.
2) Information of Members enrolled in Contractor's plan.
3) Provider claims status and payment data.
4) Health care services delivery Encounter Data.
5) Provider Network information, and
6) Financial information as specified in Exhibit A, Attachment 1, Provision 8, Administrative Duties/Responsibilities.
B. Contractor’s Management and Information System (MIS) shall have processes that support the interactions between Financial, Member/Eligibility; Provider; Encounter Claims; Quality Management/Quality Improvement/Utilization; and Report Generation subsystems. The interactions of the subsystems must be compatible, efficient and successful. Contractor shall staff with personnel with expertise and experience necessary to support the MIS system at the commencement of the Operations Period and for the duration of this Contract.
C. Contractor shall comply with all DHCS mandated testing of the MIS to determine Contractor compliance with MIS requirements.
