Md. Code Regs. 10.67.03.11

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.67.03.11 - Management Information System and Data Reporting

An MCO applicant shall include in its application the following information or descriptions:

A. A description of the applicant's management information system, including, but not limited to:

(1) Capacities, including:

(a) The ability to generate and transmit electronic claims data consistent with the Medicaid Statistical Information System (MSIS) requirements or successor systems;

(b) The ability to collect and report data on enrollee and provider characteristics and on all services furnished to enrollees through an encounter data system;

(c) The ability to screen the data collected for completeness, logic, and consistency; and

(d) The ability to collect and report data from providers in standardized formats using secure information exchanges and technologies utilized for Medicaid quality improvement and care coordination efforts;

(2) Software,

(3) Characteristics, and

(4) Ability to interface with other systems;

B. A description of the applicant's operational procedures for generating service-specific encounter data;

C. Evidence of the applicant's ability to report, on a monthly basis, service-specific encounter data in UB04 or CMS1500 format;

D. A description of the applicant's operational procedures for generating financial reports, including, but not limited to:

(1) Annual audits,

(2) Annual financial statements, and

(3) Quarterly unaudited financial statements;

E. Evidence of the applicant's ability to collect and report all data necessary to derive indicators for Healthcare Effectiveness Data and Information Set (HEDIS); and

F. A description of the applicant's procedures for verifying the accuracy and timeliness of reported data, including data from network providers the MCO was compensating on the basis of capitation payments or other payment arrangements that are not fee-for-service.

Md. Code Regs. 10.67.03.11

Regulations .11 recodified from 10.09.64.11 effective 46:22 Md. R. 976, eff. 11/1/2019