PROGRAM MANAGEMENT BUSINESS AREA PROGRAM MANAGEMENT REPORTING CHECKLIST PROGRAM MANAGEMENT REPORTING (PM) CHECKLIST
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1 STATE: DATE OF REVIEW: REVIEWER: PROGRAM MANAGEMENT REPORTING (PM) CHECKLIST PROGRAM MANAGEMENT REPORTING (PM) CHECKLIST BACKGROUND Background for this checklist: 1. This checklist is intended to assess the adequacy of the way the MMIS supports Program Management by managing information and providing reports. 2. The criteria in this checklist are mainly based on the MMIS requirements in the State Medicaid Manual (). The MMIS requirements in the have been used for decades of MMIS certification. The language used in the criteria has been modernized to reflect 21 st century terminology. Additional criteria have been added to align with Industry Best Practices (). Many of these have become standards in many States. If a State requests an function in its RFP or System Requirements Document, it will be considered a requirement to be reviewed during MMIS certifications Sources for the criteria in this checklist are as follows: State Medicaid Manual, MMIS Section, available from Document 45 Industry Best Practices. Items are selected from RFPs for MMISs developed by states and approved by CMS. CFR Code of Federal Regulations, available from Reference # PM1 Business Objectives Analyze Medicaid program costs and trends to predict impact of policy changes on programs. PM2 Monitor payment processes and predict trends. BUSINESS OBJECTIVES Comments PM3 Analyze provider performance to show extent of participation and service delivery. PM01
2 Reference # PM4 PM5 PMSS1 Business Objectives BUSINESS OBJECTIVES Analyze Beneficiary enrollment, participation, and program usage to predict utilization trends. Maintain an efficient and effective management reporting process Add State-specific business objectives for the Program Management Reporting checklist here. Comments PM1 ANALYZE MEDICAID PROGRAM COSTS AND TRENDS TO PREDICT IMPACT OF POLICY CHANGES ON PROGRAMS PM1.1 PM1.2 PM1.3 PM1.4 PM1.5 PM1.6 Provides information to assist management in fiscal planning and control. Provides information required in the review and development of medical assistance policy and regulations. Prepares information to support the preparation of budget allocations for the fiscal year. Supports the projection of the cost of program services for future periods. Compares current cost with previous period cost to establish a frame of reference for analyzing current cash flow. Compares actual expenditures with budget to determine and support control of current and projected financial position. PM02
3 PM1 ANALYZE MEDICAID PROGRAM COSTS AND TRENDS TO PREDICT IMPACT OF POLICY CHANGES ON PROGRAMS PM1.7 PM1.8 PM1.9 PM1.10 PM1.11 PM1.12 PM1.13 PM1.14 Analyzes various areas of expenditure to determine areas of greatest cost. Provides data necessary to set and monitor rate-based reimbursement, e.g., institutional per diems and Managed Care Organization (MCO) capitation. Maintains provider, recipient, claims processing, and other data to support agency management reports and analyses. Provides counts of services based on meaningful units such as but not limited to: Service category (e.g., days, visits, units, prescriptions) Unduplicated claims Unduplicated beneficiaries Unduplicated providers Supports online real time summary information such as, but not limited to, number and type of providers, beneficiaries and services. Tracks claims processing financial activities and provides reports on current status of payments. Provides the capability to produce unduplicated counts within a type of service and in total by month. Reports the utilization and cost of services against benefit limitations. PM03
4 PM1 ANALYZE MEDICAID PROGRAM COSTS AND TRENDS TO PREDICT IMPACT OF POLICY CHANGES ON PROGRAMS PM1.15 PM1.16 PM1.17 PM1.18 Assists in determining reimbursement methodologies by providing expenditure data through service codes including: Healthcare Common Procedure Coding System (HCPCS), current version International Classification of Diseases (ICD), Clinical Modifier, current version National Drug Code (NDC), current version Produces an annual hospice report showing a comparison of hospice days versus inpatient days for each enrolled hospice Beneficiary and for all hospice providers. Analyzes break-even point between Medicare and Medicaid payments. Analyzes cost-effectiveness of managed care programs versus fee-for-service. PM1.19 Tracks impact of Medicare drug program. CFR PM1.20 PM1SS.1 Reports on any change from baseline for any program or policy change. Add State-specific criteria for this business objective here. PM04
5 PM2 MONITOR PAYMENT PROCESSES AND PREDICT TRENDS PM2.1 PM2.2 PM2.3 PM2.4 PM2.5 PM2.6 PM2.7 PM2.8 Reviews errors in claim and payment processing to determine areas for increased claims processing training and provider billing training. Provides claims processing and payment information by service category or provider type to analyze timely processing of provider claims according to requirements (standards) contained at 42 CFR Monitors third party avoidance and collections per State plan. Retains all information necessary to support State and Federal initiative reporting requirements. Provides access to information such as, but not limited to, paid amounts, outstanding amounts and adjustment amounts to be used for an analysis of timely reimbursement. Displays information on claims at any status or location such as, but not limited to, claims backlog, key entry backlog, pend file status, and other performance items. Identifies payments by type such as, but not limited to, abortions and sterilizations. Develops third party payment profiles to determine where program cost reductions might be achieved. PM05
6 PM2 MONITOR PAYMENT PROCESSES AND PREDICT TRENDS PM2.9 PM2.10 PM2SS.1 Maintains information on per diem rates, Diagnosis Related Groups (DRG), Resource Utilization Groups (RUG), and other prospective payment methodologies according to the State plan and monitors accumulated liability for deficit payments. Automatically alerts administration when significant change occurs in daily, weekly, or other time period payments. Add State-specific criteria for this business objective here. PM3 ANALYZE PROVIDER PERFORMANCE TO SHOW EXTENT OF PARTICIPATION AND SERVICE DELIVERY PM3.1 PM3.2 PM3.3 Reviews provider performance to determine the adequacy and extent of participation and service delivery. Reviews provider participation and analyzes provider service capacity in terms of Beneficiary access to health care. Analyzes timing of claims filing by provider to ensure good fiscal controls and statistical data. PM06
7 PM3 ANALYZE PROVIDER PERFORMANCE TO SHOW EXTENT OF PARTICIPATION AND SERVICE DELIVERY PM3.4 PM3.5 Provides access to information for each provider on payments to monitor trends in accounts payable such as, but not limited to, showing increases/decreases and cumulative year-to-date figures after each claims processing cycle. Produces information on liens and providers with credit balances. PM3.6 Produces provider participation analyses and summaries by different select criteria such as, but not limited to: Payments Services Types of services Beneficiary eligibility categories PM3.7 Provides information to assist auditors in reviewing provider costs and establishing a basis for cost settlements. PM3.8 Monitors individual provider payments. PM3SS.1 Add State-specific criteria for this business objective here. PM07
8 PM4- ANALYZE BENEFICIARY ENROLLMENT, PARTICIPATION AND PROGRAM USAGE TO PREDICT UTILIZATION TRENDS PM4.1 PM4.2 PM4.3 PM4.4 PM4.5 PM4.6 PM4.7 PM4.8 PM4.9 Reviews the utilization of services by various Beneficiary categories to determine the extent of participation and related cost. Analyzes progress in accreting eligible Medicare buy-in Beneficiaries. Supports analyses of data on individual drug usage. Presents geographic analysis of expenditures and Beneficiary participation. Provides Beneficiary data (including Long Term Care (LTC), Early Periodic Screening, Diagnosis and Treatment (EPSDT), and insurance information) for designated time periods. Summarizes expenditures, based on type of Federal expenditure and the eligibility and program of the Beneficiary. Provides eligibility and Beneficiary counts and trends by selected data elements such as, but not limited to, aid category, type of service, age and county. Provides Beneficiary enrollment and participation analysis and summary, showing utilization rates, payments and number of beneficiaries by eligibility category. Provides the ability to request information online and to properly categorize services based on benefit plan structure. PM08
9 PM4- ANALYZE BENEFICIARY ENROLLMENT, PARTICIPATION AND PROGRAM USAGE TO PREDICT UTILIZATION TRENDS PM4.10 PM4SS.1 Reports on dual eligibles pre and post Medicare Part D implementation. Add State-specific criteria for this business objective here. PM5 MAINTAIN AN EFFECTIVE AND EFFICIENT MANAGEMENT REPORTING PROCESS PM5.1 PM5.2 PM5.3 Supports report balancing and verification procedures. Maintains comprehensive list of standard PM reports and their intended use (business area supported). Maintains a list of users of each standard PM report. PM5.4 Maintains online access to at least four (4) years of selected management reports and five (5) years of annual reports. PM5.5 Meets State defined time frames and priorities for processing user requests. PM5SS.1 Add State-specific criteria for this business objective here. PM09
10 PMSS1 FIRST STATE-SPECIFIC OBJECTIVE PMSS1.1 Add criteria based on the APD, RFP, etc., that are relevant to this State-specific objective. PM10
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