5 Administration and Number and/or percent of Data source: Reports to DOH operation: The State aggregated performance on delegated administrative Medicaid Agency (SMA) measure reports generated functions. retains ultimate authority by the MCO and reviewed by Data collection responsible and responsibility for the the DOH that contain party: MCO. operation of the waiver discovery, remediation, and Frequency of data collection: program by exercising system improvement for Monthly. oversight of the ongoing compliance of the Sampling: 100% review. performance of waiver assurances. Data aggregation responsible functions by contracted party: MCO. entities. Number and/or percent of Frequency of data aggregation MCO administrative and and analysis: Monthly. quality assurance reports approved by DOH prior to implementation by the MCO. 6 Financial accountability: The State provides Percent of providers who Data source: Routine Medicaid The DOH maintains evidence that claims are have payment recouped for claims verification audits. financial accountability coded and paid for in waiver services without Data collection responsible through payment of claims accordance with the supporting documentation. party: MCO. for services that are reimbursement Frequency of data collection: authorized and furnished to methodology specified in Continuously and ongoing. HCBS participants by the approved waiver and Sampling: 90% CI. qualified providers. only for services rendered. Data aggregation responsible party: MCO. The State must Frequency of data aggregation demonstrate that it has and analysis: Continuously and designed and implemented ongoing. an adequate system for Percent of claims verified Data source: MCO's compliance insuring financial through the MCO's report. accountability of the waiver compliance audit to have paid Data collection responsible program. in accordance with the party: MCO. participant's waiver treatment Frequency of data collection: Plan. Quarterly or Continuously and On-going. Sampling: 95% CI. Data aggregation responsible
5 Administration and operation: The State Medicaid Agency (SMA) retains ultimate authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by contracted entities. Number and/or percent of aggregated performance measure reports generated by the MCO and reviewed by the DOH that contain discovery, remediation, and system improvement for ongoing compliance of the assurances. Number and/or percent of MCO administrative and quality assurance reports approved by DOH prior to implementation by the MCO. Data source: Reports to DOH on delegated administrative functions. Data collection responsible party: MCO. Frequency of data collection: Monthly. Sampling: 100% review. Data aggregation responsible party: MCO. Frequency of data aggregation and analysis: Monthly. 6 Financial accountability: The DOH maintains financial accountability through payment of claims for services that are authorized and furnished to HCBS participants by qualified providers. The State must demonstrate that it has designed and implemented an adequate system for insuring financial accountability of the waiver program. The State provides evidence that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver and only for services rendered. Percent of providers who have payment recouped for waiver services without supporting documentation. Data source: Routine Medicaid claims verification audits. Data collection responsible party: MCO. Frequency of data collection: Continuously and ongoing. Sampling: 90% CI. Data aggregation responsible party: MCO. Frequency of data aggregation and analysis: Continuously and ongoing. Percent of claims verified through the MCO's compliance audit to have paid in accordance with the participant's waiver treatment Plan. Data source: MCO's compliance report. Data collection responsible party: MCO. Frequency of data collection: Quarterly or Continuously and On-going. Sampling: 95% CI. Data aggregation responsible