Does the use CPEs? Yes No N/A I-2-c: Certifying Public When CPEs are made, does the waiver specify: Expenditures The state and/or local government agencies that certify the expenditures? Yes No The processes used to ensure that CPEs are based on total computable waiver costs? Yes No The processes to verify that the CPEs are eligible for federal financial participation? Yes No Do the billing validation methods address the three essential tests (below): I-2-d: Billing Validation The individual was eligible for Medicaid waiver payment on the date of Process service? Yes No The service was included in the participant’s approved service plan? Yes No; and The services were provided? Yes No No review required I-2-e: Billing and Claims Record Maintenance Requirement I-3: Payment Analyst Notes Are payments for all waiver services made through an approved MMIS? I-3-a: Methods of Payments -- Yes No MMIS If No, does the waiver specify: The processes that are used to make payment? Yes No How the processes ensure the maintenance of a proper trail? Yes No That providers may receive payment directly from the Medicaid agency? Yes No When payments for waiver services are made by a managed care entity or entities, does the waiver describe how the monthly capitated payments are made to the managed care entity or entities? Yes No N/A Does the Medicaid agency make payments directly to providers of waiver I-3-b: Direct Payment services? Yes No When a limited fiscal agent is employed, does the waiver specify: The entity or entities that as a limited fiscal agent? Yes No The payment functions performed by the limited fiscal agent? Yes No
I-2-c: Certifying Public Expenditures Does the use CPEs? Yes No N/A When CPEs are made, does the waiver specify: The state and/or local government agencies that certify the expenditures? Yes No The processes used to ensure that CPEs are based on total computable waiver costs? Yes No The processes to verify that the CPEs are eligible for federal financial participation? Yes No I-2-d: Billing Validation Process Do the billing validation methods address the three essential tests (below): The individual was eligible for Medicaid waiver payment on the date of service? Yes No The service was included in the participant’s approved service plan? Yes No; and The services were provided? Yes No I-2-e: Billing and Claims Record Maintenance Requirement No review required I-3: Payment Analyst Notes I-3-a: Methods of Payments -- MMIS Are payments for all waiver services made through an approved MMIS? Yes No If No, does the waiver specify: The processes that are used to make payment? Yes No How the processes ensure the maintenance of a proper trail? Yes No That providers may receive payment directly from the Medicaid agency? Yes No When payments for waiver services are made by a managed care entity or entities, does the waiver describe how the monthly capitated payments are made to the managed care entity or entities? Yes No N/A I-3-b: Direct Payment Does the Medicaid agency make payments directly to providers of waiver services? Yes No When a limited fiscal agent is employed, does the waiver specify: The entity or entities that as a limited fiscal agent? Yes No The payment functions performed by the limited fiscal agent? Yes No
CMSInstrumentforReviewingHCBSWaiverApplications-January2015.docx