AttachmentJ.1.BZPICUSOWAPPL-endAmendment1.doc

Medicare-Medicaid Data Match Program (Medi-Medi) Policies and Procedures Manual

K.L. MEDI-MEDI POLICIES AND PROCEDURES MANUAL

Medicare-Medicaid Data Match Program

(Medi-Medi)

Policies and Procedures Manual

August 20, 2007

Table of Contents 1Chapter 1.

Purpose and Background

11.1 Purpose of the Policies and Procedures Manual

11.2 Vision

11.3 Functional Statement

11.4 Definition of Fraud, Waste, and Abuse

11.4.1 Fraud

11.4.2 Waste

11.4.3 Abuse

11.5 Medi-Medi History

11.6 Contractual Structure

11.7 State References

1Chapter 2.

Roles and Responsibilities of Partners

12.1 State Medicaid Agency

12.2 Centers for Medicare & Medicaid Services (CMS)

12.3 Zone Program Integrity Contractor (ZPIC)

12.4 Law Enforcement Agencies

12.5 One Program Integrity System Integrator (OPISI)

12.6 Medi-Medi National Coordinator

1Chapter 3.

Implementing Medi-Medi

13.1 Implementation Process and Timeline

13.2 Project Initiation Meeting

13.2.1 Timing

13.2.2 Meeting Location

13.2.3 Attendees

13.2.4 Meeting Materials

13.2.5 Meeting Agenda Items / Decisions

13.2.6 Meeting Minutes

13.3 Project Management Plan

13.3.1 Develop Project Management Plan

13.3.2 Revise Project Management Plan

1Chapter 4.

Data Use Agreement (DUA)

14.1 Purpose of DUA

14.2 Executing a DUA

1Chapter 5.

Computer Matching Agreement

15.1 Purpose and Authority for the Computer Matching Agreement

15.2 The Global CMA

15.2.1 Timeline for the Original Global CMA

15.2.2 Development of the Original Global CMA

15.2.3 Renewal of the Original Global CMA

15.3 New States Joining Medi-Medi

1Chapter 6.

Joint Operating Agreement

16.1 Purpose of the Joint Operating Agreement

16.2 Instructions for Customizing the JOA

16.2.1 Section 1. Introduction

16.2.2 Section 2. Implementation

16.2.3 Section 3. Dispute Resolution

16.2.4 Section 4. Communications Plan

16.2.5 Section 5. Steering Committee

16.2.6 Section 6. Training and Information Sharing

16.2.7 Section 7. Connectivity and Data Sharing

16.2.8 Section 8. Data Matching

16.2.9 Section 9. Data Analysis

16.2.10 Section 10. Investigation and Referral

16.3 Process for Executing the Initial JOA

16.4 Annual Review of the JOA

16.5 Other Revisions to the JOA

1Chapter 7.

Program-Level Training and Information Sharing

17.1 Initial Formal Cross-Training

17.1.1

17.1.2 Format

17.1.3 Location and Logistics

17.1.4 Content

17.2 Project-Specific Training Sessions

17.2.1

17.2.2

17.2.3 Location and Logistics

17.2.4 Content

17.3 Subject-Matter Experts

17.3.1 Medicare Subject-Matter Experts

17.3.2 Medicaid Subject-Matter Experts

17.4 Co-Locate Staff

17.5 Sharing Documents

17.5.1 Methods for Sharing Documents

17.5.2 Documents to be Shared

17.5.3 Quality Control Process

17.6 Program Management Meetings

17.6.1 Timing

17.6.2 Agenda

17.6.3 Meeting Location

17.6.4

17.6.5

1Chapter 8.

State and Regional Steering Committees

18.1 Naming Protocols

18.2 Membership

18.2.1 Suggested Membership

18.2.2 Inviting Members

18.2.3 Leadership

18.2.4 Facilitation

18.2.5 Members’ Decision Making

18.2.6 Other Attendees

18.2.7 Changes in Membership

18.3 Initial Meeting

18.3.1 Timing and Purpose

18.3.2 Recommended Draft Agenda

18.3.3 Location

18.4 Medi-Medi Steering Committee Charter

18.4.1 Customizing and Ratifying the Initial Charter

18.4.2 Modifying the Charter

18.5 Regular Meetings

18.5.1 Frequency

18.5.2

18.5.3 Attendance

18.5.4 Meeting Logistics

18.5.5 Process for Creating the Agenda

18.5.6 Suggested Agenda

18.5.7

18.6 Other Regular Meetings

1Chapter 9.

Data Connectivity and Sharing

19.1 Medi-Medi Data Workgroup

19.2 Connectivity Process

19.2.1 Responsibility in States without One PI

19.2.2 Responsibility in States with One PI

19.3 Information Technology (IT) Plan

19.4 Connectivity

19.4.1 Connectivity Decisions in States Without One PI

19.4.2 Connectivity in States With One PI

19.4.3 Transitioning to One PI

19.5 Process for Establishing a T1 Line

19.6 Data Sources

19.6.1 Source Data Research

19.6.2 Examples of Data Sources

19.7 Data Dictionaries

19.7.1 Purpose of a Data Dictionary

19.7.2 Elements in a Data Dictionary

19.7.3 Other Guidelines

19.8 Data Cleansing and Validation

19.9 Security

1Chapter 10.

Data Matching

110.1 Data Matching Process

110.1.1 Responsibility in States without One PI

110.1.2 Responsibilities in States with One PI

110.2 Data Matching Protocol

110.3 Beneficiary Data Matching

110.3.1 Options for Data Matching

110.3.2 Beneficiary Cross-Reference File

110.4 Provider Data Matching

110.4.1 Options for Data Matching

110.4.2 Provider Cross-Reference File

110.5 Other Potential Cross-Reference Files

110.5.1 Drug Code Cross-Reference File

110.6 Data Matching Tools

1Chapter 11.

Data Analysis

111.1 Data Analysis Plan

111.2 Approaches to Data Analysis

111.2.1 Top Down Approach

111.2.2 Bottom-Up Approach

111.3 Data Analysis Projects

111.3.1 Routine Projects

111.3.2 Unique Projects

111.4 Tools for Conducting Data Analysis

111.4.1 Responsibilities in States without One PI

111.4.2 Responsibilities in States with One PI

111.4.3 Data Analysis Tools

111.5 Matched Data Reports

111.6 Cross Claims Analysis Catalog

1Chapter 12.

Fraud, Waste, and Abuse – Process Management

112.1 Definitions

112.1.1 Leads (“Initiation of an Issue”)

112.1.2 Investigations

112.1.3 Joint Investigations

112.1.4 Referral

112.1.5 Case

112.1.6 Joint Cases

112.2 Medi-Medi FWA Process

112.2.1 Overview

112.3 Initiation of an Issue

112.3.1 Leads

112.3.2 Investigations

112.3.3 Referrals

112.3.4 Referral Package

112.3.5 Law Enforcement Requests for Information

1Chapter 13.

Reporting

113.1 Tracking

113.2 Workload Reporting

113.3 Monthly Status Reports

113.4 Cross Claims Analysis Catalog

113.5 National Report

1Chapter 14.

National Collaboration

114.1 Document Sharing

114.2 Medi-Medi National Call

114.2.1 Frequency of Calls

114.2.2

114.2.3 Participants on the Medi-Medi National Call

114.2.4

114.2.5 Presentations

114.2.6 Minutes

114.3 Annual National Conference <Proposed>

114.3.1 Scheduling and Logistics

114.3.2 Participants

114.3.3

114.3.4

114.3.5 Minutes

114.3.6 Materials

1Chapter 15.

Medi-Medi Online Information Library

115.1 Accessing the Online Information Library

115.2 National Site

115.2.1 Maintaining the National Site

115.2.2 Process for Posting Documents

115.3 Program Sites

115.3.1 Create Program Website

115.3.2 Obtain Access to the Program Sites

115.3.3 Process for Posting Documents

Appendices 1Appendix A. Description of PPM Templates

1Appendix B. Joint Operating Agreement Template

1Appendix C. Project Management Plan Template

1Appendix D. Information Technology Plan Template

1Appendix E. Data Matching Protocol Template

1Appendix F. Data Analysis Plan Template

1Appendix G. Steering Committee Charter Template

1Appendix H. Information Packet

1Appendix I. Cross-Reference File Examples

1Appendix J. Data Matching and Analysis Tools

1Appendix L. Acronyms

Summary of Tables

1Table 1. State Medicaid Agency Suggested Activities.

1Table 2. CMS Roles and Responsibilities.

1Table 3. ZPIC Roles and Responsibilities.

1Table 4. Law Enforcement Roles and Responsibilities.

1Table 5. OPISI Roles and Responsibilities, where Applicable.

1Table 6. Required Implementation Activities.

1Table 7. Decision/Discussion Points for Project Initiation Meeting.

1Table 8 Summary of Documents to Be Shared

1Table 9. Steering Committee Representation.

1Table 10. Suggested Agenda Items for Initial Steering Committee Meeting

1Table 11. Draft Meeting Agenda Items for Regular Steering Committee Meetings.

1Table 12. Comparison of Transfer Mechanisms.

1Table 13. Medicare Data Sources.

1Table 14. Examples of Medicaid Data Sources.

1Table 15. Examples of Non-CMS Data Sources.

1Table 16. Documents Shared on National Site of the Medi-Medi Online Information Library.

1Table 17. List of ZPIC Deliverables

1Table 18. January 2007 NDC - HCPCS Crosswalk for Medicare Part B Drugs

Summary of Figures 1Figure 1. Pilot States

1Figure 2. FWA Case Development Process and Roles of Medi-Medi Partners

1Figure 3. Referral Process and Roles of Medi-Medi Partners.

Purpose and Background Purpose of the Policies and Procedures Manual This manual provides guidance to the Medicare-Medicaid Data Match Program (“Medi-Medi”) Zone Program Integrity Contractors (ZPICs), the Centers for Medicare & Medicaid Services (CMS), and state Medicaid agencies in implementing and operating a Medi-Medi program. The manual contains information about:

· Purpose and Background

· Roles and Responsibilities of Partners

· Implementing Medi-Medi

· Data Use Agreement

· Computer Matching Agreement

· Joint Operating Agreement

· Program-Level Training and Information Sharing

· State and Regional Steering Committees

· Data Connectivity and Sharing

· Data Matching

· Data Analysis

· Fraud, Waste, and Abuse – Process Management

· Reporting

· National Collaboration

· Medi-Medi Online Information Library This manual also includes several appendices, with templates and other information, which may be used by Medi-Medi partners in implementing and operating a program.

ZPICs shall adhere to the requirements in the Medicare Program Integrity Manual (PIM) , maintained by CMS. The PIM is referenced throughout this manual where its requirements apply to specific issues.

Parts of the Medi-Medi program are customizable, in order to allow maximum flexibility and in recognition of the uniqueness of each state Medicaid program. Medicaid programs are very different in each state. Beyond certain requirements, states have substantial flexibility to customize their Medicaid programs, including setting eligibility and service coverage rules, and determining how services are administered, such as through fee-for-service or managed care arrangements. State Medicaid programs also vary in terms of state agency structures and data management. Therefore, to be effective, ZPICs must have an understanding of how each state operates and maintains data.

State Medicaid agencies also differ in terms of their resource levels. States may experience state-level hiring freezes, which impact the state’s ability to commit staffing resources to Medi-Medi. Several states with high rates of fraud and abuse have been working collaboratively with federal and state law enforcement for years. Therefore, since communication channels are already established, the implementation of Medi-Medi in those states, in terms of communication and collaboration, should be easier.

Because of the differences between states, the partners in a given program are encouraged to actively collaborate on how to customize the program to fit the needs of all the partners, within the parameters allowed by the applicable laws, regulations, PIM requirements, and statement of work (SOW) requirements.

Vision The Medicare-Medicaid Data Match Program (Medi-Medi) is a partnership between Medicaid and Medicare that enhances collaboration and reduces fraud, waste, and abuse (FWA).

Functional Statement Medi-Medi is accomplished by matching Medicaid and Medicare data to identify improper billing and utilization patterns.

Medi-Medi includes state, regional, and national efforts and requires collaboration among state Medicaid agencies, CMS, and state and federal law enforcement officials.

Definition of Fraud, Waste, and Abuse ZPICs shall adhere to the definitions of fraud, waste, and abuse stated in the PIM (and presented below). It is important to note that state Medicaid agencies and Medicaid Fraud Control Units (MFCUs) in some states use different definitions. For example, in one state, the MFCU is restricted from investigating beneficiary fraud; therefore, the definition of fraud for the purpose of program integrity activities in that state does not include “beneficiaries” as it does for the ZPIC.

Fraud

The PIM defines fraud as the intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and the individual makes known that the deception could result in some unauthorized benefit to himself/herself or some other person.

The most common kinds of fraud are false statements and/or misinterpretations. The violators could be, but are not limited to, providers, beneficiaries, or employees of a provider.

Waste

<To be determined> Abuse

The PIM defines abuse as billing for services that are not covered or are not correctly coded.

Medi-Medi History Since 2001, CMS has implemented ten Medi-Medi pilot programs. The first state to be implemented was California. In the summer of 2003, six states were brought into the Medi-Medi program in the second phase: Pennsylvania, North Carolina, Texas, Florida, Illinois, and New Jersey. During 2004, two state programs, Ohio and Washington, were implemented. The final state, New York, was brought on board in the fall of 2005. Figure 1 illustrates the pilot states.

The Deficit Reduction Act (DRA) of 2005, enacted in February 2006, provided consistent funding for the expansion of Medi-Medi from a pilot program to a national program. However, the DRA does not mandate that state Medicaid agencies participate.

Figure 1. Pilot States

More information about the history of Medi-Medi and currently participating states is available on the Medi-Medi Online Information Library web site and the Information Packet in Appendix H

REF _Ref168377925 \h Error! Reference source not found..

<The address of the Medi-Medi Online Information Library will be added.> Contractual Structure CMS is responsible for contracting with a ZPIC to administer the Medi-Medi program in each state or region. The ZPIC is responsible for program integrity services for all Medicare claim types, including Parts A, B, C, and D, Regional Home Health Intermediary (RHHI), and Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), and Medi-Medi. The Medi-Medi program is one of the task orders for each of seven ZPICs (one ZPIC per zone). Each Medi-Medi task order will have a Medi-Medi government task leader (GTL). Each state and/or regional program will be a separate task on the relevant ZPICs’ Medi-Medi task order.

State References This manual refers to the “state Medicaid agency” as the partner to the Medi-Medi program. By state Medicaid agency, the PPM is referring to the single state agency responsible for Medicaid and/or the program integrity unit/organization responsible for investigating fraud, waste, and abuse in Medicaid. CMS recognizes that states have different structures and that the program lead from each state may be organizationally located in different areas of the state structure. Upon agreeing to partner, CMS will work with the state contact to assign the appropriate person or persons to oversee the program. If the program integrity function exists outside of the single state agency, CMS will encourage both the single state agency and the program integrity staff to be leaders in the Medi-Medi program.

This manual refers to the Medicaid Fraud Control Unit (MFCU) as the state-level law enforcement organization that will be invited to participate in the steering committee and to which state Medicaid agencies will refer cases. However, CMS recognizes that there are several states that have exemptions from the MFCU requirement and the law enforcement element is established in a different way. For ease of reference, the PPM uses MFCU, but recognizes that each state program may be different.

Roles and Responsibilities of Partners The success of the Medi-Medi program depends on the collaboration of multiple partners, including:

· State Medicaid agencies

· The Centers for Medicare & Medicaid Services (CMS)

· Zone Program Integrity Contractors (ZPICs)

· State and federal law enforcement agencies, including

· Medicaid Fraud Control Units (MFCU)

· The United States Department of Health and Human Services Office of the Inspector General (HHS/OIG)

· The Federal Bureau of Investigation (FBI)

· United States Attorney’s Office (USAO)

· One Program Integrity Systems Integrator (OPISI)

· Medi-Medi National Coordinator

The following sections provide information on the roles and responsibilities of each partner in supporting the Medi-Medi program. Refer to the information packet in Error! Reference source not found. for a chart summarizing the roles and responsibilities.

State Medicaid Agency The participation of the state Medicaid agency in Medi-Medi is optional. However, the benefits of the program, in terms of fraud, waste, and abuse identification and recovery, as well as enhanced collaboration are strong incentives for participation. Once a state Medicaid agency agrees to participate, there are certain activities that states are encouraged to complete. These activities support program success and positive outcomes. Each state will make decisions about which entities to involve in the process of implementing Medi-Medi based on current agency structure and how the state Medicaid agency decides to coordinate internally. Table 1 summarizes the suggested activities relevant to the state Medicaid agency.

Table 1. State Medicaid Agency Suggested Activities.

Implementation Activities

Appendix C

Appendix B

Ongoing Activities

* OPISI’s participation is applicable to states where One PI is implemented

Centers for Medicare & Medicaid Services (CMS) CMS is the federal agency that funds and administers the Medi-Medi program. CMS partners with state Medicaid agencies to cooperatively facilitate the program and contracts with ZPICs to administer the program. Table 2 summarizes the roles and responsibilities of CMS in Medi-Medi.

Table 2. CMS Roles and Responsibilities.

Implementation Activities

Ongoing Activities

* OPISI’s participation is applicable to states where One PI is implemented

Zone Program Integrity Contractor (ZPIC) The ZPIC is under contract to CMS to administer the Medi-Medi program. ZPICs shall collaborate with all of the partners and view both CMS and the state Medicaid agency as equal partners in the program. Table 3 summarizes the responsibilities of the ZPIC in the program.

Table 3. ZPIC Roles and Responsibilities.

Implementation Activities

Ongoing Activities

* OPISI’s participation is applicable to states where One PI is implemented

Law Enforcement Agencies It is not mandatory for law enforcement agencies to participate in the Medi-Medi program. However, the benefits of the program, in terms of fraud, waste, and abuse identification and recovery, as well as enhanced collaboration are strong incentives for participation. Once a law enforcement agency agrees to participate, there are certain resources that should be committed and activities that should be completed to support program success and positive outcomes. Table 4 summarizes the responsibilities relevant to the law enforcement agency.

Table 4. Law Enforcement Roles and Responsibilities.

Ongoing Activities

One Program Integrity System Integrator (OPISI) The One PI System Integrator (OPISI) is an organization contracted with and funded by CMS. It is charged with building and maintaining the One PI System. The One PI System consists of a database which houses Medicare and Medicaid data along with a portal which allows access to the data and contains tools to analyze the data. Table 5 lists the roles and responsibilities of OPISI in states where One PI is implemented.

Table 5. OPISI Roles and Responsibilities, where Applicable.

Implementation Activities

Ongoing Activities

Medi-Medi National Coordinator The Medi-Medi program requires national coordination in: providing assistance and training; compiling information on best practices, challenges, and outcomes; and facilitating information-sharing between state Medi-Medi programs and between partners within state Medi-Medi programs.

The National Coordinator’s primary functions include:

· Providing information and assistance;

· Maintaining a secure website to share program information; and

· Supporting national collaboration.

<Additional information on the National Coordinator will be added.>

Implementing Medi-Medi

· Participate in project initiation meeting

· Provide input to Project Management Plan

· Participate in project initiation meeting

· Collaborate with ZPIC on Project Management Plan

· Convene project initiation meeting

· Develop Project Management Plan

· Prepare all meeting agendas and minutes In states with One PI

· Participate in the project initiation meeting

· Provide input to the Project Management Plan

Implementation Process and Timeline The first step in establishing a Medi-Medi program is developing a partnership between CMS and the Medicaid agency in the relevant state (or states). Once the partnership is established, CMS initiates implementation by contracting with a ZPIC to administer the Medi-Medi state or regional program. The details of whether the program is for a single state or for a specific region will be described in the ZPIC’s statement of work (SOW). The Medi-Medi program is considered fully operational when all required implementation activities listed in Table 6 are complete.

There are a number of activities that must occur during implementation. Some activities may occur simultaneously, while other activities must occur consecutively. Table 6 summarizes the implementation steps and responsible parties. Information regarding the project initiation meeting and the Project Management Plan are provided in this chapter, as they only relate to the implementation period. Information regarding the remaining activities can be found in the sections shown in the last column of Table 6, as they are part of broader activities and responsibilities that recur throughout the life of the Medi-Medi program.

Table 6. Required Implementation Activities.

* OPISI’s participation is applicable to states where One PI is implemented

Implementation typically takes one year, though the timeframe varies depending on a number of factors, such as resource commitments and connectivity challenges. Suggestions for resource commitments and overcoming challenges are presented in the sections of the manual describing each of the implementation activities.

It is important to note that the ZPIC and the OPISI shall not engage in activities that may result in adverse actions against beneficiaries or providers until the CMA is executed. In other words, the ZPIC and the OPISI, as applicable, may receive and match Medicaid and Medicare data and the ZPIC may perform data analyses. However, the ZPIC shall not act on the results of the analyses; for example, the ZPIC shall not turn over matched data to the state Medicaid agency or law enforcement or take any adverse actions, such as conducting an investigation or medical review, until the CMA is signed.

State Medicaid agencies are encouraged to participate in the other implementation activities while awaiting the review and execution of the JOA. It is a best practice for state-level Medi-Medi programs to sign the JOA as soon as possible, as the JOA clarifies the working relationship between the state Medicaid agency and the ZPIC. However, it is at the discretion of the state Medicaid agency whether to participate in other implementation activities while awaiting the JOA.

Project Initiation Meeting The ZPIC shall convene separate project initiation meetings for each state program and, as applicable, regional programs. The project initiation meetings differ from the kickoff meetings, as kickoff meetings are between CMS and the ZPIC for the purposes of discussing the new contract. Project initiation meetings include the state Medicaid agency and OPISI, as applicable.

Timing The ZPIC shall convene the project initiation meeting in consultation with CMS, the state Medicaid agency, and OPISI, as applicable, as soon as possible after the contract award.

Meeting Location

The project initiation meeting shall be held in-person at the state Medicaid agency, if possible. If space is not available at the state agency, the meeting shall be held at location approved by the state Medicaid agency program lead.

Attendees

The CMS Government Task Leader (GTL) shall invite appropriate individuals to attend the project initiation meeting. At a minimum, the attendees of the project initiation meeting will include the following:

· The state Medicaid agency program lead;

· The ZPIC project manager;

· The CMS GTL; and

· The OPISI GTL.

It is expected that the discussion will include technical issues, such as connectivity; therefore, individuals with the appropriate technical knowledge should be included in the meeting.

Meeting Materials

The ZPIC shall prepare all materials for the project initiation meeting, and provide copies to all attendees. This includes, but is not limited to, the Project Management Plan and the Global CMA. As applicable, the ZPIC shall consult with OPISI for material content related to One PI.

Meeting Agenda Items / Decisions The ZPIC shall submit a draft meeting agenda to CMS, the state Medicaid agency, and OPISI prior to the meeting. After incorporating their comments, the ZPIC shall distribute the final meeting agenda to meeting participants. The meeting agenda should, at a minimum, include the items listed in Table 7.

At the conclusion of the meeting, specific decisions regarding implementation and operation of the program should be made. Table 7 summarizes the actions/decisions by agenda item.

Table 7. Decision/Discussion Points for Project Initiation Meeting.

I. Joint Operating Agreement

· Discuss the purpose of the JOA.

· Discuss procedure for state-level review of the JOA.

· Plan a separate meeting, via conference call or in person, between the state Medicaid agency, the ZPIC, and OPISI* to discuss each section of the JOA that is not addressed in the project initiation meeting.

· Provide an overview of the timeline for adding the state to the Global CMA.

· Discuss the state signature page and what can and cannot be added to that page.

· Discuss the procedure for state-level review of the CMA, including timelines and identification of management personnel that will need to sign the document.

· Present the proposed Project Management Plan.

· Plan a separate meeting, via conference call or in person, between the state Medicaid agency, the ZPIC, and OPISI* to tailor the plan to the state program and determine the timing of the activities in the Project Management Plan.

· Clarify the state-level of access to Medi-Medi (matched) data that is allowed.

· Discuss the source for Medicaid data.

· Discuss documentation sharing related to data sources.

· Make a preliminary decision on the best method for providing Medicaid data.

· Make a preliminary decision on whether and how the state Medicaid agency will access Medi-Medi (matched) data.

· Make a preliminary decision regarding the timing of the first steering committee meeting.

· Make a preliminary decision regarding the format and timing of the cross-training.

· Provide instructions for how to post documents to the online library.

· Agree on the types of information/documents that each partner will contribute.

* OPISI’s participation is applicable to states where One PI is implemented.

The ZPIC shall submit a draft of the meeting minutes to the CMS GTL, the state Medicaid agency program lead, and OPISI, as applicable. Comments from CMS, the state Medicaid agency, and OPISI shall be solicited. The ZPIC shall submit the final meeting minutes to CMS after incorporating comments from meeting participants. Upon CMS approval, the ZPIC shall distribute final meeting minutes to all meeting participants and post them to the Online Information Library (0, section 0).

Project Management Plan The purpose of the Project Management Plan is to define the steps and timeline for implementing Medi-Medi. The Project Management Plan should include the timeline, resources requirement, and responsible parties for each action item during Medi-Medi implementation and operation. The Project Management Plan template is available in Appendix C.

Develop Project Management Plan

The ZPIC shall customize the Project Management Plan template and present the plan to the state Medicaid agency during the project initiation meeting (the template is a guide). Based on the decisions made during the project initiation meeting and in collaboration with state Medicaid agency, the ZPIC shall revise the Project Management Plan.

After incorporating comments from CMS and the state Medicaid agency, the ZPIC shall submit the final Project Management Plan to CMS. The state Medicaid agency should indicate in writing (via email) to CMS that the final Project Management Plan is acceptable. CMS will not approve the final Project Management Plan before receiving the state Medicaid agency’s written notice indicating acceptance.

Revise Project Management Plan

The Project Management Plan should be revised, as necessary. The revised plan should be reviewed by the state Medicaid agency. CMS will not approve the revised Project Management Plans unless the state Medicaid agency submits written notice indicating acceptance.

Data Use Agreement (DUA)

· Review and approve DUA

· Obtain necessary signatures from CMS staff None

· Obtain the DUA form and instructions

· Complete the forms and obtain necessary signatures

· Forward completed form to CMS for approval None

Purpose of DUA The Data Use Agreement (DUA) is an agreement that must be executed prior to the disclosure of data from CMS’ Systems of Record to ensure that the disclosure will comply with the requirements of the Privacy Act, the Privacy Rule, and CMS data release policies. It must be completed prior to the release of, or access to, specified data files containing protected health information and individual identifiers.

If the ZPIC does not already have access to Medicare data, it shall complete a DUA in order to obtain access to Medicare data that will be used for Medi-Medi purposes. If the ZPIC already has a DUA and access to the needed Medicare data, a new request is not needed. However, an update is required should the ZPIC need to access Medicare data files not covered by an existing DUA.

Executing a DUA The DUA form and instructions may be obtained at:

http://www.cms.hhs.gov/cmsforms/downloads/cms-r-0235.pdf.

The ZPIC shall work with the CMS Medi-Medi GTL to obtain the necessary information to complete the form and obtain clearance from CMS.

<Details of the process for DUA request and update will be added.>

Computer Matching Agreement

· Negotiate original Global CMA

· Provide the Global CMA form and instructions to new programs

· Sign the Global CMA

· Provide details for the state signature page

· Obtain necessary signatures from the state Medicaid agency

· Forward completed form to CMS for approval

· Sign the Global CMA state signature page(s)

Purpose and Authority for the Computer Matching Agreement The Computer Matching Agreement (CMA) is a formal agreement between the state Medicaid agency and CMS. According to CMS’ Office of Information Services:

“The Computer Matching and Privacy Protection Act (CMPPA) of 1988 amended the Privacy Act (the Act) of 1974 ... to protect individuals’ rights to privacy in situations where there is a computerized comparison of two or more systems of records.”

The data matching occurring through the Medi-Medi program qualifies as a “matching program” because Medicaid and Medicare data are being matched for the purpose of identifying potential fraud, waste, and abuse, and the result of the matching may result in adverse action for the beneficiaries and/or providers. The CMA is required to detail the way in which the data will be shared and matched, and to provide notification to the public that a comparison is occurring that may result in adverse actions against individuals or organizations. CMS has a specific process for developing and approving CMAs. Medi-Medi utilizes a single Global CMA relevant to all state programs. 0, section 5.2 explains the development of the original Global CMA and the timeline for renewing the original Global CMA. 0, section 5.3 describes the process for adding new states participating in Medi-Medi to the Global CMA.

The Global CMA CMS developed a single Global CMA in an effort to streamline the CMA process for Medi-Medi. The original Global CMA was negotiated and executed with California. All other states that participate in Medi-Medi will “join” the Global CMA by adding a state signature page to the Global CMA. The state signature page is the only part of the Global CMA that can be customized. The remaining sections of the Global CMA have common language that is consistent for all states.

Timeline for the Original Global CMA

The Global CMA is effective for 18 months. It may be renewed for an additional 12 months. After the renewal period, the Global CMA must be renegotiated with the original state, California.

· Global CMA effective date: January 28, 2007

· Global CMA renewal date: June 28, 2008

· Global CMA sunset date: June 28, 2009

Development of the Original Global CMA

The process for developing the original Global CMA is summarized below. These are the same steps that will need to be taken when the original Global CMA must be redeveloped by June 28, 2009.

· CMS and California’s Department of Health Care Services (DHCS), the state agency that administers California’s Medicaid program, negotiated the Global CMA.

· CMS, DHCS, and the Program Safeguard Contractor (Medi-Medi contractor prior to ZPICs) signed the Global CMA.

· The CMS Office of Financial Management Program Integrity Group (OFM/PI) Director, the CMS Privacy Officer, and the CMS Chief Information Officer (CIO) approved and signed the Global CMA.

· The Department of Health and Human Services (HHS) Data Integrity Board (DIB) approved the Global CMA and the DIB Chair signed the Global CMA.

· The Global CMA was provided to Congress and the Office of Management and Budget for a 40-day review period.

· The Global CMA was published in the Federal Register for a 30-day comment period.

· The Global CMA became effective on <insert effective date>.

Renewal of the Original Global CMA

The Global CMA expires after 18 months. Three months prior to the expiration date of the Global CMA, the CMS Medi-Medi GTL will initiate the renewal process. The CMS Medi-Medi GTL will provide a copy of the necessary form to the state Medicaid agencies participating in Medi-Medi, the ZPICs, and OPISI within three months of the expiration of the Global CMA.

The ZPIC and OPISI shall sign the requested form to renew the Global CMA for each state. The state agencies will need to sign the requested form as well in order for Medi-Medi to continue in the state.

After the 12 month renewal period, the Global CMA must be reconsidered and reviewed using the process detailed in 0, section 0.

New States Joining Medi-Medi When a new state joins Medi-Medi, the state Medicaid agency must join the existing single Global CMA.

The CMS Medi-Medi GTL will discuss the contents and timeline for joining the Global CMA during the project initiation meeting. The CMS Medi-Medi GTL will provide an electronic copy of the Global CMA to the state Medicaid agency, the ZPIC, and OPISI, as applicable, as soon as possible once the project is initiated. The CMS Medi-Medi GTL will also provide the state Medicaid agency with assistance as needed.

The language in the Global CMA shall not be changed when adding a new state; however, the state signature page may be customized. The state Medicaid agency should review the Global CMA and either accept or reject the agreement in its entirety.

In order to participate in the Medi-Medi program, the state Medicaid agency must sign the Global CMA.

The state Medicaid agency program lead is responsible for obtaining the necessary signature from the state Medicaid agency for the signature page of the Global CMA.

Once the state signature page is signed by CMS, the state Medicaid agency, the ZPIC, and OPISI, as applicable, the agreement is effective for the state program.

It is important to note that the Global CMA timeline is relevant to all Medi-Medi programs, regardless of when the program was initiated or when each state Medicaid agency joined the Global CMA. There is only one Global CMA.

Joint Operating Agreement

· Provide technical guidance on the JOA customization

· Mediate disputes between the state Medicaid agency and the ZPIC

· Accept the JOA

· Provide input to the ZPIC on the JOA

· Provide written approval of the JOA

· Initiate ongoing reviews of the JOA, as appropriate

In all states

· Customize the JOA

· Solicit input from the state Medicaid agency

· Receive approval for the JOA from the state Medicaid agency

· Submit the JOA to CMS

· Post the JOA to the Online Information Library

· Facilitate annual and ongoing reviews and revisions of the JOA In states with One PI

· Solicit input from the OPISI

· Receive approval for the JOA from OPISI In states with One PI

· Provide input to the ZPIC on the JOA

· Provide written approval of the JOA

· Initiate ongoing reviews of the JOA

Purpose of the Joint Operating Agreement In general, much of the ZPICs’ activities are governed by CMS’ Program Integrity Manual (PIM) and the Medi-Medi Policies and Procedures Manual (PPM). However, the state Medicaid agency is not governed by the PIM. The Joint Operating Agreement (JOA) is an agreement between the state Medicaid agency and the ZPIC to establish guidelines, duties, and shared expectations of how each will conduct business with the other. The JOA will include any agreement between the state Medicaid agency and ZPIC on program implementation and operation that is not specified in this manual. CMS also has a role in mediating any disputes that may arise between the state Medicaid agency and the ZPIC, as well as giving technical guidance during the development of the JOA. In states where One PI is implemented, OPISI shall be involved in the development of the JOA.

Instructions for Customizing the JOA The JOA template is available in Appendix B

HYPERLINK \l "AppendixB" of this manual (the template is a guide). The following provides instructions on each section of the JOA.

The ZPIC shall customize the JOA template with input from the state Medicaid agency and OPISI, as applicable. The template is a guide and includes suggested language. The language may be changed at the agreement of the ZPIC and the state Medicaid agency.

Section 1. Introduction

This section describes the purpose of Medi-Medi and the JOA. It also describes how the JOA should be maintained and updated.

Section 2. Implementation

This section describes the overall implementation process and each party’s responsibilities. The section requires the ZPIC to include the steps for implementing Medi-Medi as part of the project management plan.

Section 3. Dispute Resolution

This section describes how disagreements between the ZPIC and the state Medicaid agency will be resolved. It is recommended that the disagreements be brought to the attention of the CMS GTL for assistance.

Section 4. Communications Plan

This section outlines the requirements for establishing points of contact at the ZPIC, state Medicaid agency, and OPISI, as applicable, and the regular meeting and work groups.

The ZPIC, the state Medicaid agency, and OPISI, as applicable, should establish points of contact to clarify communications between organizations. The JOA template provides suggestions of “leads” in the areas of the overall project, IT, data analysis, and investigations. The ZPIC, state Medicaid agency, and OPISI, as applicable, should revise and add to these roles as appropriate.

Section 5. Steering Committee

This section outlines the responsibilities of the ZPIC, the state Medicaid agency, and OPISI, as applicable, with respect to the steering committees. The ZPIC is responsible for steering committee logistics, including setting agendas and distributing minutes, while the state Medicaid agency serves as co-chair. Both parties and OPISI are active members of the committee.

Section 6. Training and Information Sharing

In this section, the ZPIC, the state Medicaid agency, and OPISI, as applicable, acknowledge that each party will provide training to the other party and share information with each other as needed. The way in which training shall be provided should be described.

Section 7. Connectivity and Data Sharing

This section outlines how the ZPIC, the state Medicaid agency, and OPISI, as applicable, will work together to share the necessary data. The material should be customized to show how connectivity will be established; e.g., T1 line. The section also describes the responsibilities for developing the IT Plan.

Section 8. Data Matching

This section defines the responsibilities of the ZPIC, the state Medicaid agency, and OPISI, as applicable, in data matching. It also describes the development of the Data Matching Protocol.

Section 9. Data Analysis

This section describes the development of a Data Analysis Plan and the process for prioritizing projects and sharing results.

Section 10. Investigation and Referral

This section describes the investigation and referral processes for joint investigations. The JOA clarifies the rules that the ZPIC and the state Medicaid agency must adhere to outside of the PIM and the PPM. It provides a forum for the partners to agree on how to work together on joint investigations.

Process for Executing the Initial JOA The ZPIC, the state Medicaid agency, and OPISI shall discuss the timeline and contents of the JOA during the project initiation meeting. Based on the results of this meeting, the ZPIC shall customize the JOA template collaboratively with the state Medicaid agency and OPISI. CMS will provide technical assistance on the customization on an as-needed basis.

If, after reasonable efforts by the ZPIC, there are issues that the state Medicaid agency, the ZPIC, and OPISI, as applicable, cannot agree upon, any of the parties may notify CMS of such issues. CMS will coordinate the disputes so that the implementation process is not delayed.

The ZPIC, the state Medicaid agency, and OPISI, as applicable, should agree to the content of the JOA, as it details how the partners will work together. The JOA is not a contract. Therefore, the state Medicaid agency is not required to provide signatures for the JOA. In place of signing the JOA, the state Medicaid agency can inform the ZPIC through an email or formal letter that the JOA accurately reflects how the parties will work together to implement and operate the Medi-Medi program.

The ZPIC shall distribute a copy of the final JOA to the state Medicaid agency program lead and the OPISI project lead, and post the JOA to the Medi-Medi Online Information Library (0, section 0). The state Medicaid agency program lead should disseminate the final JOA within the agency.

Annual Review of the JOA The ZPIC, the state Medicaid agency, and OPISI, as applicable, should review and revise the JOA at least annually.

The revised JOA should be approved by the ZPIC, the state Medicaid agency, and OPISI, as applicable, and be submitted to CMS by the ZPIC. Refer to 0, section 6.3 of this manual for instructions on dispute resolution and dissemination of the final JOA.

Other Revisions to the JOA The ZPIC, the state Medicaid agency, and OPISI may revise the JOA on an as-needed basis, as long as the changes are agreed upon by all parties in accordance with a process that all parties establish during implementation.

The ZPIC shall update the JOA on the Medi-Medi Online Information Library when there is a change to the JOA.

Program-Level Training and Information Sharing

· Share educational materials and maintain key documents that explain the agency’s program and operational environment

· Provide Medicare and Medicaid subject-matter experts as needed

· Provide data and policy background information about Medicaid to the ZPIC

· Provide project-specific information on Medicaid data and policies to the ZPIC

· Provide subject-matter experts to the ZPIC as needed

· Share educational materials and maintaining key documents that explain the agency’s program and operational environment

· Provide data and policy background information about Medicare to the state Medicaid agency

· Provide project-specific information on Medicare data and policies to the state Medicaid agency

· Provide subject-matter experts to the state Medicaid agency as needed

· Provide ZPIC staff to work onsite at the state Medicaid agency, as reasonable and appropriate, upon approval of the state Medicaid agency

· Share customized documents that guide the implementation and operation of each Medi-Medi program

· Share educational materials and maintaining key documents that explain the agency’s program and operational environment In states with One PI

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