Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.
Frequently Asked Questions
Upon analysis by states, what if an edit is found to be in conflict with a state law or regulation, but is currently included within a National Correct Coding Initiative (NCCI) methodology?
CMS allows states to consider edits on an individual, state-by-state basis. If a state determines that an edit in the Medicaid NCCI methodologies conflicts with one or more state laws, regulations, administrative rules, or payment policies, the state can request permission from CMS to deactivate the conflicting edit. States are not afforded the flexibility to deactivate edits after March 31, 2011, due to a lack of operational readiness.
If a state determines and documents that there is no other feasible way to comply with Medicaid NCCI edits, the state can send a request to deactivate that edit or those individual edits using the NCCI mailbox at NCCIPTPMUE@cms.hhs.gov. The request must include sufficient primary source documentation of the conflicting state law, regulation, administrative rule, or payment policy. States are no longer required to send NCCI deactivation requests to CMS Regional Offices.
Care managers often do not document data elements in the assessment and care plan measures unless the member has "a problem." For example, they may not document that they assessed the member's vision or need for an assistive device if no problem was identified. How can states or plans address this issue?
Managed Long Term Services and Supports (MLTSS) plan managers should provide training on proper documentation practices to care managers and other delegated staff. States and MLTSS plans could consider including data field entry options to remind care managers to record all results of the assessment, even if findings are negative, that is, the member does not have a problem or need assistance or services. For example, states and plans could include a question in the member’s record that requires the care manager to document both whether an assessment was performed and whether a problem was identified, along with another required field to include the details of the problem if there was a problem identified.
How will the Medicaid Eligibility Quality Control (MEQC) program be realigned under the final regulation issued July 5, 2017?
As reconfigured under the final regulation of July 5, 2017, MEQC will work in conjunction with the Payment Error Rate Measurement (PERM) program. In those years when states undergo their triennial PERM reviews, the states will not conduct MEQC pilots. The latter will only be required in the two off-years between PERM review years. CMS has restructured the MEQC program so that it more effectively complements the PERM program and provides states with the necessary flexibility and opportunity to target specific problems or high-interest areas during the two off-years of the PERM cycle.
How does Medicaid Eligibility Quality Control (MEQC) differ from Payment Error Rate Measurement (PERM)?
The MEQC requirements on active case reviews generally mirror the requirements of the eligibility component of PERM reviews. The regulation requires that states perform reviews of a sample of active Medicaid and Children’s Health Insurance Program (CHIP) cases to identify new eligibility approvals and renewals that were made in error. As in PERM, states will be required to submit case-level reports on the sampled cases they review and corrective action plans that describe steps taken to remediate the errors found.
However, in contrast to PERM, when states identify errors in their active Medicaid and CHIP cases, they will be required to undertake a payment review. This will consist of a review of all claims paid over the first three months after an erroneous eligibility determination was made, and a summary of the overstated or understated liability. States will in turn be required to submit adjustments to the amount of federal financial participation (FFP) claimed through the CMS-64 reporting process for Medicaid and the CMS-21 reporting process for CHIP. The adjustments are required for identified claims in which too much or too little FFP was received. There is no payment review or re-crediting requirement in PERM, although disallowance of FFP can be taken in states whose PERM error rate exceeds the national threshold of 3% based on a formula described at 42 CFR 431.1010. MEQC contains no such disallowance provision.
The MEQC program also contains one other significant element that is not found in PERM. Besides the requirement that states review at least 400 cases in their active case universe (including a minimum of 200 cases), MEQC requires states to review at least 400 negative case actions. At least 200 of these must be Medicaid and 200 must be CHIP. Negative case actions involve erroneous denials of Medicaid or CHIP eligibility or erroneous terminations from Medicaid or CHIP. This is an area with no PERM counterpart in which states will be developing case-level reporting and corrective actions. Negative case action reviews will not be triggered by PERM findings. Largely for this reason, the regulation requires that states pull their sample of these from the entire Medicaid and CHIP universe of cases. By sampling from the full range of Medicaid and CHIP cases, states should be able to obtain an overview of those sectors in their programs that may be especially vulnerable to improper denials or terminations.
What was the traditional Medicaid Eligibility Quality Control (MEQC) program based on and how has it changed?
The traditional MEQC program at 42 CFR § 431.810 through 431.822 was originally designed to implement sections 1902(a)(4) “Administration Methods for Proper and Efficient Operation of the State Plan” and 1903(u) “Limitation of FFP for Erroneous Medical Assistance Expenditures” of the Social Security Act (the Act). The program required annual state reviews of Medicaid cases identified through a statistically valid statewide sample of cases selected from the state’s eligibility files. The reviews were conducted to determine whether the sampled cases meet applicable Medicaid eligibility requirements. The program evolved over time to allow states the option of selecting specific areas of focus within the Medicaid program for their annual MEQC reviews.
On July 5, 2017, CMS published a final regulation entitled “Changes to the Payment Error Rate Measurement (PERM) and Medicaid Eligibility Quality Control (MEQC) Programs (CMS-Medicaid Coordination of Benefits8- F).” This final rule updated the MEQC and PERM programs based on the changes to Medicaid and Children’s Health Insurance Program eligibility requirements under the Patient Protection and Affordable Care Act. The new regulation has restructured the MEQC program into an ongoing series of pilots that states are required to conduct during the two off-years between triennial PERM review years. The MEQC portions of the regulation are now covered by 42 CFR §§ 431.800-820.
What deliverables must states furnish to the Centers for Medicare & Medicaid Services (CMS) per the new Medicaid Eligibility Quality Control (MEQC) regulation?
The regulation requires states to submit a pilot planning document to CMS by November 1 of the year in which each state’s PERM review year ends. The pilot planning document must describe how states will conduct their active and negative case reviews and must be approved by CMS before the MEQC pilots can begin. In addition, the regulation requires states to submit case-level reports and corrective action plans to CMS by August 1 of the year after the MEQC review period ends. The specifications for the MEQC pilot planning documents are provided in the MEQC sub-regulatory guidance effective August 29, 2018. More details on the specifications of the case-level reports and corrective action plans are included in a second round of guidance, MEQC sub-regulatory guidance effective October 22, 2018.
Is there a simplified Payment Error Rate Measurement (PERM)/Medicaid Eligibility Quality Control (MEQC) timeline with milestone dates/cycles that can be provided to states (all cycles)?
The PERM/MEQC dates/cycles are as follows:
|PERM Cycle*||PERM Review Period||MEQC Planning Document Due to CMS||MEQC Review Period||MEQC Case-Level Report on Findings and CAP Due to CMS|
|Cycle 1||July 1, 2017 – June 30, 2018||November 1, 2018||January 1 – December 1, 2019||August 1, 2020|
|Cycle 2||July 1, 2018 – June 30, 2019||November 1, 2019||January 1 – December 1, 2020||August 1, 2021|
|Cycle 3||July 1, 2019 – June 30, 2020||November 1, 2020||January 1 – December 1, 2021||August 1, 2022|
CMS = Centers for Medicare & Medicaid Services
CAP = ??
What are National Correct Coding Initiative (NCCI) methodologies and are these methodologies compatible with the Medicaid program?
The NCCI methodologies are made up of the following four components:
- Sets of edits
- Definitions of types of claims subject to the edits
- Sets of claim-adjudication rules for applying the edits
- Sets of rules for addressing provider/supplier appeals of denied payments for services based on the edits
The NCCI methodologies include both NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs).
CMS issued SMDL #11-003 (PDF, 159.55 KB) on April 22, 2011, to state CMS policy on the requirement for appeals of claims for which payment was denied due to an NCCI edit. The nature of the appeals process in each state is left to the discretion of the state's Medicaid agency.
CMS currently has six methodologies for Medicare Part B. These methodologes are the following:
- NCCI PTP edits for practitioner and ambulatory surgical center (ASC) services
- NCCI PTP edits for outpatient services (including emergency department, observation, and hospital laboratory services) in hospitals reimbursed through the hospital outpatient prospective payment system (OPPS). Edits are applied to all facility therapy services billed to the Medicare Fiscal Intermediary (Part A Hospital / Part B Practitioner Medicare Administrative Contractors processing claims with the Fiscal Intermediary Shared System).
- MUE units-of-service edits for practitioner and ASC services
- MUE units-of-service edits for outpatient services in hospitals
- MUE units-of-service edits for supplier claims for durable medical equipment
- Add-on code edits for practitioner and ASC services (added in April 2013).
After review, CMS determined that the first five NCCI methodologies listed above were compatible methodologies for claims filed in Medicaid. A sixth methodology for Medicaid was added in 2012: NCCI PTP edits for Durable Medical Equipment (DME).
What National Correct Coding Initiative (NCCI) methodologies did CMS find that are not compatible with Medicaid and that are currently being utilized in the Medicare program?
CMS determined that the five NCCI methodologies that were in place in Medicare in 2010 were compatible methodologies for claims filed in Medicaid and that these five methodologies must be incorporated in a state's Medicaid Management Information System (MMIS) for provider claims filed on and after October 1, 2010.
CMS works with the NCCI contractor to identify specific edits within the five methodologies which need to be modified or deleted for Medicaid. Also, edits are developed for the Medicaid NCCI program for services and items that are not covered or not separately payable by Medicare. CMS found that most state MMISs could not accommodate the add-on code edits used in Medicare. Therefore CMS provides those edits to the states for optional use as state-specific edits.
Upon analysis by states, what if one or more edits are found that are necessary to improve correct coding within a state's Medicaid program, but are not currently included within an National Correct Coding Initiative (NCCI) methodology?
States are free to apply their own edits, in addition to the Medicaid NCCI edits, that meet the intent of the statute and would improve correct coding within their Medicaid programs. However, these state-specific edits should not be characterized as NCCI edits. If such state edits result in additional savings to the state's Medicaid program by promoting correct coding and reducing the error rate for claims payments, the state should recommend that CMS add these edits to one or more of the sets of Medicaid NCCI edits.