Precertification Pilot Overview

What Is the Precertification Pilot?

To accelerate the move toward modularity and reuse, and to facilitate lower risk, more cost-effective, and technically successful information technology (IT) solutions for Medicaid IT, the Centers for Medicare & Medicaid Services (CMS) envisions a program that permits vendors to submit modular, reusable Medicaid IT solutions for precertification. By previewing and assessing vendor solutions that meet core business function and technical criteria, CMS expects to reduce hurdles states face when procuring new technology, to increase opportunities for innovation in the solutions space, and to smooth certifications of state enterprise systems.

In October 2017, CMS launched a precertification pilot to determine the most effective approach to and process for precertifying modules. The pilot is scheduled to end in spring 2018, and coverage was limited to assessing Pharmacy and Provider Screening module solutions. The goals of the pilot were as follows:

  • Evaluate a minimum of two modules
  • Create a repeatable process
  • Assess the impact on the certification process
  • Actively engage the stakeholder community

It is important to note that pilot participation did not grant precertification to any of the piloted modules. Instead, pilot participants received a written report of the module assessment, which the participating vendors may distribute publicly.

Who Participated?

Vendors with experience in developing technology solutions were encouraged to participate. In return for their participation, pilot participants received early insight into the precertification approach. Participants also provided CMS feedback regarding the precertification process and helped refine the criteria used in evaluating modules.  

Six vendors participated in the pilot. The following modules were evaluated:

Pharmacy

  • Change Healthcare Pharmacy Solutions (CHPSI): Pharmacy Medicaid Service Product Line
  • Magellan Medicaid Administration, Inc.: Magellan RX Management
  • MedImpact Healthcare Systems, Inc.: MedImpact Pharmacy Base Management Platform
  • OptumInsight, Inc.: Pharmacy RX

Provider Screening 

  • CSRA State and Local: Transcend PE Provider Screening and Enrollment module
  • PegaSystems: Pega* 7 Platform with Pega’s Healthcare Industry Foundation and Customer Service for Healthcare Providers application
  • OptumInsight, Inc.: Provider Management Module

What Was Assessed?

Submitted modules were evaluated on specific requirements and demonstrated capabilities based on a subset of the Medicaid Enterprise Certification Toolkit (MECT) checklists, along with criteria for interoperability and open application programming interfaces. The evaluation criteria covered business functionality and technical aspects of either Pharmacy or Provider Screening modules. Vendors were assessed using the following checklists:

  • Either a Pharmacy or Provider Screening checklist
  • Access and Delivery
  • Information and Architecture
  • Integration and Utility
  • Intermediary and Interface
  • Standards and Conditions for Medicaid IT

The Precertification Checklists used in the pilot are available for download.

What's Next?

  • CMS will analyze pilot results
  • CMS will consider options for the future of the precertification program