Common use of MODEL MIS REQUIREMENTS Clause in Contracts

MODEL MIS REQUIREMENTS. 10.1.1 HMO must maintain an MIS that will provide support for all functions of HMO's processes and procedures related to the flow and use of data within HMO. The MIS must enable HMO to meet the requirements of this contract. The MIS must have the capacity and capability of capturing and utilizing various data elements to develop information for HMO administration. 10.1.2 HMO must maintain a claim retrieval service processing system that can identify date of receipt, action taken on all provider claims or encounters (i.e., paid, denied, other), and when any action was taken in real time. 10.1.3 HMO must have a system that can be adapted to the change in Business Practices/Policies within a short period of time. 10.1.4 HMO is required to submit and receive data as specified in this contract and HMO Encounter Data Submissions Manual. HMO must provide complete encounter data of all capitated services within the scope of services of the contract between HMO and TDH. Encounter data must follow the format, data elements and method of transmission specified in the contract and HMO Encounter Data Submissions Manual. HMO must submit encounter data, including adjustments to encounter data. The Encounter transmission will include all encounter data and encounter data adjustments processed by HMO for the previous month. Data quality validation will incorporate assessment standards developed jointly by HMO and TDH. Original records will be made available for inspection by TDH for validation purposes. Data which do not meet quality standards must be corrected and returned within a time period specified by TDH. 10.1.5 HMO must use the procedure codes, diagnosis codes, and other codes used for reporting encounters and fee-for-service claims in the most recent edition of the Medicaid Provider Procedures Manual or as otherwise directed by TDH. Any exceptions will be considered on a code-by-code basis after TDH receives written notice from HMO requesting an exception. HMO must also use the provider numbers as directed by TDH for both encounter and fee-for-service claims submissions. 10.1.6 HMO must have hardware, software, network and communications system with the capability and capacity to handle and operate all MIS subsystems. 10.1.7 HMO must notify TDH of any changes to HMO's MIS department dedicated to or supporting this contract by Phase I of Renewal Review. Any 1999 Renewal Contract Tarrant Service Area 101 August 9, 1999 102 updates to the organizational chart and the description of responsibilities must be provided to TDH at least 30 days prior to the effective date of the change. Official points of contact must be provided to TDH on an on-going basis. An Internet E-mail address must be provided for each point of contact. 10.1.8 HMO must operate and maintain a MIS that meets or exceeds the requirements outlined in the Model MIS Guidelines that follow: 10.1.8.1 The Contractor's system must be able to meet all eight MIS Model Guidelines as listed below. The eight subsystems are used in the Model MIS Requirements to identify specific functions or features required by HMO's MIS. These subsystems focus on the individual systems functions or capabilities to support the following operational and administrative areas: (1) Enrollment/Eligibility Subsystem (2) Provider Subsystem (3) Encounter/Claims Processing Subsystem (4) Financial Subsystem (5) Utilization/Quality Improvement Subsystem (6) Reporting Subsystem (7) Interface Subsystem

MODEL MIS REQUIREMENTS. 10.1.1 HMO must maintain an a MIS that will provide support for all functions of HMO's processes and procedures related to the flow and use of data within HMO. The MIS must enable HMO to meet the requirements of this contract. The MIS must have the capacity and capability of capturing and utilizing various data elements to develop information for HMO administration. 10.1.2 HMO must maintain a claim retrieval service processing system that can identify date of receipt, action taken on all provider claims or encounters (i.e., paid, denied, other), and when any action was taken in real time. 10.1.3 HMO must have a system that can be adapted to the change in Business Practices/Policies within a short period of time. 10.1.4 HMO is required to submit and receive data as specified in this contract and HMO Encounter Data Submissions Manual. HMO The MIS must provide complete encounter data of for all capitated services within the scope of services of the contract between HMO and TDH. Encounter data must follow the format, data elements and method of transmission specified in the contract and HMO Encounter Data Submissions Manual. HMO must submit encounter data, including adjustments to encounter data, by the 10th day of each month. The Encounter transmission will include all encounter data and encounter data adjustments processed by HMO for the previous month. Data quality validation will incorporate assessment standards developed jointly by HMO and TDH. Original records will be made available for inspection by TDH for Dallas Service Area Contract 86 validation purposes. Data which do does not meet quality standards must be corrected and returned within a time period specified by TDH. 10.1.5 HMO must use the procedure codes, diagnosis codes, and other codes used for reporting encounters and fee-for-service claims in the most recent edition of the Medicaid Provider Procedures Manual or as otherwise directed by TDH. Any exceptions will be considered on a code-by-code basis after TDH receives written notice from HMO requesting an exception. HMO must also use the provider numbers as directed by TDH for both encounter and fee-for-service claims submissionssubmission. 10.1.6 HMO must maintain accounting records for all claim payments, refunds and adjustments of payments to providers, and all premium payments, interest income and any administrative fees paid to Subcontractors for services under this contract. Provider payments for health or health related services must be reported separately from administrative payments. HMO must submit periodic reports and data to TDH as required by TDH. 10.1.7 HMO must have hardware, software, network and communications system with the capability and capacity to handle and operate all MIS subsystems. 10.1.7 10.1.8 HMO must notify TDH provide an organizational chart and description of any changes to responsibilities of HMO's MIS department dedicated to or supporting this contract Contract by Phase I of Renewal Readiness Review. Any 1999 Renewal Contract Tarrant Service Area 101 August 9, 1999 102 updates to the organizational chart and the description of responsibilities must be provided to TDH at least 30 days prior to the effective date of the change. Official points of contact must be provided to TDH on an on-going ongoing basis. An Internet E-mail address must be provided for each point of contact. 10.1.8 10.1.9 HMO must operate and maintain a MIS that meets or exceeds the requirements outlined in the Model MIS Guidelines that follow: 10.1.8.1 The Contractor's system must be able to meet all eight MIS Model Guidelines as listed below. The eight 10.1.9.1 Eight subsystems are used in the Model MIS Requirements to identify specific functions or features required by HMO's MIS. These subsystems focus on the individual systems functions or capabilities to support the following operational and administrative areas: (1) Enrollment/Eligibility Subsystem (2) Provider Subsystem (3) Encounter/Claims Processing Subsystem (4) Financial Subsystem (5) Utilization/Quality Improvement Subsystem (6) Reporting Subsystem (7) Interface Subsystem