Module 2: Form CMS-416 Overview

Module 2: Form CMS-416 Overview


Welcome to Module 2, an overview of the Form CMS-416 This module is part of the CMS web-based training for Form CMS-416 Dental Data Reporting. Please visit the CMS Web-Based Training homepage at Medicaid.gov to find links to modules covering additional topics. There, you will also find a document that contains links to all the resources mentioned in this module. For questions about the Form CMS-416 or the Oral Health Initiative, you can access the complete Form CMS-416 reporting instructions on Medicaid.gov, or email the EPSDT Technical Assistance Mailbox at [email protected] This module will cover several learning objectives and additional content related to Form CMS-416. After completing this module, you will: Know how to submit the Form CMS-416 and how to get help. You will understand the partners and processes involved with collecting and reporting Form CMS-416 data. And you will be familiar with the general principles of data quality. The content covered in this module includes: Logistics of Form CMS-416 submission. Sources of data used in Form CMS-416 reporting. And assessing and improving data quality. Let’s look at the Form CMS-416. The Form CMS-416 tracks utilization of Early and Periodic Screening, Diagnostic and Treatment services (or EPSDT services), such as well-child check-ups. You can see that the Form CMS-416 is divided into lines that track utilization of specific services, and columns that track utilization within specific age groups. Each line is also divided into categories of Medicaid and CHIP beneficiaries. We will go over these in more detail in the next few slides, as well as the other training modules available on Medicaid.gov. The Form CMS-416 is an annual report used by states to communicate important data about EPSDT service utilization in Medicaid and in those CHIP programs implemented as expansions of Medicaid. The Form CMS-416 is available online at Medicaid.gov. This form is an electronic Excel spreadsheet that is set up to perform certain arithmetic functions automatically. It cannot be modified by state users. Once each year, by April 1, states report data from the past federal fiscal year which runs from October through September. Data should be entered into the spreadsheet, as downloaded from Medicaid.gov, and submitted to CMS in the same format. The Form CMS-416 Instructions were updated in 2014 and are also available online at Medicaid.gov. Among other changes, states are now asked to include unduplicated, pending, and denied claims along with paid claims for the dental Lines. For information on changes affecting all Lines of the Form CMS-416, view the CMS December 11, 2014 Webinar Slides at Medicaid.gov. States can use the EPSDT Technical Assistance (or TA) Mailbox to: Submit the completed form. Submit the medical and dental periodicity schedules. Include a brief note, not to exceed 50 words, with the cover correspondence, explaining unique circumstances in the data being reported. And to request a 508 compliant version of the form. Federal fiscal year 2015 reporting, including data from October 1, 2014 through September 30, 2015, was due by April 1, 2016. Updated information about reporting periods and deadlines for the Form CMS-416 can be found on Medicaid.gov. Let’s talk more about the EPSDT TA Mailbox. The EPSDT TA Mailbox is the primary means of communication between states and CMS regarding the Form CMS-416. States may use the mailbox to ask questions and get technical assistance related to reporting EPSDT data. CMS staff with expertise in Form CMS-416 data manage this mailbox and will reply to your inquiries as soon as possible. You do not need to be a registered user to send emails to this mailbox. Let’s talk more about where Form CMS-416 data come from. There are two basic types of data included on Form CMS-416 reporting: Claims or Encounter data. And eligibility data. First, let’s discuss Claims and Encounter data. We will cover four questions related to claims and encounter data: Number one: what are Claims and Encounter data? Number two: how are the data collected? Number three: what are some common issues? And number four: how are the data used in the Form CMS-416? First, let’s talk about claims data. For Medicaid and CHIP agencies that administer benefits through fee-for-service plans, providers are paid after they submit a “claim” that details the services they provided. The extraction and aggregation of this information is referred to as claims data. Now let’s talk about encounter data. For Medicaid and CHIP agencies that administer benefits through Managed Care Organizations (or MCOs), the reimbursement structure is based on capitated payments to the plan for each insured Medicaid beneficiary, and MCOs report “encounters” that members have with their providers. Here, we’ll review how claims and encounter data are collected. A claim or encounter record is created every time a patient visits a provider. Follow the path of a claim or encounter record. Starting with Patients and Providers Claims and encounter data begin when a patient visits his or her medical provider and receives a service. Data are then shared with the patient’s insurer. In cases where Medicaid is the fee-for-service insurer, providers would report directly to Medicaid or its fiscal intermediary. These data will be in the form of “claims” or “encounters” depending on the type of insurer or provider. Next, the insurer aggregates the data across many patients and reports them to the state Medicaid agency or state data warehouse. Finally, these data are shared with CMS through mechanisms such as the Form CMS-416. Now let’s look at different types of Providers Several different types of providers can be involved with providing oral and dental health services to Medicaid enrollees. For the purposes of Form CMS-416 reporting, oral health services are services provided by a non-dentist provider. A “non-dentist provider” is any qualified health care practitioner who is neither a dentist nor providing services under the supervision of a dentist. Dental services are services provided by or under the supervision of a dentist. In addition to traditional dental practices, other types of dental and oral health service providers include Indian Health Service (or IHS), primary care providers, local health departments, federally qualified health centers (or FQHCs), school based health centers (or SBHCs), or rural health clinics. You can better manage and interpret data from these provider types if you understand some of their unique operational challenges. Some types of providers may submit records of patient visits a little bit differently. First, let’s look at the Indian Health Service Many Native American/American Indian who receive services through IHS are also enrolled in Medicaid and CHIP. However, those services may not be billed to Medicaid and thus not included in the 416 report. To remedy this, you may need to work with IHS facilities in your state to be sure they can, and do, bill Medicaid and CHIP for all services provided to Medicaid and CHIP enrolled children. Taking this step will also benefit the IHS because their programs will become more sustainable through the addition of Medicaid and CHIP reimbursement. The next provider type are Rural Health Clinics In many states, Rural Health Clinics do not report all procedure codes relevant to the dental visit in their claims. You may need to work with them to see if all relevant dental procedures can be reported. Now, let’s look at Federally Qualified Health Centers In many states, FQHCs do not report all procedure codes relevant to the dental visit in their claims. You may need to work with them to see if all relevant dental procedures can be reported. Some health departments provide dental and oral health services to high-need populations, frequently using funding from Title V block grants. Federal rules permit Medicaid agencies to reimburse Title V programs for providing these services to Medicaid enrollees, but approaches to documentation and reimbursement differ from state to state. You may need to work with your state’s public health agency to identify the best way to capture services paid by Medicaid. Finally, let’s look at School Based Health Centers School based health centers are organized and funded in different ways. Some are operated by FQHCs, while others are operated in cooperation with a hospital or local health department and some are funded by the school district. Like local health departments, sometimes they may be reimbursed by Medicaid but approaches to documentation and payment may differ. You may need to work with them to identify how to capture services paid by Medicaid. Here we will talk about Billing and Rendering Providers Claims and encounter files usually have fields for two types of providers: billing providers and rendering providers. Billing providers are providers who are being paid for the service. Rendering providers are those providers that actually performed the service. In dental data, this can come into play when one provider operates under the supervision of another provider: For example, a dental hygienist in a dental practice may apply fluoride varnish to a Medicaid enrollee’s teeth – and be listed as the rendering provider – but the claim would probably list the dentist who manages the practice as the billing provider. Make sure you understand how data are reported in these fields to avoid counting a claim twice. Let’s review the CMS Policy Eliminating the Free Care Rule Traditionally, Medicaid could not reimburse for services that would otherwise be provided without charge, such as by a school or local health department using other resources. In December 2014, CMS withdrew its previous guidance on “free care” and issued new guidance permitting Medicaid reimbursement for covered services in the state plan regardless of whether there is any charge for the service to the beneficiary or to others in the community. Federal financial participation is available for such services as long as all other Medicaid requirements are met. States will need to develop policies for this. Implementing this new policy could enable a state to report more dental and oral health services on the Form CMS-416. To view the new CMS policy guidance, please visit Medicaid.gov. But how will data from Form CMS-416 be used? Dental Claims and Encounter data are reported in Lines 12a through 12g of the Form CMS-416. These data can be used as a numerator for quality measures related to oral health. For example, Goal 1 of the Oral Health Initiative tracks the percentage of eligible children – or eligibles – that received a preventive dental service. The numerator for this metric comes from Line 12b of the Form CMS-416. This is also a measure in the Medicaid Child Core Set – known as PDENT. You can find the full list of measures and detailed specifications for the Medicaid Child Core Set on Medicaid.gov.If you’re wondering what is meant by “eligible children,” the Form CMS-416 instructions define “eligibles” as individuals under the age of 21 enrolled in Medicaid or a Children’s Health Insurance Program (or CHIP) Medicaid expansion program determined to be eligible for EPSDT services. You have completed the section on where Claims and Encounter data come from. Now let’s discuss Eligibility data. In this section, we will address the following four questions: Number one: what are Eligibility data? Number two: how are the data collected? Number three: what are some common issues with eligibility data? And number four: how are Eligibility data used in the Form CMS-416? Let’s review what eligibility data are. Eligibility data are information regarding the number of individuals who are both enrolled in a Medicaid or CHIP program and eligible for the EPSDT benefit. States are required to submit eligibility data on children enrolled in Medicaid and CHIP programs to CMS in a few ways in addition to the Form CMS-416, including beneficiary-level data and aggregated data. Beneficiary-level data are submitted through the Transformed Medicaid Statistical Information System (or TMSIS). States submit eligibility and claims program data to CMS through the TMSIS, including data on long-term care services, drugs, inpatient hospital stays and all other types of services. Additional aggregated data are submitted through the Statistical Enrollment Data System (or SEDS). States submit quarterly and annual enrollment data into SEDS for children covered through Medicaid, Medicaid expansion CHIP programs, and separate CHIP programs. Now let’s talk about where eligibility data come from. Eligibility data are created when patients enroll in a Medicaid or CHIP program. Important fields in eligibility data include beneficiary’s name, Medicaid ID number, date of birth, eligibility type, and date ranges of eligibility. When we say Eligibility Type, we are referring to two primary categories of eligibility for Medicaid and CHIP programs: categorically needy (which refers to eligibility categories defined in federal statutes as eligible for Medicaid services) and medically needy (which refers to the option states have to extend Medicaid eligibility to individuals whose income is too high to qualify for Medicaid, but who have high medical expenses). This information is covered in more depth in Module 3. When we talk about Date Ranges of Eligibility, we are referring to a state’s Medicaid data system, which will typically have fields that capture the beginning and end date for an individual’s eligibility. Analysts then use these fields to extrapolate an individual’s period of eligibility. Let’s follow the path of an eligibility record from patients to CMS. First we start at the Patient level. Eligibility data begin when an individual applies to a state Medicaid or CHIP program. Then, the record moves to Medicaid. Once the Medicaid and CHIP agency determines that an individual is eligible, it will create an eligibility record for that patient. Sometimes, the record will be shared with Insurers If an MCO is assigned to administer Medicaid services for an individual, the Medicaid and CHIP agency will also share the eligibility record with that MCO. Finally, the record goes to CMS. These data are aggregated and shared with CMS through mechanisms such as the Form CMS-416. It is important to understand some common issues that come up in eligibility data that can affect reporting on the Form CMS-416. Three common issues that can affect reporting included continuous enrollment, newborns and Medicaid IDs, and churn. First, let’s look at Continuous Enrollment If your state has adopted a 12-month continuous eligibility policy, this may simplify your process for calculating the subset of eligibles with at least 90 days of continuous eligibility – a critical metric on the Form CMS-416 (known as Line 1b). Please visit Medicaid.gov to learn more about continuous eligibility for Medicaid and CHIP coverage. The next area that can generate common reporting issues is Newborns and Medicaid IDs. Some Medicaid agencies temporarily assign a newborn the same Medicaid ID as her mother. Make sure you understand the timeline for these ID numbers to be adjusted to help with enrollee counts. The final major area of concern relating to reporting eligibility data is churn. Given the various options for health care coverage (Medicaid, CHIP, or a plan purchased through an exchange), families may switch coverage mid-year. This is known as “churning” between programs. Make sure to deduplicate enrollees across different programs by comparing multiple fields (such as name, date of birth, and address). Let’s review how eligibility data are used in Form CMS-416. Eligibility data are reported in Lines 1a and 1b of the Form CMS-416. These Lines can be used as denominators for several quality measures related to oral health. Recall that Goal 1 of the Oral Health Initiative tracks the percentage of eligibles that received a preventive dental service. The denominator for this metric is data from Line 1b of the Form CMS-416. Now, let’s review the importance of data quality. Knowing where your data come from is an important part of ensuring that your data are high quality, but there are several additional aspects of data quality to consider when reporting the Form CMS-416. It is important to be confident in the quality of your data. Otherwise, the data will have limited usefulness in monitoring activities, such as: Tracking changes or improvements over time (for example, OHI goals). Identifying “hotspots,” or gaps in care for specific populations. Or estimating the effect of policy changes on your population. Performing checks for each of the components of data quality will help ensure that your Form CMS-416 submission will meet the program requirements. The four primary elements of data quality are completeness, consistency, accuracy, and documentation. Completeness refers to the extent to which your dataset contains all the information needed. In reporting Form CMS-416 dental data, typical completeness checks include whether you’ve captured data from the full member population, all provider types, all delivery systems, all plans, all payment methodologies, and all services. Consistency refers to whether you apply consistent logic in assembling and calculating your information. In reporting Form CMS-416 data, consistency often comes into play when pulling claims that match the population that you are trying to represent. For example, if you run a query that identifies the pool of eligible Medicaid enrollees, it makes sense to run future queries calculating the services delivered using the same program that generated that initial pool of eligibles. Accuracy refers to how close your data are to representing reality. In reporting Form CMS-416 data, accuracy checks typically involve referencing other data or reports to help identify unexplained variation. And finally, documentation is how you explain the process for your data calculations, the structure of your data, and any manipulations you applied. In reporting Form CMS-416 data, documentation is critical to ensuring that your data can be understood, interpreted, and reproduced by any user. This diagram presents general guidance about how the components of data quality apply to Form CMS-416 reporting, and some common checks that can be done to increase your confidence in the quality of the data. More details about the data checks described below as well as how they apply to specific lines on the Form CMS-416 is provided in additional training videos available at Medicaid.gov. To ensure Completeness Make sure to check every section of the Form CMS-416 that is not “greyed” out to ensure all sections are populated. Ask yourself: Do the data you have represent the entire Medicaid and CHIP population that is eligible for the EPSDT benefit? What about all relevant providers, plans, services, and alternative payment methods? Next, we will look at Consistency Check the logic between Lines to be sure you are consistent with information across the Form CMS-416. Don’t forget to check your logic and results against reporting from the previous year. Next, we will look at reporting Accuracy One best practice for ensuring data accuracy is to conduct a Code Review. You could also consider engaging partners for their perspective on your data calculations. Lastly, look at reporting Documentation. Record inputs for future reference. And write cover correspondence if necessary. For information on how these components apply to specific dental data Lines in the Form CMS-416, you can access additional training modules on the CMS Web-Based Training homepage. Let’s review some additional suggestions for ensuring the quality of your Form CMS-416 data. When you are preparing the Form CMS-416 report, it can be helpful to check in with the people responsible in your state for submitting Transformed Medicaid Statistical Information System (or TMSIS) and Statistical Enrollment Data System (or SEDS) data to CMS. Comparing the logic used to compute EPSDT utilization and Medicaid population metrics for the Form CMS-416 with the TMSIS and SEDS logic and results can help ensure consistency and accuracy. Modules 3, 4, and 5 of this series also provide more detailed quality checks for each of the Form CMS-416 dental Lines. This chart lists several resources that can be useful for ensuring the quality of your Form CMS-416 data. Please visit Medicaid.gov to explore additional resources for quality data. Now, let’s talk about different partners and their involvement with EPSDT data reporting. There are usually several stakeholders and state agencies involved in some aspect of EPSDT benefit administration. Consider reaching out to some of the groups listed below for input on whether the “story” being told in the Form CMS-416 data reflects their experiences. Let’s review each of these partner types. First, let’s look at State Provider Associations. State provider associations can help you tune into issues providers are facing that may impact the accuracy of your data. For example, a state dental association could tell you that they’ve been getting a large volume of questions about a new service code, which may lead you to pay closer attention to how that service is captured in your claims and encounter data. Next, there are School-based Health Centers (or SBHCs). SBHCs often provide oral health services directly to Medicaid eligibles, but these services may not be reflected in claims. Reaching out to them can help you get a fuller picture of services received by eligibles. There are also the Dual Eligible Programs, Medicaid agencies, and CHIP Programs, which are responsible for administering the EPSDT benefit. State Primary Care Associations are also important partners. Primary care providers are often the first point of entry into the health care system for many Medicaid eligibles, and share information with their associations about patients’ unmet needs. This perspective can be helpful in validating your interpretation of your data. Another valuable source of information are Managed Care Plans. Managed care plans can help you understand how encounters are reported to make sure you’re capturing them correctly in your data. Title V agencies are also a useful resource. Title V agencies often provide oral health services directly to Medicaid eligibles, but these services may not be reflected in claims. Reaching out to them can help you get a fuller picture of services received by eligibles. Another knowledgeable stakeholder is your state’s WIC agency. States can use federal grant funds from the Special Supplemental Nutrition Program for Women, Infants, and Children (or WIC) program to connect low-income mothers and young children to health care services. Your state’s WIC agency may have a useful perspective on the unmet need for oral health care in low-income populations. Finally, it would be beneficial to connect with County Health Departments. County health departments may provide oral health services directly to Medicaid eligibles, but these services may not be reflected in claims. Reaching out to them can help you get a fuller picture of services received by eligibles. Now let’s think about partners in your area that impact EPSDT data reporting. Which organizations and programs would you engage to help validate your Form CMS-416 data? How would you work with them? Think about these partners and how they would participate in your data quality checks. Important partners to identify include key provider associations, CHIP agencies, Medicaid MCOs, Title V and Health Departments, and school based health centers. For example, you could reach out to key provider associations to share preliminary calculations of the PDENT measure to see if they have suggestions regarding interventions that could improve access to preventive dental health services for eligible children. Let’s review the Module 2 Summary. In this module, You learned how to submit the completed EPSDT Form CMS-416 to CMS. You learned that EPSDT data are comprised of Encounter/Claims Data and Eligibility Data. You were introduced to common issues in reporting Encounter/Claims Data and Eligibility Data. You learned that data quality consists of four components: consistency, completeness, accuracy and documentation. You learned that there are several stakeholders you can involve in the data validation process – consider using them as resources to check the quality of your data. And finally, you learned that in order to best improve the quality of your data it is important to verify all four components of quality data. Congratulations! You have completed Module 2: Form CMS-416 Overview. To access Module 3, other training modules, and relevant Form CMS-416 resources, please visit Medicaid.gov to find links to modules covering additional topics For questions about the Form CMS-416 or the Oral Health Initiative, access the complete Form CMS-416 reporting instructions on Medicaid.gov, or email the EPSDT Technical Assistance Mailbox at [email protected]

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