7500.     INTRODUCTION

The primary objective of the Medicaid Eligibility Quality Control (MEQC) System is to eliminate or substantially reduce dollar losses resulting from eligibility errors. Information concerning a sample of Medicaid cases and the claims for services provided to members of those cases during selected review months is obtained, documented on worksheets, and summarized on the Integrated Review Schedule. (See §7599, Exhibit 1.)

Case findings are summarized on the review schedule and submitted in two parts: eligibility findings after completing the eligibility review and payment findings after completing the payment review. The Sample Completion Monitoring Subsystem section, Part X of the Integrated Quality Control Data Processing System (IQCDPS) Users Manual contains instructions for automatically generating eligibility findings. The Medicaid claims subsystem section, Part XIV of that manual, contains the instructions for generating payment findings.

The data link between IQCDPS and the HCFA Data Center was implemented in April 1987. Its purpose is to provide electronic transfer of Medicaid eligibility and payment findings which States record on the integrated review schedule and transmit through the IQCDPS. Findings transmitted to the IQCDPS are the official findings for MEQC error rate purposes. Manual disposition lists are no longer required.

ROs do not request subsample cases until paid claims findings or a disposition of dropped are submitted. As a general rule, once payment findings have been submitted in an acceptable form and have been subsampled by the RO, the findings may not be changed. Eligibility findings may be changed to correct data errors until payment findings or a disposition of dropped have been submitted and subjected to subsampling.

There are four exceptions. If you:

1.    Initially report a case as dropped and the Federal reviewers are able to complete the case, then change your eligibility findings to reflect the Federal findings or complete your own eligibility review and report that finding. If the Federal reviewers return the dropped case to you for completion, take all necessary actions to complete it and report the finding.

2.    Complete a case and submit a finding and the Federal re-review demonstrates that the case was listed in error, i.e., that the case was completed even though it was not within the scope of the survey, then revise your eligibility findings and drop the case.

3.    Report an AFDC-QC case as eligible and inadvertently report the same case an ineligible for Medicaid, then revise that finding provided the error was a transcription error and not a review error.

4.    Report an eligibility finding for a case which is subsequently overturned by a hearing decision issued by a State administrative law judge or hearing officer, then revise that original finding to reflect the decision.

For each exception, revise the payment findings, if necessary, to make them consistent with any changed eligibility findings. As an extension of this "no change" policy, the IQCDPS has certain protected fields which, once paid claims findings or a disposition of dropped are transmitted to the Kansas City

Computer Center (KCCC), may only be changed through intervention by the RO. The designated protected fields are disposition, initial case eligibility status, initial case liability error, final case eligibility status, dollar amount of paid claims, revised initial case liability error, final dollar amount of case liability error, and final dollar amount of case eligibility error. All other fields contained on the Review Schedule may be changed via retransmission to the KCCC.

The submission of Table V, Universe Data by Stratum and Substratum, is required to allow Federal processing of electronically transmitted State review findings. This table shows the number of Medicaid cases and dollars paid for Medicaid cases during each month of the review period. Table V is also used to report universe data concerning Medicaid payments to Supplemental Security Income (SSI) recipients in States where Medicaid eligibility determinations are made by the Federal government (1634 contract States) and Medicaid payments to individuals covered for foster care and adoption assistance under title IV-E of the Act. This additional payment universe information is used by HCFA to determine that portion of your Medicaid grant award which is not subject to adjustment of Federal financial participation (FFP) for withholding and/or disallowance purposes.

Submit Table V when available, but no later than 4 months after the close of each 6-month reporting period.

7505.     ANALYSIS OF REPORTED DATA

The MEQC system is based on a review of a statistically valid sample of Medicaid cases. The data collected through the review process is organized, processed, and analyzed to provide a clear and concise picture of the operations of the Medicaid program.

Thorough and accurate analyses are the basis for formulating corrective actions to effectively reduce error rates and misspent dollars. The State personnel responsible for data analysis use technical formulae and computations in the data analysis process. The analysis is presented to program managers in a form that helps them decide among alternative approaches to corrective action. There is a wide range of data available for analysis through the MEQC system. States may use a number of statistical techniques which are available for data analysis such as correlation, hypothesis testing, and chi-square testing. However, since it is beyond the scope of this manual to describe use of such techniques in detail, see existing literature on these subjects.

7510.     INSTRUCTIONS

Table V contains universe statistics used in weighting statistics and also provides payment universe information necessary to adjust FFP in the States' Medicaid grant awards.

7520.     TABLE INSTRUCTIONS - TABLE V

Table V displays universe data for each month of the review period. These data are not accumulated from Review Schedules but are counts developed by the State from the Medicaid universe. Enter the total number of Medicaid cases in each stratum or substratum and the total dollars paid out each month for all Medicaid cases in each stratum. The dollars paid in each stratum or substratum are those paid in the reporting period months which are associated with cases in each of the designated stratum groups. Include adjustments made in the month in the total dollar amount, except for cost settlement adjustments not attributable to individual cases. This table must include QMB cases and payments for the appropriate strata. Case and payment totals for QMB only and MAO/QMB dual eligible cases are reported in the MAO stratum; AFDC/QMB cases are included in the AFDC stratum; and SSI/QMB cases are included in the SSI stratum.

The major stratum code designations are:

1 -- Medical Assistance Only

2 -- Aid to Families with Dependent Children

3 -- Optional

4 -- Supplemental Security Income (1634 contract States only)

5 -- Foster Care and Adoption Assistance (title IV-E)

Report strata 4 (in 1634 contract States only) and 5 to allow for elimination of associated proportions of Medicaid dollars from consideration in withholding and disallowance determinations. Do not use these universe data in weighting sample estimates.

THIS SPACE RESERVED FOR FORM HCFA 309

TABLE V

MEDICAID ELIGIBILITY QUALITY CONTROL

UNIVERSE DATA BY STRATUM OR SUBSTRATUM

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INTEGRATED REVIEW SCHEDULE

EXHIBIT 1

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INTEGRATED REVIEW SCHEDULE

EXHIBIT 1(CONT.)

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INTEGRATED REVIEW SCHEDULE

EXHIBIT 1 (CONT.)

PAGE 3

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INTEGRATED REVIEW SCHEDULE

 EXHIBIT 1 (CONT.)

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