[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR433.116]



[Page 92-93]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 433_STATE FISCAL ADMINISTRATION--Table of Contents

 

Subpart C_Mechanized Claims Processing and Information Retrieval Systems

 

Sec.  433.116  FFP for operation of mechanized claims processing and 



information retrieval systems.



    (a) Subject to 42 CFR 433.113(c), FFP is available at 75 percent of 

expenditures for operation of a mechanized claims processing and 

information retrieval system approved by CMS, from the first day of the 

calendar quarter after the date the system met the conditions of initial 

approval, as established by CMS (including a retroactive adjustment of 

FFP if necessary to provide the 75 percent rate beginning on the first 

day of that calendar quarter). Subject to 45 CFR 95.611(a), the State 

shall obtain prior written approval from CMS when it plans to acquire 

ADP equipment or services, when it anticipates the total acquisition 

costs will exceed thresholds, and meets other conditions of the subpart.

    (b) CMS will approve the system operation if the conditions 

specified in paragraphs (c) through (h) of this section are met.

    (c) The conditions of Sec.  433.112(b) (1) through (4) and (7) 

through (9), as periodically modified under Sec.  433.112(b)(2), must be 

met.

    (d) The system must have been operating continuously during the 

period for which FFP is claimed.

    (e) The system must provide individual notices, within 45 days of 

the payment of claims, to all or a sample group of the persons who 

received services under the plan.

    (f) The notice required by paragraph (e) of this section--

    (1) Must specify--

    (i) The service furnished;

    (ii) The name of the provider furnishing the service;

    (iii) The date on which the service was furnished; and

    (iv) The amount of the payment made under the plan for the service; 

and

    (2) Must not specify confidential services (as defined by the State) 

and must not be sent if the only service furnished was confidential.



[[Page 93]]



    (g) The system must provide both patient and provider profiles for 

program management and utilization review purposes.

    (h) If the State has a Medicaid fraud control unit certified under 

section 1903(q) of the Act and Sec.  455.300 of this chapter, the 

Medicaid agency must have procedures to assure that information on 

probable fraud or abuse that is obtained from, or developed by, the 

system is made available to that unit. (See Sec.  455.21 of this chapter 

for State plan requirements.)



[45 FR 14213, Mar. 5, 1980. Redesignated and amended at 50 FR 30847, 

July 30, 1985; 55 FR 4375, Feb. 7, 1990]