[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: 42CFR438.242]



[Page 232]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

        Subpart D_Quality Assessment and Performance Improvement

 

Sec.  438.242  Health information systems.



    (a) General rule. The State must ensure, through its contracts, that 

each MCO and PIHP maintains a health information system that collects, 

analyzes, integrates, and reports data and can achieve the objectives of 

this subpart. The system must provide information on areas including, 

but not limited to, utilization, grievances and appeals, and 

disenrollments for other than loss of Medicaid eligibility.

    (b) Basic elements of a health information system. The State must 

require, at a minimum, that each MCO and PIHP comply with the following:

    (1) Collect data on enrollee and provider characteristics as 

specified by the State, and on services furnished to enrollees through 

an encounter data system or other methods as may be specified by the 

State.

    (2) Ensure that data received from providers is accurate and 

complete by--

    (i) Verifying the accuracy and timeliness of reported data;

    (ii) Screening the data for completeness, logic, and consistency; 

and

    (iii) Collecting service information in standardized formats to the 

extent feasible and appropriate.

    (3) Make all collected data available to the State and upon request 

to CMS, as required in this subpart.