Medicare-Medicaid Plan Care Coordination (MMPCC) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS) Program Audit Protocol and Data Request related to MMPCC. The CMS performs its program audit activities in accordance with the MMPCC Program Audit Data Request and applies compliance standards outlined in the Program Audit Protocol and the Program Audit Process Overview document. At a minimum, CMS will evaluate cases against the criteria listed below. CMS may review factors not specifically addressed below if it is determined that there are other related MMPCC requirements not being met.
Audit Elements Tested
- Care Coordination
Inovaare compiled these tables from information contained within the CMS website and displayed the 2022 audit protocol changes in an easy-to-follow format. The red font indicates critical areas health plans need to address and the blue font indicates the actual data required. This table is available for download through the link at the bottom of the page.
Table 1: MMPCC
| COLUMN ID | FIELD NAME | FIELD LENGTH | DESCRIPTION |
| A | Enrollee First Name | 50 CHAR | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 CHAR | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 CHAR | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 CHAR | Enter the contract number (e.g., H1234) of the organization in which the enrollee is currently part. |
| E | Plan Benefit Package (PBP) | 3 CHAR | Enter the PBP (e.g., 001). |
| F | First Tier, Downstream, and Related Entities (FDR) | 70 CHAR | FDRs assigned to the enrollee (e.g., Independent Physician Association, Physicians Medical Group or Third Party Administrator, any/all third party, downstream, or related organizations that the MMP contracts with in order to implement and/or manage the care). Enter NA if not applicable. |
| G | Enrollment Effective Date | 10 CHAR | Enter the effective date of the most current/continuous enrollment for the
enrollee with the MMP. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| H | Enrollee’s Initial Risk Stratification Level | 50 CHAR | Enter the enrollee’s initial risk stratification level in accordance with the risk stratification levels set forth in the applicable demonstration three-way contract. Enter NA if no risk stratification level has been assigned. |
| I | Date of enrollee initial risk stratification level | 10 CHAR | Date of the enrollee’s initial risk stratification level assignment. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter NA if no risk stratification level has been assigned. |
| J | Date of most recent HRA | 10 CHAR | Enter the date of the enrollee’s most recently completed HRA. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no HRA was completed (e.g., when enrollee refused the HRA or was unable to be reached). If only the Initial HRA has been completed this date should equal the Initial HRA date. |
| K | Date of previous HRA | 10 CHAR | Enter the date of the enrollee’s previously completed HRA. Submit in CCYY/MM/DD format (e.g., 2020/01/01). This is the date of the most recently completed HRA prior to the date entered in Column ID J. Enter None if another HRA was not completed (e.g., when enrollee refused the HRA or was unable to be reached). |
| L | Date Initial HRA (IHRA) was completed | 10 CHAR | Enter the date of the enrollee’s IHRA completion. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no IHRA or Medicaid assessment, if allowed, was completed within the required timeframe per the applicable demonstration three-way contract. |
| M | Enrollee Risk Stratification Level at time of audit engagement letter | 50 CHAR | Enter the enrollee risk stratification
level at time of the audit engagement letter. Enter None if no risk stratification level has been assigned. |
| N | Date of most recent Individualized Care Plan (ICP) | 10 CHAR | Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the MMP did not develop an ICP. If care plan is continuous, enter the date of the most recent update. |
| O | Was an Interdisciplinary Care Team (ICT) created/identified? | 1 CHAR | Enter Y
(for Yes) if the enrollee has an ICT assigned. Enter N (for No) if the enrollee does not have an assigned ICT. |
- Yellow: Audit Review Period
- Blue: valid values
Disclaimer: The data included in these tables are transposed directly from the CMS website and have not been edited for grammar and format consistency. Inovaare distilled the content for your convenience and educational purposes; it should not be used as a substitute for health plan compliance team authorization. Due to the unique needs of health plans, the reader should consult her or his compliance officer to determine the appropriateness of the information contained herein.