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Medicaid Management Information System in Pennsylvania

November 17, 2021

Medicaid is a federal program that is managed and overseen by state governments. There are certain technological processes that allow state officials to automatically share information about Medicaid with their federal counterparts.

These requirements are important because they ensure that hospitals and health care providers treat Medicaid recipients in a manner that complies with the program's rules and regulations.

What is the Medicaid Management Information System?

Medicaid has a computer system that automatically gathers and processes data from each state's Medicaid program. This is known as the Medicaid Management Information System (MMIS).

In order to participate in Medicaid, every state has to use this system to provide details and documents that are related to the program.

In Pennsylvania, the Bureau of Data and Claims Managements (BDCM) is responsible for collecting these details and reporting them to the federal Medicaid program. To do so, the BDCM relies on the Provider Reimbursement and Operations Management Information System (PROMISe), which is the Keystone State’s equivalent of MMIS.

Medicaid Management Information System: Supported Functions

The MMIS can be used as follows:

  • To determine if a patient is eligible for Medicaid.
  • For authorizing and accepting claims.
  • Identifying any liabilities (such as unpaid medical debts) that a patient has.
  • Identifying providers' liabilities.
  • To process Medicaid enrollment applications.
  • Determining eligibility and access to certain benefits packages.

MMIS supports these very critical functions. Therefore, every state must verify that they have an efficient system that meets specific requirements.

What is the Medicaid Management Information System certification?

State agencies need to regularly inspect health care providers and confirm that they fully comply with Medicaid regulations.

This process is known as the MMIS certification. It is important because it ensures that hospitals and medical facilities are serving patients who are on Medicaid in a lawful and legally-compliant manner.

In Pennsylvania, health care providers submit documents and claims to PROMISe. In turn, PROMISe checks whether the transactions, forms, and other files abide by federal rules and digital readability requirements. After that, PROMISe will issue an MMIS certification.

When state governments want to certify health care facilities, they follow certification milestones that are based on an outline that the federal Department of Health and Human Services (HHS) established.

The first milestone entails planning and preparing for the certification process. The final one is concluded when the health care providers go over everything that's required and send their final report to the government.

Here is a list of the main systems and operations that medical facilities need to check:

  • Access and delivery (part of the technical architecture)
  • Care management
  • Decision support systems
  • FFS claims and adjudication
  • Ingratiation and utility (which is also part of the technical architecture)
  • Intermediary and interface (technical architecture)
  • Member enrollment
  • Pharmacy checklist
  • Program integrity
  • Provider management
  • Reference data management
  • Registries
  • Standards and conditions for Medicaid IT
  • Third party liabilities

Alternatively, states can create custom checklists that put the above items under different categories. In turn, they inspect every category separately.

For example, the access and delivery, integration and utility, and intermediary and interface processes typically fall under the 'Technical Architecture' category.

State governments typically publish these steps and categories on their websites.

BDCM Website

As mentioned earlier, Pennsylvania's BDCM oversees the state's MMIS operations and sends reports to the federal government.

Their website page (click here to view) goes over the state's reporting structure and how health care providers can submit their files, alongside other important details and information.

Just as with any other state, BDCM checks different functions (such as client eligibility, benefit packages, and others) based on state and/or federal milestones. Subsequently, they issue MMIS certifications to hospitals and facilities that abide by Medicaid requirements.

If you live in Pennsylvania, the easiest way to learn about BDCM's certification process is by visiting their website. In the same vein, residents of other states should check their local Medicaid office's website to find out more about how they comply with MMIS requirements.