Financial Management

A system or subsystem that calculates FFS provider payment or recoupment amounts and initiates payment or recoupment action as appropriate. The system should also support appeals, capitation payments, and generates the data for timely and accurate financial reports.

CMS-Required Outcomes (9)

Ref	Outcome	Sources
FM1	The system calculates FFS provider payment or recoupment amounts, as well as value-based and alternative payment models (APM), correctly and initiates payment or recoupment action as appropriate.	42 CFR 433.139 42 CFR 447.20 42 CFR 447.45 42 CFR 447.56 42 CFR 447.272Section 1902(a)(37) of the Act
FM2	The system pays providers promptly via direct transfer and electronic remittance advice or by paper check and remittance advice if electronic means are not available.	42 CFR 447.45 42 CFR 447.46
FM3	The system supports the provider appeals by providing a financial history of the claim along with any adjustments to the provider's account resulting from an appeal.	42 CFR 431.152
FM4	The system accurately pays per member/per month capitation payments electronically in a timely fashion. Payments account for reconciliation of withholds, incentives, payment errors, beneficiary cost sharing, and any other term laid out in an MCO contract.	42 CFR 438 42 CFR 447.56(d)
FM5	The system accurately tallies recoupments by tracking repayments and amounts outstanding for individual transactions and in aggregate for a provider.	42 CFR 447
FM6	The state recovers third party liability (TPL) payments by: · Tracking individual TPL transactions, repayments, outstanding amounts due, · Aggregating by member, member type, provider, third party, and time period, · Alerting state recovery units when appropriate, and · Electronically transferring payments to the state.	42 CFR 433.139
FM7	The system processes drug rebates accurately and quickly.	42 CFR 447.509
FM8	State and federal entities receive timely and accurate financial reports (cost reporting, financial monitoring, and regulatory reporting), and record of all transactions according to state and federal accounting, transaction retention, and audit standards.	42 CFR 431.428 42 CFR 433.32
FM9	The system tracks that Medicaid premiums and cost sharing incurred by all individuals in the Medicaid household does not exceed an aggregate limit of five percent of the family's income. If the beneficiaries at risk of reaching the aggregate family limit, the system tracks each family's incurred premiums and cost sharing without relying on beneficiary documentation.	42 CFR 447.56(f)