Intake Form Guidance

Purpose

The Streamlined Modular Certification (SMC) process uses the Intake Form Template (please reach out to your State Officer to get the template) to track information about a state’s single Medicaid Enterprise Systems (MES) system(s) or module undergoing certification. States must complete the Intake Form by entering the CMS-required outcomes and metric ID, which demonstrate compliance with relevant regulations for their specific system or module. States must also include their state-specific outcomes and the metrics used to show that the project is achieving its outcomes on a continuous basis.

Using the Intake Form

CMS requires the state to use the Intake Form throughout the entirety of the SMC process—from the approval of the Advance Planning Document (APD) to the completion of the Certification Review (CR). Following approval of their APD, a state populates the Intake Form with all outcomes and conditions for enhanced funding (CEF) for the systems or module seeking certification, providing explanations in the applicable State ORR and CR Comments column for any instances where CEFs or CMS-required outcomes do not apply. Additionally, the state must also complete the Operational Report Workbook (ORW) with the metric definitions. During the ORR and CR, the CMS Certification Team will utilize the Intake Form to record their evaluation of the state’s demonstration of compliance with CEF and outcomes. The Intake Form becomes a part of the official record of the state’s certification, inclusive of the ORR and CR.

States must always use the most current version of the Intake Form and follow the instructions noted within the first row of each page. “Evidence” refers to documentation or data that demonstrates the achievement of an outcome or condition. When filling out the Intake Form, states should take note of the following:

The state must complete the “State ORR Evidence” and “State CR Evidence” columns for the applicable review. The state must list the filename of the evidence it will use to support CEF, outcomes, and metrics at the applicable review. The filename should match what was loaded to the CMS-designated repository. (For more information on the CMS-designated repository. If a CEF or CMS-required outcome is not applicable, the state must list N/A in these columns.
The state must complete the “State ORR Comments” and “State CR Comments” to justify why a CEF or outcome is not applicable and why it is not applicable (indicate what system is performing this function if not the system being certified). The state may include additional comments or descriptions of evidence listed in these columns. If narrative is included, it should explain how the evidence meets the criteria and any other information that is needed to further evaluate the outcome or CEF.

As states prepare for their review, they must continuously add or update the Intake Form content in preparation for submission for the review. States may wish to share these interim copies with their CMS MES State Officer or CMS Certification Team for discussion or preliminary feedback. The state must upload a finalized Intake Form to the CMS-designated repository at minimum two weeks before the review date along with all other required evidence for the ORR or CR. The CMS Certification Team will use this version during their evidence review. Following completion of the review, the Intake Form will be returned to the state with the CMS Certification Team’s adjudication and comments.

States are also expected to provide required artifacts for the CMS Certification Team review as defined in the SMC Guidance. Required artifacts are documents that describe the progression of a state’s project and are not typically used as evidence for outcomes.

Tips and Best Practices

The following sections provide tips and best practices for completing the CEF tab and Outcomes & Metrics tab of the Intake Form.

Conditions for Enhanced Funding Tab Instructions

The state will use this tab to demonstrate the Conditions for Enhanced Funding‘s (CEF’s) applicability and provide evidence for the system under review.

In the Evidence columns, list the file name(s) of documents containing supporting evidence as loaded in the CMS-designated repository. For lengthy documents, use the Comments column to specify relevant sections or paragraphs to assist the CMS Certification Team in the review process. If links to PDF files are included in the Intake Form, the corresponding PDF versions of any web file must also be uploaded to the CMS-designated repository for review.

In the Comments column, the state can also describe how the contents of the evidence files meet the condition and any other information needed for evaluation. CEF criteria do not require demonstrations. States can refer to the Conditions for Enhanced Funding for example, and/or required evidence.

All CEF criteria must be listed within the Intake Form. If a condition is not applicable, the state must mark “N/A” in the “State ORR Evidence” and “State CR Evidence” columns. The state must justify why the outcome is not applicable to their system in the “Comments” column for both the ORR and CR columns.

Outcomes & Metrics Tab Instructions

The state will use this tab to demonstrate evidence for the CMS-required outcomes and any state-specific outcomes for ORRs and CRs.

The MES Module Outcomes and Metrics section in the MES Certification Repository provides a complete listing of CMS-required outcomes for each specific MES module. CMS-required outcomes are aligned with statutory, regulatory, and policy requirements with which states must demonstrate compliance when implementing modules.

For a given module, states must include in the Intake Form all CMS-required outcomes for the module being certified, as listed in the MES Certification Repository, and the state must clearly indicate which outcomes are applicable. If a given outcome is inapplicable, the state should mark “N/A” for “Metric ID”, “State ORR Evidence”, and “State CR Evidence” columns. The state must include a justification of why the outcome is inapplicable to their system in the “State ORR Comments” and “State CR Comments” columns.

In the Evidence column, list the file name(s) of documents containing supporting evidence as loaded in the CMS-designated repository. For lengthy documents, states should specify relevant sections or paragraphs within the Comments column to assist the CMS Certification Team in the review process.

State-Specific Outcomes

State-specific outcomes reflect the unique goals and characteristics of a state’s Medicaid program and focus on improvements to the program not specifically addressed by the CMS-required outcomes. These outcomes should target specific business or policy problems that should be resolved with the implementation of the new system or module, and enable the state to demonstrate direct Medicaid program benefits. The metrics related to these outcomes should show how the states will measure their success. States should work with their CMS MES State Officer to finalize outcomes and metrics that address the proposed functionality.

Numbering Conventions for State-Specific Outcomes

States will create a unique reference number for their state-specific outcomes in the Intake Form. If the outcome is a state-specific outcome and not a CMS-required outcome, use the acronym “ST”, followed by the appropriate module abbreviation and the appropriate numerical code. For example, if State “A” provides a state-specific measure for its LTSS module, the first outcome reference number would be STLTSS01. Note that these reference numbers must match the Outcome Reference # column in the Operational Reporting Workbook. (Please reach out to your State Officer to get the template.)

The CMS MES State Officer is a valuable resource if states have questions or need additional clarification. Many states employ the best practice of requesting early input that may limit the amount of rework for the state and produce a more efficient review.

Required Artifacts Tab Instructions

The state will use this tab to identify the applicable required artifacts. It is important to distinguish between required artifacts and evidence. Evidence is documentation or data that proves the achievement of an outcome, as listed in the Intake Form on the Outcomes & Metrics tab. Required Artifacts, on the other hand, are documents that demonstrate the progression of a state’s project and are not typically used as evidence for outcomes. The SMC Guidance provides minimum requirements for each of the artifacts required for an Operational Readiness Review (ORR) and Certification Review (CR).

In the “State ORR Required Artifact” and “State CR Required Artifact” columns, list the file name(s) of the documents loaded in the applicable CMS-designated repository. As necessary, use the Comments column for any additional explanation or comments related to that artifact.

Resources

For more information on CEFs and Outcomes:

States can also find more details within the SMC Guidance, including additional details on:

Scope of Certification
SMC process
Required Artifacts List
Guidelines for the Independent Third-Party Security and Privacy Assessment for Medicaid Enterprise Systems