Decision Support System & Data Warehouse

How this system supports the Medicaid Program

The Decision Support System (DSS) / Data Warehouse (DW) business area covers software tools used by authorized State employees to extract and/or analyze Medicaid data in order to inform program decisions, policy decisions, and report on the delivery of the Medicaid Program.

CMS-Required Outcomes

Each CMS-Required outcome is based on statutory or regulatory requirements. CMS-Required Outcomes and Metrics are used to demonstrate that a system is compliant with the applicable federal regulations which pertain to that specific system or module. CMS-Required outcomes form the baseline for system/module functionality, which must continue to receive enhanced federal funding for operations.

Click here to download the CMS-Required outcomes in a CSV file

Reference #	CMS Required Outcomes	Default Metrics	Regulatory Sources
DSS/DW1	The system supports various business processes' reporting requirements	- Verify and validate the CMS annual report provisions from 431.428 (1) through 431.428 (11) are met annually.	42 CFR 431.428
DSS/DW2	The solution includes analytical and reporting capabilities to support key policy decision making	- Produce data-driven reporting on transaction data and performance to meet 433.112 (b) (15).	42 CFR 433.112

State-Specific Outcomes - CMS Approved

States requesting enhanced FFP for systems that fulfill state-specific program needs, beyond minimum legal requirements and the baseline of the CMS-required outcomes, should propose State-Specific Outcomes which address the proposed enhancements.

When drafting state-specific outcomes statements, keep these tips in mind.

Examples for Decision Support Systems & Data Warehouses

We are actively gathering and evaluating outcomes statements crafted by states for this business area.

Please send examples from your state that you’d like to share to MES@cms.hhs.gov. Our team will collect and share the best examples.

Click here to download the State-Specific outcomes in a CSV file

State	Medicaid Program Goal	Outcome Statement	Metric(s)
MO		Transform MHD from a transactional, request as needed data approach to a business intelligence driven model recognizing and treating data as an asset.	Performance will be measured by: - Conducting an initial data maturity analysis and prioritizing recommendations and review every two (2) years. - Establishing a Data Governance Council who is engaged and meets at a minimum of quarterly and has at least 60% participation as measured by attendence. - Appointing Data Stewards who meet a minimum bi-monthly as measured by meeting schedule and has recommendation for data definitions of at least three (3) per month.
MO		The Data Manager will monitor report writing performance and appropriate use of standards and perform analysis for future needs.	Performance will be measured by: -100% of reports are requested through Jira Service Desk within three (3) months of Go-Live of the entire solution. -80% of reports are approved as written in the first review within six (6) months of Go-Live of the entire solution. -Semi-annually management will review administrative dashboards for volume, timeliness, and accuracy. -One (1) addidtional data mart recommended annually. -Twelve additional reports are added to the schedule annually.
NE	Increase Efficiency	The system assists the state in monitoring quality and cost by alerting appropriate staff members when state-defined thresholds against state-defined metrics have been breached. (For example, the state has decided to monitor items such as managed care payments and controlled substance.)	The system supports various business processes' reporting requirements through quick data propagation and data query returns.
NE	Increase Data Quality and Utility	The system enables the SMA to comply with federal reporting requirements. These include, but are not necessarily limited to: - TMSIS (Transformed Medicaid Statistical Information System) - CMS 416 (EPSDT) - Statistical Enrollment Data System (SEDS) - Medicaid Administrative Reporting System (MRS)	The solution includes analytical and reporting capabilities, both ad hoc and predefined to support key policy decision making/use cases and various business processes' reporting requirements. Examples include the ability to generate predictive analytics, automated DMA reports, personalized dashboards and organizational favorites for MLTC executives and policy-makers and business area leads.
NE	Increase Data Quality and Utility	Data warehouse (DW) supports seamless inbound and/or outbound data sharing through data interfaces and appropriate standards including a broad set of data from required state and federal sources.	The system enables the SMA to comply with federal reporting requirements.
NE	Increase Data Quality and Utility	The data warehouse accurately maps data from the various data streams	Expand user base of Decision Support System (DSS) to support key policy decision making/use cases and various business processes' reporting requirements. The solution includes analytical and reporting capabilities, both ad hoc and predefined to support key policy decision making/use cases and various business processes' reporting requirements.
NE	Increase Data Quality and Utility	The system performs data quality checks on inbound data (formatting, completeness, duplication, etc.). It rejects erroneous data and notifies the data source so that the data can be corrected and re-submitted.	Extensible and scalable to maintain provider, recipient, claims processing, encounter, and other data to support agency management reports and analyses.
NE	Increase Data Quality and Utility	SMA has architected the data warehouse to be extensible and scalable in order to accommodate what the state has projected its future business needs to be.	Provide tools and services to guide informed decision making within the State to ensure optimal operational and policy decisions.
NE	Increase Data Quality and Utility	SMA has a data management strategy / plan that addresses current and future needs (e.g. data fields, elements, structure, reuse of data elements and de-duplication to enforce single version of truth).	The system processes encounters from all authorized channels in approved formats and validates that encounters include all required information (in correct formats e.g. standard code sets). The system rejects invalid encounters. It identifies errors, attaches pre-defined error code(s) to rejected / denied encounters, and communicates those errors to the Managed Care Entity.
NE	Increase Data Quality and Utility	The system maintains provider, recipient, claims processing, encounter, and reference data to support agency management reports and analyses.	SMA utilizes encounter records and system generated encounter processing reports for MCO performance and contractor monitoring.
NE	Increase Data Quality and Utility	SMA utilizes encounter records to monitor quality and cost of care provided to enrollees in managed care.	SMA utilizes automated case management and reports for fraud and abuse analysis and investigations. The system provides access to post payment data and flexibility to conduct ad hoc research for a case.
NE	Increase Automation of Program Integrity Activities	SMA utilizes automated case management and reports for fraud and abuse analysis and investigations.	SMA utilizes system generated reports to evaluate program trends and identify outliers in Provider billing practices and Member service utilization to identify potential utilization anomalies.
NE	Increase Automation of Program Integrity Activities	The system generates reports to evaluate program trends and identify outliers in Provider billing practices and Member service utilization to identify potential utilization anomalies.	SMA utilizes automated case management and reports for fraud and abuse analysis and investigations.
NE	Increase Automation of Program Integrity Activities	The system provides access to post payment data and flexibility to conduct ad hoc research for a case.	SMA utilizes automated case management and reports for fraud and abuse analysis and investigations.