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Medicaid (Title XIX of the Social Security Act)
Collection, Creation and Use of Health Information


a.) Collection, Creation and Use of Health Information

The use and disclosure of health information must be restricted to purposes directly connected with plan administration.2  Every provider must agree to keep complete records of the services furnished to Medicaid enrollees and to provide such information to the state or Secretary upon request.3  Every provider must document in the medical record whether an enrollee patient has an advance directive.4  With regard to the transmission of data, states are required to operate a mechanized claims processing and information retrieval system to electronically transmit data (including individual enrollee encounter data),5 which must be capable of developing patient and provider profiles that provide information about the use of covered services and items.6

There must be a plan to evaluate the quality and appropriateness of the care and services furnished to Medicaid enrollees.7  The state must implement pre- and post-payment claims review procedures that include review of patient data and the nature of the provided service.8  The state must establish procedures for preventing unnecessary utilization of services and ensuring that payments are consistent with efficiency, economy and quality of care.9  These procedures must include a screen and review process10 for every inpatient admission11 and a requirement that provider hospitals maintain a utilization program12 that evaluates the medical necessity of all admissions, the duration of stays and any professional services provided in the hospital.13  If the state covers health home services, the plan must include methods for tracking avoidable hospital readmissions and calculating savings that result from improved care coordination and management.14



  • 2. Social Security Act §1902(a)(7)(A), 42 U.S.C. 1396a(a)(7)(A).
  • 3. Social Security Act § 1902(a)(27),  42 U.S.C. 1396a(27).
  • 4. Social Security Act § 1902(w)(1)(B), 42 U.S.C. 1396a(w)(1)(B).
  • 5. Social Security Act § 1903(r)(1), 42 U.S.C. 1396b(r)(1).
  • 6. Social Security Act § 1903(r)(2)(A), U.S.C. 1396b(r)(2)(A).
  • 7. Social Security Act § 1902(a)(33)(A), 42 U.S.C. 1396a(a)(33)(A).
  • 8. Social Security Act § 1902(a)(37)(B), 42 U.S.C. 1396a(a)(37)(B).
  • 9. Social Security Act § 1902(a)(30)(A), 42 U.S.C. 1396a(a)(30(A).
  • 10. Note: The screen and review process must be based on criteria established by independent medical professionals.  Social Security Act § 1902(a)(30)(B)(i), 42 U.S.C. 1396a(a)(30)(B)(i). 
  • 11. Social Security Act § 1902(a)(30)(B)(i), 42 U.S.C. 1396a(a)(30(B)(i).
  • 12. Social Security Act § 1903(i)(4), 42 U.S.C. 1396b(i)(4).
  • 13. Social Security Act § 1861(k)(1), 42 U.S.C. 1395x(k)(1) (available at
  • 14. Social Security Act § 1945, 42 U.S.C. 1396n (available at