MEDICAID PROGRAM INTEGRITY MANUAL 
CHAPTER 2  Collaboration with States 
 
Table of Contents 
    (Rev. 11948, Issued: 04-13-23) 
 
Transmittals for Chapter 2 
 
2.0  State Collaboration Purpose 
2.1  Implementing Collaboration with States 
  2.1.1  Implementation Process and Timeline 
  2.1.2  Initial State Collaboration Meeting 
  2.1.3  Information Exchange Agreement (IEA) 
  2.1.4  Joint Operating Agreement (JOA) 
  2.1.5  Program-Level Training and Information Sharing 
  2.1.6  Initial Formal Cross-Training 
2.2  Ongoing Collaboration with States   
  2.2.1  Program Management Meetings or Monthly Collaboration Meetings 
    2.0 - State Collaboration Purpose 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
 
The purpose of collaboration between the state Medicaid agency (SMA) and the UPIC is 
to identify state priorities, specialty areas of analytical and investigative interest, 
clarification of state policy, and to ensure there is no duplication of efforts. 
 
All leads and any new providers that the UPIC determines warrant further investigation 
shall be vetted concurrently through the SMA and CMS for approval before transitioning 
to an investigation. The UPIC shall provide the state a list of potential investigations 
generated by the data analysis, complaints, referrals, etc. If the state is conducting an 
audit or investigation of the same provider for similar Medicaid issues, CMS may cancel 
or postpone the UPIC investigation of the provider. Through this information exchange, 
CMS avoids duplicating the efforts of other Medicaid audits and investigations. 
 
Collaboration between the SMA and the UPIC may differ from state to state. While some 
states may prefer the term investigation, other states may prefer the term audit or 
review. State preference in regards to the review of Medicaid claims shall be discussed 
at the onset of the collaboration, and continue throughout the investigative and/or audit 
process. 
  
The scope and execution of program integrity activities varies by state. CMS recognizes 
that states have different structures and that the program lead from each state may be 
located in different areas of the state organizational structure. If the program integrity 
function exists outside of a single state agency, CMS will encourage both the single state 
agency and the program integrity staff to collaborate on program activities.   State 
entities that may be involved in the program integrity oversight includes the SMAs, 
Medicaid fiscal agents, Medicaid Fraud Control Units (MFCUs), State Attorneys 
General offices, and other agencies with program integrity missions, such as Medicaid 
Inspector General and State Comptroller offices. 
 
States are critical partners in stewardship of the public trust and are strongly committed 
to ensuring the accuracy of Medicaid payments and detection/prevention of fraud, waste, 
and abuse. States are required to establish and maintain program integrity activities, 
which meet federal requirements and which coordinate with federal program integrity 
efforts. 
 
 
 
 
 
 
 
  2.1 - Implementing Collaboration with States  
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
The success of the UPICs is dependent on the collaboration of all parties involved, i.e. 
CMS, SMA, and the UPIC.  This section will outline some of the steps necessary for 
implementing collaboration with the states in order for the UPIC to begin program 
integrity activities in their jurisdiction. 
 
2.1.1 - Implementation Process and Timeline 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
 
The first step in establishing an effective program is developing a partnership between 
CMS, the UPIC, and the relevant SMA. Step 2 is to document the state preferred, and 
CMS agreed upon, process for conducting investigations in that state via a Joint 
Operating Agreement (JOA).  JOAs will be initiated between each state partner and shall 
only be viable for the state as set forth in the JOA. However, with the consensus of all 
participating states, the UPIC may initiate jurisdictional program integrity projects to 
detect fraud schemes across at least two neighboring SMAs.  
 
Several activities must occur during implementation. Some activities may occur 
simultaneously, while other activities must occur consecutively. The list below 
summarizes the steps the UPIC will take when initiating collaboration with a state.    
 
a)  Convene the Initial State Collaboration Meeting 
b)  Maintain Information Exchange Agreement, if required 
c)  Develop the Joint Operating Agreement  
d)  Provide initial cross-training  
e)  Begin document sharing  
f)  Establish exchange of other sources of Medicaid data, as needed  
 
2.1.2 - Initial State Collaboration Meeting  
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
 
The UPIC shall convene separate Initial State Collaboration Meetings for each state 
program and, as applicable, jurisdictional programs. These initial meetings differ from 
kickoff meetings, as kickoff meetings are between CMS and the UPIC for the purposes of 
discussing the new contract. The Initial State Collaboration meetings include SMAs. 
 
a.  Timing 
  The Initial State Collaboration Meeting shall be held no later than 30 
calendar days after the beginning of the implementation phase of the 
contract or after the SMA agrees to collaboration. 
 
b.  Meeting Location 
 
The Initial State Collaboration Meeting shall be held in-person at the 
SMA, if possible. If space is not available at the state agency, the meeting 
shall be held at a location agreed upon between the UPIC and the SMA 
program lead.  In addition, if face-to-face contact is prohibited for public 
health reasons, other telephonic communication, such as Zoom, may be 
utilized. 
 
c.  Attendees 
 
The UPIC Program Director, or designee, shall invite appropriate 
individuals to attend the Initial State Collaboration Meeting. At a 
minimum, the attendees of the initial meeting will include the following:   
 
  State Medicaid program integrity unit lead(s), 
  UPIC Medicaid Operations Lead, 
  CMS CORs and BFLs, and 
  CMS One PI, CPI/DASG and Office of Technical Solutions 
representatives. (It is expected that the discussion at the initial 
meeting will include technical issues such as connectivity; 
therefore, individuals with the appropriate technical knowledge 
should be included in the meeting.) 
 
d.  Meeting Agenda and Other Materials 
 
The UPIC shall prepare all materials for the Initial State Collaboration 
Meeting and provide copies to all attendees, including the JOA. 
 
Prior to the meeting, the UPIC should prepare and distribute a meeting 
agenda to all participants. The meeting agenda should, at a minimum, 
include the items identified in Table 2.A. for discussion.  At the conclusion 
of the meeting, specific decisions regarding implementation and operation 
of the program should be made.  
 
Table 2.A: Decision/Discussion Points for the Initial State Collaboration 
Meeting  Agenda Item  Decisions/Discussion Points 
Joint Operating    Discuss the purpose of the JOA.  
Agreement    Discuss procedure for state-level review of the JOA.  
 
  Plan a separate meeting, via conference call or in person, 
between the SMA, and the UPIC to discuss each section of the 
JOA that is not addressed in the Initial State Collaboration 
Meeting.  
Data sources    Provide an overview of the sources of Medicare and Medicaid 
data. 
  Clarify the state-level of access to matched data that is 
allowed.  
  Discuss the source and structure of Medicaid data. 
  Discuss documentation sharing related to data sources.  
Data    Provide the options for the state to provide Medicaid data to 
connectivity  CMS via the UPIC. 
and 
  Make a preliminary decision on the best method for providing 
transmission 
Medicaid data. 
  Notify the SMA on how it will request and access matched 
data. The states are prohibited from provider data for 
Medicare only providers. 
Training and    Discuss the importance of training early in the program and 
information  provide options for initial, formal cross-training.  
sharing 
  Make a preliminary decision regarding the format and timing 
of the cross-training.  
 
e.  Meeting Minutes 
 
The UPIC shall submit a draft of the meeting minutes to the CMS COR, 
BFL, and the SMA program lead for review and approval.  The UPIC shall 
submit the final meeting minutes to CMS after incorporating comments 
from meeting participants Meeting minutes should conclude action 
items to identify deliverables that were agreed upon for the next meeting. 
Upon CMS approval, the UPIC shall distribute final meeting minutes to all 
meeting participants. 
   
2.1.3 - Information Exchange Agreement (IEA) 
 (Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
 
When a state chooses to partner with the UPIC, a JOA between the state and UPIC is 
required. However, in various states (as referenced in the decision tree below), an 
Information Exchange Agreement may remain in place until expiration or renewal as 
needed.  If the SMA request that the IEA be renewed, the current version of the IEA can 
be found in the Appendices.     
A.  IEA Decision Tree 
 
The UPICs shall coordinate data exchanges with their states according to the flowchart 
below. 
 
    If you are working with the state, use this decision tree.  If not, use the flowchart if/when 
you begin working with the state. 
 
 
   
100% Reliant on TMSIS 
for PI Purposes? 
 
(No need to access state 
   
Yes     
No 
*If IEA is already in place, keep as is. 
 
 
Once expired, no need to renew. If the 
Is IEA already in 
state has issues with not renewing,    place?  
engage CMS. 
   
If ever the data is not 100% TMSIS, go 
 
back to top of decision tree. 
  Yes 
Keep IEA in place 
 
No  until 100% TMSIS, 
Is the state asking you to  or transition to 
 
sign additional  updated JOA 
  agreements (i.e. MOU,  (referenced in the 
BAA, etc.)  Appendices ). 
 
 
No  Yes  Is the state 
 
Is a JOA in place? If  Is the UPIC  requiring any 
 
not, engage CMS to  willing to sign  additional 
 
explain how the UPIC is  agreements?  agreements (i.e. 
 
obtaining data from the    )  
 
state.  
 
 
Yes  No 
  No  Yes 
Has the  No 
  Engage CMS  Upon signing, 
UPIC or is  further 
  no additional 
the UPIC  action 
  action 
willing to  needed 
  needed. 
sign 
 
agreements?  
 
No  Yes 
 
Engage  Upon signing, no 
 
CMS  additional action 
 
needed 
 
 
    2.1.4 - Joint Operating Agreement (JOA) 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
 
a.  Purpose of the JOA 
 
In general, much of the UPICs activities are governed by CMS Task 
Order Statement of Work (TO SOW), the Medicaid PIM, and the Medicare 
PIM.  However, the SMA is not governed by the PIM. The JOA is an 
agreement between the SMA and the UPIC that establishes guidelines, 
duties, and shared expectations of how each will conduct business with the 
other. The JOA will include any agreement between the SMA and the 
UPIC on program implementation and operation that is not specified in 
this manual or the TO SOW. CMS also has a role in mediating any 
disputes that may arise between the SMA and the UPIC during the 
creation of the JOA, and it will provide technical guidance regarding the 
JOA.  
 
The template for the JOA can be found at Appendix J.. 
 
b.  JOA Template and Instructions for Customizing the JOA 
 
The UPIC shall customize the JOA template with input from the SMA. The 
template is a guide and includes suggested language, which may be 
changed pending the agreement of the UPIC and the SMA.  SMAs are 
encouraged to participate in other implementation activities while 
awaiting the review and execution of the JOA.  However, it is at the 
discretion of the SMA whether to participate in other implementation 
activities while awaiting the JOA. It is a best practice for the SMA to sign 
the JOA as soon as possible as the JOA clarifies the working relationship 
between the SMA and the UPIC. 
 
The following provides a summary for each section of the JOA: 
 
Section 1. Introduction 
 
This section describes the purpose of the coordination and the JOA. It also 
describes how the JOA should be maintained and updated. 
  
Section 2. Implementation 
 
This section describes the overall implementation process and each 
partys responsibilities.  
 
Section 3. Dispute Resolution  
  This section describes how disagreements between the UPIC and the SMA 
will be resolved. It is recommended that disagreements be brought to the 
attention of the COR/BFL team for assistance. 
  
Section 4. Communications Plan  
 
This section outlines the requirements for establishing points of contact at 
the UPIC and SMA, regular meetings, and work groups. The UPIC and 
the SMA should establish points of contact to clarify communications 
between organizations. The JOA template suggests the creation of leads 
in the areas of the overall project, IT, data analysis, and investigations. 
The UPIC and SMA, as applicable, should revise and add to these roles as 
appropriate. 
  
Section 5. Training and Information Sharing 
 
In this section, the UPIC and the SMA acknowledge that each party will 
provide training to the other party and share information with each other 
as needed. The way in which training shall be provided should also be 
described in this section. 
  
Section 6. Connectivity and Data Sharing, if applicable 
 
This section outlines how the UPIC and the SMA will work together to 
share the necessary data. Due to the nature of this content, section 6.5 
Security shall not be edited and/or revised by either the SMA or the UPIC.  
  
Section 7. Data Analysis  
   
This section describes the development of a Data Analysis Project 
Management Strategy and the process for prioritizing projects and 
sharing results. 
  
Section 8. Investigations and Referrals  
 
This section describes the investigation and referral processes for joint 
investigations. The JOA clarifies the rules outside of the PIM to which the 
UPIC and the SMA must adhere. It provides a forum through which the 
partners can agree on how to work together on joint investigations. 
 
c.  Process for Executing the Initial JOA 
   
The UPIC and the SMA shall discuss the timeline and contents of the JOA 
during the Initial State Collaboration Meeting. Based on the results of this 
meeting, the UPIC shall customize the JOA template (Appendix J) 
collaboratively with the SMA and submit to CMS for approval. CMS will  provide technical assistance on the customization as needed.  If, after 
reasonable efforts by the UPIC, there are issues that the SMA and the 
UPIC cannot agree upon, either of the parties may notify CMS. CMS will 
coordinate resolutions of the disputes so that the implementation process 
is not delayed. 
 
The UPIC and the SMA should agree to the content of the JOA, as it 
details how the partners will work together. The JOA is not a contract. 
Therefore, the SMA is not required to provide signatures for the JOA. In 
place of signing the JOA, the SMA can inform the UPIC through an e-mail 
or formal letter that the JOA accurately reflects how the parties will work 
together to implement and operate the coordinated efforts. 
 
The UPIC shall distribute a copy of the final JOA to the SMA. The SMA 
lead should disseminate the final JOA within the agency.   
 
d.  Annual Review of the JOA 
   
The UPIC and the SMA should review and revise the JOA at least 
annually.   The revised JOA should be approved by the UPIC and the SMA 
and be submitted to CMS by the UPIC.  
 
e.  Other Revisions to the JOA 
 
The UPIC and the SMA may revise the JOA on an as-needed basis, as 
long as the changes are agreed upon by both parties in accordance with a 
process that both parties establish during implementation. 
  
2.1.5 - Program-Level Training and Information Sharing 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
 
The success of the collaborative efforts in Medicaid program integrity depends on 
effective communication, information sharing, and training among partners. This section 
focuses on the training and information sharing opportunities and requirements within 
state and regional program integrity efforts. 
 
Below are the responsibilities of the UPIC in regards to training and information 
sharing: 
    
  Provide data and policy background information about Medicare to the 
SMA. 
  Provide project-specific information about Medicare data and policies to 
the SMA. 
  Provide subject-matter experts to the SMA as needed.    Share customized documents that guide the implementation and operation of 
each states program.  
  Share educational materials and maintain key documents that explain the 
agencys program and operational environment. 
 
2.1.6 - Initial Formal Cross-Training  
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
During the implementation of a new state or regional program, partners are encouraged 
to participate in an initial, broad-level training session that outlines the major data 
elements and the policies and procedures of both Medicare and Medicaid. This event will 
serve to build a foundation of understanding between partners providing a general idea 
of how each program works.  
 
The UPIC shall provide Medicare training to the SMA staff, if requested, and the SMA is 
encouraged to provide reciprocal training on Medicaid. This initial training will be 
discussed at the Initial State Collaboration Meeting and will be coordinated between the 
UPIC Manager and the SMA program leads. Together, the UPIC Manager and the SMA 
program lead will decide on the appropriate location, format, and dates for training.  
 
Should the SMA decline to participate in or provide cross-training, the UPIC Manager 
shall inform the CMS COR/BFL. The UPIC shall organize all formal training events 
upon the request of the SMA program lead. 
 
a.  Attendees 
The SMA, the UPIC and One PI representatives (for discussions on data, 
connectivity and access) shall attend the initial training session. 
  
b.  Format 
Outside of a Public Health Emergency (PHE), it is recommended that the 
initial training session occur in person.  Virtual training may be used in 
lieu of in-person training for the convenience of all parties.  Options for 
the format include multiple sessions of training spread out over a period 
of time or a multi-day retreat. For follow-up sessions, virtual training is 
recommended.  The UPIC Manager and the SMA will determine which 
format is most appropriate.  
 
c.  Location and Logistics 
For in-person training, the initial training should be held at the SMA if 
there is conference space available. If there is no conference space 
available, the UPIC shall arrange for a site that is acceptable to the SMA 
program lead.  
  d.  Content  
Training should be focused on two main componentspolicy and data. 
The SMA and the UPIC Medicaid Operations Lead shall work together to 
determine the agenda items for training.  
 
The CMS COR/BFL will provide the UPIC with a presentation that gives 
an overview of national Medicare policy for use in the training session. 
However, the UPIC may produce a custom presentation tailored to the 
needs of the program, as appropriate. The UPIC will also encourage the 
SMA to provide materials for training which are customized or from 
existing training efforts.  
 
The data portion of the training should include guidance on how the data 
systems are established and updated.  
 
2.2 - Ongoing Collaboration with States 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
 
Once the UPIC has established a working relationship with the SMA, the UPIC will need 
to continue ongoing communication and collaboration.  This ongoing collaboration will 
be conducted via the Program Management Meeting or Monthly Collaboration Meeting. 
 
2.2.1 - Program Management Meetings or Monthly Collaboration 
Meetings 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
  
UPICs shall facilitate additional program management meetings with CMS and the 
SMAs. The purpose of these meetings is to discuss the programs progress, identify issues 
and resolutions, and discuss the planned activities for the following month.  
 
In the implementation phase, these meetings have various names including case 
coordination meetings or executive meetings. During the Initial State Collaboration 
Meeting, the partners will discuss the timing and purpose of the project management 
meetings, which shall be facilitated by the UPIC.  
 
a.  Timing 
The UPIC shall convene the project management meetings on an agreed 
upon recurring basis, based on the availability of the COR/BFL and SMA 
program lead. CMS recommends these meetings be held on a monthly 
basis.   
 
The CMS, the UPIC, and the SMA must have regularly scheduled standing 
meetings to discuss ongoing issues and to make sure that all members of 
the team are fully informed on all issues.      
b.  Agenda 
The UPIC shall provide a draft agenda to the attendees prior to each 
meeting.  The agenda should contain, at a minimum, the following areas 
for discussion: 
 
  Status of current workload, 
  Development of new Proactive Data Projects, 
  Data analytic findings, 
  Administrative actions, 
  State Issues/recommendations, and 
  CPI Feedback/Input.  
 
The CMS COR/BFL and the SMA program lead may provide comments on 
the agenda. The UPIC shall incorporate requested changes to the agenda 
and provide a final agenda prior to the meeting. 
 
c.  Meeting Location 
The meetings will be held virtually via conference call or video 
conference. The UPIC is encouraged to use web-based technology that 
allows participants to share and view common applications, such as 
PowerPoint, live during the meeting.   
 
d.  Attendees 
The UPIC shall invite the following individuals to the project management 
meetings or monthly collaboration meetings: 
 
  SMA Program Integrity Director or Inspector General, or designee 
  UPIC Medicaid Operations Lead or designee  
  UPIC Data Analyst or Manager  
  CMS COR/BFL.  
 
The attendees may bring additional individuals to the meeting. The 
attendees should inform the UPIC in advance who will be joining the 
meeting.  
 
e.  Meeting Minutes 
The UPIC shall be responsible for drafting the meeting minutes and be 
willing to make appropriate changes as requested by either CMS or the 
SMA.  
 
 
 
 
   
 
 
Transmittals Issued for this Chapter 
Rev #  Issue Date  Subject  Impl Date  CR# 
Updates of Publication (Pub.) 100-
R11948MPI  04/13/2023  05/15/2023  13141 
15, Including Revisions to Chapters 
1 and 2, and the Addition of 
Chapters 3, 4, 5, and Appendices 
 
Update to the Medicaid Program 
R3MPI  02/02/2018  04/03/2018  10340 
Integrity Manual (PIM) 
 
R1MPI 09/23/2011  Initial Publication of Manual  09/23/2011  NA 
 
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