Form Cms-R-0235m - Medicaid Agency Data Use Agreement

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
INSTRUCTIONS FOR COMPLETING THE MEDICAID AGENCY DATA USE AGREEMENT (DUA)
This agreement, which ensures compliance with the requirements of the Privacy Act, is required for a State
Medicaid Agency to receive LTC/MDS data deriving from Medicare and private pay residents, and must be
completed prior to the release of these files to the Medicaid Agency. No DUA is needed for release of LTC/MDS
data derived exclusively from Medicaid residents; however, see the instruction below for item #5 in regard to
this. Note that all data releases to the Medicaid Agency, including releases for Medicaid-only residents, must
be electronically tracked for purposes of HIPAA compliance.
Instructions for the completion of the agreement follow:
Before completing the DUA, please note that the language contained in this agreement cannot be
altered in any form.
• First paragraph, enter the name of the State.
• Item #1, enter the name of the State.
• Item #5, “Files,” is pre-completed to show “LTC/MDS Resident Assessment Data File(s).” This wording
is general and covers all MDS data. This all-inclusive language will reliably guide the technical staff who
must retrieve the data. Item #5, “Year(s):” The Medicaid Agency may choose the time period for which it
wishes to receive data, from a point in the past through up to 10 years into the future (see the Item #6 dis­
cussion of retention date). Examples are: “1998-2000;” “2001;” and “From 1998 through [insert date 10
years in the future].”
• Medicaid Agencies must remain aware that the use of all the MDS data, regardless of program source, is
limited to the purpose indicated in Item #4, i.e., for Medicaid program use. In addition, Medicaid
Agencies must abide by all the restrictions regarding the MDS data, regardless of source, that are based
on the Privacy Act and other law and regulation, and as expressed throughout this DUA.
• Item #6 says that the group of data files indicated in Item #5 may be retained by the Medicaid Agency for
a period of 10 years after the approval date (CMS’ signature date) of the DUA. This date, which is 10
years in the future, is called the “retention date.” For cases in which the Medicaid Agency receives data
in an ongoing manner, the retention date does not move forward with each data release. For example, data
released two months prior to the retention date (9 years and 10 months after the DUA approval date) may
only be kept by the Medicaid Agency for two months. If it wishes to continue receiving data beyond the
10 year point, the Medicaid Agency must contact CMS at least 30 days prior to the retention date (and
preferably 3-4 months prior) to request another DUA covering the period following the 10 year retention
date.
• Item #14 is to be completed by the State Medicaid Agency.
• Item #15 is to be completed by the State Medicaid Agency Custodian. Enter the Custodian’s name, the
State Medicaid Agency organizational unit, Address, Phone Number (including area code), and E-Mail
Address (if applicable). The Custodian of files is defined as that person who will have actual possession
of and responsibility for the data files. This will typically be the manager of the Medicaid agency unit
with responsibility for the data files. If the person signing for the Medicaid agency as User is the same
person as the Custodian, that person can appear and sign in both places.
If there are additional Custodians who are not direct Medicaid agency employees, such as academic or
other consulting contractors, who assist the Medicaid agency in its use of the data for the purposes indicated
in Item #4, an appropriate lead or managerial person from each such organization must complete and sign
the Multi-Signature Addendum form.
Form CMS-R-0235M (07/07) EF 07/2007
1

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