100-15 Medicaid Program Integrity Manual: Chapter 2 – Collaboration with States

M EDICAID P ROGRAM I NTEGRITY M ANUAL
C HAPTER 2 – Collaboration with States
Table of Contents
(Rev. 14275, Issued: 12-23-25)
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
2.3 	Support to States on Appeals

2.0 - State Collaboration Purpose
(Rev. 13494; Issued: 12-23-25; Effective: 01-26-26; Implementation:01-26-26)
The purpose of collaboration between the state Medicaid agency (SMA) and the UPIC is
to identify state priorities, share CMS priorities and expectations, 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. 12871; Issued: 10-11-24; Effective: 11-14-24; Implementation: 11-14-24)
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. 12871; Issued: 10-11-24; Effective: 11-14-24; Implementation: 11-14-24)
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
Agreement
• 	Discuss the purpose of the JOA.
• 	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.

Agenda
Item
Decisions/Discussion Points
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
connectivity
and
transmission
• 	Provide the options for the state to provide Medicaid data to
CMS via the UPIC.
• 	Make a preliminary decision on the best method for providing
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
information
sharing
• 	Discuss the importance of training early in the program and
provide options for initial, formal cross-training.
• 	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. 12871; Issued: 10-11-24; Effective: 11-14-24; Implementation: 11-14-24)
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 decision
tree below.

If you are working with the state, use this decision tree. If not, use the decision tree
if/when you begin working with the state.
100% Reliant on TMSIS
for PI Purposes?
(No need to access state
data)
Yes
*If IEA is already in place, keep as is.
Once expired, no need to renew. If the
state has issues with not renewing,
engage CMS.
If ever the data is not 100% TMSIS, go
back to top of decision tree.
No
Is IEA already in
place?
Yes
Keep IEA in place
until 100% TMSIS,
or transition to
updated JOA
(referenced in the
Appendices ).
No
Is the state asking you to
sign additional agreements
(i.e. MOU, BAA, etc.)
Is the state
requiring any
additional
agreements (i.e.
)
No
No
further
action
needed
Yes
Has the
UPIC or is
the UPIC
willing to
sign
agreements?
No
Engage
CMS
Yes
Upon signing, no
additional action
needed
Yes
Is the UPIC
willing to sign
agreements?
No
Engage CMS
Yes
Upon signing,
no additional
action needed.
No
Is a JOA in place? If
not, engage CMS to
explain how the UPIC is
obtaining data from the
state.

2.1.4 - Joint Operating Agreement (JOA)
(Rev. 13494; Issued: 12-23-25; Effective: 01-26-26; Implementation:01-26-26)
a. 	Purpose of the JOA
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 party’s
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. 12871; Issued: 10-11-24; Effective: 11-14-24; Implementation: 11-14-24)
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 state’s program.

• 	Share educational materials and maintain key documents that explain the
agency’s 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 components—policy 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. 12871; Issued: 10-11-24; Effective: 11-14-24; Implementation: 11-14-24)
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. 13494; Issued: 12-23-25; Effective: 01-26-26; Implementation:01-26-26)
UPICs shall facilitate additional program management meetings with CMS and the
SMAs. The purpose of these meetings is to discuss the program’s 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 Data Project Records,
• 	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.

2.3 – Support to States on Appeals
(Rev. 12871; Issued: 10-11-24; Effective: 11-14-24; Implementation: 11-14-24)
As part of the collaboration with SMAs, the UPICs will support the states on appeals
related to the UPIC’s investigations/audits as outlined in the TO SOW and with this
manual at 4.4 – State Appeal Process.

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date 	CR#
R13494MPI 	12/23/2025 Updates of Chapters 1-5 in
Publication (Pub.) 100-15, Including
Updates to the Guidance
Terminology, Existing Definitions,
and Details to Standing Guidance
01/26/2026 	14275
R12871MPI 	10/11/2024 Updates of Chapter 1, Chapter 2,
Chapter 3, Chapter 4, and
Appendices in Publication (Pub.)
100-15, Including Auditing of
Program Integrity Activities in
Managed Care Plans
11/14/2024 	13720
R11948MPI 	04/13/2023 Updates of Publication (Pub.) 100-
15, Including Revisions to Chapters
1 and 2, and the Addition of
Chapters 3, 4, 5, and Appendices
05/15/2023 	13141
R3MPI 	02/02/2018 Update to the Medicaid Program
Integrity Manual (PIM) 04/03/2018 	10340
R1MPI 	09/23/2011 	Initial Publication of Manual 	09/23/2011 	NA
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