Use the links below to download request documents and access
- The Coordination of Benefits Agreement (COBA) Specification Worksheet
enables states to specify the intended use of COBA-acquired data.
Data Use Agreement (DUA) Forms
governing states' access to Medicare data.
- On the website for CMS DUAs (linked above), there are a
number of DUA forms available to site visitors. With requests
for Medicare data facilitated by the State Data Resource Center,
State Medicaid Agencies only need the new, additional data use, update, and
addendum versions of these forms. In addition, State Medicaid Agencies should
submit an appropriate DUA form, as part of their data request
package, to MMCO directly through the State Data Resource Center
and not to any other organization.
- The Data Use Agreement (DUA) Addendum is required to add
analytic and administrative downstream users to the DUA for
Medicare data requests for Medicare-Medicaid care coordination
and program integrity activities.
- The Data Use Agreement (DUA) Attachment A supplements CMS
DUA forms for downstream users that are providers, specifying
Medicare-Medicaid care coordination.
File Transfer (EFT) Setup Form and
EFT Partner Server Questionnaire
- The Electronic File Transfer (EFT) Setup Form and EFT Partner Server Questionnaire enables State Medicaid Agencies to
establish electronic feeds of Medicare data.
Information Exchange Agreement (IEA)
- The Information Exchange Agreement (IEA) establishes the
terms governing states' access to Medicare data for the purpose
of Medicare-Medicaid care coordination or program integrity.
Historical A/B Worksheet
- The Historical A/B worksheet is a key document in the
Historical A/B data request package, enabling states to specify
which data types and variables of Medicare Parts A & B data are
needed and how they will be used. This worksheet includes
additional tabs for assessments data. These tabs enable states to
specify which variables from MDS, OASIS, Swing Bed, and IRF-PAI
assessments are needed as part of an Assessments data request
Part D Worksheet
- The Part D worksheet is a key document in the Part D data
request package, enabling states to specify which data types and
variables of Medicare Parts D data are needed.