WMS MMDL Service Request Form

First Name *

Last Name *

Email *

Daytime Phone Number (where you can be contacted with follow up questions) *

Are you a CMS employee? *

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Please provide your 4 character CMS user ID *

Please complete the following information related to your specific request

Specific Request *

Password Reset Request

Enter Username *

MMDL General Question

Please describe your question *

Report/SPA # *

Form/Section *

WMS General Question

Please describe your question *

Waiver/Report # *

Appendix/Section *

MMDL Problem

Please describe your issue *

Report/SPA # *

Form/Section *

WMS Problem

Please describe your issue *

Waiver/Report # *

Appendix/Section *

Policy Content

Please describe your policy question *

Printing

Please describe your printing request *

Waiver/Report/SPA # *

Appendix/Form/Section *

1915(b) - Update End Date

Please describe your 1915(b) end date change request *

Waiver # *

Renewal # *

Other

Please describe your request *

New User Request

Type of User *

Justification/Project Name *

Please indicate Central Office or for which region you are requesting access *

Enter CMS Role *

Enter State *

Enter State Role *

Deadline

Deadline Justification

I am requesting help with the following module(s): 1915(c) Waiver
372 Report
1915(b) Waiver
Medicaid Payment Suspensions State Annual Report (MPS)
Children's Health Insurance Program (CHIP) Eligibility
Medicaid Alternative Benefit Plan (ABP)
Medicaid Premiums and Cost Sharing (MPC)
Balancing Incentive Program (BIP) (No longer active in MMDL)
Health Homes State Plan Amendment (HHS) (No longer active in MMDL)
Medicaid State Plan Eligibility (No longer active in MMDL)

CMS Role	Abilities in WMS	Abilities in MMDL
CMS Auxiliary Staff (CMS Aux Staff)	Browse all waivers/reports	(CHIP, ABP, MPC) Browse all SPAs (MPS) Browse all reports
Regional Office (RO) Staff (CMS RO Staff)	Within their region: read waivers/reports, enter comments, request IRAI, recommend approval	(CHIP, ABP, MPC) Within their region: read SPAs, enter comments, unlock SPAs, set regional office assignment (MPS) Within their region: read reports, enter comments
Regional Office (RO) System Administrator/ Operations Manager (CMS RO Sys/OP Mgr)	Within their region: read waivers/reports, enter comments, request IRAI, unlock 372 reports, set regional office assignment, create new/edit existing regional office user profiles	(CHIP, ABP, MPC) Within their region: read SPAs, enter comments, unlock SPAs, set regional office assignment, create new/edit existing regional office user profiles (MPS) Within their region: read reports, enter comments, create new/edit existing regional office user profiles
Regional Office (RO) Associate Regional Administrator (ARA) (CMS RO ARA)	Within their region: read waivers/reports, enter comments, request IRAI/RAI, unlock 372 reports, set regional office assignment, approve waivers/reports, renumber waivers, create new/edit existing regional office user profiles	(CHIP, ABP, MPC) Within their region: read SPAs, enter comments, request RAI, unlock SPAs, set regional office assignment, approve/reject SPAs, create new/edit existing regional office user profiles (MPS) Within their region: read reports, enter comments, create new/edit existing regional office user profiles
Central Office (CO) Staff (CMS CO Staff)	All submissions: read waivers/reports, enter comments for submissions, request IRAI, set central office regional assignment, recommend approval	(CHIP, ABP, MPC) All submissions: read SPAs, enter comments, unlock SPAs, set central office regional assignment (MPS) All submissions: read reports, enter comments
Central Office (CO) System Administrator (CMS CO Sys)	All submissions: read waivers/reports, enter comments, request IRAI, unlock 372 reports, set central office regional assignment, recommend approval, create new/edit existing central office and regional office user profiles	(CHIP, ABP, MPC) All Submissions: read SPAs, enter comments, unlock SPAs, create new/edit existing central office and regional office user profiles (MPS) All Submissions: read reports, enter comments for reports, create new/edit existing central office and regional office user profiles
Central Office (CO) Operations Manager (CMS CO OP Mgr)	All submissions: read waivers/reports, enter comments, request IRAI/RAI, unlock 372 reports, set central office regional assignment, approve/disapprove a submission, renumber waivers, terminate waivers, create new/edit existing central office and regional office user profiles	(CHIP, ABP, MPC) All submissions: read SPAs, enter comments, request RAI, unlock SPAs, set central office regional assignment, approve/reject SPAs, create new/edit existing central office and regional office user profiles (MPS) All submissions: read reports, enter comments, create new/edit existing central office and regional office user profiles

State Role	Abilities in WMS	Abilities in MMDL
State Auxiliary (State Auxiliary)	Within their state: read all submissions	(CHIP, ABP, MPC) Within their state: read all SPAs (MPS) Within their state: read all reports
State Staff (State Staff)	Within their state: read all submissions for the state, create and edit waivers/reports they have been assigned or assigned to by another user	(CHIP, ABP, MPC) Within their state: read, create, edit, and withdraw SPAs (MPS) Within their state: Read, create, edit, and withdraw reports
State System Manager (State Sys/OP Mgr)	Within their state: read, create, edit all waivers/reports, assign state users to edit waivers/reports, create new/edit existing state user profiles	(CHIP, ABP, MPC) Within their state: read, create, edit, withdraw SPAs, assign state users to edit SPAs, create new/edit existing state user profiles (MPS) Within their state: read, create, edit, submit, withdraw reports, create new/edit existing state user profiles
State Medicaid Director (State Medicaid Dir)	Within their state: read, create, edit, submit, unsubmit, and withdraw all waivers/reports, assign state users to edit waivers/reports, create new/edit existing state user profiles	(CHIP, ABP, MPC) Within their state: read, create, edit, submit, unsubmit, and withdraw all SPAs, assign state users to edit SPAs, create new/edit existing state user profiles (MPS) Within their state: read, create, edit, submit and withdraw reports, create new/edit existing state user profiles

Waiver Management System (WMS) and Medicaid Model Data Lab (MMDL) Request Form