Clinical Practice Guidelines. The HMO must adopt not less than two evidence-based clinical practice guidelines for each applicable HMO Program. Such practice guidelines must be based on valid and reliable clinical evidence, consider the needs of the HMO’s Members, be adopted in consultation with contracting health care professionals, and be reviewed and updated periodically, as appropriate. The HMO must develop practice guidelines based on the health needs and opportunities for improvement identified as part of the QAPI Program. The HMO may coordinate the development of clinical practice guidelines with other HHSC HMOs to avoid providers in a Service Area receiving conflicting practice guidelines from different HMOs. The HMO must disseminate the practice guidelines to all affected Providers and, upon request, to Members and potential Members. The HMO must take steps to encourage adoption of the guidelines, and to measure compliance with the guidelines, until such point that 90% or more of the Providers are consistently in compliance, based on HMO measurement findings. The HMO must employ substantive Provider motivational incentive strategies, such as financial and non-financial incentives, to improve Provider compliance with clinical practice guidelines. The HMO’s decisions regarding utilization management, Member education, coverage of services, and other areas included in the practice guidelines must be consistent with the HMO’s clinical practice guidelines.
Clinical Practice Guidelines. The MCO must adopt not less than two (2) evidence-based clinical practice guidelines for each applicable MCO Program. Such practice guidelines must be based on valid and reliable clinical evidence, consider the needs of the MCO’s Members, be adopted in consultation with Network Providers, and be reviewed and updated periodically, as appropriate. The MCO must develop practice guidelines based on the health needs and opportunities for improvement identified as part of the QAPI Program. The MCO may coordinate the development of clinical practice guidelines with other HHSC MCOs in a Service Area to avoid providers receiving conflicting practice guidelines from different MCOs. The MCO must disseminate the practice guidelines to all affected Providers and, upon request, to Members and potential Members. The MCO must take steps to encourage adoption of the guidelines, and to measure compliance with the guidelines, until such point that 90% or more of the Providers are consistently in compliance, based on MCO measurement findings. The MCO must employ substantive Provider motivational incentive strategies, such as financial and non-financial incentives, to improve Provider compliance with clinical practice guidelines. The MCO’s decisions regarding utilization management, Member education, coverage of services, and other areas included in the practice guidelines must be consistent with the MCO’s clinical practice guidelines.
Clinical Practice Guidelines. (2 pages per MCO Program bid) There is significant evidence that medical professionals are often slow to adopt evidence-based clinical practice guidelines.
Clinical Practice Guidelines. (2 pages per MCO Program bid) There is significant evidence that medical professionals are often slow to adopt evidence-based clinical practice guidelines.
1. For each MCO Program bid, describe two (2) clinical guidelines that are relevant to the enrolled populations and that the Respondent believes are currently not being adhered to at a satisfactory level.
2. Describe what steps the Respondent will take to increase compliance with the clinical guidelines noted in its response to question number 1 above.
3. Provide a general description of the Respondent’s process for developing and updating clinical guidelines, and for disseminating them to participating Providers.
Clinical Practice Guidelines. The CONTRACTOR shall utilize evidence-based clinical practice guidelines in its Population Health Programs (see Section 2.8.6 of this Agreement). The guidelines shall be reviewed and revised whenever the guidelines change and at least every two (2) years. The CONTRACTOR is required to maintain an archive of its clinical practice guidelines for a period of five (5) years. Such archive shall contain each clinical guideline as originally issued so that the actual guidelines for prior years are retained for Program Integrity purposes.
Clinical Practice Guidelines. The Contractor shall: Adopt, disseminate, and monitor the use of clinical practice guidelines relevant to Enrollees that: Are based on valid and reliable clinical evidence or a consensus of health care professionals or professionals with expertise in the assessment and delivery of long‑term services and supports in the relevant field, community‑based support services or the Contractor’s approved behavioral health performance specifications and Clinical Criteria; Stem from recognized organizations that develop or promulgate evidence‑based clinical practice guidelines, or are developed with involvement of board‑certified providers from appropriate specialties or professionals with expertise in the assessment and delivery of long‑term services and supports; Do not contradict existing Massachusetts‑promulgated guidelines as published by the Department of Public Health, the Department of Mental Health, or other State agencies; Prior to adoption, have been reviewed by the Contractor’s Medical Director, as well as other One Care Plan practitioners and Network Providers, as appropriate; and Are reviewed and updated, as appropriate, or at least every two (2) years. Guidelines shall be reviewed and revised, as appropriate based on changes in national guidelines, or changes in valid and reliable clinical evidence, or consensus of health care and LTSS professionals and providers; For guidelines that have been in effect two years or longer, the Contractor must document that the guidelines were reviewed with appropriate practitioner involvement, and were updated accordingly; Disseminate, in a timely manner, the clinical guidelines to all new Network Providers, to all affected providers, upon adoption and revision, and, upon request, to Enrollees and Eligible Beneficiaries. The Contractor shall make the clinical and practice guidelines available via the Contractor’s Web site. The Contractor shall notify providers of the availability and location of the guidelines, and shall notify providers whenever changes are made; Establish explicit processes for monitoring the consistent application of clinical and practice guidelines across Utilization Management decisions and Enrollee education; and Submit to EOHHS a listing and description of clinical guidelines adopted, endorsed, disseminated, and utilized by the Contractor, upon request.
Clinical Practice Guidelines. Provider and Contracted Providers shall exercise good faith efforts to adopt and utilize the Clinical Practice Guidelines adopted by Company. (State Contract §1.8.5)
Clinical Practice Guidelines. The Contractor shall develop or adopt practice guidelines that are disseminated to Providers, and, upon request, to Enrollees and Potential Enrollees. The guidelines shall be based on valid and reliable medical/behavioral health evidence or consensus of health professionals; consider the needs of Enrollees; developed or adopted in consultation with contracting health professionals, and reviewed and updated periodically.
Clinical Practice Guidelines. The CONTRACTOR shall utilize evidence-based clinical practice guidelines in its disease management programs and shall measure performance against at least two (2) important aspects of each of the guidelines annually as required in Section 2.8. The guidelines shall be reviewed and revised at least every two (2) years or whenever the guidelines change.
27. The renumbered Section 2.15.6.1 shall be amended by adding new text and shall read as follows:
2.15.6.1 Annually, beginning with HEDIS 2010, the CONTRACTOR shall complete all HEDIS measures designated by NCQA as relevant to Medicaid. The only exclusion from the complete Medicaid HEDIS data set shall be dental measures. The HEDIS measure results shall be reported separately for each Grand Region in which the CONTRACTOR operates. The CONTRACTOR shall contract with an NCQA certified HEDIS auditor to validate the processes of the CONTRACTOR in accordance with NCQA requirements. Audited HEDIS results shall be submitted to TENNCARE, NCQA and TENNCARE’s EQRO annually by June 15 of each calendar year.
28. The renumbered Section 2.15.6.2 shall be amended by adding new text and shall read as follows:
Clinical Practice Guidelines. 7.1. Societies will base Clinical Practice Guidelines on scientific evidence.
7.2. Societies will follow a transparent Guideline development process that is not subject to Company influence. For Guidelines and Guideline Updates published after adoption of the Code, Societies will publish a description of their Guideline development process, including their process for identifying and managing conflicts of interest, in Society Journals or on Society websites.
7.3. Societies will not permit direct Company support of the development of Clinical Practice Guidelines or Guideline Updates.
