Delegated Quality Management and Utilization Management Functions. The Contractor must demonstrate that it retains accountability for all QM and UM programs functions, including those that are delegated to other entities. The Contractor must make available to the Department, any records, documents, and data detailing its oversight of delegated QM and UM program functions. In addition, the Contractor must ensure that delegated entities make available to the Department, any records, documents, and data detailing the delegated QM and UM program functions undertaken by the entity of behalf of the Contractor.
Delegated Quality Management and Utilization Management Functions. The CHC-MCO may not structure compensation or payments to individuals or entities that conduct Utilization Management activities so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary services to any Participant.
Delegated Quality Management and Utilization Management Functions. The PH-MCO may not structure compensation or payments to individuals or entities that conduct Utilization Management activities so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary services to any Member.
Delegated Quality Management and Utilization Management Functions. The CHIP-MCO may not structure compensation or payments to individualsor entitiesthatconductUtilization Management activities so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary services to any Enrollee.
