EQRO Monitoring Plan. Beginning in Intergovernmental Agreement year two, DHCS shall monitor the counties at least once per year through the External Quality Review Organizations (EQRO) pursuant to 42 CFR 438.350: 1) Except as provided in §438.362, a qualified EQRO performs an annual EQR for each contracting MCO or PIHP; 2) The EQRO has sufficient information to use in performing the review; a) The contractor shall make the following data elements available, including but not limited to; i. Number of days to first DMC-ODS service at appropriate level of care after referral; ii. Existence of a 24/7 telephone access line with prevalent non-English language(s); iii. Access to DMC-ODS services with translation services in the prevalent non-English language(s); and iv. Number, percentage of denied and time period of authorization requests approved or denied. 3) The information used to carry out the review must be obtained from the EQR-related activities described in §438.358. a) A detailed technical report that describes the manner in which the data from all activities conducted in accordance with § 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO or PIHP. The report must also include the following for each activity conducted in accordance with § 438.358: i. Objectives. ii. Technical methods of data collection and analysis. iii. Description of data obtained. iv. Conclusions drawn from the data. b) An assessment of each PIHP's strengths and weaknesses with respect to the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries. c) Recommendations for improving the quality of health care services furnished by each PIHP. d) As the State determines, methodologically appropriate, comparative information about all PIHPs. e) An assessment of the degree to which each PIHP has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR. 4) The information provided to the EQRO in accordance with paragraph (c) of this section is obtained through methods consistent with the protocols established under §438.352; and 5) The results of the reviews are made available as specified in §438.364(a)(1)(i) through (a)(1)(iv).
Appears in 8 contracts
Samples: Standard Agreement, Standard Agreement, Intergovernmental Agreement
EQRO Monitoring Plan. Beginning in Intergovernmental Agreement year two, DHCS shall monitor the counties at least once per year through the External Quality Review Organizations (EQRO) pursuant to 42 CFR 438.350:
1) Except as provided in §438.362, a qualified EQRO performs an annual EQR for each contracting MCO or PIHP;
2) The EQRO has sufficient information to use in performing the review;
a) The contractor shall make the following data elements available, including but not limited to;
i. Number of days to first DMC-ODS service at appropriate level of care after referral;
ii. Existence of a 24/7 telephone access line with prevalent non-English language(s);
iii. Access to DMC-ODS services with translation services in the prevalent non-English language(s); and
iv. Number, percentage of denied and time period of authorization requests approved or denied.
3) The information used to carry out the review must be obtained from the EQR-related activities described in §438.358.
a) A detailed technical report that describes the manner in which the data from all activities conducted in accordance with § 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO or PIHP. The report must also include the following for each activity conducted in accordance with § 438.358:
i. Objectives.
ii. Technical methods of data collection and analysis.
iii. Description of data obtained.
iv. Conclusions drawn from the data.
b) An assessment of each PIHP's strengths and weaknesses with respect to the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries.
c) Recommendations for improving the quality of health care services furnished by each PIHP.
d) As the State determines, methodologically appropriate, comparative information about all PIHPs.
e) An assessment of the degree to which each PIHP has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR.
4) The information provided to the EQRO in accordance with paragraph (c) of this section is obtained through methods consistent with the protocols established under §438.352; andunder
5) The results of the reviews are made available as specified in §438.364(a)(1)(i) through (a)(1)(iv).
Appears in 1 contract
Samples: Standard Agreement
EQRO Monitoring Plan. Beginning in Intergovernmental Agreement year two, DHCS shall monitor the counties at least once per year through the External Quality Review Organizations (EQRO) pursuant to 42 CFR 438.350:438.350:
1) Except as provided in §438.362, a qualified EQRO performs an annual EQR for each contracting MCO or PIHP;
2) The EQRO has sufficient information to use in performing the review;
a) The contractor shall make the following data elements available, including but not limited to;
i. Number of days to first DMC-ODS service at appropriate level of care after referral;referral;
ii. Existence of a 24/7 telephone access line with prevalent non-English language(s);
iii. Access to DMC-ODS services with translation services in the prevalent non-English language(s); and
iv. Number, percentage of denied and time period of authorization requests approved or denied.
3) The information used to carry out the review must be obtained from the EQR-related activities described in §438.358.438.358.
a) A detailed technical report that describes the manner in which the data from all activities conducted in accordance with § 438.358 were aggregated and analyzed, and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the MCO or PIHP. The report must also include the following for each activity conducted in accordance with § 438.358:
i. Objectives.
ii. Technical methods of data collection and analysis.
iii. Description of data obtained.
iv. Conclusions drawn from the data.
b) An assessment of each PIHP's strengths and weaknesses with respect to the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries.
c) Recommendations for improving the quality of health care services furnished by each PIHP.
d) As the State determines, methodologically appropriate, comparative information about all PIHPs.
e) An assessment of the degree to which each PIHP has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's EQR.
4) The information provided to the EQRO in accordance with paragraph (c) of this section is obtained through methods consistent with the protocols established under §438.352; andunder
5) The results of the reviews are made available as specified in §438.364(a)(1)(i) through (a)(1)(iv).a)(1)(iv).
Appears in 1 contract
Samples: Intergovernmental Agreement
