External Quality Review Contractor a. The County must assist the Department and the external quality review organization under contract with the Department in completing all County reviews in accordance with protocols found as part of the Balanced Budget Act of 1997 (BBA). These protocols guide the external, independent review of the quality outcomes and timeliness of, and access to, services provided by the County under this contract.
b. The County must assist the Department and the external quality review organization under contract with the Department in identification of provider and member information required to carry out annual, external independent reviews of access, timeliness and quality outcomes based on on-site or off-site reviews. This includes arranging orientation meetings for physician office staff concerning medical chart review, and encouraging attendance at these meetings by County and physician office staff as necessary. The provider of service may elect to have charts reviewed on-site or off-site.
c. The purposes of the EQRO review are:
1) To validate data and information including performance measures submitted by the counties to the DHCAA for the purpose of quality assessment. Validation may include the review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias, and in accord with standards for data collection and analysis.
2) To validate County Performance Improvement Projects (PIPs) to ensure that PIPs are designed, conducted and reported in a methodologically sound manner.
3) To review compliance with structural and operation standards established by the state.
4) To provide DHCAA and the County with information about their performance that is not available from other sources of data.
5) To provide information that will aid DHCAA and the County in interpreting other sources of data, such as encounter data.
6) To provide insight and information about factors that influenced differences in program performance among similar populations.
7) To provide information that is useful to programs for their ongoing quality improvement processes.
8) To provide information that will be useful to DHCAA in fulfilling its oversight role for developing the County’s contract requirements.
d. When the external quality review organization under contract with the Department identifies an adverse quality finding that needs to be followed up on, the County must:
1) Assign a staff person(s) to conduct follow-up with the provider...
External Quality Review Contractor. 1. The HMO must assist the Department and the external quality review organization under contract with the Department in identification of provider and enrollee information required to carry out on-site or off-site medical chart reviews. This includes arranging orientation meetings for HMO Contract for February 1, 2006 - December 31, 2007 physician office staff concerning medical chart review, and encouraging attendance at these meetings by HMO and physician office staff as necessary. The provider of service may elect to have charts reviewed on-site or off-site.
2. When the professional review organization under contract with the Department identifies an adverse health situation in which follow-up is needed to determine whether appropriate care was provided, the HMO must:
a. Assign a staff person(s) to conduct follow-up with the provider(s) concerning each adverse health situation identified by the Department’s external quality review organization, including informing the provider(s) of the finding and monitoring the provider’s resolution of the finding;
b. Inform the HMO’s QAPI Committee of the final finding and involve the QAPI Committee in the development, implementation and monitoring of the corrective action plan; and
c. Submit a corrective action plan or an opinion in writing to the Department within 60 days that addresses the measures that the HMO and the provider intend to take to resolve the finding. The HMO’s final resolution of all cases must be completed within six months of HMO notification. A case is not considered resolved by the Department until the Department approves the response provided by the HMO and provider.
3. The HMO will facilitate training provided by the Department to its providers.
External Quality Review Contractor. 1. The HMO must assist the Department and the external quality review organization under contract with the Department in identification of provider and enrollee information required to carry out on-site or off-site medical chart reviews. This includes arranging orientation meetings for physician office staff concerning medical chart review, and encouraging attendance at these meetings by HMO and physician office staff as necessary. The provider of service may elect to have charts reviewed on-site or off-site.
2. When the professional review organization under contract with the Department identifies an adverse health situation in which follow-up is needed to determine whether appropriate care was provided, the HMO must:
a. Assign a staff person(s) to conduct follow-up with the provider(s) concerning each adverse health situation identified by the Department’s external quality review organization, including informing the provider(s) of the finding and monitoring the provider’s resolution of the finding;
b. Inform the HMO’s QAPI Committee of the final finding and involve the QAPI Committee in the development, implementation and monitoring of the corrective action plan; and
c. Submit a corrective action plan or an opinion in writing to the Department within 60 days that addresses the measures that the HMO and the provider intend to take to resolve the finding. The HMO’s final resolution of all cases must be completed within six months of HMO notification. A case is not considered resolved by the Department until the Department approves the response provided by the HMO and provider.
3. The HMO will facilitate training provided by the Department to its providers.
External Quality Review Contractor a. The HMO must assist the Department and the external quality review organization under contract with the Department in identification of provider and enrollee information required to carry out on-site or off-site medical chart reviews. This includes arranging orientation meetings for physician office staff concerning medical chart review, and encouraging attendance at these meetings by HMO and physician office staff as necessary. The provider of service may elect to have charts reviewed on-site or off-site.
b. When the professional review organization under contract with the Department identifies an adverse health situation in which follow-up is needed to determine whether appropriate care was provided, the HMO will be responsible for the following tasks:
1) Assign a staff person(s) to conduct follow-up with the provider(s) concerning each adverse health situation identified by the Department's professional review organization, including informing the provider(s) of the finding and monitoring the provider's resolution of the finding; HMO Contract for January 1, 2002 - December 31, 2003
2) Inform the HMO's QAPI Committee of the final finding and involve the QAPI Committee in the development, implementation and monitoring of the corrective action plan; and
3) Submit a corrective action plan or an opinion in writing to the Department within 60 days that addresses the measures that the HMO and the provider intend to take to resolve the finding. The HMO's final resolution of all cases must be completed within six (6) months of HMO notification. A case is not considered resolved by the Department until the Department approves the response provided by the HMO and provider.
c. The HMO will facilitate training provided by the Department to its providers.
