Common use of External Quality Review Requirements Clause in Contracts

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an external quality of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860 (d) and Title 42, USC, Section 1396u-2(c)(2). Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State in the conduct of this review. A. External Accountability Set (EAS) Performance Measures The (EAS) performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. iii. Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Quality Improvement Projects (QIPs) 1) For this Contract, Contractor is required to conduct or participate in two Quality Improvement Projects (QIPS) approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two QIPS for each contract. a) One QIP must be either an internal quality improvement project (IQIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC or and IQIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP unless otherwise approved by DHCS. 3) Contractor shall comply with MMCD All Plan letter 11-002, as well as any subsequent updates, and shall use the QIP reporting format as designated therein to request approval of proposed QIPs from DHCS and to report at least annually to DHCS on the status of each QIP. The required documentation for QIP proposals and for QIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIP.

Appears in 1 contract

Samples: Service Agreement

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External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an external quality External Quality Review of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860 (d) and Title 42, USC, Section 1396u-2(c)(2), and CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State contracted with DHCS in the conduct of this review. A. External Accountability Set (EAS) Performance Measures The (EAS) EAS performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-DHCS developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. The EAS performance measures consists of a set of Healthcare Effectiveness Data Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 2) Contractor shall calculate and report all EAS performance measures at the county levellevel unless otherwise approved by DHCS. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-DHCS- developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. b) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. c) Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. iii. d) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Quality Performance Improvement Projects (QIPsPIPs) 1) For this Contract, Contractor is required to conduct or participate in two Quality Improvement Projects (QIPS2) PIPs per year, approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two QIPS (2) PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One QIP PIP must be either an internal quality performance improvement project (IQIPIPIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four two (42) DHCS health plan contactors contractors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP PIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation this Contract’s operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC or and IQIP and/or IPIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP PIP unless otherwise approved by DHCS. 3) Contractor shall comply with MMCD All Plan letter 11APL 16-002, as well as any subsequent updates, 018 and shall use the QIP PIP reporting format as designated therein to request approval of proposed QIPs PIPs from DHCS and to report at least annually to DHCS on the status of each QIPPIP. The required documentation for QIP PIP proposals and for QIP PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIPPIP.

Appears in 1 contract

Samples: Healthcare Agreement

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an external quality External Quality Review of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860 (d) and Title 42, USC, Section 1396u-2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State contracted with DHCS in the conduct of this review. A. External Accountability Set (EAS) Performance Measures The (EAS) EAS performance measures consist of a set of Healthcare Effectiveness Health Plan Employer Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-DHCS developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. b) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. c) Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ DHCS notification that the Contractor has performed at or below the MPL for the period under review. iii. d) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Participation in LHD Sponsored QI Contractors in San Diego GMC shall participate in an LHD sponsored Quality Improvement committee review of quality issues, including but not limited to, Grievance trends and patterns in the Healthy San Diego GMC pilot project. D. Performance Improvement Projects (QIPsPIPs) 1) For this Contract, Contractor is required to conduct or participate in two Quality Improvement Projects (QIPS2) PIPs per year, approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two QIPS PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One QIP PIP must be either an internal quality performance improvement project (IQIPIPIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors contractors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP PIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation this Contract’s operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC or and IQIP and/or an IPIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP PIP unless otherwise approved by DHCS. 3) Contractor shall comply with MMCD All Plan letter 11APL 16-002018, as well as any subsequent updates, and shall use the QIP PIP reporting format as designated therein to request approval of proposed QIPs PIPs from DHCS and to report at least annually to DHCS on the status of each QIPPIP. The required documentation for QIP PIP proposals and for QIP PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIPPIP.

Appears in 1 contract

Samples: Contract for Health Care Services

External Quality Review Requirements. At least annually or as designated by DHCSCDHS, DHCS CDHS shall arrange for an external quality of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR 22, CCR, Section 53860 (d) and Title 42, USC, Section 1396u-2(c)(21396a(30)(C). Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State in the conduct of this review. A. External Accountability Set (EAS) Performance Measures The External Accountability Set (EAS) performance measures consist consists of a set of Healthcare Effectiveness Health Plan Employer Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS ) and CDHS developed performance measures selected by DHCS CDHS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCSCDHS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCSCDHS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCSCDHS-selected EQRO. Rates for other standardized and/or DHCSCDHS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS CDHS no later than June 15 of each year or such date as established by DHCSCDHS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCSCDHS-established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. Improvement plans are due to the DHCS CDHS within 60 calendar days of the DHCSCDHS’ notification that the Contractor has performed at or below the MPL for the period under review. . iii. Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCSmeasures. These measures may will be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCSrates. DHCS CDHS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS CDHS on an annual basis. By August 1 of each year, DHCS CDHS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Quality Improvement Projects (QIPs) 1) For this Contract, Contractor is required to conduct or and/or participate in two four (4) Quality Improvement Projects (QIPS) approved by DHCSProjects. If Contractor holds For Contractors holding multiple Medi-Cal managed care contracts with DHCScontracts, Contractor is each contracted entity will be required to conduct or and/or participate in two QIPS for each contractfour QIPs. 1) Among the four QIPs: a) One QIP must be either an plan-specific (“internal quality improvement project (IQIPQIP”) b) or a small group collaborative (SGC) facilitated by a One must be in collaboration with at least one other health plan or DHCS. The SGC (“small -group collaborative”) Collaboratives must include a minimum of four two (42) DHCS CDHS health plan contactors Contractors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC collaborative must agree to the same goal, timelines for development, implementation, and measurement. Contracting health Health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. Contractors may include only one county in a collaborative regardless of whether the health plan’s contract covers multiple counties. However, if multiple counties are to be included, Contractor shall demonstrate that the measurement strategies are adequate to assess the impact of the intervention within each county. CDHS must approve the Contractor’s proposal before the Contractor proceeds with their intended approach for multiple county measurement. c) One must be the state-wide collaborative QIP (“Cal-QIP”) 2) Among the above listed four QIPs: a) One must be non-clinical (i.e., availability, accessibility or cultural competency of services; appeals, grievances, and complaints); and b) One QIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation start date of this Contract is after the Statewide Collaborative has begun implementationclinical (i.e., upon DHCS’s approval, Contractor may substitute a SGC to improve clinical services or and IQIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP unless otherwise approved by DHCSclinical interventions). 3) Contractor shall comply with MMCD All Plan letter 11-002, as well as any subsequent updates, and shall use the QIP reporting format as designated therein NCQA Quality Improvement Activity form to request approval propose initiation of proposed QIPs from DHCS and to report at least annually to DHCS on the status of each QIP. The required documentation for QIP proposals project and for QIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and resultssubsequent periodic reporting. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIP.

Appears in 1 contract

Samples: Standard Agreement (Molina Healthcare Inc)

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an external quality External Quality Review of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860 (d) and Title 42, USC, Section 1396u-2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State contracted with DHCS in the conduct of this review. A. External Accountability Set (EAS) Performance Measures The (EAS) performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. i) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. ) Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. iii. ) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Quality Performance Improvement Projects (QIPsPIPs) 1) For this Contract, Contractor is required to conduct or participate in two Quality Improvement Projects (QIPS2) PIPs per year, approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two QIPS PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One QIP PIP must be either an internal quality performance improvement project (IQIPPIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP PIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC or and IQIP and/or PIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP PIP unless otherwise approved by DHCS. 3) Contractor shall comply with MMCD All Plan letter 11APL 16-002018, as well as any subsequent updates, and shall use the QIP PIP reporting format as designated therein to request approval of proposed QIPs PIPs from DHCS and to report at least annually to DHCS on the status of each QIPPIP. The required documentation for QIP PIP proposals and for QIP PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIPPIP.

Appears in 1 contract

Samples: Service Agreement

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External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an external quality External Quality Review of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860 (d) and 53860(d), Title 42, USC, Section 1396u-2(c)(21396u- 2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State contracted with DHCS in the conduct of this review. Contractor shall comply with the following requirements, as well as the activities specified in APL 17-014, including the external quality review protocol issued by CMS which provides detailed instructions on how to complete the activities. A. External Accountability Set (EAS) Performance Measures The (EAS) EAS performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. iii. Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Quality Performance Improvement Projects (QIPsPIPs) 1) For this Contract, Contractor is required to conduct or participate in PIPs, including any PIP required by CMS, in accordance with 42 CFR 438.330. Contractor shall conduct or participate in, at a minimum, two Quality Improvement Projects (QIPS2) PIPs per year, as approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two QIPS PIPs for each contract. a) One QIP must be either an internal quality improvement project (IQIP) . At its sole discretion, DHCS may require Contractor to conduct or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating participate in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC or and IQIP in place of the Statewide Collaborativeadditional PIPs. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP unless otherwise approved by DHCS. 3) Contractor shall comply with MMCD All Plan letter 11APL 17-002014, as well as any subsequent updates, and shall use the QIP PIP reporting format as designated therein to request approval of proposed QIPs PIPs from DHCS and to report at least annually to DHCS on the status of each QIP. The required documentation for QIP proposals and for QIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and resultsPIP. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIP.

Appears in 1 contract

Samples: Service Agreement

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an external quality of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860 (d) and Title 42, USC, Section 1396u-2(c)(2)reviews. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State in the conduct of this review. A. External Accountability Set (EAS) Performance Measures The (EAS) EAS performance measures consist of a set of Healthcare Effectiveness Health Plan Employer Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously also referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-DHCS developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-DHCS established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ DHCS notification that the Contractor has performed at or below the MPL for the period under review. iii. Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, Audit and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Participation in LHD Sponsored QI Contractors in San Diego GMC shall participate in an LHD sponsored Quality Improvement committee review of quality issues, including but not limited to, Grievance trends and patterns in the Healthy San Diego GMC pilot project. D. Quality Improvement Projects (QIPs) 1) For this Contract, Contractor is required to conduct or participate in two Quality Improvement Projects (QIPSQIPs) approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two QIPS QIPs for each contract. a) One QIP must be either an internal quality improvement project (IQIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors contractors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation this Contract’s operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC or and an IQIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP unless otherwise approved by DHCS. 3) Contractor shall comply with MMCD All Plan letter Letter 11-002, as well as any subsequent updates, and shall use the QIP reporting format as designated therein to request approval of proposed QIPs from DHCS and to report at least annually to DHCS on the status of each QIP. The required documentation for QIP proposals and for QIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIP.

Appears in 1 contract

Samples: Healthcare Agreements

External Quality Review Requirements. At least annually or as designated by DHCS, DHCS shall arrange for an external quality External Quality Review of care review of the Contractor by an entity qualified to conduct such reviews in accordance with Title 22 CCR Section 53860 (d) and 53860(d), Title 42, USC, Section 1396u-2(c)(21396u- 2(c)(2), and 42 CFR 438.350, 438.358, and 438.364. Contractor shall cooperate with and assist the External Quality Review Organization (EQRO) designated by the State contracted with DHCS in the conduct of this review. A. External Accountability Set (EAS) Performance Measures The (EAS) EAS performance measures consist of a set of Healthcare Effectiveness Data and Information Set (HEDIS®) measures developed by the National Committee for Quality Assurance (NCQA). The EAS performance measures may also include other standardized performance measures and/or DHCS developed performance measures selected by DHCS for evaluation of health plan performance. 1) On an annual basis, Contractor shall submit to an on-site EAS Compliance Audit (previously referred to as the Health Plan Employer Data and Information Set (HEDIS®) Compliance Audit™) to assess the Contractor’s information and reporting systems, as well as the Contractor’s methodologies for calculating performance measure rates. Contractor shall use the DHCS-selected contractor for performance of the EAS/HEDIS Compliance Audit and calculation of DHCS-developed performance measures that constitute the EAS. Compliance Audits will be performed by an EQRO as contracted and paid for by the State. 2) Contractor shall calculate and report all EAS performance measures at the county level. a) HEDIS rates are to be calculated by the Contractor and verified by the DHCS-selected EQRO. Rates for other standardized and/or DHCS-developed performance measures will be calculated by the Contractor, DHCS staff or the EQRO, as directed by DHCS. b) Contractor shall report audited results on the EAS performance measures to DHCS no later than June 15 of each year or such date as established by DHCS. Contractor shall initiate reporting on EAS performance measures for the reporting cycle following the first year of operation. 3) Contractor shall meet or exceed the DHCS-established Minimum Performance Level (MPL) for each HEDIS measure, and any other EAS performance measures required pursuant to of this Provision. a) For each measure that does not meet the MPL set for that year, or is reported as a “Not Report” (NR) due to an audit failure, Contractor must submit a plan outlining the steps that will be taken to improve the subsequent year’s performance. i. b) The improvement plan must include, at a minimum, identification of the team that will address the problem, a root cause analysis, identification of interventions that will be implemented, and a proposed timeline. ii. c) Improvement plans are due to the DHCS within 60 calendar days of the DHCS’ notification that the Contractor has performed at or below the MPL for the period under review. iii. d) Additional reporting may be required of the Contractor until such time as improvement is demonstrated. B. Under/Over-Utilization Monitoring In addition to the EAS performance measures, Contractor shall submit to an audit of, and report rates for, an Under/Over-Utilization Monitoring Measure Set based upon selected HEDIS Use of Service measures or any other standardized or DHCS-developed utilization measures selected by DHCS. These measures may be audited as part of the EAS/HEDIS Compliance Audit, and these rates shall be submitted with the EAS audited rates or separately as directed by DHCS. DHCS will bear the costs associated with the Compliance Audit as performed by the contracted EQRO. The measures selected for inclusion in the set will be chosen by DHCS on an annual basis. By August 1 of each year, DHCS will notify Contractors of the HEDIS and other EAS performance measures selected for inclusion in the following year’s Utilization Monitoring measure set. C. Quality Performance Improvement Projects (QIPsPIPs) 1) For this Contract, Contractor is required to conduct or participate in two Quality Improvement Projects (QIPS2) PIPs per year, approved by DHCS. If Contractor holds multiple managed care contracts with DHCS, Contractor is required to conduct or participate in two QIPS PIPs for each contract. At its sole discretion, DHCS may require Contractor to conduct or participate in additional PIPs. a) One QIP PIP must be either an internal quality performance improvement project (IQIPIPIP) or a small group collaborative (SGC) facilitated by a health plan or DHCS. The SGC must include a minimum of four (4) DHCS health plan contactors and must use standardized measures and clinical practice guidelines. Additionally, all contracting health plans participating in a SGC must agree to the same goal, timelines for development, implementation, and measurement. Contracting health plans participating in a SGC must also agree on the nature of contracting health plan commitment of staff and other resources to the collaborative project. b) One QIP PIP must be a DHCS facilitated Statewide Collaborative. If the Contract Operation operation start date of this Contract is after the Statewide Collaborative has begun implementation, upon DHCS’s approval, Contractor may substitute a SGC or and IQIP and/or IPIP in place of the Statewide Collaborative. 2) If this Contract covers multiple counties, Contractor must include all counties in a QIP PIP unless otherwise approved by DHCS. 3) Contractor shall comply with MMCD All Plan letter 11APL 16-002018, as well as any subsequent updates, and shall use the QIP PIP reporting format as designated therein to request approval of proposed QIPs PIPs from DHCS and to report at least annually to DHCS on the status of each QIPPIP. The required documentation for QIP PIP proposals and for QIP PIP status reports shall include but is not limited to: a) In-depth qualitative and quantitative analysis of barriers and results. b) Evidence-based interventions and best practices, when available, and system wide intervention, when appropriate. c) Interventions that address health disparities. d) Measurement of performance using objective quality indicators. e) Strategies for sustaining and spreading improvement beyond the duration of the QIPPIP.

Appears in 1 contract

Samples: Service Agreement

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