Common use of Other Discharge Appeals Clause in Contracts

Other Discharge Appeals. The Contractor must comply with the termination of services Appeal requirements for individuals receiving services from a comprehensive outpatient rehabilitation facility, skilled nursing facilities, or home health agency at 42 C.F.R. §§ 422.624 and 422.626. Quality Improvement Program Quality Improvement (QI) Program The Contractor shall: Deliver quality care that enables Enrollees to stay healthy, get better, manage chronic illnesses and/or disabilities, and maintain/improve their quality of life. Quality care refers to: Quality of physical health care, including primary and specialty care; Quality of behavioral health care focused on recovery, resiliency and rehabilitation; Quality of LTSS; Adequate access and availability to primary, behavioral health care, specialty health care, pharmacy, and LTSS providers and services; Continuity and coordination of care across all care and services settings, and for transitions in care; and Enrollee experience and access to high quality, coordinated, and culturally competent clinical care and services, inclusive of LTSS across the care continuum. Apply the principles of continuous quality improvement (CQI) to all aspects of the Contractor’s service delivery system through ongoing analysis, evaluation and systematic enhancements based on: Quantitative and qualitative data collection and data‑driven decision‑making; Up‑to‑date evidence‑based practice guidelines and explicit criteria developed by recognized sources or appropriately certified professionals or, where evidence‑based practice guidelines do not exist, consensus of professionals in the field; Feedback provided by Enrollees and Network Providers in the design, planning, and implementation of its CQI activities; and Issues identified by the Contractor, EOHHS and/or CMS. Ensure that the QI requirements of this Contract are applied to the delivery of primary and specialty health care services, Behavioral Health Services, community‑based services, and LTSS. QI Program Structure The Contractor shall maintain a well‑defined QI organizational and program structure that supports the application of the principles of CQI to all aspects of the Contractor’s service delivery system. The QI program must be communicated in a manner that is accessible and understandable to internal and external individuals and entities, as appropriate. The Contractor’s QI organizational and program structure shall comply with all applicable provisions of 42 C.F.R. § 438, including Subpart D, Quality Assessment and Performance Improvement, 42 C.F.R. § 422, Subpart D Quality Improvement, and shall meet the quality management and improvement criteria described in the most current NCQA Health Plan Accreditation Requirements. The Contractor shall: Establish a set of QI functions and responsibilities that are clearly defined and proportionate to, and adequate for, the planned number and types of QI initiatives to ensure completion of QI initiatives in a competent and timely manner; Ensure that such QI functions and responsibilities are assigned to individuals with the appropriate skill set to oversee and implement an organization‑wide, cross‑functional commitment to, and application of, CQI to all clinical and non‑clinical aspects of the Contractor’s service delivery system; Seek the input of providers and medical professionals representing the composition of the Contractor’s Provider Network in developing functions and activities; Establish internal processes to ensure that the QM activities for PCP, specialty, and Behavioral Health Services, community‑based services, and LTSS reflect utilization across the network and include all of the activities in this Section 2.13 of this Contract and, in addition, the following elements: A process to utilize Healthcare Plan Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Services (CAHPS), CAHPS Home and Community‑Based Survey (HCBS CAHPS), the Health Outcomes Survey (HOS) and other measurement results in designing QI activities; A medical record review process for monitoring Provider Network compliance with policies and procedures, specifications and appropriateness of care. Such process shall include the sampling method used which shall be proportionate to utilization by service type. The Contractor shall submit its process for medical record reviews and the results of its medical record reviews to EOHHS; A process to measure Network Providers and Enrollees, at least annually, regarding their satisfaction with the Contractor’s One Care Plan. The Contractor shall submit a survey plan to EOHHS for approval and shall submit the results of the survey to EOHHS and CMS; A process to measure clinical reviewer consistency in applying Clinical Criteria to Utilization Management activities, using inter‑rater reliability measures; A process for including Enrollees and their families in Quality Management activities, as evidenced by participation in Consumer advisory boards; and In collaboration with and as further directed by XXXXX, develop a customized medical record review process to monitor the assessment for and provision of LTSS, including the assessment of care between settings and a comparison of services and supports received with those in the Enrollee’s treatment/service plan. Have in place, and submit to EOHHS and CMS annually, a written description of the QI Program that delineates the structure, goals, and objectives of the Contractor’s QI initiatives. Such description shall: Address all aspects of health care, including specific reference to behavioral health care and to LTSS, with respect to monitoring and improvement efforts, and integration with physical health care. Behavioral health and LTSS aspects of the QI program may be included in the QI description, or in a separate QI Plan referenced in the QI description; Address the roles of the designated physician(s), behavioral health clinician(s), community‑based service providers, and LTSS providers with respect to QI program; Identify the resources dedicated to the QI program, including staff, or data sources, and analytic programs or IT systems; and Include organization‑wide policies and procedures that document processes through which the Contractor ensures clinical quality, access and availability of health care and services, and continuity and coordination of care. Such processes shall include, but not be limited to, Appeals and Grievances and Utilization Management; In the first Demonstration Year, submit to EOHHS and CMS a QI Work Plan that shall include the following components or other components as directed by EOHHS and CMS: Planned clinical and non‑clinical initiatives; The objectives for planned clinical and non‑clinical initiatives; The short‑ and long‑term time frames within which each clinical and non‑clinical initiative’s objectives are to be achieved; The individual(s) responsible for each clinical and non‑clinical initiative; Any issues identified by the Contractor, EOHHS, Enrollees, and providers, and how those issues are tracked and resolved over time; Program review process for formal evaluations that address the impact and effectiveness of clinical and non‑clinical initiatives at least annually; and Process for correcting deficiencies. Evaluate the results of QI initiatives at least annually, and submit an updated QI work plan with the results of the evaluation to the EOHHS QM manager and CMT. The evaluation of the QI program initiatives shall include, but not be limited to, the results of activities that demonstrate the Contractor’s assessment of the quality of physical and behavioral health care rendered, the effectiveness of LTSS services, and accomplishments and compliance and/or deficiencies in meeting the previous year’s QI Strategic Work Plan; and Maintain sufficient and qualified staff employed by the Contractor to manage the QI activities required under the Contract, and establish minimum employment standards and requirements (e.g. education, training, and experience) for employees who will be responsible for QM. QI staff shall include: At least one designated physician, who shall be a medical director or associate medical director, at least one designated behavioral health clinician, and a professional with expertise in the assessment and delivery of long‑term services and supports with substantial involvement in the QI program; A qualified individual to serve as the QI Director who will be directly accountable to the Contractor’s contract manager or equivalent position, and, in addition, if the Contractor offers multiple products or services in multiple states, will have access to the Plan’s executive leadership team. This individual shall be responsible for: Overseeing all QI activities related to Enrollees, ensuring compliance with all such activities, and maintaining accountability for the execution of, and performance in, all such activities; Maintaining an active role in the Contractor’s overall QI structure; Ensuring the availability of staff with appropriate expertise in all areas, as necessary for the execution of QI activities including, but not limited to, the following: Physical and behavioral health care; Pharmacy management; Care management; LTSS;

Other Discharge Appeals. The Contractor must comply with the termination of services Appeal requirements for individuals receiving services from a comprehensive outpatient rehabilitation facility, skilled nursing facilities, or home health agency at 42 C.F.R. §§ 422.624 and 422.626. Quality Improvement Program Quality Improvement (QI) Program The Contractor shall: Deliver quality care that enables Enrollees to stay healthy, get better, manage chronic illnesses and/or disabilities, and maintain/improve their quality of life. Quality care refers to: Quality of physical health care, including primary and specialty care; Quality of behavioral health care focused on recovery, resiliency and rehabilitation; Quality of LTSS; Adequate access and availability to primary, behavioral health care, specialty health care, pharmacy, and LTSS providers and services; Continuity and coordination of care across all care and services settings, and for transitions in care; and Enrollee experience and access to high quality, coordinated, and culturally competent clinical care and services, inclusive of LTSS across the care continuum. Apply the principles of continuous quality improvement (CQI) to all aspects of the Contractor’s service delivery system through ongoing analysis, evaluation and systematic enhancements based on: Quantitative and qualitative data collection and data‑driven decision‑making; Up‑to‑date evidence‑based practice guidelines and explicit criteria developed by recognized sources or appropriately certified professionals or, where evidence‑based practice guidelines do not exist, consensus of professionals in the field; Feedback provided by Enrollees and Network Providers in the design, planning, and implementation of its CQI activities; and Issues identified by the Contractor, EOHHS and/or CMS. Ensure that the QI requirements of this Contract are applied to the delivery of primary and specialty health care services, Behavioral Health Services, community‑based services, and LTSS. QI Program Structure The Contractor shall maintain a well‑defined QI organizational and program structure that supports the application of the principles of CQI to all aspects of the Contractor’s service delivery system. The QI program must be communicated in a manner that is accessible and understandable to internal and external individuals and entities, as appropriate. The Contractor’s QI organizational and program structure shall comply with all applicable provisions of 42 C.F.R. § 438, including Subpart D, Quality Assessment and Performance Improvement, 42 C.F.R. § 422, Subpart D Quality Improvement, and shall meet the quality management and improvement criteria described in the most current NCQA Health Plan Accreditation Requirements. The Contractor shall: Establish a set of QI functions and responsibilities that are clearly defined and proportionate to, and adequate for, the planned number and types of QI initiatives to ensure completion of QI initiatives in a competent and timely manner; Ensure that such QI functions and responsibilities are assigned to individuals with the appropriate skill set to oversee and implement an organization‑wide, cross‑functional commitment to, and application of, CQI to all clinical and non‑clinical aspects of the Contractor’s service delivery system; Seek the input of providers and medical professionals representing the composition of the Contractor’s Provider Network in developing functions and activities; Establish internal processes to ensure that the QM activities for PCP, specialty, and Behavioral Health Services, community‑based services, and LTSS reflect utilization across the network and include all of the activities in this Section 2.13 of this Contract and, in addition, the following elements: A process to utilize Healthcare Plan Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Services (CAHPS), CAHPS Home and Community‑Based Survey (HCBS CAHPS), the Health Outcomes Survey (HOS) and other measurement results in designing QI activities; A medical record review process for monitoring Provider Network compliance with policies and procedures, specifications and appropriateness of care. Such process shall include the sampling method used which shall be proportionate to utilization by service type. The Contractor shall submit its process for medical record reviews and the results of its medical record reviews to EOHHS; A process to measure Network Providers and Enrollees, at least annually, regarding their satisfaction with the Contractor’s One Care Plan. The Contractor shall submit a survey plan to EOHHS for approval and shall submit the results of the survey to EOHHS and CMS; A process to measure clinical reviewer consistency in applying Clinical Criteria to Utilization Management activities, using inter‑rater reliability measures; A process for including Enrollees and their families in Quality Management activities, as evidenced by participation in Consumer advisory boards; and In collaboration with and as further directed by XXXXXEOHHS, develop a customized medical record review process to monitor the assessment for and provision of LTSS, including the assessment of care between settings and a comparison of services and supports received with those in the Enrollee’s treatment/service plan. Have in place, and submit to EOHHS and CMS annually, a written description of the QI Program that delineates the structure, goals, and objectives of the Contractor’s QI initiatives. Such description shall: Address all aspects of health care, including specific reference to behavioral health care and to LTSS, with respect to monitoring and improvement efforts, and integration with physical health care. Behavioral health and LTSS aspects of the QI program may be included in the QI description, or in a separate QI Plan referenced in the QI description; Address the roles of the designated physician(s), behavioral health clinician(s), community‑based service providers, and LTSS providers with respect to QI program; Identify the resources dedicated to the QI program, including staff, or data sources, and analytic programs or IT systems; and Include organization‑wide policies and procedures that document processes through which the Contractor ensures clinical quality, access and availability of health care and services, and continuity and coordination of care. Such processes shall include, but not be limited to, Appeals and Grievances and Utilization Management; In the first Demonstration Year, submit to EOHHS and CMS a QI Work Plan that shall include the following components or other components as directed by EOHHS and CMS: Planned clinical and non‑clinical initiatives; The objectives for planned clinical and non‑clinical initiatives; The short‑ and long‑term time frames within which each clinical and non‑clinical initiative’s objectives are to be achieved; The individual(s) responsible for each clinical and non‑clinical initiative; Any issues identified by the Contractor, EOHHS, Enrollees, and providers, and how those issues are tracked and resolved over time; Program review process for formal evaluations that address the impact and effectiveness of clinical and non‑clinical initiatives at least annually; and Process for correcting deficiencies. Evaluate the results of QI initiatives at least annually, and submit an updated QI work plan with the results of the evaluation to the EOHHS QM manager and CMT. The evaluation of the QI program initiatives shall include, but not be limited to, the results of activities that demonstrate the Contractor’s assessment of the quality of physical and behavioral health care rendered, the effectiveness of LTSS services, and accomplishments and compliance and/or deficiencies in meeting the previous year’s QI Strategic Work Plan; and Maintain sufficient and qualified staff employed by the Contractor to manage the QI activities required under the Contract, and establish minimum employment standards and requirements (e.g. education, training, and experience) for employees who will be responsible for QM. QI staff shall include: At least one designated physician, who shall be a medical director or associate medical director, at least one designated behavioral health clinician, and a professional with expertise in the assessment and delivery of long‑term services and supports with substantial involvement in the QI program; A qualified individual to serve as the QI Director who will be directly accountable to the Contractor’s contract manager or equivalent position, and, in addition, if the Contractor offers multiple products or services in multiple states, will have access to the Plan’s executive leadership team. This individual shall be responsible for: Overseeing all QI activities related to Enrollees, ensuring compliance with all such activities, and maintaining accountability for the execution of, and performance in, all such activities; Maintaining an active role in the Contractor’s overall QI structure; Ensuring the availability of staff with appropriate expertise in all areas, as necessary for the execution of QI activities including, but not limited to, the following: Physical and behavioral health care; Pharmacy management; Care management; LTSS;