PLAN COMPLIANCE EVALUATION PROGRAM Sample Clauses

PLAN COMPLIANCE EVALUATION PROGRAM. 1. The ADMINISTRATION shall conduct periodical evaluations of the INSURER's compliance with all terms and conditions of this contract including, but not limited to, quality, appropriateness, timeliness and reasonableness of cost and administrative expenses, said evaluation to be defined as the Plan Compliance Evaluation Program. 2. Said program will evaluate compliance of the following aspects in each areas/regions: a) Eligibility and enrollment b) Services to beneficiaries and participating providers c) Coverage of benefits d) Reporting e) Financial requirements f) Rules and Regulations g) Plan initiatives h) Quality, appropriateness, timeliness and cost of services i) Utilization j) Fraud and abuse k) Accessibility l) Grievances and Complaint handling m) Information Systems n) Electronic standards, security and privacy compliance as provided by HIPAA to include review of timetables for compliance and implementation plans o) Such aspects which the ADMINISTRATION considers necessary in order to evaluate full compliance with this contract. 3. The evaluation process will be performed throughout the contract year using specific evaluating parameters. All parameters will be derived exclusively from the Request for Proposals, the INSURER's Proposal and this contract. Each area/region will contain several parameters with each parameter having a specific numeric value adding up a subtotal per area/region and a total for the aggregate of all area/regions of evaluation. Results will be presented in a Plan Compliance Evaluation Report. The evaluating parameters will be presented to the INSURER prior to commencement of the evaluation process. 4. The INSURER shall comply with the penalties set for each parameter within the range of values predetermined by the ADMINISTRATION.

PLAN COMPLIANCE EVALUATION PROGRAM. 1. The ADMINISTRATION shall conduct periodical evaluations of the MBHO's compliance with all terms and conditions of this contract including, but not limited to, quality, appropriateness, timeliness and reasonableness of cost and administrative expenses, said evaluation to be defined as the Plan Compliance Evaluation Program. 2. Said program will evaluate compliance of the following aspects in each areas/regions as follows: The ADMINISTRATION will be responsible for contract compliance related to: a) Eligibility b) Reporting c) Utilization d) Fraud and abuse e) Grievances and Complaint handling f) Financial requirements g) Cost of services h) Information Systems i) Services to beneficiaries and participating providers (shared responsibility) j) Coverage of benefits (shared responsibility) k) Electronic standards, security and privacy compliance as provided by HIPAA to include review of timetables for compliance and implementation plans l) Rules and Regulations m) Such aspects which the ADMINISTRATION considers necessary in order to evaluate full compliance with this contract. ASSMCA and the ADMINISTRATION will be responsible for monitoring contract compliance related to: a) Clinical Management and Practice Guidelines b) Disease Management and formulary management c) Measuring accessibility, quality, appropriateness and timeliness of services according to performance standards set forth and established by the Department of Health and ASSMCA and any other performance measures in place and followed by the Health Reform Program d) Services to beneficiaries and participating mental health providers (shared responsibility) e) Coverage of benefits (shared responsibility)

PLAN COMPLIANCE EVALUATION PROGRAM. 1. The ADMINISTRATION shall conduct periodical evaluations of the INSURER's compliance with all terms and conditions of this contract including, but not limited to, quality, appropriateness, timeliness and reasonableness of cost and administrative expenses, said evaluation to be defined as the Plan Compliance Evaluation Program. 2. Said program will evaluate compliance of the following aspects in each areas/regions: a) Eligibility and enrollment b) Services to beneficiaries and participating providers c) Coverage of benefits d) Reporting e) Financial requirements f) Rules and Regulations g) Plan initiatives h) Quality, appropriateness, timeliness and cost of services i) Utilization j) Fraud and abuse k) Accessibility