Common use of Provider Profiling Clause in Contracts

Provider Profiling. 2.7.3.1. The Contractor must conduct profiling activities for PCPs, Behavioral Health Providers, LTSS providers, dental providers, vision providers and, as directed by EOHHS, specialty providers, at least annually. As part of its quality activities, the Contractor must document the methodology it uses to identify which and how many providers to profile and to identify measures to use for profiling such providers. 2.7.3.2. Provider profiling activities must include, but are not limited to: 2.7.3.2.1. Developing provider-specific reports that include a multi- dimensional assessment of a provider‘s performance using clinical, administrative, and Enrollee satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population; 2.7.3.2.2. Establishing provider, group, or regional benchmarks for areas profiled, where applicable, including Contractor- specific benchmarks, if any; 2.7.3.2.3. Providing feedback to providers regarding the results of their performance and the overall performance of the Provider Network; and 2.7.3.2.4. Designing and implementing quality improvement plans for providers who receive a relatively high denial rate for prospective, concurrent, or retrospective service authorization requests, including referral of these providers to the Network Management staff for education and technical assistance and reporting results annually to EOHHS. 2.7.3.3. The Contractor shall use the results of its provider profiling activities to identify areas of improvement for providers, and/or groups of providers. The Contractor shall: 2.7.3.3.1. Establish provider-specific quality improvement goals for priority areas in which a provider or providers do not meet established Contractor standards or improvement goals; 2.7.3.3.2. Develop and implement incentives, which may include financial and non-financial incentives, to motivate providers to improve performance on profiled measures; 2.7.3.3.3. Conduct on-site visits to Network Providers for quality improvement purposes; and 2.7.3.3.4. At least annually, measure progress on the Provider Network and individual providers‘ progress, or lack of progress, towards meeting such improvement goals. 2.7.3.4. The Contractor shall maintain regular, systematic reports, in a form and format approved by EOHHS, of the above-mentioned provider profiling activities and related Quality Improvement activities pursuant to Section 2.13. Moreover, the Contractor shall submit to EOHHS, upon request, such reports or information that would be contained therein. The Contractor shall also submit summary results of such provider profiling and related Quality Improvement activities as a component of its annual evaluation of the QM/QI program.

Provider Profiling. 2.7.3.1. The Contractor must conduct profiling activities for PCPs, Behavioral Health Providers, LTSS providers, dental providers, vision providers and, as directed by EOHHS, specialty providers, at least annually. As part of its quality activities, the Contractor must document the methodology it uses to identify which and how many providers to profile and to identify measures to use for profiling such providers. 2.7.3.2. Provider profiling activities must include, but are not limited to: 2.7.3.2.1. Developing provider-specific reports that include a multi- multi-dimensional assessment of a provider‘s provider’s performance using clinical, administrative, and Enrollee satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population; 2.7.3.2.2. Establishing provider, group, or regional benchmarks for areas profiled, where applicable, including Contractor- Contractor-specific benchmarks, if any; 2.7.3.2.3. Providing feedback to providers regarding the results of their performance and the overall performance of the Provider Network; and 2.7.3.2.4. Designing and implementing quality improvement plans for providers who receive a relatively high denial rate for prospective, concurrent, or retrospective service authorization requests, including referral of these providers to the Network Management staff for education and technical assistance and reporting results annually to EOHHS. 2.7.3.3. The Contractor shall use the results of its provider profiling activities to identify areas of improvement for providers, and/or groups of providers. The Contractor shall: 2.7.3.3.1. Establish provider-specific quality improvement goals for priority areas in which a provider or providers do not meet established Contractor standards or improvement goals; 2.7.3.3.2. Develop and implement incentives, which may include financial and non-financial incentives, to motivate providers to improve performance on profiled measures; 2.7.3.3.3. Conduct on-site visits to Network Providers for quality improvement purposes; and 2.7.3.3.4. At least annually, measure progress on the Provider Network and individual providers‘ ’ progress, or lack of progress, towards meeting such improvement goals. 2.7.3.4. The Contractor shall maintain regular, systematic reports, in a form and format approved by EOHHS, of the above-mentioned provider profiling activities and related Quality Improvement activities pursuant to Section 2.13. Moreover, the Contractor shall submit to EOHHS, upon request, such reports or information that would be contained therein. The Contractor shall also submit summary results of such provider profiling and related Quality Improvement activities as a component of its annual evaluation of the QM/QI program.

Provider Profiling. 2.7.3.12.8.7.1. The Contractor must conduct profiling activities for PCPs, Behavioral Health behavioral health Providers, LTSS providers, dental providers, vision providers and, as directed by EOHHSDMAS, specialty providers, at least annually. As part of its quality activities, the Contractor must document submit to DMAS by December 31 of each year for review and approval prior to its use the methodology it uses to identify which and how many providers to profile and to identify measures to use for profiling such providers. 2.7.3.22.8.7.2. Provider profiling activities must include, but are not limited to: 2.7.3.2.12.8.7.2.1. Developing provider-specific reports that include a multi- dimensional assessment of a provider‘s provider’s performance using clinical, administrative, and Enrollee satisfaction indicators of care that are accurate, measurable, and relevant to the enrolled population; 2.7.3.2.22.8.7.2.2. Establishing provider, group, or regional benchmarks for areas profiled, where applicable, including Contractor- specific benchmarks, if any; 2.7.3.2.32.8.7.2.3. Providing feedback to providers regarding the results of their performance and the overall performance of the Provider Network; and 2.7.3.2.42.8.7.2.4. Designing and implementing quality improvement plans for providers who receive a relatively high denial rate for prospective, concurrent, or retrospective service authorization requests, including referral of these providers to the Network Management network management staff for education and technical assistance and reporting results annually to EOHHSDMAS. 2.7.3.32.8.7.2.5. The Contractor shall use the results of its provider profiling activities to identify areas of improvement for providers, and/or groups of providers. The Contractor shall: 2.7.3.3.12.8.7.2.5.1. Establish provider-specific quality improvement goals for priority areas in which a provider or providers do not meet established Contractor standards or improvement goals; 2.7.3.3.22.8.7.2.5.2. Develop and implement incentives, which may include financial and non-financial incentives, to motivate providers to improve performance on profiled measures; 2.7.3.3.32.8.7.2.5.3. Conduct on-site visits to Network Providers network providers for quality improvement purposes; and 2.7.3.3.42.8.7.2.5.4. At least annually, measure progress on the Provider Network and individual providers‘ ’ progress, or lack of progress, towards meeting such improvement goals. 2.7.3.42.8.7.2.6. The Contractor shall maintain regular, systematic reports, in a form and format approved by EOHHSDMAS, of the above-above- mentioned provider profiling activities and related Quality Improvement activities pursuant to Section 2.132.17. Moreover, the Contractor shall submit to EOHHSDMAS, upon request, such reports or information that would be contained therein. The Contractor shall also submit summary results of such provider Provider profiling and related Quality Improvement quality improvement activities as a component of its annual evaluation of the QM/QI program.