Common use of Quality Assessment and Performance Improvement Clause in Contracts

Quality Assessment and Performance Improvement. The Contractor will establish and implement a system of Quality Assessment and Performance Improvement (QAPI) as required by 42 CFR 438.200-438.242 and a Utilization Management (UM) program as required by 42CFR 456 and stated within the MCO Policy and Procedure Guide. The Contractor will have an ongoing Continuous Quality Improvement (CQI) program for the services furnished to its members that meets the requirements of 42CFR 438.200. The Contractors Medical Director will be responsible for managing the CQI program. The Contractor will submit, annually by December 15, its QAPI Quality Assessment Workplan, UM Workplan and Program Integrity Plan to SCDHHS for review and approval. Any subsequent changes or revisions must be submitted to SCDHHS for approval prior to implementation. The full scope of QAPI, and UM requirements are outlined in the MCO Policy and Procedure Guide, Quality Assessment and Utilization Management Requirements. The Contractor is required to conduct performance improvement projects as specified in the MCO Policy and Procedure Guide. The Contractor will agree to an External Quality Review, review of QAPI / CQI / UM Quality Assessment Committee meeting minutes and annual medical audits to ensure that it provides quality and accessible health care to Medicaid MCO program members, in accordance with standards contained in the MCO Policy and Procedure Guide and under the terms of this Contract. Such audits shall allow SCDHHS or its duly authorized representative to review individual medical records, identify and collect management data, including but not limited to survey and other information concerning the use of services and the reasons for disenrollment. It is agreed that the standards by which the Contractor will be surveyed and evaluated will be at the sole discretion and approval of SCDHHS. If deficiencies are identified, the Contractor must formulate a Plan of Correction (POC) incorporating a timetable within which it will correct deficiencies identified by such evaluations and audits. SCDHHS must prior approve the POC and will monitor the Contractor's progress in correcting the deficiencies. See MCO Policy and Procedure Guide. The Contractor must attain accreditation by a nationally recognized organization such as the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) within a reasonable time period, not to exceed four years from the initial county network approval date. SCDHHS will consider other nationally recognized organizations, but prior approval from the SCDHHS QAPI department must be obtained prior to survey application. The Contractor must attain accreditation by the National Committee for Quality Assurance (NCQA). If the Contractor is not currently accredited by NCQA, the Contractor must attain accreditation by meeting NCQA’s accreditation standards. Accreditation must be completed by December 31, 2012 and must be maintained during the life of this Contract. The Contractor must provide SCDHHS’ Division of Managed Care with a copy of all correspondence with NCQA regarding the application process and the accreditation requirements. Failure to obtain NCQA accreditation by December 31, 2012 and maintain the accreditation thereafter shall be considered a breach of this Contract and shall result in termination of this Contract. Achievement of provisional accreditation status shall require a plan of correction within thirty (30) calendar days of receipt of the Final Report from NCQA and may result in termination of this Contract.

Quality Assessment and Performance Improvement. The Contractor will establish and implement a system of Quality Assessment and Performance Improvement (QAPI) as required by 42 CFR §§438.200-438.242 and a Utilization Management (UM) program as required by 42CFR 42 CFR Part 456 and stated detailed within the MCO Policy and Procedure Guide. The Contractor will have an ongoing Continuous Quality Improvement (CQI) program for the services furnished to its members that meets the requirements of 42CFR 438.200. The Contractors Medical Director will be responsible for managing the CQI program. The Contractor will submit, submit annually by December 15, 15th its QAPI Quality Assessment QA Workplan, UM Workplan and Program Integrity Plan Workplan to SCDHHS for review and approval. Any subsequent changes or revisions must be submitted to SCDHHS for approval prior to implementation. The full scope of QAPI, QAPI and UM requirements are outlined in the MCO Policy and Procedure Guide, Quality Assessment and Utilization Management Requirements. The Contractor is required to conduct performance improvement projects as specified in the MCO Policy and Procedure Guide. The Contractor will agree agrees to an External Quality Review, review of QAPI / CQI / UM Quality Assessment Committee meeting minutes and annual medical audits to ensure that it provides quality and accessible health care to Medicaid MCO program members, in accordance with standards contained in the MCO Policy and Procedure Guide and under the terms of this Contract. Such audits shall allow SCDHHS or its duly authorized representative to review individual medical records, identify and collect management data, including but not limited to survey and other information concerning the use of services and the reasons for disenrollment. It is agreed that the standards by which the Contractor will be surveyed and evaluated will be at the SCDHHS’ sole discretion and approval of SCDHHSapproval. If deficiencies are identified, the Contractor must formulate a Plan of Correction (POC) incorporating a timetable within which it will correct deficiencies identified by such evaluations and audits. SCDHHS must prior approve the POC and will monitor the Contractor's progress in correcting the deficiencies. See MCO the Policy and Procedure Guide. The Contractor must attain accreditation by a nationally recognized organization such as the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) within a reasonable time period, not to exceed four years from the initial county network approval date. SCDHHS will consider other nationally recognized organizations, but prior approval from the SCDHHS QAPI department must be obtained prior to survey application. The Contractor must attain accreditation by the National Committee for Quality Assurance (NCQA). If the Contractor is not currently accredited by NCQA, the Contractor Accreditation must attain accreditation by meeting meet NCQA’s 2012 accreditation standards. Accreditation must , be completed by December 31, 2012 2012, and must be maintained during the life of this Contract. The Contractor must provide SCDHHS’ Division Department of Managed Care with a copy of all correspondence with NCQA regarding the application process and the accreditation requirements. Failure to obtain NCQA accreditation by December 31, 2012 and maintain the accreditation thereafter shall be considered a breach of this Contract and shall result in termination of this Contractits termination. Achievement of provisional accreditation status shall require a plan of correction POC within thirty (30) calendar days of receipt of the Final Report from NCQA and may result in termination of this Contract. Contractors who are NCQA accredited for the SCDHHS Medicaid Product as of December 31, 2012, may satisfy this requirement by adding the HCK product to the Contractor’s NCQA accreditation at the time of their next Medicaid accreditation survey following the deadline.

Quality Assessment and Performance Improvement. The Contractor will establish and implement a system of Quality Assessment and Performance Improvement (QAPI) as required by 42 CFR §§438.200-438.242 and a Utilization Management (UM) program as required by 42CFR 42 CFR Part 456 and stated detailed within the MCO Policy and Procedure Guide. The Contractor will have an ongoing Continuous Quality Improvement (CQI) program for the services furnished to its members that meets the requirements of 42CFR 438.200. The Contractors Medical Director will be responsible for managing the CQI program. The Contractor will submit, annually by December 15, its QAPI Quality Assessment Workplan, UM Workplan and Program Integrity Plan to SCDHHS the Department for review and approval. Any subsequent changes or revisions must be submitted to SCDHHS the Department for approval prior to implementation. The full scope of QAPI, QAPI and UM requirements are outlined in the MCO Policy and Procedure Guide, Quality Assessment and Utilization Management Requirements. The Contractor is required to conduct performance improvement projects as specified in the MCO Policy and Procedure Guide. The Contractor will agree agrees to an External Quality Review, review of QAPI / CQI / UM Quality Assessment Committee meeting minutes and annual medical audits to ensure that it provides quality and accessible health care to Medicaid MCO program membersMembers, in accordance with standards contained in the MCO Policy and Procedure Guide and under the terms of this Contract. Such audits shall allow SCDHHS the Department or its duly authorized representative to review individual medical records, records and identify and collect management data, including including, but not limited to to, survey and other information concerning the use of services and the reasons for disenrollment. It is agreed that the standards by which the Contractor will be surveyed and evaluated will be at the Department’s sole discretion and approval of SCDHHSapproval. If deficiencies are identified, the Contractor must formulate a Plan of Correction (POC) incorporating a timetable within which it will correct deficiencies identified by such evaluations and audits. SCDHHS The Department must prior approve the POC and will monitor the Contractor's progress in correcting the deficiencies. See the MCO Policy and Procedure Guide. The Contractor must attain accreditation by a nationally recognized organization such as the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) within a reasonable time period, not to exceed four years from the initial county network approval date. SCDHHS will consider other nationally recognized organizations, but prior approval from the SCDHHS QAPI department must be obtained prior to survey application. The Contractor must attain accreditation by the National Committee for Quality Assurance (NCQA). If the Contractor is not currently accredited by NCQA, the Contractor must attain accreditation by meeting NCQA’s accreditation standards. Accreditation must be completed standards by December 31, 2012 and must be maintained during 2012. Thereafter, the life of this Contract. The Contractor must provide SCDHHS’ Division of Managed Care with a copy of all correspondence with NCQA regarding obtain the application process and the accreditation requirements. Failure to obtain NCQA accreditation by December 31, 2012 and maintain of “Excellent” in the accreditation thereafter shall be considered a breach of this Contract and shall result in termination of this Contract. Achievement of provisional accreditation status shall require a plan of correction within thirty (30) calendar days of receipt of the Final Report from NCQA and may result in termination of this Contractnext review period.

Quality Assessment and Performance Improvement. The Contractor will establish and implement a system of Quality Assessment and Performance Improvement (QAPI) as required by 42 CFR §§438.200-438.242 and a Utilization Management (UM) program as required by 42CFR 42 CFR §456 and stated within the MCO Policy and Procedure Guide. The Contractor will have an ongoing Continuous Quality Improvement (CQI) program for the services furnished to its members that meets the requirements of 42CFR 438.200. The Contractors Medical Director will be responsible for managing the CQI program. The Contractor will submit, submit annually by December 15, 15th its QAPI Quality Assessment QA Workplan, UM Workplan and Program Integrity Plan Workplan to SCDHHS for review and approval. Any subsequent changes or revisions must be submitted to SCDHHS for approval prior to implementation. The full scope of QAPI, QAPI and UM requirements are outlined in the MCO Policy and Procedure Guide, Quality Assessment and Utilization Management Requirements. The Contractor is required to conduct performance improvement projects as specified in the MCO Policy and Procedure Guide. The Contractor will agree to an External Quality Review, review of QAPI / CQI / UM Quality Assessment Committee meeting minutes and annual medical audits to ensure that it provides quality and accessible health care to Medicaid MCO program members, in accordance with standards contained in the MCO Policy and Procedure Guide and under the terms of this Contract. Such audits shall allow SCDHHS or its duly authorized representative to review individual medical records, identify and collect management data, including but not limited to survey and other information concerning the use of services and the reasons for disenrollment. It is agreed that the standards by which the Contractor will be surveyed and evaluated will be at the sole discretion and approval of SCDHHS. If deficiencies are identified, the Contractor must formulate a Plan of Correction (POC) incorporating a timetable within which it will correct deficiencies identified by such evaluations and audits. SCDHHS must prior approve the POC and will monitor the Contractor's progress in correcting the deficiencies. See MCO the Policy and Procedure Guide. The Contractor must attain accreditation by a nationally recognized organization such as the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) within a reasonable time period, not to exceed four years from the initial county network approval date. SCDHHS will consider other nationally recognized organizations, but prior approval from the SCDHHS QAPI department must be obtained prior to survey application. The Contractor must attain accreditation by the National Committee for Quality Assurance (NCQA). If the Contractor is not currently accredited by NCQA, the Contractor Accreditation must attain accreditation by meeting meet NCQA’s 2012 accreditation standards. Accreditation must , be completed by December 31, 2012 2012, and must be maintained during the life of this Contract. The Contractor must provide SCDHHS’ Division of Managed Care SCDHHS with a copy of all correspondence with NCQA regarding the application process and the accreditation requirements. Failure to obtain NCQA accreditation by December 31, 2012 and maintain the accreditation thereafter shall be considered a breach of this Contract and shall result in termination of this Contract. Achievement of provisional accreditation status shall require a plan of correction within thirty (30) calendar days of receipt of the Final Report from NCQA and may result in termination of this Contract. Contractors who are NCQA accredited for the SCDHHS Medicaid Product as of December 31, 2012, may satisfy this requirement by adding the HCK product to the Contractor’s NCQA accreditation at the time of their next Medicaid accreditation survey following the deadline.