Quality Management and Improvement. The process for conducting outcome reviews, data analysis, policy evaluation, and technical assistance internally and externally to improve the quality of care to Enrollees.
Quality Management and Improvement. PacifiCare shall maintain an ongoing Quality Management and Improvement Program (“QI Program”) to assess and improve the quality of clinical care and the quality of service provided to Members under the Managed Care Plans. The QI Program shall be maintained in accordance with the requirements of State and Federal Law and the standards of Accreditation Organizations. Medical Group shall, at the written request of PacifiCare, make available its Participating Providers who are physicians to serve on PacifiCare’s QI Committee. Medical Group shall establish and maintain an independent quality improvement committee which shall meet as frequently as advisable (but not less than ten (10) times throughout the year). A member of the PacifiCare medical services staff may participate in Medical Group’s quality improvement committee meetings. Medical Group shall keep minutes of its quality improvement committee and subcommittee meetings, copies of which shall be made available to PacifiCare upon ten (10) days’ written notice by PacifiCare to Medical Group. If the functions of the quality improvement committee are performed together with its utilization review committee, Medical Group shall implement and maintain procedures which maintain all applicable confidentiality protections for quality assurance activities and decisions. Medical Group shall develop and provide for PacifiCare’s review and approval written procedures for focused review or remedial action whenever it is determined by PacifiCare’s QI Committee that inappropriate or substandard Covered Services have been furnished or Covered Services that should have been furnished have not been furnished. Upon request, PacifiCare shall assist Medical Group in the formulation of such focused review and remedial procedures.
Quality Management and Improvement. The process for conducting outcome reviews, data analysis, policy evaluation, and technical assistance internally and externally to improve the quality of care to Enrollees. Quarterly Business Review or QBR – Quarterly in-person meetings between Covered California and Contractor at Covered California headquarters to report and review program performance results including all Services and components of the program, i.e., clinical, financial, contractual reporting requirements, customer service, appeals and any other program recommendations. Regulations – The regulations adopted by Covered California Board. (California Code of Regulations, Title 10, Chapter 12, § 6400, et seq.) Risk-Adjusted Premiums – Actuarially calculated premiums utilizing risk adjustment. Risk-Based Capital or RBC – The approach to determine the minimum level of capital needed for protection from insolvency based on an organization’s size, structure, and retained risk. Factors in the Risk Adjustment – An actuarial tool used to calibrate premiums paid to Health Benefits Plans or Health Insurance Issuers based on geographical differences in the cost of health care and the relative differences in the health risk characteristics of enrollees enrolled in each plan. Risk adjustment establishes premiums, in part, by assuming an equal distribution of health risk among Health Benefits Plans in order to avoid penalizing enrollees for enrolling in a Health Benefits Plan with higher than average health risk characteristics. Run-Out Claims – All claims presented and adjudicated after the end of a specified time period where the health care service was provided before the end of the specified time period.
Quality Management and Improvement. The process for conducting outcome reviews, data analysis, policy evaluation, and technical assistance internally and externally to improve the quality of care to Enrollees. – Quarterly in-person meetings between Covered California and Contractor at Covered California headquarters to report and review program performance results including all Services and components of the program, i.e., clinical, financial, contractual reporting requirements, customer service, appeals and any other program recommendations.
Quality Management and Improvement. Health Plan shall maintain an ongoing Quality Management and Improvement Program ("QI Program") to assess and improve the quality of clinical care and the quality of service provided to Members under the Managed Care Plans. The QI Program shall be maintained in accordance with the requirements of State and Federal Law and the standards of Accreditation Organizations. Medical Group and its Participating Providers shall participate, cooperate and comply with the QI Program. Medical Group shall, at the written request of Health Plan, make available its Participating Providers who are physicians to serve on Health Plan's QI Committee. Medical Group shall establish and maintain an independent quality improvement committee which shall meet as frequently as necessary, but at least monthly. A member of the Health Plan medical services staff may participate in Medical Group's quality improvement committee meetings. Medical Group shall keep minutes of its quality improvement committee meetings, a copy of which shall be made available to Health Plan upon ten (10) days written notice by Health Plan to Medical Group. If the functions of the quality improvement committee are performed by the Medical Group's utilization review committee, each committee must hold separately convened meetings and the minutes of each meeting must be separately maintained Medical Group shall develop written procedures for focused review or remedial action whenever it is determined by Health Plan's QI Committee that inappropriate or substandard Covered Services have been furnished or Covered Services that should have been furnished have not been furnished. Upon request, Health Plan shall assist Medical Group in the formulation of such focused review and remedial procedures.
Quality Management and Improvement. Administrator shall maintain an ongoing quality management and improvement program to assess and improve the quality of clinical care and the quality of Behavioral Health Services and Intellectual/Developmental Disability Services provided to Members under the Managed Care Plans and in accordance with applicable state and federal laws, rules and regulations.
Quality Management and Improvement. PacifiCare shall maintain an ongoing Quality Management and Improvement Program (“QI Program”) to assess and improve the quality of clinical care and the quality of service provided to Members under the
Quality Management and Improvement. The process for conducting outcome reviews, data analysis, policy evaluation, and technical assistance internally and externally to improve the quality of care to Enrollees. Quarterly Business Review or QBR – Quarterly in-person meetings between Covered California and Contractor at Covered California headquarters to report and review program performance results including all Services and components of the program, i.e., clinical, financial, contractual reporting requirements, customer service, appeals and any other program recommendations. Reconciliation Process – Covered California and CalHEERS engage in a cyclically occurring Reconciliation Process with each QHP and QDP Issuer participating in the individual market. . The Reconciliation Process is leveraged to monitor and facilitate all eligibility and enrollment reconciliation efforts with the QHP and QDP Issuers as defined in the “Data Integrity Reconciliation Process Guide.” As a component of the Reconciliation Process, the Dispute Process provides a platform for Issuer enrollment and eligibility disputes to be assessed. . Assessment of each enrollment dispute includes focused analysis of operational cause, risk, and enterprise-wide impact. . Regulations – The regulations adopted by Covered California Board. . (California Code of Regulations, Title 10, Chapter 12, §t 6400, et seq.) Risk-Adjusted Premiums – Actuarially calculated premiums utilizing risk adjustment. Risk-Based Capital or RBC – The approach to determine the minimum level of capital needed for protection from insolvency based on an organization’s size, structure, and retained risk. . Factors in the RBC formula are applied to assets, premium, and expense items. . The factors vary depending on the level of risk related to each item. . The higher the risk related to the item, the higher the factor, and vice versa.
Quality Management and Improvement. The process for conducting outcome reviews, data analysis, policy evaluation, and technical assistance internally and externally to improve the quality of care to Enrollees. Quarterly Business Review or QBR – Quarterly in-person meetings between Covered California and Contractor at Covered California headquarters to report and review program performance results including all Services and components of the program, i.e., clinical, financial, contractual reporting requirements, customer service, appeals and any other program recommendations. Reconciliation Process – Covered California and CalHEERS engage in a cyclically occurring Reconciliation Process with each QHP and QDP Issuer participating in the individual market. The Reconciliation Process is leveraged to monitor and facilitate all eligibility and enrollment reconciliation efforts with the QHP and QDP Issuers as defined in the “Data Integrity Reconciliation Process Guide.” As a component of the Reconciliation Process, the Dispute Process provides a platform for Issuer enrollment and eligibility disputes to be assessed. Assessment of each enrollment dispute includes focused analysis of operational cause, risk, and enterprise-wide impact. Regulations – The regulations adopted by Covered California Board. (California Code of Regulations, Title 10, Chapter 12, §t 6400, et seq.) Risk-Adjusted Premiums – Actuarially calculated premiums utilizing risk adjustment. Risk-Based Capital or RBC – The approach to determine the minimum level of capital needed for protection from insolvency based on an organization’s size, structure, and retained risk. Factors in the RBC formula are applied to assets, premium, and expense items. The factors vary depending on the level of risk related to each item. The higher the risk related to the item, the higher the factor, and vice versa. Risk Adjustment – An actuarial tool used to calibrate premiums paid to Health Insurance Issuers based on geographical differences in the cost of health care and the relative differences in the health risk characteristics of Enrollees enrolled in each plan. Risk adjustment establishes premiums, in part, by assuming an equal distribution of health risk among Health Benefits Plans in order to avoid penalizing Enrollees for enrolling in a Health Benefits Plan with higher than average health risk characteristics.
Quality Management and Improvement. The process for conducting outcome reviews, data analysis, policy evaluation, and technical assistance internally and externally to improve the quality of care to Enrollees. Quarterly Business Review or QBR – Quarterly in-person meetings between the Exchange and Contractor at the Exchange headquarters to report and review program performance results including all Services and components of the program, i.e., clinical, financial, contractual reporting requirements, customer service, appeals and any other program recommendations. Regulations – The regulations adopted by the Exchange Board. (California Code of Regulations, Title 10, Chapter 12, § 6400, et seq.) Risk-Adjusted Premiums – Actuarially calculated premiums utilizing risk adjustment. Risk-Based Capital or RBC – The approach to determine the minimum level of capital needed for protection from insolvency based on an organization’s size, structure, and retained risk. Factors in the RBC formula are applied to assets, premium, and expense items. The factors vary depending on the level of risk related to each item. The higher the risk related to the item, the higher the factor, and vice versa. Risk Adjustment – An actuarial tool used to calibrate premiums paid to Health Benefits Plans or Health Insurance Issuers based on geographical differences in the cost of health care and the relative differences in the health risk characteristics of Enrollees enrolled in each plan. Risk adjustment establishes premiums, in part, by assuming an equal distribution of health risk among Health Benefits Plans in order to avoid penalizing Enrollees for enrolling in a Health Benefits Plan with higher than average health risk characteristics. Run-Out Claims – All claims presented and adjudicated after the end of a specified time period where the health care service was provided before the end of the specified time period.
