Quality Management System and Quality Improvement Program. The Contractor shall implement and operate an internal quality management (QM) system and quality improvement (QI) program in compliance with 42 CFR § 438.240 which:
a. Provides for review by appropriate health professionals of the process followed in providing Covered Services to Enrollees;
b. Provides for systematic data collection of performance and patient outcomes;
c. Provides for interpretation and dissemination of performance and outcome data to Plan providers and Outside Providers approved for referrals for specialty;
d. Provides for the prompt implementation of modifications to the Contractor's policies, procedures and/or processes for the delivery of Covered Services as may be indicated by the foregoing;
e. Provides for the maintenance of sufficient encounter data to identify each practitioner providing services to Enrollees, specifically including the unique physician identifier for each physician; and
f. Complies with Miss. Code Xxx. § 00-00-000 et. seq. (1972, as amended), of the Health Maintenance Organization, Preferred Provider Organization and Other Prepaid Health Benefit Plan Protection Act and Miss. Code Xxx. § 00-00-000 (1972, as amended) of the Patient Protection Act of 1995. The Contractor will have a written description of the QM program that focuses on health outcomes and that includes the following:
a. Detailed objectives, a definition of the scope of the program, planned projects or activities for the year and the methodology for identifying other projects that require evaluation.
b. Composition of the QM committee.
c. Procedures for remedial action when deficiencies are identified.
d. Specific types of problems requiring corrective action.
e. Provisions for monitoring and evaluating corrective action to ensure that actions for improvement have been effective.
f. Procedures for provider review and feedback on results.
g. Semi-annual planned evaluation of the QM program as part of the Internal Audit that includes:
i. Description of completed and ongoing QI activities including case management effectiveness evaluation;
ii. Identified issues, including tracking of issues over time;
iii. Trending of measures to assess performance in quality of clinical care and quality of service to Enrollees; and
iv. An analysis of whether there have been demonstrated improvements in the quality of clinical care and quality of service to Enrollees; and overall effectiveness of the QM program.
h. The Contractor must have in effect mechanisms to assess...
Quality Management System and Quality Improvement Program. Contractor shall implement and operate an internal QM system and quality improvement (QI) program in compliance with 42 C.F.R. § 438.240 which:
1. Provides for review by appropriate health professionals of the process followed in providing covered services to Members;
2. Provides for systematic data collection of performance and Member outcomes;
3. Provides for interpretation and dissemination of performance and outcome data to contracted providers and Non-Contracted Providers approved for referrals for primary and specialty;
4. Provides for the prompt implementation of modifications to Contractor's policies, procedures and/or processes for the delivery of covered services as may be indicated by the foregoing;
5. Provides for the maintenance of sufficient encounter data to identify each practitioner providing services to Members, specifically including the unique physician identifier for each physician; and
6. Complies with Miss. Code Xxx. § 00-00-000 et. seq. (1972, as amended), of the Health Maintenance Organization, Preferred Provider Organization and Other Prepaid Health Benefit Plan Protection Act and Miss. Code Xxx. § 00-00-000 (1972, as amended) of the Patient Protection Act of 1995. Contractor will have a written description of the QM program specific to CHIP that focuses on health outcomes and that includes the following:
1. A written program description including an Annual QM Program Work Plan; detailed objectives, accountabilities and time frames; definition of the scope of the QM program, and an Annual Program Evaluation. Detailed requirements are included in Exhibit F, CHIP Quality Management, of this Contract.
2. A work plan and timetable for the coming year which clearly identifies target dates for implementation and completion of all phases of all QM activities, consistent with the clinical Performance Measures and targets put forth by DOM, including, but not limited to:
a. Data collection and analysis;
b. Evaluation and reporting of findings;
c. Implementation of improvement actions where applicable; and
d. Individual accountability for each activity.
3. Composition of the QM committee including, at a minimum, a physical and Behavioral Health provider.
4. Procedures for remedial action when deficiencies are identified.
5. Specific types of problems requiring corrective action.
6. Provisions for monitoring and evaluating corrective action to ensure that actions for improvement have been effective.
7. Procedures for provider review and fee...
