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 the quality and appropriateness of care furnished to enrollees with special health care needs. i. The Contractor must identify opportunities to access health care disparities. The Contractor will submit a copy of this evaluation to the Division semi-annually. The QM program description will be submitted to the Division for written approval prior to implementation and annually thereafter. The Division reserves the right to expand the QM Program as needed to assure quality beneficiary care. Upon request, the Contractor will make available to its Enrollees and practitioners information about the Plan’s QI program and a report on the Plan’s progress in meeting its goal.
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Samples: Contract Between the State of Mississippi Division of Medicaid and a Care Coordination Organization (Cco), Contract, Contract
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 C.F.R. § 438.240 which:
a. 1. Provides for review by appropriate health professionals of the process followed in providing Covered Services covered services to EnrolleesMembers;
b. 2. Provides for systematic data collection of performance and patient outcomes;
c. 3. Provides for interpretation and dissemination of performance and outcome data to Plan providers contracted Providers and Outside Non-Contracted Providers approved for referrals for primary and specialty;
d. 4. Provides for the prompt implementation of modifications to the Contractor's policies, procedures and/or processes for the delivery of Covered Services covered services as may be indicated by the foregoing;
e. 5. Provides for the maintenance of sufficient encounter data to identify each practitioner providing services to EnrolleesMembers, specifically including the unique physician identifier for each physician; and
f. 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. The Contractor will have a written description of the QM program that focuses on health outcomes and that includes the following:
a. Detailed 1. A written program description including an Annual QM Program Work Plan; detailed objectives, a accountabilities and time frames; definition of the scope of the QM program, planned projects or activities and an Annual Program Evaluation. Detailed requirements are included in Exhibit G, 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 methodology clinical Performance Measures and targets put forth by the Division, 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 identifying other projects that require evaluationeach activity.
b. 3. Composition of the QM committeecommittee including a physical and behavioral health Provider.
c. 4. Procedures for remedial action when deficiencies are identified.
d. 5. Specific types of problems requiring corrective action.
e. 6. Provisions for monitoring and evaluating corrective action to ensure that actions for improvement have been effective.
f. 7. Procedures for provider Provider review and feedback on results.
g. Semi-annual planned 8. Annual performance evaluation of the QM program as part of the Internal Audit that includes:
i. a. Description of completed and ongoing QI QM activities including case management Care Management effectiveness evaluation;
ii. b. Identified issues, including tracking of issues over time;
iii. c. Trending of measures to assess performance in quality of clinical care and quality of service to EnrolleesMembers; and
iv. d. An analysis of whether there have been demonstrated improvements in Members’ health outcomes, the quality of clinical care and quality of service to EnrolleesMembers; and overall effectiveness of the QM programprogram (e.g., improved HEDIS® scores).
h. 9. The Contractor must have in effect mechanisms to assess the quality and appropriateness of care furnished to enrollees Members with special health care needs.
i. 10. The Contractor must identify opportunities to access address health care disparities. The Contractor will submit a copy of this evaluation Annual Program Description, Annual Program Evaluation and Annual Work Plan to the Division semi-annuallyannually for review and approval. The QM program description description, including the Annual Work Plan, will be submitted to the Division for written approval prior annually. The Contractor will also submit regular quarterly work plan updates to implementation and annually thereafterthe Division. The Division reserves the right to expand the QM Program as needed to assure quality beneficiary Member care. Upon request, the The Contractor will make available to its Enrollees Members and practitioners Providers information about the Plan’s QI QM program and a report on the PlanContractor’s progress in meeting its goalgoal annually. This information must be reviewed and approved by the Division prior to distribution.
Appears in 2 contracts
Samples: Contract Between the State of Mississippi Division of Medicaid and a Coordinated Care Organization (Cco), Contract Between the State of Mississippi Division of Medicaid and a Care Coordination Organization
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 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 the quality and appropriateness of care furnished to enrollees with special health care needs.
i. The Contractor must identify opportunities to access health care disparities. The Contractor will submit a copy of this evaluation to the Division semi-annually. The QM program description will be submitted to the Division for written approval prior to implementation and annually thereafterannually. The Division reserves the right to expand the QM Program as needed to assure quality beneficiary care. Upon request, the Contractor will make available to its Enrollees and practitioners information about the Plan’s QI program and a report on the Plan’s progress in meeting its goal.
Appears in 1 contract
Samples: Contract
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 provides for review by appropriate health professionals of the process followed in providing Covered Services to Enrollees;
b. Provides provides for systematic data collection of performance and patient outcomes;
c. Provides provides for interpretation and dissemination of performance and outcome data to Plan providers and Outside Providers approved for referrals for specialty;
d. Provides 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 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 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 followingincludes:
a. Detailed 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 composition of the QM committee.;
c. Procedures procedures for remedial action when deficiencies are identified.;
d. Specific specific types of problems requiring corrective action.;
e. Provisions provisions for monitoring and evaluating corrective action to ensure that actions for improvement have been effective.;
f. Procedures procedures for provider review and feedback on results.;
g. Semisemi-annual planned evaluation of the QM program as part of the Internal Audit that includes:
i. Description (1) description of completed and ongoing QI activities including case management effectiveness evaluation;
ii. Identified (2) identified issues, including tracking of issues over time;
iii. Trending (3) trending of measures to assess performance in quality of clinical care and quality of service to Enrollees; and
iv. An (4) 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 the Contractor must have in effect mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs.
i. The the Contractor must identify opportunities to access health care disparities. The Contractor will submit a copy of this evaluation to the Division semi-annually. The QM program description will be submitted to the Division for written approval prior to implementation and annually thereafter. The Division reserves the right to expand the QM Program as needed to assure quality beneficiary care. Upon request, the Contractor will make available to its Enrollees and practitioners information about the Plan’s QI program and a report on the Plan’s progress in meeting its goal.
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