Utilization/Quality Improvement Subsystem. (A) The System implemented by CONTRACTOR must include a Utilization/Quality Improvement Subsystem that combines data from other subsystems, and/or external systems, to:
(i) Produce reports for analysis which focus on:
a. The review and assessment of quality of care given;
b. Detection of overutilization and underutilization of services; and
c. Development of user-defined reporting criteria and standards.
(ii) Profiles utilization of providers and members and compares them against experience and norms for comparable individuals;
(iii) Support the quality assessment function;
(iv) Track utilization control function(s) and monitor inpatient admissions, emergency room use, ancillary, and out-of-area services.
(v) Produce health care provider profiles, occurrence reporting, monitoring and evaluation studies, and member satisfaction survey compilations;
(vi) Integrate, at CONTRACTOR's discretion, with CONTRACTOR's manual and automated processes or incorporate other software reporting and/or analysis programs; and
(vii) Incorporate and summarize information from member surveys, provider and member complaints, and appeal processes.
(B) Functions and features of the Utilization/Quality Improvement Subsystem are:
(i) Supports CONTRACTOR processes to monitor and identify deviations in patterns of treatment from recognized standards or norms or standards specified by HHSC;
(ii) Provides feedback information for monitoring progress toward goals, identifying optimal practices, and promoting continuous improvement;
(iii) Supports development of cost and utilization data by provider and service;
(iv) Provides aggregate performance and outcome measures using standardized quality indicators similar to HEDIS or as specified by HHSC.
(v) Supports focused quality of care studies;
(vi) Supports the management of referral/utilization control processes and procedures including prior authorization and precertifications and denials of services;
(vii) Monitors primary care provider referral patterns;
Utilization/Quality Improvement Subsystem. The quality management/quality improvement/utilization review subsystem combines data from other subsystems, and/or external systems, to produce reports for analysis which focus on the review and assessment of quality of care given, detection of over and under utilization, and the development of user defined reporting criteria and standards. This system profiles utilization of providers and enrollees and compares them against experience and norms for comparable individuals. This system also supports the quality assessment function. The subsystem tracks utilization control function(s) and monitoring inpatient admissions, emergency room use, ancillary, and out-of-area services. It provides provider profiles, occurrence reporting, and monitoring and evaluation studies. The subsystem may integrate HMO's manual and automated processes or incorporate other software reporting and/or analysis programs. The subsystem incorporates and summarizes information from enrollee surveys, provider and enrollee complaints, and appeal processes. Functions and Features:
(1) Supports provider credentialing and recredentialing activities.
(2) Supports HMO processes to monitor and identify deviations in patterns of treatment from established standards or norms. Provides feedback information for monitoring progress toward goals, identifying optimal practices, and promoting continuous improvement.
(3) Supports development of cost and utilization data by provider and service.
(4) Provides aggregate performance and outcome measures using standardized quality indicators similar to HEDIS or as specified by TDH.
(5) Supports quality-of-care Focused Studies. 1999 Renewal Contract Bexar Service Area August 9, 1999
(6) Supports the management of referral/utilization control processes and procedures, including prior authorization and precertifications and denials of services.
(7) Monitors primary care provider referral patterns.
(8) Supports functions of reviewing access, use and coordination of services (i.e. actions of Peer Review and alert/flag for review and/or follow-up; laboratory, x-ray and other ancillary service utilization per visit).
(9) Stores and reports patient satisfaction data through use of enrollee surveys.
(10) Provides fraud and abuse detection, monitoring and reporting.
(11) Meets minimum report/data collection/analysis functions of Article XI and Appendix A - Standards For Quality Improvement Programs.
(12) Monitors and tracks provider and enrollee complaints and appeal...
Utilization/Quality Improvement Subsystem. The quality management/quality improvement/utilization review subsystem combines data from other subsystems, and/or external systems, to produce reports for analysis which focus on the review and assessment of quality of care given, detection of over and under utilization, and the development of user defined reporting criteria and standards. This system profiles utilization of providers and enrollees and compares them against experience and norms for comparable individuals. This subsystem also supports the quality assessment function. The subsystem tracks utilization control function(s) and monitoring inpatient admissions, emergency room use, ancillary, Long Term Care and out-of-area services. It provides provider profiles, occurrence reporting, monitoring and evaluation studies. The subsystem may integrate HMO's manual and automated processes or incorporate other software reporting and/or analysis programs. The subsystem incorporates and summarizes information from enrollee TDHS/HMO CONTRACT August 11, 1999
Utilization/Quality Improvement Subsystem. The Contractor shall capture and maintain a patient-level record of each service provided to Members using CMS 1500, UBO4, NCPDP, HIPAA code sets or other Claim or Claim formats that shall meet the reporting requirements in this Contract. The computerized database must contain and hold a complete and accurate representation of all services covered by the Contractor, and by all providers and Subcontractors rendering services for the contract period. The Contractor shall be responsible for monitoring the integrity of the database and facilitating its appropriate use for such required reports as encounter data, and targeted performance improvement studies. Contractor shall comply with the requirements of 42 CFR 455.20 (a) by employing a selected sample method approved by CMS and the Department of verifying with Members whether the services billed by provider were received. The utilization/quality improvement subsystem combines data from other subsystems, and/or external systems, to produce reports for analysis which focus on the review and assessment of access, availability and continuity of services, quality of care given, detection of over and under utilization of services, and the development of user-defined reporting criteria and standards. This system profiles utilization of Providers and Members and compares them against experience and norms for comparable individuals. The subsystem shall support tracking utilization control function(s) and monitoring activities, including Geo Network for all Encounters in all settings particularly in-patient and outpatient care, emergency room use, outpatient drug therapy, EPSDT and out-of-area services. It shall complete provider profiles; occurrence reporting, including adverse incidents and complications, monitoring and evaluation studies; Members and Providers aggregate Grievances and Appeals; effects of educational programs; and Member/Provider satisfaction survey compilations. The subsystem may integrate the Contractor’s manual and automated processes or incorporate other software reporting and/or analysis programs. The Contractor’s utilization/quality improvement subsystem shall contain such items as: monitoring of primary care and specialty provider referral patterns processes to monitor and identify deviations in patterns of treatment from established standards or norms, performance and health outcome measures using standardized indicators. The quality improvement subsystem will be based upon nationally recogn...
