Current through Register Vol. 30, No. 38, September 20, 2024
A. A contractor
shall comply with Quality Management/Utilization Management (QM/UM)
requirements specified in this Section and in contract. The contractor shall
ensure compliance with QM/UM requirements that are accomplished through
delegation or subcontract with another party.
B. In addition to any requirements specified
in contract, a contractor shall:
1. Submit to
the Administration a written QM/UM plan that includes a description of the
systems, methodologies, protocols, and procedures to be used in:
a. Monitoring and evaluating the types of
services provided,
b. Identifying
the numbers and costs of services provided,
c. Assessing and improving the quality and
appropriateness of care and services,
d. Evaluating the outcome of care provided to
members, and
e. Determining the
actions necessary to improve service delivery;
2. Submit the QM/UM plan to the
Administration on an annual basis within timelines specified in contract. If
the QM/UM plan is changed during the year, the contractor shall submit the
revised plan to the Administration before implementation;
3. Receive approval from the Administration
before implementing the initial or revised QM/UM plan;
4. Ensure that a QM/UM committee operates
under the control of the contractor's medical director and includes
representation from medical and executive management personnel. The committee
shall:
a. Oversee the development, revision,
and implementation of the QM/UM plan; and
b. Ensure that there are qualified QM/UM
personnel and sufficient resources to implement the contractor's QM/UM
activities; and
5.
Ensure that the QM/UM activities include at least:
a. Prior authorization for non-emergency or
scheduled hospital admissions;
b.
Concurrent review of inpatient hospitalization;
c. Retrospective review of hospital
claims;
d. Program and provider
audits designed to detect over- or under-utilization, service delivery
effectiveness, and outcome;
e.
Medical records audits;
f. Surveys
to determine satisfaction of members;
g. Assessment of the adequacy and
qualifications of the contractor's provider network;
h. Review and analysis of QM/UM
data;
i. Measurement of performance
using objective quality indicators;
j. Ensuring individual and systemic quality
of care;
k. Integrating quality
throughout the organization;
l.
Process improvement;
m.
Credentialing a provider network;
n. Resolving quality of care grievances;
and
o. Quality improvement
activities focused on improving the quality of care and the efficient,
cost-effective delivery and utilization of services.
C. A member's primary care
provider shall maintain medical records that:
1. Conform to professional medical standards
and practices for documentation of medical diagnostic and treatment
data;
2. Facilitate follow-up
treatment; and
3. Permit
professional medical review and medical audit processes.
D. Within 30 days following termination of
the contract between a subcontractor and a contractor, the subcontractor or the
subcontractor's designee shall forward to the primary care provider medical
records or copies of medical records of all members assigned to the
subcontractor or for whom the subcontractor has provided services.
E. The Administration shall monitor each
contractor and the contractor's providers to ensure compliance with
Administration QM/UM requirements and adherence to the contractor's QM/UM plan.
1. A contractor and the contractor's
providers shall cooperate with the Administration in the performance of the
Administration's QM/UM monitoring activities; and
2. A contractor and the contractor's
providers shall develop and implement mechanisms for correcting deficiencies
identified through the Administration's QM/UM monitoring.
