New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 308 - MANAGED CARE PROGRAM
Part 21 - QUALITY MANAGEMENT
Section 8.308.21.15 - QUALITY MANAGEMENT COMMITTEE
Universal Citation: 8 NM Admin Code 8.308.21.15
Current through Register Vol. 35, No. 18, September 24, 2024
The MCO must have a planned, systematic and ongoing process for monitoring, evaluating and improving the quality and appropriateness of services provided to its members. A QM committee will provide oversight to quality monitoring and improvement activities, including safety review and the assignment of accountability.
A. Quality review:
(1) The MCO shall
establish a review committee to act as the leadership body for QI activities.
The review committee acts to identify and facilitate the accomplishment of a
planned, systematic, valid, and valuable QM plan for members and its
providers.
(2) The review committee
will monitor key services delivered to members and associated supportive
processes to include:
(a) the utilization of
services;
(b) its member
satisfaction;
(c) its clinical
services, including disease management; and
(d) its administrative services.
(3) The review committee is
authorized to take action upon issues related to member care and make
recommendations related to contracts, compensation, and provider
participation.
B. Critical incident review:
(1)
The MCO shall establish a review committee to review events that result in a
serious and undesired consequence; events that are not a result of an
underlying health condition or from a risk inherent in providing health
services, including:
(a) death;
(b) disability; and
(c) injury or harm to the member.
(2) The committee is authorized to
make recommendations for the prevention from future harm of its members, as
well as its system process improvement.
C. Oversight: The MCO will provide HSD with reports and records to ensure compliance with quality review and critical incident review requirements as detailed in the medicaid managed care services agreement or the managed care policy manual.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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