CA Clinical guidelines
CA | FL | NY"Article V...
X. Quality Assurance/Professional Review/Utilization Control System...c. Physicians and other appropriate licensed professionals who provide care to the PCCM plan's members are an integral part of the QA program;
d. Appropriate care which is consistent with professionally recognized standards of practice is not withheld or delayed for any reason; including a potential financial gain or incentive to the PCCM plan or its providers;
e. The PCCM plan does not exert economic pressure to cause providers of services or institutions to render care beyond the scope of their training or experience, or to cause institutions to grant privileges to health care providers that would not otherwise be granted; and
f. Service elements addressed, including accessibility, availability and continuity of care..." California Contract, pages 28-30.
"7. Quality of Care Standards. Providers will adhere to or exceed the quality assurance standards established by MediPass.
a. Childhood Immunizations. MediPass promotes immunizations as an effective intervention to prevent infections in children. The MediPass Primary Care Provider will provide or manage services such that children will receive vaccinations for Diphtheria, Tetanus, Pertussis, Polio, measles, Haemophilus influenza b, and Hepatitis B according to the recommended immunization schedule issued by the American Academy of pediatrics, the Advisory Committee of immunization Practices of the U.S. Public Health Service and/or the Academy of Family Physicians.
b. Child Health Check-Up. MediPass realizes that periodic well-child visits furnish providers with an excellent opportunity to assess children for physical, developmental, behavioral and emotional difficulties. During the first year of life, well-child visits are of particular importance. Consistent with the Medicaid Child Health Check Up, formerly called the EPSDT, and the Medicaid Child Health Monitoring Standards, MediPass has adopted the goal that over 80% of recipients will receive Child Health Check Up screenings by age on month: during two, four, six, nine, 12, 15, and 18 months of age: and once per year for ages two through 20 years of age. The MediPass Primary Care Provider will provide or manage services such that all recipients under 21 years of age will receive any appropriate Child Health Check Up screenings.
c. Adult Health Screening. MediPass recognizes that giving adults periodic health screenings improves long-term outcomes for the recipients. During these screening, providers are afforded opportunities to conduct risk assessments, diagnose problems and furnish treatments that improve the quality of the recipient's life. The MediPass Primary Care Provider will provide or manage services such that a health screening will be performed, if due, on recipients aged 21 years or older in accordance with recommendations in the Medicaid Physician Coverage and Limitations Handbook.
d. Comprehensive Diabetes Care.
1. Diabetic Renal Examinations. MediPass is committed to reducing the incidence of diabetes-induced blindness in MediPass recipients. Early intervention and continual monitoring of diabetic eye disease could reduce the incidence of diabetes related blindness. Based on guidelines proposed by the American Diabetic Association, and the American Academy of Ophthalmology, the MediPass Primary American Care Provider will provide or manage services such that the recipients with a history of diabetes will receive at least one fundoscopic exam every 12 months.2. Glycohemoglobin Levels. MediPass acknowledges that tight control of blood glucose levels can delay the onset and slow the progression of many of the side effects from diabetes. Glycohemoglobin is one laboratory indicator of how well a recipient's blood sugar is controlled. Consistent with the American Diabetic Association recommendations, the MediPass Primary Care Provider will provide or manage services such that recipients with a history of diabetes will receive glycohemoglobin determinations at least twice a year.
3. Lipid Levels. MediPass recognizes the direct link between hyperlipidemia, secondary hyperlipoproteinemias and diabetes mellitus. By closely monitoring lipids and lipoprotein levels in diabetics, better control and maintenance of diabetes is possible. Consistent with the recommendations of the American Diabetes Association, the MediPass Primary Care Provider will provide or manage services such that the recipients with a history of diabetes will receive lipid and lipoprotein determinations annually. If any anomalies are found in the annual baseline, additional studies should be conducted as medically necessary.
e. Mammography screening. MediPass recognizes that breast cancer is one of the most common malignancies affecting women. Early detection and treatment of breast cancer improves the probability of long-term survival. Mammography screening is one technique used for detection of breast cancer. The MediPass Primary Care provider will provide or manage services such that female recipients will receive mammography screening consistent with the recommendations in the Medicaid Physician Coverage and Limitations Handbook.
f. Cervical Cancer Screening. MediPass is committed to reducing the incidence of cervical cancer. Early detection and treatment of cervical cancer improves the probability of long-term survival. Cervical cancer can be detected in its early stages by regular screening using a Papanicolaou (Pap) test. Consistent with the recommendations by the American College of Obstetricians and Gynecologists, American Medical Association, American Cancer Society and the U.S. Preventative Service Task Force, the MediPass Primary Care Provider will provide or manage services such that female recipient's between ages 18 and 64 years, or if younger than 18 years, who have been sexually active, will receive at lest one pap test every two years. " Florida Agreement, pages 14-17.
"16.5 Standards of Care
The (PCP/Contractor) must adopt practice guidelines consistent with current standards of care, taking into consideration recommendations of professional specialty groups such as the American Academy of Pediatrics, the U.S. Task Force on Preventive Care, the New York State Child/Teen Health Program (C/THP) standards for provision of care to individuals under age 21, the American College of Obstetricians and Gynecologists and the AIDS Institute Clinical Standards for Adult and Pediatric Care." New York Contract, page 38.