Linkage between performance measures and service duties
AL | KY | NE "Section Eighteen: Agency Monitoring...
II. Medical Record Reviews
Randomly during the fourth quarter after a PMP begins participating in the Patient 1st Program, or in response to complaints or unusual utilization patterns, Medicaid will perform on-site medical reviews of Patient 1st Program PMPs. A random statistical sample of the PMP's assigned recipients is drawn prior to the review and the Medicaid claims history for these patients is analyzed. The purpose of this review is to assure PMPs are following guidelines for the performance of case management services, to give the Agency an opportunity to collect data concerning quality initiatives not available through the collection of claims data and to provide opportunity for face-to-face Agency contact with the PMP...The review form will include elements of review specific to PMP responsibilities and priority areas for data collection. See Attachment Six." Alabama PMP, page 23.
"V. It is agreed that the Department and/or Medicaid program will: ...
D. Utilize data relating to utilization by enrollees to determine whether primary physicians or clinics are within acceptable KenPAC practice and use patterns using the methodology in Appendix A of this agreement." Kentucky Agreement, page 4."9.19.1 Performance Measures: In addition to developing and implementing the NHC program according to policy and procedures, the Contractor shall follow QA/QI methodologies, adhere to all specified reporting requirements, assist the Department in validating that services provided were authorized, and comply with all elements pursuant to this contract." Nebraska Contract, page 111.
"ARTICLE VIII
8.O GOALS/MEASURES THE PROVISION OF THE BASIC BENEFITS PACKAGE...8.10 Goal: Operationalizing the requirements for complying with HEALTH CHECK (EPSDT).
8.10.1 Initial Measure: A workplan that identifies the Contractor's strengths and areas for improvement in the above stated goal, a proposed corrective action plan, and the method that will be utilized by the Contractor to evaluate the effectiveness of the activities.
The workplan shall include a description and documentation to establish that the Contractor is able to adequately meet the following requirements:
(a) The Contractor's HEALTH CHECK (EPSDT) program and how the Contractor will ensure that children receive HEALTH CH ECK (E PS DT) services including follow-up treatment and subsequent medical, hearing, vision, and dental exams. Include a description of the Contractor's process for reminders, follow-up, and outreach to HEALTH CHECK (EPSDT) eligible clients and method to communicate HEALTH CHECK (EPSDT) requirements to providers. Describe the Contractor's process for HEALTH CHECK (EPSDT) outreach activities, immunizations and coordinated child wellness and prevention care;
(b) Goals for achieving compliance with the recommended participation rate;
(c) Compliance with the sixty (60) day requirements for a screening examination upon request by a client, and subsequent screening exams according to the appropriate periodicity schedules;
(d) The Contractor's immunization program, and protocols for participation in the Vaccine for Children program as well as coordination of related screening, treatment and reporting activities with State and Local Public Health Agencies;
(e) The Contractor's outreach program, and protocols for coordination with State and Local public health agencies on assessment, reporting and other educational services, e.g., screening for Elevated Blood Lead Levels, reporting to public health agencies and follow-up care for lead poisoned children will be accomplished;
(f) The Contractor's level of participation with maternal and child health programs and activities; and
(g) The Contractor's process for referrals to pediatric subspecialty providers, as well as the Contractor's capacity to provide such services.
The workplan shall include a detailed description of how these, and similar, policies and procedures will be implemented. Describe any written protocols, training and education that will be provided to staff, providers and clients.
The initial workplan shall be submitted and approved by the Department prior to July, 1999.
The Contractor's internal operations manual addressing the requirements shall be included with the initial workplan. Proposed printed materials shall be included as part of the workplan, along with a timetable for development and printing that incorporates the requirement for review by the Department, and an anticipated distribution plan.
8.10.2 Ongoing Measure: A progress report that identifies the outcome of the proposed workplan identified above. The progress report shall be submitted and approved by the Department on a quarterly basis and shall address activities completed during the reporting period.
The Contractor shall be required to address specific issues, problems and how the Contractor resolved such issues.
8.10.3 Minimum Requirement: The Contractor shall be considered in compliance with this requirement as long as the procedures are effectively being utilized by the Contractor on an ongoing basis. The Contractor shall demonstrate compliance with all related NHC policy and procedure. The Department will not unreasonably withhold approval, and shall work with the Contractor to meet this requirement.
At a minimum, the Contractor shall complete at least one activity to educate the client and/or provider about the above NHC requirements that will facilitate provider performance, member education and utilization management on a quarterly basis.
8.11 Goal: Operationalizing the requirements for the provision of the Basic Benefits Package.
8.11.1 Initial Measure: A workplan that identifies the Contractor's strengths and areas for improvement in the above stated goal, a proposed corrective action plan, and the method that will be utilized by the Contractor to evaluate the effectiveness of the activities.
The workplan shall identify the Contractor's understanding of the each service, pursuant to 471 NAC. The workplan shall include a description of how the Contractor will operationalize the Department's interpretation of the service and how the Contractor shall communicate this to the providers in the Contractor's network and to the client. The workplan shall include a description or matrix describing access, minimum allowances, referral and prior authorization patterns for all services included in the Basic Benefits Package.
The workplan shall include a detailed description of how these, and similar, policies and procedures will be implemented. Describe any written protocols, training and education that will be provided to staff, providers and clients.
The initial workplan shall be submitted and approved by the Department prior to July,1999.
The Contractor's internal operations manual addressing the requirements shall be included with the initial workplan.
Proposed printed materials shall be included as part of the workplan, along with a timetable for development and printing that incorporates the requirement for review by the Department, and an anticipated distribution plan.
8.11.2 Ongoing Measure: A progress report that identifies the outcome of the proposed workplan identified above. The progress report shall be submitted and approved by the Department on a quarterly basis and shall address activities completed during the reporting period.
The Contractor shall be required to address specific issues, problems and how the Contractor resolved such issues.
8.11.3 Minimum Requirement: The Contractor shall be considered in compliance with this requirement as long as the procedures are effectively being utilized by the Contractor on an ongoing basis. The Contractor shall demonstrate compliance with all related NHC policy and procedure and a willingness to work with the Department in the interpretation of service delivery. The Department will not unreasonably withhold approval, and shall work with the Contractor to meet this requirement.
At a minimum, the Contractor shall complete at least one activity to educate the client and/or provider about the above NHC requirements that will facilitate provider performance, member education and utilization management on a quarterly basis." Nebraska Contract, page 120.