us-de/policy/cms/chip-state-plan/compiled/current-state-plan/page-25

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us-de/policy/cms/chip-state-plan/compiled/current-state-plan/page-25 — Page 25 · Axiom

DELAWARE HEALTHY CHILDREN PROGRAM (DHCP) 25

Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Internal Staff

The State’s enrolled populations for the Title XIX and the Title XXI programs are too small to require separate internal programs for the MCOs. Therefore, internal staff and internal committees may serve both populations. A clear definition will be made during reporting.

The MCO must designate a quality assurance and utilization management coordinator, who is either the MCO's medical director or a person who directly reports to the medical director. This individual is responsible for the development and implementation of the quality assurance program. The coordinator must have adequate and appropriate experience in successful utilization management and quality assurance programs and be given sufficient time and support staff to carry out the MCO's utilization management and quality assurance functions. This person, or persons, will also be responsible for assuring the interface and support of the EQRO and State quality assurance functions as necessary.

Quality Assurance Committee

MCOs must have a quality assurance committee that assists the coordinator in carrying out all quality assurance functions. This committee must satisfy the DSS's requirements and, at a minimum:

(a)Demonstrate that the Committee will have oversight…#

(a) Demonstrate that the Committee will have oversight responsibility and input on all quality assurance and utilization management activities;

(b)Demonstrate that the committee has accountability to…#

(b) Demonstrate that the committee has accountability to the MCOs governing board;

(c)Ensure membership on the committee and active…#

(c) Ensure membership on the committee and active participation by individuals representative of the MCOs provider community; and

(d)Demonstrate that the contractor will secure adequate…#

(d) Demonstrate that the contractor will secure adequate insurance for members of the committee and subcommittees.

Quality Assurance and Utilization Management Coordinator

The coordinator and the quality assurance committee must be accountable to the MCO's governing body.

The qualifications and responsibilities must include but need not be limited to what follows below. Specifically, the coordinator must:

(a) Be licensed to practice medicine in the United States and be board- certified or board-eligible in his or her field of specialty;