Page 34

Model Application Template for the State Children’s Health Insurance Program

Effective Date:

Approval Date: September 19, 2002 34 Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

The Department has established access to quality care, and the appropriateness of care, as performance measures for KidCare Share and KidCare Premium. These performance goals and methods of assuring their attainment are more fully described in Section 9. Methods to measure quality and appropriateness of care include the following:

Managed Care For clients enrolled in managed care, the Department establishes and provides monitoring and oversight to ensure that quality control requirements are met. Managed Care Entities (MCEs) are required to have a quality assurance system in place that focuses on quality improvement. System activities include:

• Collecting systematic data on performance and patient results; • Monitoring health care services through medical records review, clinical studies, physician peer review, and monitoring of health outcomes; • Developing and monitoring of health education and outreach for clients • Establishing and monitoring member services to handle client issues; • Establishing mechanisms for preauthorization and review of denials; • Monitoring access standards; • Monitoring fraud and abuse; • Establishing and monitoring a client grievance and complaint resolution system; • Evaluating client satisfaction; • Providing information to providers, evaluating provider satisfaction and resolving provider concerns; and • Establishing procedures for ongoing quality improvement with written procedures for taking appropriate remedial action and