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

Effective Date:

Approval Date: September 19, 2002 35 correcting deficiencies.

The Department has established quality control mechanisms for managed care which include ongoing monitoring of contract compliance, including the areas of covered services; service delivery; access standards; health education and outreach; pharmacy formulary; linkages to other services; records requirements; care standards; encounter reporting on encounters and quality assurance/improvement activities; marketing; member services; health outcomes, including measuring HEDIS indicators; minimum required performance standards; and financial stability. The Department contracts with a Quality Assurance Organization to assist in the oversight of managed care under both Title XIX and Title XXI. The Contractor’s responsibilities include but are not limited to, medical records review, technical assistance, health outcome analysis and quality assurance monitoring of each managed care entity.

Fee-For-Service Quality assurance mechanisms in the fee-for-service Medicaid system are listed below. These are employed under fee-for-service for KidCare Share and KidCare Premium. Through these mechanisms, quality problems are identified and addressed. Providers found to have quality problems are asked to prepare quality improvement plans.

1. Staff from the Division of Medical Programs watch for provider abuses of the Medicaid system. Such abuses are referred to the Office of the Inspector General (OIG) for review. 2. OIG has many tasks to assure medical quality. a. Face-to-face client surveys regarding quality of care and access to care. b. Investigations of referrals from within DPA; the Department of State Police; the Department of Public Health; and from the state’s peer review organization. c. Audits of providers who fall outside accepted norms for claims activity. d. Peer review coordination of medical necessity and over- utilization issues. 3. The state’s Medical Management Information System (MMIS) includes many edits to prevent abuse and excessive billings. New ones are created regularly. 4. DPA operates a toll-free hotline for clients to report any problems