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Effective Date: April 1, 2009

Approval Date: ____________ 40

• Ongoing review of provider networks to assure contract standards and requirements are met. • Monitoring access and availability of HMO providers including after hours calls. • Reviewing and analyzing HMO reports and encounter data. • Conducting routine medical audits of care and audits of contract compliance and performance. • Determining the need for corrective action for identified problems, developing (with the HMO) a corrective action plan and monitoring the results. • Providing ongoing technical assistance to and a forum for open communications with the HMOs to assure a thorough understanding of contract responsibilities. Host regular meetings with HMO medical staff. • Comprehensive review of HMO operations in conjunction with the PRO. • Conducting formal member satisfaction studies. (CAHPS is utilized.) • Continuous communication with community and advocacy groups.

External Quality Review Organization monitoring functions include:

• Random review of medical records maintained by direct service providers for overall access to care, quality of care, identification of potential areas for quality improvement. • Individual case reviews. • Focused studies of specific aspects of care. HEDIS standards are used wherever appropriate. • Joint review of HMO operations with the State. • Health Plan performance standards. • Health care data analysis. • Host focus groups (which include HMO direct service providers), with State input, to review certain aspects of managed care and the impact on the quality of care.

In addition, all HMOs are required to comply with regulations promulgated by the Department of Health and Senior Services in consultation with the Department of Banking and Insurance. These regulations address all aspects of the HMO operations and include methods for assuring the quality and appropriateness of care. The regulations, as well as the contract with the Department of Human Services, require each HMO to have an internal system for monitoring quality. The regulations also require that an HMO audit be performed every three years by an external quality review organization approved by the Department.

For commercial lines of business, the Department of Health and Senior Services has also created a data reporting system to collect standardized, reliable and comparable information about access, availability of services and quality from each HMO. This system is built around multiple data sources