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

Effective Date:

Approval Date: 7-2 the substance of such allegations; ● Substance of any findings from such proceedings; ● Sanctions imposed by Medicare or Medicaid; ● Names and relevant information of providers who shall serve as on-call designees for the provider (applies to non-staff, group models only).

Health plans must ensure that all on-call providers are in compliance with plan credentialing standards, including any non-participating providers serving in this capacity;

● Attention of provider as to validity of information provided; ● Information from other HMOs or hospitals with which provider has been associated regarding professional misconduct or medical malpractice, and associated judgments/settlements, and any reports of professional misconduct by a hospital; ● Review of provider’s physical site of practice; ● Review of provider’s capacity to provide such services, based on practice size and available resources; and ● Review of National Practitioner Data Bank profile

Health plans must re-credential their providers at least once every two years. During such re-credentialing, health plans should re-examine the items covered during the initial credentialing, as well as complaints lodged against the provider by plan members and results of chart audits and other quality reviews.

7.1.2.

Performance measurement

As stated above in section 7.1, health plans are required to submit specific quality performance data on an annual basis which is consistent with the New York State Department of Health Quality Assurance Reporting Requirement (QARR). These data are used to compare health plan performance on an annual basis, both on an individual plan and statewide basis. The measures are a combination of measures from the National Committee for Quality Assurance (NCQA) Health Plan Employer Data Base Information Set (HEDIS® 2005), and child and adolescent care measures developed by the New York State Department of Health (NYSDOH). The measures change each year. Specific measures and performance can be examined in the New York State CHIP Annual Report.

Other information collected by the Department and used in the performance measurement includes the following:

Membership

● Member months of enrollment by age, sex and payer ● Enrollment by county

Utilization

● Frequency of selected conditions ● Inpatient care ● Ambulatory care ● Disenrollment rate