Page 49

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

Effective Date:

Approval Date: 49 service and review of notices of denials. ♦ Member Access to Service and Utilization of Service is evaluated by site examination of PHP policies and practices and encounter data claim validation.

♦ Member Educational Plans and Provider Information are evaluated by site examination of PHP policies, practices and materials. ♦ Preventive care, adequacy of medical or dental record keeping; ♦ Operation and outcome of referral procedures; ♦ Medication reviews; ♦ Appointment systems; ♦ After-hours call-in system; ♦ Emergency services; ♦ Denials of service; ♦ PHP-initiated disenrollments; ♦ The access plan and out-of-plan access; ♦ Encounter data management; and ♦ Timeliness and appropriateness of referrals. ♦ DMAP also reviews for compliance with its Administrative Rules which set standards for access, provider credentialling and other structural measures of quality.

Oregon's PHPs have adopted selected elements of NCQA standards as the basis for their quality improvement programs, credentialing systems, record keeping, and utilization review. DMAP also contracts with an External Quality Review Organization (EQRO) for medical record review of a representative sample of OHP Medicaid clients to determine the quality of care they receive. Recent EQRO studies include prenatal care, diabetes management and depression.

Access and Member Satisfaction DMAP conducts surveys of members to determine satisfaction with access to medical services in terms of distance and appointment availability. Americans with Disabilities Act (ADA) access is reviewed in the survey of adult populations and children’s access to service with the children's form of the Consumer Assessment of Health Plans Study (CAHPS) survey. Oregon has established a biennial member satisfaction survey using the nationally standardized CAHPS instrument to assess members experiences of access, satisfaction, and system performance.

Quality Assurance and Utilization Review Oregon has built on the successful design, implementation, and improvement of the OHP Quality Improvement Program for CHIP OHP