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Effective Date:
Approval Date:
Updated and amended effective August 24, 2001
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7.1.1.
Quality standards
The Department has established Quality Management and Utilization Management requirements to which the insurer is contractually bound. See Appendix E (Provided in the original State Plan) which contains requirements as specified in the Departments Request for Procurement.
7.1.2.
Performance measurement
In addition to evaluating contractors based on their overall NCQA accreditation ratings, the program also conducts Health Employer Data Information Set (HEDIS) reviews which compare the CHIP population with the commercial subscribers of the insurer. In addition, the program has started doing direct comparisons of its HEDIS data with medical assistance programs regionally and nationally.
During FY 2000 the Department, for the first time, began collecting HEDIS data and will continue to do so annually thereafter.
The Department is utilizing the technical assistance (TA) services funded through the Maternal and Child Health Bureau and sponsored in collaboration with the Center for Medicare and Medical Services. Under this initiative, referred to as CompCare, Pennsylvania has requested assistance from Health Systems Research, Inc. (HSR) in developing a system to monitor and measure the quality of care provided under the program. The specific goals of the project include:
• Assessing the capacity of contracting plans to collect and submit data; • Presenting and facilitating the selection of a set of appropriate, feasible indicators of the quality of care provided to children under CHIP; • Identifying data sources for each of the selected indicators; and • Pilot-testing the data collection plan to analyze and interpret the selected indicators.
To assist in the initial step of the TA project effort, HSR contracted with NCQA’s Quality Solution Group to conduct a readiness assessment of the Department’s contracted health