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41 Effective Date: July 1, 2009

Approval Date: • Applying utilization controls for FFS coverage that are consistent with all current utilization review requirements under the state’s Medicaid plan. Examples of controls include external review of hospital claims data, exception-to-policy procedures, data audits, pre- authorization for extended coverage utilization, and drug utilization review; • Performing at minimum annual, on-site quality and operational reviews of the MCO contractors; • Reviewing of the MCOs by an External Quality Review Organization (EQRO), as required by federal law (Section 1902 (a) (30) (C) of the Social Security Act); • Requiring that MCOs maintain an internal program of quality assurance, as required by federal regulations (42 CFR 434.34); • Performing biennial client satisfaction surveys; • Monitoring of actions, grievances and appeals at both the health plan level and the Medicaid state agency level.

Will the State utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards

In addition to the utilization controls described in Section 3.2, National Committee for Quality Assurance (NCQA) standards are the guidelines for contract requirements and monitoring. Generally, the NCQA standards address the following: • Quality Management and Improvement – program structure, program operations, health services contracting, availability of practitioners; • Accessibility of services, member satisfaction, health management systems, primary care provider role, scope and content of clinical quality improvement (QI) activities, clinical measurement activities, effectiveness of the QI program, and delegation of QI activity; • Utilization Management; • Credentialing and Re-credentialing; • Members’ Rights and Responsibilities; and • Preventative Health Services and Medical Records. Quality standards for FFS will be consistent with all quality utilization review requirements under the state’s Medicaid plan, and the additional quality activities listed in Section 7.1