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• Disenrollment rates • Encounter data validity audit (DVA) • External Quality Review (EQR)

Performance improvement projects: Each HMO must report in detail on at least two performance improvement projects conducted by the organization in the previous year. Topics may be clinical or non-clinical and should relate to priority areas specified by the DHFS in the HMO contract.

Other performance improvement tools include: • MEDDIC-MS Goal-setting Process • Care Analysis Projects • Best practices symposium-diffusion of innovation • HMO Report Card • New Enrollee Health Needs Assessment (NEHNA) survey • Stay Safe & Healthy enrollee safety education initiative • External Quality Review reports • Technical assistance, training • Biannual QAPI recertification audit reports • HMO performance improvement projects • DHFS Strategic plan and biannual strategic plan assessment • HMO Accreditation Incentive Program • Other pay-for-performance incentives are in development.

Structure and process tools-in contract (subject to certification and recertification review) • Written HMO access and availability standards • HMO must provide written assurance of network adequacy • Geo-access review of HMO provider network • Coordination and continuity of care policies • UM/UR, denial criteria and policies • Clinical practice guidelines; development, update and dissemination policies • Enrollee rights protections and policies • Medical records content and confidentiality protections and policies • Enrollment and disenrollment policies • Grievance and complaint policies • Internal advocate and grievance processes, formal and informal • Delegation policies and agreements • Demand management system (nurse line or phone triage) policies • Provider/practitioner credentialing/recredentialing policies

WISCONSIN

Effective Date:

Approval Date: 36