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Title: Section 98-1.12 - Quality management program

Effective Date


98-1.12 Quality management program. (a) An MCO shall develop and implement a quality management program, that is supervised by the medical director and that includes organizational arrangements and ongoing procedures for the identification, evaluation, resolution and follow-up of potential and actual problems in health care administration and delivery to enrollees. MCOss shall include in such quality management programs standards for management of access to, continuity and quality of care and, except for PCPCPs, utilization and cost of services.
(b) MCOs shall also develop a quality assessment and performance improvement program that includes performance and outcome-based quality standards for enrollee health status, satisfaction, and for MLTCPs, functional status also. The program shall achieve required minimum levels of performance on standardized quality measures established by the commissioner. In the case of an HIV SNP, the quality indicator measures must include HIV-specific quality measures.

(c) A health information system shall be maintained that collects, analyzes, integrates, and reports data necessary to develop and implement the quality assurance and performance improvement programs.

(d) The quality assessment and performance improvement programs shall be approved by the commissioner prior to issuance of a certificate of authority and monitored periodically thereafter by the commissioner.

(e) The quality assessment organizational arrangements and ongoing procedures must be fully described in written form, provided to all members of the governing authority, providers and staff, and made available to enrollees in the MCO.
(f) The organizational arrangements for the quality assessment program must be clearly defined and transmitted to all individuals involved in the quality assessment program, and should include, but not be limited to, the following:
(1) an internal quality assurance committee or comparable designated committee responsible for quality assurance activities;
(i) accountability of the committee to the governing authority of the MCO, including periodic written and oral reports to the governing authority;
(ii) participation from an appropriate base of providers and support staff;
(iii) regularly scheduled meetings at appropriate periodic intervals, no fewer than four per year; and
(iv) minutes or records of the meetings, describing in detail the actions of the committee, including the medical charts reviewed, problems discussed, recommendations made, and any other pertinent discussions and activities; and

(2) a peer review committee responsible for monitoring provider performance.
(g) The quality assurance procedures shall include defined methods for the identification and selection of clinical and administrative problems. Input for problem identification should come from multiple sources, including but not limited to medical chart reviews, member complaints, epidemiological data, utilization data, patient surveys, utilization review, and other data which identify patterns of care, and shall cover all MCO services. Methods shall be established by which potential problems are selected and scheduled for further study.
(h) An MCO shall document the manner by which it examines actual and potential problems in health care administration and delivery to enrollees. While a variety of methods may be utilized, the following components should be present:
(1) the existence of procedures for the analysis;
(2) the acquisition of sufficient data to perform a meaningful analysis; for example, a statistically valid sample size for medical chart review; and
(3) involvement of appropriate clinical personnel, including physicians and other providers for peer review.
(i) The quality assurance activities shall include the development of timely and appropriate recommendations. For problems in health care administration and delivery to enrollees that are identified, the MCO must demonstrate an operational mechanism for responding to those problems. Such a mechanism should include:
(1) development of appropriate recommendations for corrective action or, when no action is indicated, an appropriate response;
(2) assignment of responsibility at the appropriate level or with the appropriate person for the implementation of the recommendation; and
(3) implementation of action which is appropriate to the subject or problem in health care administration and delivery to enrollees.
(j) There shall be evidence of adequate follow-up on recommendations. The MCO must be able to demonstrate that recommendations of the committee responsible for quality assurance activities are reviewed in a timely manner, in order to:
(1) assure the implementation of action relative to the recommendations;
(2) assess the results of such action; and
(3) provide for revision of recommendations or actions and continued monitoring when necessary.
(k) Physicians and other health professionals providing covered services to enrollees shall be licensed, certified and currently registered, in accordance with New York State law. MCOs must develop and utilize credentialing and recredentialing processes, consistent with generally accepted standards, that are performed under the direction of the medical director.

(l) Whenever a health care professional is unable to provide health care services due to a final disciplinary action by a state licensing board or other governmental agency that impairs the health care professional’s ability to practice, the MCO must take immediate action, upon receipt of notice, to remove the professional from the network.

(m) Laboratory, pathology and radiology services shall be under the direction of a qualified medical professional.
(n) The MCO shall require and assure that the medical records of enrollees be retained for six years after the date of service rendered to enrollees, and in the case of a minor, for three years after majority or six years after the date of the service, whichever is later.

(o) The MCO or, if specifically provided for in the contract, the contracted provider must provide to each health care provider or to each IPA with which the MCO contracts a provider manual which, unless otherwise provided for in the contract, shall contain a description of the policies and operating procedures established by the MCO for the provision of covered services to enrollees of the MCO, and include provider rights. The provider manual shall be furnished to the provider prior to the effective date of the provider’s participation in the network and subsequent to the satisfactory completion of the MCO’s credentialing process, and shall be amended as the MCO’s operational policies change. Revisions to the provider manual may be provided through provider bulletins or other communication to providers; however, revisions must be incorporated in the appropriate section of the manual.


VOLUME A-2 (Title 10)