Processing Requirements. The Utilization/Quality Improvement function must include the following capabilities: 1. Maintain Provider credentialing and recredentialing activities. 2. Maintain Contractor’s processes to monitor and identify deviations in patterns of treatment from established standards or norms. Provide feedback information for monitoring progress toward goals, identifying optimal practices, and promoting continuous improvement. 3. Maintain development of cost and utilization data by Provider and services. 4. Provide aggregate performance and outcome measures using standardized quality indicators similar to Medicaid HEDIS as specified by the Department. 5. Support focused quality of care studies. 6. Support the management of referral/utilization control processes and procedures. 7. Monitor PCP referral patterns. 8. Support functions of reviewing access, use and coordination of services (i.e. actions of peer review and alert/flag for review and/or follow-up; laboratory, x-ray and other ancillary service utilization per visit). 9. Store and report Member satisfaction data through use of Member surveys, Grievance/Appeals processes, etc. 10. Provide Fraud, Waste and Abuse detection, monitoring and reporting.
Appears in 4 contracts
Sources: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract