Quality Management Program Clause Samples

Quality Management Program. To adopt and maintain a Quality Management Program consistent with BLUE CROSS standards and approved by BLUE CROSS. This program will cover all Covered Medical Services provided or arranged by PARTICIPATING MEDICAL GROUP for Members. PARTICIPATING MEDICAL GROUP agrees to allow on-site review(s) of its Quality Management Program by BLUE CROSS staff. A. The Quality Management Program shall: (1) Provide for Quality Management review by PARTICIPATING MEDICAL GROUP Physicians and other Health Professionals. (2) Provide for review of all services provided to Members by PARTICIPATING MEDICAL GROUP. (3) Stress health outcomes by providing health education and wellness programs for Members. B. The Quality Management Program shall include, but not be limited to the following activities: (1) Credentialing, recredentialing and peer review of all PARTICIPATING MEDICAL GROUP Physicians and allied Health Professional providers. (2) Credentialing, recredentialing and peer review of all Health Professionals or providers under contract with or employed by PARTICIPATING MEDICAL GROUP. (3) Incident identification and risk management. (4) Member grievance resolution. (5) General and focused health care audits. (6) Development and implementation of appropriate recommendations. (7) Documentation of remedial procedures for instances of inappropriate or substandard service(s) and/or failure to provide needed Medically Necessary Covered Medical Service(s). C. BLUE CROSS shall validate PARTICIPATING MEDICAL GROUP’s development and implementation of the Quality Management Program through regular audit activities in accordance with the Operations Manual and as follows: (1) The BLUE CROSS Quality Management Department shall review PARTICIPATING MEDICAL GROUP’s Quality Management Program on an annual basis through a scheduled on-site audit. (2) The AIM Quality Management Representative shall notify PARTICIPATING MEDICAL GROUP of any deficiencies or areas needing improvement. (3) PARTICIPATING MEDICAL GROUP shall take corrective action to eliminate any deficiencies in areas needing improvement within a reasonable period of time. (4) BLUE CROSS shall conduct follow-up reviews as necessary. D. PARTICIPATING MEDICAL GROUP shall: (1) Make available to BLUE CROSS all minutes and notes from any and all Quality Management Committees and/or activities which specifically relate to Members. (2) Provide BLUE CROSS with access to all PARTICIPATING MEDICAL GROUP Quality Management data directly or in...

Quality Management Program. An ongoing review process and plan which functions to define, monitor, review, and recommend corrective action for managing and improving the quality of health care services to Members.

Quality Management Program. Contractor shall maintain a quality management program to review the quality of Covered Services provided by Participating Providers and other subcontractors. Contractor’s quality management program shall be subject to review by the Exchange annually to evaluate Contractor’s compliance with requirements set forth in the Quality, Network Management and Delivery System Standards. Contractor shall coordinate and cooperate with the Exchange in developing the Quality, Network Management and Delivery System Standards, including (i) participating in meetings and other programs as reasonably requested from time to time by the Exchange, and (ii) providing mutually agreed upon data and other information required under the Quality, Network Management and Delivery System Standards and (iii) as otherwise reasonably requested by the Exchange. The parties acknowledge and agree that quality related activities contemplated under this Article 4 will be subject to and conducted in compliance with any and all applicable laws, rules and regulations including those relating the confidentiality of medical information and will preserve all privileges set forth at Health and Safety Code § 1370.

Quality Management Program. Contractor shall maintain a quality management program to review the quality of Specialized Health Care Services provided by Participating Providers and other subcontractors. Contractor’s quality management program shall be subject to review by Covered California annually to evaluate Contractor’s compliance with requirements set forth in the Quality, Network Management and Delivery System Standards. Contractor shall coordinate and cooperate with Covered California in developing the Quality, Network Management and Delivery System Standards, including (i) participating in meetings and other programs as reasonably requested from time to time by Covered California, (ii) providing mutually agreed upon data and other information required under the Quality, Network Management and Delivery System Standards, and (iii) as otherwise reasonably requested by Covered California. The parties acknowledge and agree that quality related activities contemplated under this Article 4 will be subject to and conducted in compliance with any and all applicable laws, rules and regulations including those relating the confidentiality of medical information and will preserve all privileges set forth at Health and Safety Code § 1370. Consistent with Covered California's mission to promote better care, better health and lower cost as part of a Quality Improvement Strategy, Contractor agrees to: (a) Implement a quality assurance program in accordance with 28 CCR § 1300.70, for evaluating the appropriateness and quality of the covered services provide to members; (b) Maintain a system of accountability for quality improvement in accordance with all applicable statutes and regulations, monitoring, evaluating and taking effective action to address any needed improvements, as identified by Covered California, in the quality of care delivered to members; and (c) Work with Covered California to craft a quality improvement program that is dental-specific and tailored to the Covered California population.

Quality Management Program. Contractor shall maintain a quality management program to review the quality of Specialized Health Care Services provided by Participating Providers and other subcontractors. Contractor’s quality management program shall be subject to review by the Exchange annually to evaluate Contractor’s compliance with requirements set forth in the Quality, Network Management and Delivery System Standards. Contractor shall coordinate and cooperate with the Exchange in developing the Quality, Network Management and Delivery System Standards, including (i) participating in meetings and other programs as reasonably requested from time to time by the Exchange, and (ii) providing mutually agreed upon data and other information required under the Quality, Network Management and Delivery System Standards and/or (iii) as otherwise reasonably requested by the Exchange. The parties acknowledge and agree that quality related activities contemplated under this Article 4 will be subject to and conducted in compliance with any and all applicable laws, rules and regulations including those relating the confidentiality of medical information and will preserve all privileges set forth at Health and Safety Code 1370. Consistent with The Exchange's mission to promote better care, better health and lower cost as part of a Quality Improvement Strategy, Contractor agrees to: (a) Implement a quality assurance program in accordance with Title 28, CCR, § 1300.70, for evaluating the appropriateness and quality of the covered services provide to members; (b) Maintain a system of accountability for quality improvement in accordance with all applicable statutes and regulations, monitoring, evaluating and taking effective action to address any needed improvements, as identified by the Exchange, in the quality of care delivered to members; and (c) Work with Exchange to craft a quality improvement program that is dental-specific and tailored to the Exchange population.

Quality Management Program. The Contractor shall have an ongoing quality management program for the services it furnishes to members. The quality management program shall include but is not limited to:

Quality Management Program. The functions, including, but not --------------------------- limited to, credentialing and certification of providers, review and audit of medical and other records, outcome rate reviews, peer review and provider appeals and grievance procedures performed or required by Foundation, an Affiliate, a Payor, or any other permitted person or entity, to review and improve the quality of Covered Medical Services rendered to Beneficiaries.

Quality Management Program. The Contractor shall ensure its Quality Management (QM) program addresses GFS requirements. The HCA, Office of the State Auditor, or any of their duly-authorized representatives, may conduct announced and unannounced: Surveys, audits and reviews of compliance with licensing and certification requirements and the terms of this Contract; Audits regarding the quality, appropriateness, and timeliness of Behavioral Health services provided under this Contract; and Audits and inspections of financial records, related to GFS services. The Contractor shall participate with HCA in review activities. Participation will include at a minimum: The submission of requested materials necessary for an HCA initiated review within thirty (30) days of the request. The completion of site visit protocols provided by HCA. Assistance in scheduling interviews and agency visits required for the completion of the review. The Contractor shall notify HCA when an entity other than the State Auditor performs any audit described above related to any activity contained in this Contract. HCA defined reporting and data submission methods for Performance Measurement and Reporting: The Contractor shall comply with the reporting and data submissions requirements as directed by HCA and shall make reports available to HCA at least annually through the HCA monitoring process or more frequently, as requested by HCA. Should HCA adopt a subsequent set of requirements during the term of this Contract, HCA shall update the performance requirements as necessary. All performance measures are subject to an audit.

Quality Management Program. See Section 4 “Other Contractual Requirements” for more details, requirements, and performance measures The scope of this Contract includes the requirement for a Quality Management Program established by the Contractor as a minimum framework for the Contractor for self-monitoring, self-evaluation, and self-reporting. The Contractor’s Quality Management Program requires a continuous process of self-monitoring and self-evaluation of performance. The expectation is all performance failures will be identified and addressed by the Contractor without Department involvement. When performance failures are identified, the Contractor is expected to correct the failures and review its Operations Plan and Quality Management Plan to determine changes needed to prevent additional performance failures. The Contractor is expected to document all changes and make all documentation available to the Department for review upon request. The Quality Management Program should include a system of checks and balances for the Contractor to validate their operations and provide a consistent and baseline approach to Quality Management practices to ensure compliance with all Contract performance measures. The Quality Management Program should identify the individuals responsible for quality control measures and specific actions that are used to ensure quality results. Quality Management consists of three primary components: Quality Checks, Quality Control Reviews (Back Checks), and Quality Assurance Reviews (Process Reviews).