Common use of Quality Monitoring Clause in Contracts

Quality Monitoring. 4.9.1 ASES, in strict compliance with applicable provisions of 42 CFR 438.204 and other federal and Puerto Rico regulations, shall evaluate the delivery of health care by the Contractor’s Provider Network. Such quality monitoring shall include monitoring of all the Contractor’s Quality Improvement programs described in Article 12 of this Contract. ASES shall monitor the following items, among others: 4.9.1.1 The availability of Covered Services; 4.9.1.2 The adequacy of the Contractor’s Provider Network; 4.9.1.3 The Contractor’s coordination and continuity of care for Enrollees; 4.9.1.4 The coverage and authorization of Covered Services and Benefits; 4.9.1.5 The Contractor’s policies and procedures for selection and retention of Providers; 4.9.1.6 The Contractor’s compliance with Enrollee information requirements in accordance with 42 CFR 438.10; 4.9.1.7 The Contractor’s compliance with Puerto Rico and federal privacy laws and regulations relative to confidentiality of Enrollee information; 4.9.1.8 The Contractor’s compliance with Enrollment and Disenrollment requirements and limitations; 4.9.1.9 The Contractor’s Grievance System; 4.9.1.10 The Contractor’s oversight of all Subcontractor relationships and delegations; 4.9.1.11 The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and, upon request, to Enrollees, and Providers’ application of the Guidelines; 4.9.1.12 The Contractor’s quality assessment and performance improvement program; and 4.9.1.13 The Contractor’s Information Systems to ensure it supports initial and ongoing review of Puerto Rico’s quality strategy.