Common use of QUALITY STANDARDS AND MANAGEMENT Clause in Contracts

QUALITY STANDARDS AND MANAGEMENT. A. The Contractor shall demonstrate its ability to meet HCA’s quality standards in areas of staffing, procedures, criteria, regulatory standards, review management, and internal quality management of fraud, abuse prevention and detection. B. The Contractor shall ensure its TPA/FFS UR staff possesses sufficient and relevant current knowledge of the requirements of this Scope of Work; the Medical Assistance Division Program Rules and the applicable Federal regulations; HCA-approved review criteria; and HCA-approved detailed review procedures. C. The Contractor shall maintain a level of work performance consistent with high professional standards in the industry. All employees assigned to perform work relating to this PSC will be capable, efficient, and no less qualified than other employees of the Contractor performing the same or similar work. D. The Contractor shall cooperate with HCA when a decision is made to audit the Contractor’s work and performance or is otherwise required for the purpose of assessing program performance measures and reporting assurances to the federal Centers for Medicare and Medicaid Services (CMS). The Contractor shall cooperate fully with HCA to prepare complete documentation, participate in audits, provide a workspace and workstation for use by the HCA auditor, and otherwise allow HCA to access its utilization management system to view recipient and provider records and documentation. At a minimum, the Contractor's compliance will be evaluated in the following areas: 1. The New Mexico Medical Assistance Division Program Rule was followed for each review; 2. HCA-approved review criteria and tools were properly applied to each review;

QUALITY STANDARDS AND MANAGEMENT. A. The Contractor shall demonstrate its ability to meet HCAHSD’s quality standards in areas of staffing, procedures, criteria, regulatory standards, review management, and internal quality management of fraud, abuse prevention and detection. B. The Contractor shall ensure its TPA/FFS UR staff possesses sufficient and relevant current knowledge of the requirements of this Scope of Work; the Medical Assistance Division Program Rules and the applicable Federal regulations; HCAHSD-approved review criteria; and HCA-HSD- approved detailed review procedures. C. The Contractor shall maintain a level of work performance consistent with high professional standards in the industry. All employees assigned to perform work relating to this PSC will be capable, efficient, efficient and no less qualified than other employees of the Contractor performing the same or similar work. D. The Contractor shall cooperate with HCA HSD when a decision is made to audit the Contractor’s work and performance or is otherwise required for the purpose of assessing program performance measures and reporting assurances to the federal Centers for Medicare and Medicaid Services (CMS). The Contractor shall cooperate fully with HCA HSD to prepare complete documentation, participate in audits, provide a workspace and workstation for use by the HCA auditor, HSD auditor and otherwise allow HCA HSD to access to its utilization management system to view recipient and provider records and documentation. At a minimum, the Contractor's compliance will be evaluated in the following areas: 1. The New Mexico Medical Assistance Division Program Rule was followed for each review; 2. HCAHSD-approved review criteria and tools were properly applied to each review; 3. HSD-approved Standard Operating Procedures were followed; and 4. HSD-approved Turn-Around-Times were followed. HSD will inform the Contractor in the event that additional performance measures are required.

QUALITY STANDARDS AND MANAGEMENT. A. The Contractor shall demonstrate its ability to meet HCAHSD’s quality standards in areas of staffing, procedures, criteria, regulatory standards, review management, and internal quality management of fraud, abuse prevention and detection. B. The Contractor shall ensure its TPA/FFS UR staff possesses sufficient and relevant current knowledge of the requirements of this Scope of Work; the Medical Assistance Division Program Rules and the applicable Federal regulations; HCAHSD-approved review criteria; and HCAHSD-approved detailed review procedures. C. The Contractor shall maintain a level of work performance consistent with high professional standards in the industry. All employees assigned to perform work relating to this PSC will be capable, efficient, efficient and no less qualified than other employees of the Contractor performing the same or similar work. D. The Contractor shall cooperate with HCA HSD when a decision is made to audit the Contractor’s work and performance or is otherwise required for the purpose of assessing program performance measures and reporting assurances to the federal Centers for Medicare and Medicaid Services (CMS). The Contractor shall cooperate fully with HCA HSD to prepare complete documentation, participate in audits, provide a workspace and workstation for use by the HCA auditor, HSD auditor and otherwise allow HCA HSD to access to its utilization management system to view recipient and provider records and documentation. At a minimum, the Contractor's compliance will be evaluated in the following areas: 1. The New Mexico Medical Assistance Division Program Rule was followed for each review; 2. HCAHSD-approved review criteria and tools were properly applied to each review; 3. HSD-approved Standard Operating Procedures were followed; and 4. HSD-approved Turn-Around-Times were followed. HSD will inform the Contractor in the event that additional performance measures are required.