Medi-Cal Audit Crosswalk · Medi-Cal Policy Institute 476 Ninth Street Oakland, CA 94607 Tel: (510)...

Prepared for the Medi-Cal Policy Institute

by

Kristine Thurston, Meshell Hicks,Lana Cotner, and Steve Friedmand

of NCQA

Medi-Cal Audit Crosswalk

A Comparison of the NCQA Accreditation Standardsand Medi-Cal Regulatory Oversight Requirements for

Managed Care Organizations

January 2001

Acknowledgments

NCQA could not have completed this project without the assistance of the staff of the Department of ManagedHealth Care (formerly part of the Department of Corporations) and the Department of Health Services’ Medi-CalManaged Care Division. Specifically, we are grateful to Dr. Mary Fermazin, Rose Recostodio, Nelita Co, and IleneListrom of the Medi-Cal Managed Care Division’s Office of Clinical Standards and Quality, and Joyce Vermeereschand Mary Weig of the Department of Managed Health Care’s Office of Oversight Standards and Research and Of-fice of Health Plan Oversight, respectively. We thank them for the assistance they provided in making this documentan accurate reflection of the responsibilities Medi-Cal health plans have in meeting quality oversight requirements.We also thank Chris Perrone of the Medi-Cal Policy Institute for his helpful feedback on drafts of this document.

About NCQA

The National Committee for Quality Assurance (NCQA) is a private, nonprofit organization dedicated to improvingthe quality of health care delivered to people everywhere. NCQA has been the leader in developing performancemeasurement and accreditation standards for health plans since its inception in 1979. NCQA manages the evolutionof HEDIS®, the performance measurement tool used by more than 90 percent of the nation’s health plans. NCQA isgoverned by a board of directors that includes employers, consumer and labor representatives, health plans, qualityexperts, policy makers, and representatives from organized medicine to assure it maintains its independence.(HEDIS® is a registered trademark of NCQA.)

About the Medi-Cal Policy Institute

The Medi-Cal Policy Institute, established in 1997 by a grant from the California HealthCare Foundation, is an in-dependent source of information on the Medi-Cal program. The Institute seeks to facilitate and enhance the devel-opment of effective policy solutions with the interests of Medi-Cal recipients guiding this work. The Institute con-ducts and commissions research, distributes information about the program and its recipients, highlights the pro-gram’s successes, and identifies the challenges ahead. It collaborates with a broad spectrum of policymakers, re-searchers, providers, Medi-Cal beneficiaries, and other stakeholders who are working to create a more effectiveMedi-Cal program.

Copyright © 2001 Medi-Cal Policy Institute

ISBN 1-929008-50-3

Medi-Cal Policy Institute476 Ninth StreetOakland, CA 94607Tel: (510) 286-8976Fax: (510) 238-1382www.medi-cal.org

A project of the California HealthCare Foundation

Additional copies of this report can be obtained by calling the Institute at (510) 587-3199. The report is also avail-able as a PDF on the Web site at www.medi-cal.org.

Table of Contents

Introduction .................................................................................................................................................1

Methodology ................................................................................................................................................1

Key Findings ................................................................................................................................................2

Implications and Next Steps .......................................................................................................................3

Definitions and Acronyms ..........................................................................................................................4

Quality Improvement..................................................................................................................................5QI 1 Program Structure .............................................................................................................................5QI 2 Program Operations ........................................................................................................................11QI 3 Health Services Contracting............................................................................................................12QI 4 Availability of Practitioners ............................................................................................................12QI 5 Accessibility of Services .................................................................................................................18QI 6 Member Satisfaction .......................................................................................................................24QI 7 Health Management Systems ..........................................................................................................27QI 8 Clinical Practice Guidelines ............................................................................................................28QI 9 Continuity and Coordination of Care ..............................................................................................29QI 10 Clinical Measurement Activities...................................................................................................35QI 11 Intervention and Follow-up for Clinical Issues.............................................................................41QI 12 Effectiveness of the QI Program ...................................................................................................45QI 13 Delegation of QI Activity..............................................................................................................48

Utilization Management ...........................................................................................................................53UM 1 Utilization Management Structure ................................................................................................53UM 2 Clinical Criteria for UM Decisions...............................................................................................54UM 3 Appropriate Professional ..............................................................................................................56UM 4 Timeliness of UM Decisions ........................................................................................................57UM 5 Medical Information .....................................................................................................................60UM 6 Denial Notices...............................................................................................................................60UM 7 Evaluation of New Technology ....................................................................................................62UM 8 Satisfaction with the UM Process .................................................................................................62UM 9 Emergency Services......................................................................................................................63UM 10 Procedures for Pharmaceutical Management..............................................................................64UM 11 Ensuring Appropriate Service and Coverage..............................................................................67UM 12 Triage and Referral for Behavioral Health Care .........................................................................68UM 13 Delegation of UM .......................................................................................................................69

Credentialing and Recredentialing..........................................................................................................75CR 1 Credentialing Policies ....................................................................................................................75CR 2 Credentialing Committee ...............................................................................................................75CR 3 Initial Primary Source Verification................................................................................................76CR 4 Application and Attestation ...........................................................................................................76CR 5 Initial Sanction Information ...........................................................................................................77CR 6 Initial Credentialing Site Visits......................................................................................................78CR 7 Recredentialing Primary Source Verification ................................................................................78CR 8 Recredentialing Sanction Information ...........................................................................................79CR 9 Performance Monitoring ................................................................................................................80CR 10 Practitioner Appeal Rights ...........................................................................................................80

CR 11 Assessment of Organizational Providers .....................................................................................81CR 12 Delegation of Credentialing .........................................................................................................82

Members’ Rights and Responsibilities ....................................................................................................85RR 1 Statement of Members’ Rights and Responsibilities .....................................................................85RR 2 Distribution of Rights Statements to Members and Practitioners ..................................................86RR 3 Policies for Complaints and Appeals .............................................................................................86RR 4 Appropriate Handling of Complaints and Appeals ........................................................................96RR 5 Subscriber Information ..................................................................................................................96RR 6 Privacy and Confidentiality..........................................................................................................100RR 7 Marketing Information.................................................................................................................105RR 8 Delegation of Members’ Rights and Responsibilities..................................................................106

Preventive Health ....................................................................................................................................111PH 1 Adoption of Preventive Health Guidelines ..................................................................................111PH 2 Distribution of Guidelines to Practitioners...................................................................................114PH 3 Health Promotion with Members .................................................................................................115PH 4 Delegation of Preventive Health ..................................................................................................116

Medical Records ......................................................................................................................................121MR 1 Medical Record Documentation Standards.................................................................................121MR 2 Compliance with NCQA Medical Records Standards ................................................................122

Appendix: NCQA MCO Accreditation Program.................................................................................123

Medi-Cal Audit Crosswalk 1

Introduction

In 1998, the California Legislature passed two bills mandating state agencies to reduce duplicative over-sight in their medical audit programs.1 In response, the California Department of Health Services (DHS)and Department of Managed Health Care (DMHC) have been examining the ways in which they canstreamline their oversight processes.2 As part of this effort, both agencies have expressed interest in ex-ploring the feasibility of recognizing the health plan accreditation program of the National Committee forQuality Assurance (NCQA) to satisfy some of their requirements, a process called “deeming.”

The Medi-Cal Audit Crosswalk (“Crosswalk”) is designed to help state officials and health plan execu-tives understand the opportunities for streamlining oversight requirements for Medi-Cal plans and toidentify areas where deeming may be appropriate. The Crosswalk highlights the similarities and differ-ences among NCQA’s accreditation standards and the requirements specified by each of the major over-sight entities for Medi-Cal plans.

These entities and their respective standards are:

! National Committee for Quality Assurance (NCQA) - 2000 MCO Accreditation Standards;

! Health Care Financing Administration (HCFA) - Interim Quality Improvement System forManaged Care (QISMC) Guidelines (September 1998);

! California Department of Managed Health Care (DMHC) - Knox Keene Plan Act of 1975(KKA), California Code of Regulations (CCR), and California Health and Safety Code (CAHSC); and

! California Department of Health Services (DHS), Medi-Cal Managed Care Division (MMCD) -Medi-Cal Plan Contract.

The Crosswalk includes two major components: a comparison of the standards or requirements of eachentity (columns 1-4) and an assessment of the degree of similarity among these requirements (column 5).

Methodology

The NCQA Accreditation Standards anchor the comparison of each entity’s requirements. As the anchor,the NCQA standards determine what elements are included in the Crosswalk and the order in which theseelements appear. Consequently, oversight elements not addressed by NCQA do not appear in the Cross-walk. For example, NCQA does not currently address financial solvency requirements, so these do notappear in the Crosswalk. As an aid to the reader, italics are used throughout the Crosswalk to highlightthe key words or phrases that link the NCQA standards to the corresponding standards of HCFA, DMHC,and DHS.

The Crosswalk draws from two previous comparisons of oversight requirements of managed care healthplans:

! The Department of Corporations’ draft matrix of on-site medical survey oversight require-ments, dated June 28, 1999. This matrix compares the standards in effect in 1999 for DOC,HCFA, DHS, and NCQA.

! A cursory comparison of the 1999 NCQA Accreditation Standards for managed care organiza-tions with HCFA’s September 1998 Interim QISMC guidelines, compiled by HCFA in consul-tation with NCQA. Subsequent to completion of this Crosswalk, HCFA updated the Interim

1 Assembly Bill 162 and Assembly Bill 1959 were signed into law in September 1998.2 When it was established in July 2000, the Department of Managed Health Care assumed the regulatory oversightresponsibilities for managed care health plans that had been the purview of the Department of Corporations.


QISMC Guidelines to incorporate the Medicare+Choice Final Regulations. As this Crosswalkwent to print, HCFA had not released the final QISMC regulations.

A draft of the comparison of this Crosswalk was provided to DHS and DMHC staffs, who were asked tocomment, correct, and update their respective oversight language citations. This final version of theCrosswalk reflects the numerous comments received from the two agencies. The authors have made everyreasonable attempt to ensure the accuracy of the content.

The final step was to assess the degree of similarity among the four sets of requirements and provide ananalysis of the observed variation. The designations used to reflect the degree of similarity are:

! Highly Consistent: The intent of the standards are similar if not identical.

! Consistent with Variation: The intent of the standards is consistent, but the detailed opera-tional requirements vary.

The phrase “Do Not Address” is used in cases where an oversight entity did not address a particular stan-dard. The degree of similarity for these standards was determined by evaluating the comparability of thestandards among each of the other entities.

The Crosswalk is intended to be used in consultation with the documents each oversight entity referencesto enforce health plan compliance; it is not intended to be a complete mapping of specific requirements.NCQA, HCFA, and DHS have performance measurement reporting requirements that have not been in-cluded in the Crosswalk. A more thorough explanation of how performance measures are incorporatedinto NCQA’s accreditation program is provided in the appendix.

Key Findings

1. Among all four sets of requirements, most global standards are Highly Consistent, with the majorityof variation occurring among supporting standards.

In examining the requirements used by each of the respective oversight bodies, we find that the intent ofthe language is similar if not identical for the majority of the global standards.

Example: NCQA Standards QI 13 Delegation of Quality Improvement, UM 13 Delegation of Utili-zation Management, RR 8 Delegation of Members’ Rights and Responsibilities, and PH 5 Delegationof Preventive Health. All four entities’ sets of standards mandate oversight of delegated activities andwritten documents that describe delegation agreements. NCQA’s standards are the most specific, re-quiring a detailed description of the delegation agreement.

The majority of variation occurs at the supporting standard level, where each entity operationalizes itsrequirements. Much of the observed variation pertains to the content of written documents required byeach entity; the established timeframes; and the parties responsible for quality oversight.

Example: NCQA Standard UM6 Denial Notices. Whereas NCQA formally requires that plans pro-vide an opportunity for the treating physician to discuss medical necessity decisions with the plan’sphysician reviewer, DMHC and DHS do not.

Example: NCQA Standard RR6 Privacy and Confidentiality. Although all four sets of standards re-quire plans to implement extensive policies to protect the confidentiality of members’ medical infor-mation, NCQA also requires that the plan identify a committee to be responsible for developing andoverseeing confidentiality issues. In addition, NCQA requires plans to develop a full range of policesand procedures that protect the confidentiality of medical information when a member is incapaci-tated. Neither the DMHC nor DHS requirements address these issues.


2. HCFA standards are Highly Consistent with NCQA standards.

As demonstrated throughout this Crosswalk, the NCQA and HCFA standards are generally highly con-sistent. In developing its QISMC guidelines, HCFA examined the standards of various health care ac-crediting bodies. In many cases, the intent and often the language of HCFA’s QISMC standards areequivalent to NCQA’s standards.

In a limited number of cases, NCQA and HCFA have standards where neither DMHC nor DHS have acorresponding requirement.

Example: NCQA Standard QI 8 Clinical Practice Guidelines. NCQA and HCFA have very similarintent and language relating to the clinical guidelines including guidelines based on reasonable medi-cal evidence and the need for network providers to be involved in the adoption of the guidelines.Neither DMHC nor DHS address the development and dissemination of clinical guidelines. DMHChas utilization management guidelines that require similar development and review standards. DHShas standards that address guidelines for preventive care.

Implications and Next Steps

This Crosswalk reveals the enormous opportunities that exist for DHS and DMHC to streamline their cur-rent review processes for Medi-Cal managed care plans. The Crosswalk demonstrates that there is a highdegree of consistency between many of the DHS and DMHC requirements, as well as among the NCQAstandards and the standards of all three government oversight entities.

As a next step, the state should convene a work group to evaluate the potential to recognize, or deem,those NCQA accreditation standards that were found to be consistent with the state’s oversight standards.The work group might also consider mandating NCQA accreditation, phased in over an appropriate time-frame. Only two Medi-Cal plans are currently NCQA accredited for their Medicaid products; however,the majority of health plans in California are participating in NCQA’s accreditation program for theircommercial products.

The work group should include members of each of the respective review bodies currently involved insurveying health plans, and representatives of the Medi-Cal health plans. We recommend that their analy-sis include all requirements of each of the programs, including standards and performance measures.

In cases where the state chooses, or is legally required, to maintain standards that are different fromNCQA’s standards, including standards not addressed by NCQA (e.g., financial solvency), the state couldcoordinate its review for those standards with a plan’s NCQA survey. Alternatively, the state could con-tract for the review of these additional standards.

Either recognizing or requiring NCQA accreditation would reduce the burden on plans of having multiplesurveyors reviewing the same information. In addition, both options have the potential to decrease thestate’s cost of oversight of NCQA accredited plans and free up resources within DHS and DMHC to fo-cus on other aspects of health plan regulatory oversight not addressed by NCQA accreditation.

Mandating accreditation would increase the comparability of survey results across all plans by having asingle reviewer. Small Medi-Cal plans, however, commonly express concern about the costs of bringingtheir organizations into compliance with NCQA Accreditation standards and of being surveyed. It is im-portant to note that Medi-Cal plans are currently required to meet the oversight requirements of at leasttwo other entities within California whose standards are similar to those of NCQA. If NCQA accredita-tion is required, the costs of being surveyed by NCQA might be offset by the reduction in duplicativeoversight currently taking place. In addition, NCQA survey costs are typically lower for plans that havesmall enrollment and/or with less complex, centralized organizational structures than for larger plans withdecentralized structures.


Definitions and Acronyms

A number of acronyms have been used to reduce the volume of text contained in the Crosswalk. Pleaseuse the information below as a reference when reviewing the contents of the Crosswalk.

NCQA Standards

QI Quality Management and Improvement

UM Utilization Management

CR Credentialing

RR Rights and Responsibilities

PH Preventive Health

MR Medical Record

NCQA Definitions

Appeal – A formal request by a practitioner or member for reconsideration of a decision, such as autilization review recommendation, a benefit payment, an administrative action, or a quality-of-careor service issue, with the goal of finding a mutually acceptable solution. (NCQA uses the term “ap-peal” in lieu of “grievance.”)

Complaint – An expression of dissatisfaction by a member, either oral or written.

Grievance – A term commonly used to describe requests for an MCO to change a decision. NCQAclassifies all such requests as stages in the appeals process.

Oversight Entities and Regulatory Language References

CA HSC California Health and Safety Code (refers to Sections)

CCR California Code of Regulations (refers to Rules)

DHS Department of Health Services

DMHC Department of Managed Health Care

HCFA Health Care Financing Administration

KKA Knox Keene Plan Act of 1975

MMCD Medi-Cal Managed Care Division

NCQA National Committee for Quality Assurance

QISMC Quality Improvement System for Managed Care

DHS Acronyms and Notations

IQIP Internal Quality Improvement Program

EQRO External Quality Review Organization

Where * appears in the Crosswalk, DHS has commented that a “proposed contract amendment” in-cludes requirements that apply to the standards being compared.


Quality ImprovementQI 1 Program Structure

QI 1 Program Structure

NCQA HCFA DMHC DHSDEGREE OF SIMILARITY

& COMMENTS

QI 1 – The MCO's quality im-provement structures and proc-esses are clearly defined andresponsibility is assigned to ap-propriate individuals.

QI Program Structure:

! Written description

! Accountable to govern-ing body

! Update of program de-scription

! Designated physician

! Committee (QIC)

! Role of committeestructure

! Workplan

! Resources

Elements in place for 12 months.

1.3.1 Definitions (Description ofthe QI process)

1.6.1 The organization’s QAPI pro-gram is administered through clearand appropriate administrative ar-rangements.

1.6.1.4 There is formal and ongoingcommunication and collaborationamong the policymaking body thatoversees the QAPI program and theother functional areas of the organi-zation, e.g., health services man-agement, and member services.

Rule 1300.67.3(a)(2) Staffing in medi-cal and other health services and infiscal and administrative services suffi-cient to result in the effective conduct ofthe plan’s business.

Rule 1300.67.3(a)(3) Written proce-dures for the conduct of the business ofthe plan, including the provision ofhealth care services, in order to provideeffective controls.

Section 1370 Review of Quality ofCare, Etc., Peer Review CommitteesEvery plan shall establish procedures inaccordance with Department regulationsfor continuously reviewing the quality ofcare, performance of medical personnel,utilization of services, and costs.

Rule 1300.70(b)(2)(A) Must be a writ-ten QA plan with goals, objectives, or-ganizational arrangements, includingstaffing, QA methodology, scope ofprogram, and required levels of activity.

Rule 1300.70(b)(2)(B) Written docu-ments shall delineate QA authority,function and responsibility, and provideevidence that the plan has establishedquality assurance activities and that theplan's governing body has approved theQA program. To the extent that plan'sQA responsibilities are delegated withinthe plan or to a contracting provider,the plan's documents shall provide evi-dence of an oversight mechanism forensuring that delegated QA functionsare adequately performed.

6.5 Quality ImprovementSystem

6.5.1 General Require-ment

6.5.1.1 Written Descrip-tion

6.5.2.3 QI Committee

6.5.2.1 Accountability

6.5.2.4 Medical Director

6.5.3 Systemic Process ofQuality Improvement

Highly consistent

NCQA, HCFA, DMHC, and DHS havethe same intent—that plans establish aquality program and establish a similarQI structure.

Differences include:

! NCQA requires the QI Pro-gram to be in place for 12months. The other programshave no specific time element,but require fully implementedprograms and/or multi-year QIprojects.

! DMHC’s quality program re-quirements are broader and as-sess additional quality controlaspects, including financial is-sues and facility quality controlissues such as the workabilityof X-ray equipment.

! HCFA’s quality program de-scription is also broadly de-scribed.

! The other organizations requirespecific clinical leadership, butHCFA allows administrators toassume leadership roles.

Quality Improvement



& COMMENTS


Rule 1300.70(b)(2)(C) The plan's gov-erning body, its QA committee, if any,and any internal or contracting providersto whom QA responsibilities have beendelegated, shall each meet on a quar-terly basis, or more frequently if prob-lems have been identified, to overseetheir respective QA program responsi-bilities;

Rule 1300.70(b)(2)(D) QA programshall be supervised by a designated phy-sician….

Rule 1300.70(b)(2)(F) There must beadministrative and clinical staff supportwith sufficient knowledge and experi-ence to assist in carrying out their as-signed QA activities for the plan anddelegated entities.

QI 1.1 – A written description ofthe QI program outlines the pro-gram structure

Elements include:

! Goals

! Objectives

! Structure of program

! Delegation



Domain 4 - Delegation agreements

Section 1370 Review of Quality ofCare, Etc., Peer Review CommitteesEvery plan shall establish procedures inaccordance with Department regulationsfor continuously reviewing the quality ofcare, performance of medical personnel,utilization of services, and costs.

Rule 1300.70(b)(2)(A) Must be a writ-ten QA plan with goals, objectives, or-ganizational arrangements, includingstaffing, QA methodology, scope of pro-gram, and required levels of activity

Rule 1300.70 (b)(2)(B) Written docu-ments shall delineate QA authority,function and responsibility, and provideevidence that the plan has establishedquality assurance activities and that the




6.5.3 Systemic Process ofQuality Improvement

6.5.2.6 Delegation of QIPActivities

Highly consistent

All four sets of requirements state thatthe program description must containlanguage regarding structure, commit-tee authority, scope of activities, anddelegated activities.

NCQA and HCFA have separate stan-dards for describing specific delegationagreements and oversight (NCQA-QI13 and QISMC-Domain 4).

DMHC and DHS specify that the pro-gram structure must include an organi-zation chart. Although this is not a spe-cific standard requirement for NCQAand HCFA, most QI programs describethe program using an organizationchart. NCQA requests this information

Quality Improvement



& COMMENTS


plan's governing body has approved theQA program. To the extent that plan'sQA responsibilities are delegated withinthe plan or to a contracting provider,the plan's documents shall provide evi-dence of an oversight mechanism forensuring that delegated QA functionsare adequately performed.

in its preassessment materials.

QI 1.2 – The QI program is ac-countable to the governing body.

1.6.1.1 The policymaking bodyoversees and is accountable for theQAPI program.

“…the policy making body is thegoverning body or a committee ofsenior executives that exercisesgeneral oversight over the organi-zation’s management, policies, andprocedures.”

Rule 1300.70(b)(2)(B) Written docu-ments must delineate QA authority,function, responsibility… governingbody has approved the QA Program.

Rule 1300.70(b)(2)(C) The plan's gov-erning body, its QA committee, if any,and any internal or contracting providersto whom QA responsibilities have beendelegated, shall each meet on a quar-terly basis, or more frequently if prob-lems have been identified, to overseetheir respective QA program responsi-bilities.

DMHC Comment

The KKA requires that the QA commit-tee, if there is one, must meet quarterlyor more often if problems are identified,and must report quarterly to the Board.The plan’s governing body alone mayoversee the QA program, by receivingand reviewing quarterly reports that in-clude findings and actions of the QAprogram and identify those internal orcontracting provider components whichthe QA program has identified as pre-senting significant or chronic quality ofcare issues.


6.5.2.2 Governing Body

Highly consistent

All four sets of standards require thatthe governing body assume ultimateresponsibility for the QI program.

QI 1.3 – The program descrip-tion is evaluated annually and

1.6.2 The organization formallyevaluates, at least annually, the ef-

Rule 1300.70(b)(2)(C) The plan's gov-erning body, its QA committee, if any,

6.5.1 Written Description Consistent with variation

Quality Improvement



& COMMENTS


updated as necessary. fectiveness of the QAPI programstrategy

and any internal or contracting providersto whom QA responsibilities have beendelegated, shall each meet on a quar-terly basis, or more frequently if prob-lems have been identified, to overseetheir respective QA program responsi-bilities;

6.5.1.1 (A) Evaluation ofQI objectives

6.5.1.1 (G) Annual reportAnnual evaluation


6.5.2.3 Quality Improve-ment Committee

NCQA, HCFA, and DHS require aformal annual evaluation of the QIprogram and the status of its QI activi-ties. The evaluation must include ananalysis of barriers to improvement.

DMHC does not require a formal an-nual evaluation. DMHC requires theplans to submit quarterly reports to theplan’s governing body. Although thesereports may include “year-to-date” orcumulative quarterly information, aformal evaluation of the success ordeficiencies of various QI activities arenot specifically required.

QI 1.4 – A designated physicianhas substantial involvement inthe implementation of the QIprogram.

1.6.1.2 A designated senior officialis responsible for QAPI programadministration.

Rule 1300.70(b)(2)(D) Implementationof the QA program shall be supervisedby a designated physician(s).

6.2.2 (G) Medical Direc-tor



Consistent with variation

NCQA, DMHC, and DHS require thata designated physician be involvedsignificantly in implementing the QIprogram. HCFA does not require phy-sician leadership, and allows a seniorofficial to be responsible for the pro-gram.

QI 1.5 – A committee overseesand is involved in QI activities.

1.6.1.1 The policy-making bodyoversees and is accountable for theQAPI program.

Rule 1300.70(b)(2)(C) The plan's gov-erning body its QA committee, if any,and any internal or contracting providersto whom QA responsibilities have beendelegated, shall each meet on a quar-terly basis, or more frequently if prob-lems have been identified, to overseetheir respective QA program responsi-bilities;


Highly consistent

All four sets of standards require plansto develop a primary QI committee tocoordinate and provide oversight of theQI program.

Even if there is a primary QI commit-tee, DMHC requires that the boardreview detailed quarterly reports.

Quality Improvement



& COMMENTS


QI 1.6 – The program descrip-tion specifies the:

! Role

! Structure

! Function, including fre-quency of meetings ofthe QI committee andother relevant commit-tees



Rule 1300.70(b)(2)(B) Written docu-ments shall delineate QA authority,function and responsibility, and provideevidence that the plan has establishedquality assurance activities and that theplan's governing body has approved theQA program. To the extent that plan'sQA responsibilities are delegated withinthe plan or to a contracting provider, theplan's documents shall provide evidenceof an oversight mechanism for ensuringthat delegated QA functions are ade-quately performed.

Rule 1300.70(b)(2)(C) The plan's gov-erning body, its QA committee, if any,and any internal or contracting providersto whom QA responsibilities have beendelegated, shall each meet on a quarterlybasis, or more frequently if problemshave been identified, to oversee theirrespective QA program responsibilities;





6.5.2.7 Coordination withOther Management Ac-tivities

Highly consistent

None of the standards prescribe spe-cific committees, but imply that thecommittee structure include appropri-ate membership to address the fullscope of quality issues.

QISMC is the least specific of all of thesets of requirements.

QI 1.7 – The annual QI workplan, or schedule of activities.

Elements include:

! Objectives, scope

! Activities planned for theyear

! Time frame of each ac-tivity

1.3.1.1 A project is an initiative bythe organization to measure its ownperformance in one or more of thefocus areas described in 1.3.4 and1.3.5, undertake system interven-tions to improve its performance,and follow-up on the effectivenessof those interventions.

1.3.1.2 Project topics and the qual-ity indicators used to assess each

Rule 1300.70(b)(2)(A) Must be a writ-ten QA plan with goals, objectives, or-ganizational arrangements, includingstaffing, QA methodology, scope of pro-gram, and required levels of activity

6.5.1.1 (E) Written De-scription. A description ofspecific QOC studies tobe undertaken over aprescribed period, theresponsible individu-als,….(also requires anover all evaluation of theeffectiveness of QIP).

6.5.3 Systematic Process

Highly consistent

All four sets of standards require sys-tematic tracking of QI activities using aQI work plan or schedule of QI proj-ects.


! NCQA requires a work planthat includes specific struc-

Quality Improvement



& COMMENTS


! Person responsible foreach activity

! Planned monitoring ofpreviously identified is-sues

! Planned evaluation of theQI program

project are chosen either by theorganization itself, or by HCFA orby the State Medicaid agency eitherfor an individual organization or ona national or Statewide basis.

1.3.1.3 A project will be consideredto have achieved demonstrable im-provement in a focus area duringany review year in which an im-provement meeting the minimumthresholds of standard 1.4.4 is at-tained.

1.3.1.4 The first review year beginson a date established by HCFA orby the State Medicaid agency.

1.3.2 Phase-in requirements. Anorganization has a two-year phase-in period during which its projectsare not required to achieve demon-strable improvement. Includes re-lated subsections 1.3.2.1 through1.3.2.2.2

of QI

6.5.3.1 General Require-ments

6.5.3.2 Quality of CareStudies*

6.5.3.3 Collaborative Ini-tiative*

6.5.3.4 IQIPS*

DHS comment* Proposed contractamendments

tures.

! NCQA, HCFA, and DHS re-quire an annual QI evaluation.NCQA requires this to bescheduled on the work plan.HCFA and DHS do not requirethe work plan to include thedate of the annual evaluation

! DHS’s language is very similarto NCQA’s wording. However,DHS includes a list of pre-scriptive QI activities thatcontains the type and numberof studies.

QI 1.8 – The QI program re-sources are adequate to meet itsneeds.

Editorial Note:

NCQA assesses three resourceareas:

! Staffing

! Data resources

! Analytical resources

1.5 Health Information System (de-scribes IS resources)

1.5.2.1 The organization reviewsreport data for accuracy, complete-ness; logic, and consistency. (de-scribes data resources)

1.6.2 The organization formallyevaluates, at least annually, the ef-fectiveness of the QAPI programstrategy, and makes necessarychanges.


Rule 1300.70(b)(2)(F) There must beadministrative and clinical staff supportwith sufficient knowledge and experi-ence to assist in carrying out their as-signed QA activities for the plan anddelegated entities.

6.4.1.4 Management In-formation System

6.5.1.1 (C) & (E) WrittenDescription

6.5.2.6 (D) Assurance anddocumentation that sub-contractor has the ad-ministrative capacity, taskexperience, and budget-ary resources to fulfill itsresponsibilities

Highly Consistent

Although the language varies amongthe standards, the intent is consistent.

NCQA specifically asks the plan todescribe and evaluate the three re-source elements cited in the far-leftcolumn.

The other sets of standards refer to IS,administrative, and staffing resources,as well as the need to obtain valid dataand analysis.

Quality Improvement


& COMMENTS


QI 2 Program Operations

QI 2 – The MCO’s quality im-provement program is fully op-erational.

Elements include:

! Documented QI com-mittee activities, includ-ing:

- Recommends policy

- Review QI activities

- Institutes actions

- Follows-up

! Signed and dated con-temporaneous minutes

! Documentation thatpractitioners activityparticipate

! All elements have beenin place for at least 12months.

1.6.1 The organization’s QAPI pro-gram is administered through clearand appropriate administrativearrangements.

1.6.1.1 The policymaking bodyoversees and is accountable for theQAPI program.


1.6.1.3 Employed or affiliated pro-viders and consumers actively par-ticipate in the QI Program.

Rule 1300.70(a)(1) The QA programmust be directed by providers and mustdocument that the quality of care pro-vided is being reviewed, that problemsare identified, effective action is takento improve care when deficiencies areidentified, and follow up is plannedwhen indicated.

Rule 1300.70(b)(1)(C) Physicians whoprovide care to the plan’s enrollees arean integral part of the plan’s QA pro-gram.

Rule 1300.70(b)(2)(B) Written docu-ments shall delineate QA authority,function and responsibility, and provideevidence that the plan has establishedquality assurance activities and that theplan's governing body has approved theQA program. To the extent that plan'sQA responsibilities are delegated withinthe plan or to a contracting provider, theplan's documents shall provide evidenceof an oversight mechanism for ensuringthat delegated QA functions are ade-quately performed.

Rule 1300.70(b)(2)(C) The plan's gov-erning body, its QA committee, if any,and any internal or contracting providersto whom QA responsibilities have beendelegated, shall each meet on a quarterlybasis, or more frequently if problemshave been identified, to oversee theirrespective QA program responsibilities.



6.5.1.1 (F) Written de-scription (states that theplan demonstrates physi-cians’ and other profes-sionals’ involvement.)

6.5.2.3 QI Committee

6.5.2.5 Provider Partici-pation (Describes accessto medical records and QIcooperation.)

6.5.2.6 (C) & (F) Dele-gation of QI Activities

6.5.3 Systematic Processof Quality Improvement

Highly consistent

Although language varies, the intent ofall four sets of standards is that com-mittees:

! Meet to address QI activities,

! Document these activities, and

! Demonstrate active practitionerparticipation in the QI com-mittee membership.

Only NCQA requires documentationthat all elements have been in place atleast 12 months.

Quality Improvement


& COMMENTS


QI 3 Health Services Contracting

QI 3 – Contracts with individualpractitioners and organizationalproviders, including those mak-ing UM decisions, specify thatcontractors cooperate with themanaged care organization'squality improvement program.

Elements Include:

! Practitioner and Providercontracts must include

- access to medical re-cords

- cooperation with QIactivities

! Practitioner contracts

- can not prohibit opencommunication

- must have an af-firmative open com-munication after7/1/98

2.2.5 Contracts may not limit a pro-vider’s ability to counsel or advise aMedicare or Medicaid enrollee.

3.1.1 The organization maintainsand monitors a network of appro-priate providers, supported bywritten arrangement, that is suffi-cient to provide adequate access tocovered services and to meet theneeds of the population served.…agreements must conform tothese standards.

3.3.1.7 The organization does notprohibit providers from advocatingon behalf of enrollees within theutilization management process.

Rule 1300.51 Requires contracts tocomply with the requirements of Rule1300.70. Contracts are filed during thelicensing process and are reviewed atthat time. (Rule 1300.70 describes QIprogram)

6.5.2.5 Provider Partici-pation

(Addresses)

! Access to records

! QI cooperation


All four sets of standards have thesame intent regarding access to recordsand provider cooperation with the QIprogram.

NCQA and DHS have formally in-serted this requirement into practitionerand provider contracts. HCFA andDMHC contracts only refer broadly torecord access and cooperation with QIactivities.

NCQA and HCFA mandate opencommunication. DMHC and DHS donot address this issue.

QI 3 Health Services Contracting

QI 4 Availability of Practitioners

QI 4 – The MCO ensures that itsnetwork is sufficient in numbersand types of practitioners.

Elements include:

! Considers linguistic andcultural needs of mem-bers

Domain 1 (1.1-1.6.1.4) – QualityAssessment

3.1 Availability and accessibility.The organization ensures that allcovered services, including addi-tional or supplemental servicescontracted for by or on behalf ofMedicare or Medicaid enrollees,

Rule 1300.67.2(a) Basic and specializedservices must be located within reason-able proximity of the business or resi-dence of enrollees, and so located as tonot result in unreasonable barriers toaccessibility.

Rule 1300.67.2(c) Emergency servicesmust be available and accessible 24

6.6 Provider Network andGeographic Assess

6.6.2 Network Capacity

6.6.15 Contract Employ-ment Terminations“…provider networkmeets the ethnic, cultural,

Highly consistent

All four sets of standards demonstratethe intent to establish and monitor theavailability of practitioners.

Each set of standards includes a QIprocess that monitors, assesses, identi-fies opportunities, implements inter-ventions, and measures the effective-

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! PCP (Primary Care Pro-vider)

- Definition

- Standards

- analysis of data

- opportunities for im-provement

- interventions

- measures effective-ness

! SCP (Specialty CareProvider)

- definition

- standards

- analysis of data

- opportunities for im-provement

- interventions

- measures effective-ness


are available and accessible.

3.1.6 An established organizationseeking an expansion of its servicearea demonstrates that the numbersand types of providers available toenrollees are sufficient to meet theprojected needs of the populationand area to be served.

hours a day, seven days a week.

Rule 1300.67.2(d) The ratio of enrol-lees to staff must be such as to assure allservices are available on an appropriatebasis. …shall be one FTE physician per1200 members … one FTE PCP for2000 members.

Rule 1300.67.2(e) A plan shall provideaccessibility to medically required spe-cialists.

Rule 1300.67.2(f) Each plan shall havea documented system for monitoring andevaluating accessibility, including asystem for addressing problems thatdevelop, which includes but is not lim-ited to waiting time and appointments.

Rule 1300.67.2(g) The health educationprogram informs enrollees of accessi-bility of services in accordance with theenrollees need for such information re-garding that plan or area.

Section 1367.69 Plan must provide di-rect access to obstetricians/ gynecolo-gists to serve as primary care physiciansfor women patients.

(Quality Process)

Rule 1300.70(a)(1) The QA programmust (be directed by providers andmust) document that the quality of careprovided is being reviewed, that prob-lems are identified, effective action istaken to improve care when deficienciesare identified, and follow up is plannedwhen indicated

and linguistic needs …”

6.10 Cultural and Lin-guistic Services Require-ments

(QI process)

6.5 QI System

6.5.1.1(D) Review ofAvailability

6.5.2 QIP AdministrativeServices

6.5.3 Systematic Processof QI

6.5.3.4 Internal Qualityimprovement projects*(availability, culturalneeds)

ness of those interventions.

NCQA, HCFA and DHS addressmembers’ special and cultural needs.DMHC does not address this issue

Of the four sets of standards, DHS’slanguage is the most prescriptive. Itsets benchmarks for the percentage ofenrollment in a practice, and mandatesthe ratio of physicians to members, aswell as time and distance availabilitystandards.

DMHC also sets availability standards.

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Rule 1300.70(a)(3) A plan's QA pro-gram must address service elements,including accessibility, availability, andcontinuity of care. A plan's QA programmust also monitor whether the provisionand utilization of services meets profes-sionally recognized standards of prac-tice.

QI 4.1 – In creating andmaintaining its delivery systemof practitioners, the MCO takesinto consideration assessedspecial and cultural needs andpreferences.

2.2.2.1 The organization ensuresthat all services, both clinical andnon-clinical, are accessible to allenrollees, including those with lim-ited English proficiency or readingskills, with diverse cultural andethnic backgrounds, the homelessand individuals with physical andmental disabilities.

3.1.5 The organization ensures thatservices are provided in a culturallycompetent manner to all enrollees,including: those with limited Eng-lish proficiency or reading skills,those with diverse cultural and eth-nic backgrounds, the homeless, andindividuals with physical and men-tal disabilities.

DMHC does not address culturalneeds/preferences.


6.6.15 Contract Employ-ment Terminations –“…provider networkmeets the ethnic, cultural,and linguistic needs …”

6.10 Cultural and Lin-guistic Services Require-ments

Highly consistent

Both HCFA and DHS language is morespecific concerning cultural needs thanNCQA’s requirement.

DHS and HCFA include members whoare limited because they are minors ordisabled.

DMHC does not address cultural needsor preferences.

QI 4.2 – The MCO implementsmechanisms designed to ensurethe availability of primary carepractitioners.

Elements include:

! Defining PCPs

! Standards for numberand geographic distribu-

3.1.1 The organization maintainsand monitors a network of appro-priate providers, supported bywritten arrangements, that is suffi-cient to provide adequate access tocovered services and to meet theneeds of the population covered.

3.1.1.1 Primary care providers. Theorganization offers a panel of pri-mary care providers from which the


Rule 1300.67.2(d) The ratio of enrol-lees to staff must assure all services areavailable on an appropriate basis.

6.6 Provider Network andGeographic Assess

6.6.1 Time and distance

Standard.

6.6.2 Network Capacity

6.6.6 Provider to MemberRatios 6.6.6 Provider toMember Ratios

Highly consistent

DHS’s standards for both ratio andgeographic distribution are more pre-scriptive than the other standards. DHSrequires:

! PCPs will be located within 30minutes or 10 miles of mem-bers

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& COMMENTS


tion

! Monitor, analyze, iden-tify opportunities for im-provement, implementinterventions, and meas-ure effectiveness

enrollee may select a personal pri-mary care provider.

3.2.1 Use of a health care profes-sional who is formally designatedas having primary responsibility forcoordinating the enrollee’s overallhealth care. Includes subsections3.2.1.1 through 3.2.1.2.

(QI assessment process)

Domain 1 – Quality Assessment

1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurement andintervention, demonstrable andsustained improvement in signifi-cant aspects of clinical care andnon-clinical services that can beexpected to have a beneficial effecton health outcomes and enrolleesatisfaction.

1.1.3 Corrects significant systemicproblems that come to its attentionthrough internal surveillance, com-plaints, or other mechanisms.

1.2.1 The organization measures itsperformance, using standard meas-ures established or adopted byHCFA or by the State Medicaidagency, and reports its performanceto the applicable agency.

1.2.2 The organization achieves anyminimum performance levels thatmay be established by HCFA or bythe State Medicaid agency with

(Quality Process)


Rule 1300.70(a)(3) The QA programmust monitor availability and accessi-bility of care, and take action when indi-cated.

6.9.9 Primary Care Phy-sician Selection

(QI process)

6.5 QI System

6.5.1.1(D) Review ofAvailability




! PCP 1:2000 members

! Total physicians 1:1200

DMHC has ratio standards of:

! PCP 1:2000 members

! Physician 1:1200 members

NCQA allows plans to develop theirown standards. NCQA accepts moni-toring the number of sites acceptingnew patients (open panels) as a geo-graphic measurement.

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respect to the standard measures.

1.2.3 The organization meets anygoals for performance improvementon specific measures that may beestablished for that particular or-ganization by HCFA or by the StateMedicaid agency.

1.3 Performance ImprovementProjects

1.3.5 Non-clinical focus areas. Non-clinical focus areas applicable to allenrollees include availability, ap-peals, and other complaints. In-cludes all subsections from 1.3.5.1through 1.3.5.3.

1.4.1 Selection of topics. Withineach required focus area, the or-ganization selects a specific topic ortopics to be addressed by a project.Includes subsections 1.4.1.1through 1.4.1.3.

1.4.3 Data collection and method-ology. Assessment of the organiza-tion’s performance on the selectedindicators is based on systematic,ongoing collection and analysis ofvalid and reliable data. Includessubsections 1.4.3.1 through1.4.3.2.2.

1.5.1 The system collects data onenrollee and provider characteris-tics, and on services furnished toenrollees, as needed to guide theselection of performance improve-ment project topics and to meet the

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data collection requirements forperformance improvement projects.

1.5.2 The organization ensures thatinformation and data received fromproviders are accurate, timely, andcomplete. Includes subsection1.5.2.1 and 1.5.2.2.

2.4.4.1 The information is used todevelop activities under the organi-zation’s QAPI program, both toimprove the issue resolution proc-ess itself, and to make improve-ments that address other systemissues raised in the issue resolutionprocess.

QI 4.3 – The MCO implementsmechanisms designed to ensurethe availability of specialty careproviders.

Elements include:

! Defining SCPs. SCPmust include:

- OB/Gyn

- Behavioral health

- High-volume SCPs

! Standards for numberand geographic distribu-tion

! Monitor, analyze, iden-tify opportunities for im-provement, implementinterventions, and meas-ure effectiveness

3.1.1.2 Specialists. The organiza-tion provides or arranges for neces-sary specialty care, includingwomen’s health services. The or-ganization allows women directaccess to a women’s health spe-cialist within the network forwomen’s routine and preventivehealth care services while the or-ganization maintains a primary careprovider or some other means forcontinuity of care.

(QI assessment process) Domain 1 –Quality Assessment. The followingQISMC guidelines apply to QI4.3:

1.1.2, 1.1.3, 1.2.1, 1.2.2, 1.2.3, 1.3and Performance ImprovementProjects, 1.3.5, 1.4.1, 1.4.3, 1.5.1,1.5.2, and 2.4.4.1 (See QI 4.2 above


Rule 1300.67.2(d) The ratio of enrolleesto staff must be such as to assure allservices are available on an appropriatebasis.

Rule 1300.67.2(e) A plan shall provideaccessibility to medically required spe-cialists.

Section 1367.69 Plan must provide di-rect access to obstetrcians/gynecologiststo serve as primary care physicians forwomen patients.

(Quality Process)

Rule 1300.70(a)(1) The QA program

6.6.4 Access Require-ments – “…ensuresMembers access to allMedically Necessary spe-cialists…”

6.6.5 Specialists

6.6.7.6 Pregnant Women:Referrals to Specialists

6.7.9 Local MentalHealth Coordination

6.7.9.1 Memo of Under-standing (MOU)

(Describes plan’s respon-sibility to coordinatemental health services w/the mental health plan.)

(QI process)

Highly consistent

All four sets of standards indicate thatspecialists must be available to mem-bers.

NCQA, DMHC, and DHS specifysome of the types of specialists thatmust be monitored. NCQA requires aplan to monitor at least OB/GYNs,behavioral health, and high volumespecialists.

NCQA does not state that OB/GYNsmust be included as PCPs, or does itspecify the ratio of providers to mem-bers.

Editorial Note:DHS carves out behavioral health forMedi-Cal plans. Responsibilities forcoordination of care and provision ofservices are outlined in the MOU.

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for text). must (be directed by providers andmust) document that the quality of careprovided is being reviewed, that prob-lems are identified, effective action istaken to improve care when deficienciesare identified, and follow up is plannedwhen indicated

Rule 1300.70(a)(3) The Plan mustmonitor that the provision and utiliza-tion of services meets professionallyrecognized standards.

6.5 QI System

6.5.1.1 (D) Review ofAvailability



6.5.3.4 Internal QualityImprovement Projects*(Describes availability,cultural needs)


QI 5 Accessibility of Services

QI 5 – The MCO establishesmechanisms to assure the acces-sibility of:

! Primary care services

! Behavioral health serv-ices

! Member servicesQI 5 Accessibility of Services

3.1.3 When medically necessary,the organization makes servicesavailable 24 hours a day, 7 days aweek.

3.1.4 The organization ensures thatthe hours of operation of its provid-ers are convenient to and do notdiscriminate against enrollees.

3.1.7.1 Establishes standards fortimeliness of access to care andmember services that meet or ex-ceed such standards as may be es-tablished by HCFA or the StateMedicaid agency, continuouslymonitors its provider network’scompliance with these standards,and takes corrective action as nec-essary.


Section 1367(e)(1) All services shall bereadily available at reasonable times toall enrollees. To the extent feasible, theplan shall make all services readily ac-cessible to all enrollees.

Rule 1300.67.2 Within each servicearea of a plan, basic health care servicesand specialized health care servicesshall be readily available and accessibleto each of the plan's enrollees

Rule 1300.67.2(b) Hours of operationand provision for after-hour servicesshall be reasonable;

Rule 1300.67.2(c) Emergency healthcare services shall be available and ac-cessible within the service area twenty-four hours a day, seven days a week;

Rule 1300.67.2(f) Each health careservice plan shall have a documentedsystem for monitoring and evaluating

6.5.7 Availability andAccessibility

6.5.7.1 General Require-ment

6.5.7.2 Emergency Care

6.5.7.3 Urgent Care

6.5.7.4 First PrenatalVisit

6.5.7.5 Waiting Times

6.5.7.6 Telephone Proce-dures

Access Survey - EQRO

6.6.17 Adequate Facili-ties, includes requirementto provide all medicalcare necessary underemergency circumstanceson a 24 hour a day, 7


Medical Access

The intent of all four sets of standardsis to assure that medical services areaccessible to members.

HCFA and DHS guidelines specify theadoption of HCFA or State Medicaidagency standards. NCQA allows anMCO to develop its own standards.

DHS requirements include prescriptivetime frames.

HCFA standards state all medicallynecessary services are available 24/7,and specify the adoption of HCFA orState Medicaid agency standards.

DMHC language is broader. It speci-fies 24/7 only for ER, but states thatother services should be provided in atimely and appropriate manner. It also

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1.2.2 The organization achieves anyminimum performance levels thatmay be established by HCFA or bythe State Medicaid agency withrespect to the standard measures.



accessibility of care, including a systemfor addressing problems that develop,which shall include, but is not limitedto, waiting time and appointments;

Rule 1300.67.2(g) The health educationprogram informs enrollees of accessi-bility of services in accordance with theenrollees need for such information re-garding that plan or area.

(Quality Process)


Rule 1300.70(a)(3) A plan's QA pro-gram must address service elements,including accessibility, availability,continuity of care. A plan's QA programmust also monitor whether the provisionand utilization of services meets profes-sionally recognized standards of prac-tice.

days a week.

(QI process)

6.5 QI System




6.7.9 Local MentalHealth Coordination

6.7.9.1 Memo of Under-standing

(Describes plan’s respon-sibility to provide MHservices)

DHS CommentNCQA focuses on ap-pointment time and not onreimbursement of serv-ices.

states that health education informsenrollees

Behavioral Health

NCQA has specific behavioral healthaccess standards. The other three setsof requirements either do not coverbehavioral health care or include ac-cess to behavioral health in the broaderaccess statements.

DHS has a memorandum of under-standing that requires plans to provideaccess to MH. However, specifics ofaccess and availability standards residein the MH contract.

All standards require the plan tomonitor access using the QI process.

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1.3.5 Non-clinical focus areas. Non-clinical focus areas applicable to allenrollees include: availability, ap-peals, and other complaints. In-cludes all subsection from 1.3.5.1through 1.3.5.3.



1.5.1 The system collects data onenrollee and provider characteris-tics, and on services furnished toenrollees, as needed to guide theselection of performance improve-ment project topics and to meet thedata collection requirements forperformance improvement projects.


2.4.4.1 The information is used todevelop activities under the organi-

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zation’s QAPI program, both toimprove the issue resolution proc-ess itself, and to make improve-ments that address other systemissues raised in the issue resolutionprocess.

QI 5.1 – The MCO establishesstandards for access to medicalcare.

Elements include:

! Preventive care

! Routine care

! Urgent

! Emergency

! After-hours care

! Telephone service

2.2.2.2 The organization ensuresthat enrollee’s have the right to ac-cess emergency health care serv-ices.


3.1.4 The organization ensures thatthe hours of operation of its provid-ers are convenient to and do notdiscriminate against enrollees.


Section 1367(e)(1) All services shall bereadily available at reasonable times toall enrollees. To the extent feasible, theplan shall make all services readily ac-cessible to all enrollees.

Rule 1300.67.2 Within each servicearea of a plan, basic health care servicesand specialized health care servicesshall be readily available and accessibleto each of the plan's enrollees

Rule 1300.67.2(b) Hours of operationand provision for after-hour servicesshall be reasonable;

Rule 1300.67.2(c) Emergency healthcare services shall be available and ac-cessible within the service area twenty-four hours a day, seven days a week;


6.5.7.1 General Require-ment


6.5.7.3 Urgent Care

6.5.7.4 First PrenatalVisit

6.5.7.5 Waiting Times

6.5.7.6 Telephone Proce-dures

Access Survey - EQRO

6.6.17 Adequate Facili-ties, includes requirementto provide all medicalcare necessary underemergency circumstanceson a 24 hour a day, 7days a week basis.

Highly consistent

Both HCFA and DHS have some pre-scriptive standards.

QISMC references standards estab-lished by HCFA or the State Medicaidagency.

DHS requires:

! Emergency – Immediate

! Urgent – within 48 hours

! First Prenatal Visit – withinone week

NCQA allows plans to establish theirown medical access standards. How-ever, NCQA mandates plans establish abroader number (5) of standards.

QI 5.2 – The hours of operationand service availability for be-havioral health care reflect theneeds of members needing be-havioral health care.

Elements include:


3.1.4 The organization ensures thatthe hours of operation of its provid-ers are convenient to and do not

DMHC does not specifically addressbehavioral health

DMHC CommentThis is subject to all other accessibilityrequirements but is not specifically ad-dressed.


6.7.3.3 Mental Health

6.7.3.4 Alcohol and DrugTreatment Services

6.7.9 Local Mental


NCQA has established prescriptivestandards for behavioral health access.

The other three sets of requirementseither do not cover behavioral healthcare or include access to behavioral

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! Non-threatening emer-gency within 6 hours

! Urgent care 48 hours

! Routine appointmentwithin 10 working days

! Telephone answeredwithin 30 seconds

! Abandonment ratewithin 5%

discriminate against enrollees.


Health Coordination

6.7.9.1 Memo of Under-standing

(Describes plan’s respon-sibility to provide MHservices)

MMCD Policy letter 00-01 (Clarifies relationshipbetween DHS and MHP.)

health in the broader access statements.

DHS carves out behavioral health butmandates emergency access. DHS alsorequires plans to have a formal asso-ciation (MOU) with behavioral healthproviders (MHP).

Per the policy letter, the MHP is re-sponsible for identifying behavioralhealth providers and established avail-ability standards. Therefore, in evalu-ating the combined relationship be-tween plans and MHP, the DHS stan-dards are very similar in scope andintent to NCQA.

QI 5.3 - 5.6 – In general, stan-dards 5.3 – 5.6 refer to themonitoring and QI efforts aroundaccess and availability.

The MCO:

! Collects and analyzesdata to measure its per-formance against thestandards

! Identifies opportunitiesfor improvement

! Implements strong ac-tions

! Measures effectiveness





1.2.1 The organization measures itsperformance, using standard meas-ures established or adopted byHCFA or by the State Medicaid

Rule 1300.67.2(f) Each plan shall havea documented system for monitoringand evaluating accessibility, including asystem for addressing problems thatdevelop, which includes but is not lim-ited to waiting time and appointments.

(Quality Process)


Rule 1300.70(a)(3) A plan's QA pro-gram must address service elements,including accessibility, availability,continuity of care. A plan's QA programmust also monitor whether the provisionand utilization of services meets profes-

(QI process)

6.5 QI System




Highly consistent

All four sets of standards require on-going performance monitoring, analy-sis of data, and appropriate interven-tions to improve performance.

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agency, and reports its performanceto the applicable agency.




1.3.5 Non-clinical focus areas. Non-clinical focus areas applicable to allenrollees include: availability, ap-peals, and other complaints. In-cludes all subsection from 1.3.5.1through 1.3.5.3.



sionally recognized standards of prac-tice.

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QI 6 Member Satisfaction

QI 6 – The MCO implementsmechanisms to assure membersatisfaction.

Elements include:

! (QI 6.1) – Evaluation of

- member complaintsand appeals

- member satisfaction

1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurement andintervention, demonstrable andsustained improvement in signifi-cant aspects of clinical care andnon-clinical services that can beexpected to have a beneficial effecton health outcomes and enrollee

Section 1368(a)(1) Establish andmaintain a grievance system underwhich enrollees may submit their griev-ances to the Plan. Each system shallprovide reasonable procedures in accor-dance with department regulations thatshall ensure adequate consideration ofenrollee grievances and rectificationwhen appropriate.

6.5.6.4 (B)MembersGrievance System

6.5.6.7 Member Satisfac-tion

Surveys

(QI process)

6.5 QI System


NCQA requires plans to assess twoareas of member satisfaction: membersatisfaction surveys & aggregate com-plaint data.

DHS also assesses complaints andmember satisfaction surveys.

HCFA’s and DMHC’s measurement of

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surveys

! (QI 6.2 to QI-6.6) – Usesthe QI process to

- collect valid data

- analyze data

- identify opportunitiesfor improvement

- implement interven-tions

- measure effectiveness

! QI 6.7 – Informs practi-tioners and providers ofmember satisfaction ac-tivities


satisfaction.


1.3.5 – 1.3.5.2 Non-clinical focusareas. Non-clinical focus areas ap-plicable to all enrollees include:availability, appeals, and othercomplaints. Includes all subsectionsfrom 1.3.5.1 through 1.3.5.3 - Ap-peals, grievances, and other com-plaints





1.2.3 The organization meets anygoals for performance improvementon specific measures that may beestablished for that particular or-ganization by HCFA or by the State

DMHC Comment

The Department has interpreted Rule1300.70 in conjunction with Rule1300.68 to require plans to identify andcorrect quality, accessibility, and conti-nuity of care issues in complaints.).

Rule 1300.68(a) The system shall beestablished, pursuant to written proce-dures, for the receipt, handling and dis-position of complaints. An officer of theplan shall be designated as having pri-mary responsibility for the maintenanceof such procedures and for the review oftheir operations and for the utilization ofany emergent patterns of grievances inthe formulation of policy changes andprocedural improvements in the plan’sadministration.

Rule 1300.68(c) As to each complaintreceived in person or by telephone at agrievance location, a written record shallbe made, including the date, identifica-tion of the individual recording thegrievance, and disposition. A writtenrecord of tabulated grievances shall bereviewed periodically by the governingbody of the plan, the public policy bodycreated pursuant to Section 1300.69, andby an officer of the plan or his desig-nate, and the review procedure shall bedocumented, including documentationof the procedure or mechanism used inconsideration of tabulating grievancesperiodically in relation to policy and




DHS Comment

DHS requires patient sat-isfaction surveys as partof its Member Rights andResponsibilities contractrequirements (6.5.6.7).The CAHPS®2.0H survey,which is part of the QIprogram requirement, canserve as a substitute forthe patient satisfactionsurvey. DHS will onlyrequire the CAHPS® sur-vey to be administeredevery other year. (9/5/00DHS)

member satisfaction is limited to as-sessment of aggregate complaint data.

All four sets of standards express theintent that member satisfaction data beassessed within the QI process.

Only NCQA requires the plan to pro-vide practitioners data concerningmember satisfaction.

CAHPS is a registered trademark of the Agency for Healthcare Research and Quality.

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Medicaid agency.






2.4.4.1 The information is used todevelop activities under the organi-zation’s QAPI program, both toimprove the issue resolution proc-ess itself, and to make improve-

procedure review.

Rule 1300.68(h) A grievance systemshall provide for a prompt review ofcomplaints by the management or su-pervisory staff responsible for the serv-ices or operations, which are the subjectof the complaint.

(Quality Process)



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ments that address other systemissues raised in the issue resolutionprocess.


QI 7 Health Management Systems

QI 7 - The MCO identifiesmembers with at least twochronic conditions and offersappropriate services and pro-grams to assist in managing theirconditions.

Elements include:

! Programs must include:

- identified population

- outreach to affectedpopulation

- analysis of baselinedata

- targeted actions

- practitioner involve-ment

- strategy to evaluateeffectiveness of pro-gram

! At least 20% of affectedpopulation must partici-pate in one program

! Practitioners must be in-formed about program

! Plan must measure ef-fectiveness of programsusing 12 months of data

3.1.1.3 Complex needs - The or-ganization has procedures approvedby HCFA or the State Medicaidagency for: the identification ofindividuals with complex or seriousmedical conditions; an assessmentof those conditions; the identifica-tion of medical procedures to ad-dress and/or monitor the conditions;and a treatment plan appropriate tothose conditions that specifies anadequate number of direct accessvisits to specialists to accommodateimplementation of the treatmentplan. Also, treatment plans aretime-specific and updated periodi-cally by the primary care provider.

1367.5 Diabetic education (describesdiabetic education including helping themember to gain understanding of thediabetic disease process and how toavoid frequent hospitalizations andcomplications).

6.5.3.4* (States that QItopics will pertain to thecare of both acute andchronic conditions.)

6.7.2.1 Major OrganTransplant

6.7.3.2 California Chil-dren’s Services

6.7.3.7 Directly ObservedTherapy for Treatment ofTB

6.7.4.11 Services for Per-sons with DevelopmentalDisabilities

6.7.4.4 EPSDT IncludingCase Management Serv-ices

6.7.7.1 (C) Patient Edu-cation and clinical coun-seling


NCQA, DMHC, and DHS requirevarious levels of educational programsthat address chronic illness. However,none of the other standards is compre-hensive enough to meet NCQA’s re-quirements.

NCQA’s standards are the most com-plex, and require a full spectrum ofservices to help members live withillness. These programs are broad andinclude more than distribution ofguidelines or intensive case manage-ment. Examples of appropriate issuesinclude diabetes, high-risk pregnancy,and asthma programs.

NCQA also requires that the effective-ness of the programs be measured us-ing 12 months of data.

Some of the DHS IQIPs relate to un-specified chronic conditions.

DMHC and DHS have more generalchronic illness education programs.DMHC has a diabetic educational pro-gram.

DHS has several patient education pro-grams that reflect similar chronic is-sues. DHS programs include diabetes,asthma, and hypertension.

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HCFA requires plans to address indi-viduals with complex or serious medi-cal conditions; assess those conditions;identify medical procedures to addressand/or monitor the conditions; and es-tablish treatment plans appropriate tothose conditions. These requirementsare general and broad. Further, it is notclear that the programs are addressingchronic illnesses.

Note that NCQA does not referencespecific illnesses. However, NCQArequires action on two illnesses.


QI 8 Clinical Practice Guidelines

QI 8.1–8.5 – The MCO is ac-countable for adopting and dis-seminating practice guidelinesfor the provision of acute andchronic care services that arerelevant to its enrolled member-ship.

Guideline standards require:

! At least two guidelines

! Guidelines can not ad-dress UM, medical rec-ord documentation crite-ria, or preventive guide-lines

! Guidelines are based onreasonable medical evi-dence

! Involves practitioners inthe adoption of clinical

3.4.1 The organization adopts anddisseminates practice guidelines.

3.4.1.1 Guidelines are based onreasonable medical evidence or aconsensus of health care profes-sionals in a particular field, con-sider the needs of the enrolledpopulation, are developed in con-sultation with contracting healthcare professionals, and are re-viewed and updated periodically.

Does not address

Editorial note

DMHC provided the following refer-ences, however they refer to UM guide-lines.

Section 1363.5(a) Plan must discloseprocesses of utilization review. Man-agement upon request, and section1463.5(b)(4) and (5): disclose criteria tothe provider and enrollee in that speci-fied case and to the public for specificprocedures or conditions, upon request.

Section 1363.5(b) The Plan’s criteria orguidelines shall be developed with in-volvement from actively practicinghealthcare providers, be consistent withsound clinical principles and processes,be evaluated and updated if necessary,at least annually [emphasis added], andbe disclosed to providers and to the en-

Does not address

DHS Comment

DHS has PreventiveHealth Standards (6.5,3.3 and 6.7.6).

6.5.3.5 (E) Plans mayadopt evidence-basedstandards or guidelineswith input from appropri-ate network providers

Highly consistent

NCQA and HCFA guideline require-ments are highly consistent.

NCQA and HCFA have identical intentand similar language relating to theadoption of guidelines based on rea-sonable medical evidence.

! NCQA and HCFA both specifythe need for network providersto be involved in the adoptionof the guidelines.

! NCQA guidelines must be re-viewed at least every twoyears. HCFA guidelines are re-viewed periodically.

! Although the HCFA standardsdo not specify distribution ofthe guidelines, this is impliedin its language.

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practice guidelines

! Develops a mechanismfor reviewing the guide-lines at least every twoyears and updating themas necessary

! Distributes the guide-lines to practitioners

! Annually measures per-formance against al leasttwo guidelines and 2 as-pects of care for bothguidelines

rollee in a particular case, and to thepublic upon request.

NCQA requires performance meas-urement.

The DMHC and DHS do not addressclinical guidelines

! DMHC has UM guidelines thatrequire similar developmentaland review standards, but theseguidelines do not apply toNCQA’s QI 8 standard.

! DHS’ standards address onlypreventive guidelines.

QI 8.6 –Decision making inutilization management, membereducation, interpretation of cov-ered benefits, and other areas towhich the clinical guidelines areapplicable is consistent with theguidelines.

3.4.1.3 Decisions with respect toutilization management, enrolleeeducation, coverage of services,and other areas to which the guide-lines are applicable are consistentwith the guidelines.

Does not address Does not address Highly consistent

NCQA’s and HCFA’s language is al-most identical.


QI 9 Continuity and Coordination of Care

QI 9 – The MCO ensures thecontinuity and coordination ofcare that members receive.

Elements include:

! Coordination betweenmedical practitioners andproviders

! Coordination betweenmedical and behavioralhealth practitioners

! Coordination of mem-ber’s care when a practi-

3.1.1.4 Medicare organization in-forms beneficiaries of their right tomaintain access to specialists in thecase of an involuntary terminationof the organization or specialistsfor a reason other than for cause.

3.2. Continuity and Coordination ofCare

3.6 Enrollee Health Records andCommunication of Clinical Infor-mation

Section 1367(d) The Plan shall furnishservices in a manner providing continu-ity of care and ready referral of patientsto other providers at times as may beappropriate and consistent with goodprofessional practice.

Rule 1300.67.1 Continuity of Care

Rule 1300.70 Health Care Service PlanQA Program

6.5.3.2 (B) 6 Quality ofCare Studies* – Continu-ity of care.

6.5.10.1 Medical CaseManagement

6.5.10.3 Referrals andFollow-up Care

6.5.10.4 Coordination ofCare

6.5.10.6 Continuity ofCare


Medical Care

All four sets of standards require as-sessment of continuity and coordina-tion of care.

Behavioral Health

NCQA and DHS require a number ofspecific coordination of care activitiesbetween medical and behavioral healthpractitioners.

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tioner terminates withthe network

! Continued access to adiscontinued practitio-ner.


6.5.10.7 Targeted CaseManagement

MMCD Policy Letter00-01 (Relates to conti-nuity and coordination ofmedical and behavioralhealth conditions.)

Termination of practitioners

Both NCQA and HCFA require transi-tion of member care when the practi-tioner terminates. DMHC addresses itonly in broad terms.

QI 9.1 – The MCO monitors thecontinuity and coordination ofcare that members receive acrosspractices and provider sites, in-cluding at a minimum primarycare practice sites with 50 ormore members.

At a minimum monitoring in-cludes:

! Practitioners with 50 ormore members

! At least 3-4 types of pro-vider sites

! Monitors at least every 2years

3.2 Continuity and Coordination ofCare

3.2.1 Use of a health care profes-sional who is formally designatedas having primary responsibility forcoordinating the enrollee’s overallhealth care. Includes subsections3.2.1.1 through 3.2.1.2.

3.2.2 Programs for coordination ofcare that includes coordination ofservices with community and socialservices generally available throughcontracting or non-contracting pro-viders in the area served by the or-ganization.

3.6 Enrollee Health Records andCommunication of Clinical Infor-mation

3.6.3.1 A provider making a refer-ral transmits necessary informationto the provider receiving the refer-ral.

3.6.3.2 A provider furnishing areferral service reports appropriateinformation to the referring pro-vider.

Section 1367(d) The Plan shall furnishservices in a manner providing continu-ity of care and ready referral of patientsto other providers at times as may beappropriate and consistent with goodprofessional practice.

Rule 1300.67.1 Continuity of Care

Rule 1300.67.1(c) maintenance andready availability of medical records,with sharing within the plan of all perti-nent information relating to the healthcare of each enrollee,

Rule 1300.67.1(e) An adequate systemof documentation of referrals to physi-cians or other health professionals. Themonitoring of the follow up of enrollees’health care documentation shall be theresponsibility of the health care serviceplan and associated health profession-als.


6.5.10.1 Medical CaseManagement




6.5.10.7 Targeted CaseManagement

Highly consistent

All sets of standards address the conti-nuity and coordination of medical care.Both NCQA and HCFA focus on pri-mary care practitioners. DMHC ad-dresses continuity of care on the broadscale, while DHS focuses on specificservices aside from primary care.

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3.6.3.3 Providers request informa-tion from other treating providersas necessary to provide care.

3.6.3.4 If the organization offers apoint-of-service benefit or otherbenefit providing coverage of serv-ices by non-network providers, theorganization transmits informationabout services used by an enrolleeunder the benefit to the enrollee’sprimary care provider

QI 9.2 – Ensures continuity andcoordination between medicaland behavioral health practitio-ners by monitoring collabora-tion.

Monitoring includes:

! Exchange information inan effective, timely andconfidential manner, in-cluding patient approvedcommunications betweenmedical practitioners andbehavioral health practi-tioners and providers.

! Appropriate diagnosisand treatment and refer-rals of behavioral healthdisorders commonlyseen by PCPs

! Use of Psychopharma-cological drugs

! Management of patientswith coexisting medicaland behavioral health

3.2.3 Procedures for timely com-munication of clinical informationamong providers, as specified instandard 3.6.

(Quality Process)


Rule 1300.70(a)(3) The Plan’s QA pro-gram must address …Continuity of care.





MMCD Policy Letter00-01 (Relates to conti-nuity and coordination ofmedical and behavioralhealth conditions.)


NCQA and DHS standards identifyspecific continuity and coordination ofcare activities between medical andbehavioral health practitioners. TheDMHC and HCFA standards includeonly broad statements.

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conditions

QI 9.3-9-4 – The MCO collectsand analyzes data to evaluatecontinuity and coordination ofcare.

The MCO implements interven-tions to improve continuity andcoordination of care.

Elements address:

! Medical Care

! Behavioral Health








(Quality Process)



(Quality Process)


Highly consistent

All four sets of standards require on-going performance monitoring, analy-sis of data, and appropriate interven-tions to improve performance.

Although DHS carves out mentalhealth for its contracted plans, NCQAwould say they are still responsible forcontinuity and coordination of care andwould therefore need to meet the re-quirements of this standard.

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1.3.1.1 A project is an initiative bythe organization to measure its ownperformance in one or more of thefocus areas described in 1.3.4 and1.3.5, undertake system interven-tions to improve its performance,and follow-up on the effectivenessof those interventions.

1.3.4.7 Clinical focus Areas…Continuity and coordination of care.




1.5.2 The organization ensures that

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information and data received fromproviders are accurate, timely, andcomplete. Includes subsection1.5.2.1 and 1.5.2.2.


QI 9.5 – When a practitioner’scontract is discontinued, givencertain conditions, the MCOallows members to have contin-ued assess to that practitionerunder the following circum-stances:

! Member is receiving ac-tive treatment for chronicor acute medical condi-tion can access their dis-continued practitionerthrough the current pe-riod of active treatmentor 90 days, whichever isshorter

! Members in their secondor third trimester ofpregnancy have access totheir discontinued prac-titioner through the post-partum period.

3.1.1.4 Medicare organization in-forms beneficiaries of their right tomaintain access to specialists in thecase of an involuntary terminationof the organization or specialistsfor a reason other than for cause.

Section 1367(d) The Plan shall furnishservices in a manner providing continu-ity of care and ready referral of patientsto other providers at times as may beappropriate consistent with good profes-sional practice.

Does not address

Editorial note

DHS provided the follow-ing reference, however itaddresses maintainingcontinuity of care when amember has a complexmedical condition andbecomes eligible forMedi-Cal. NCQA’s stan-dard is addressing conti-nuity of care when a pro-vider’s contract is discon-tinued.

MMCD Policy 00002Medi-Cal Managed CareMedical Exemptions


NCQA requires MCOs to provide ac-cess to a practitioner when a member iscurrently receiving active treatment oris in the middle of a pregnancy. NCQAhas identified the conditions that allowthis service and prescriptive time-frames.

HCFA also has a continued accessregulation; however, this regulation ismore general.

DMHC addresses this issue broadly.DHS does not address the issue.

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QI 10 Clinical Measurement Activities

QI 10 – The MCO uses datacollection, measurement, andanalysis to track clinical issuesthat are relevant to its popula-tion.

Studies include:

! Good study design

- relevant to member-ship

- objective and quanti-fiable

- based on scientificknowledge

- established goals andbenchmarks

! Acceptable methodology

- population based

- appropriate sampling

- valid data

! Analysis

- Qualitative analysis

- Analysis of causeQI 10 Clinical Measurement Activities



1.3.4 Clinical Focus Areas. Clinicalfocus areas applicable to all enrol-lees. Includes all subsections from1.3.4.1 through 1.3.4.7

1.3.6 Special projects.

1.3.6.1 HCFA or State Medicaidagency an organization to conductparticular projects that are specificto the organization and that relate totopics and involve quality indica-tors of HCFA’s or the State Medi-caid agency’s choosing.

1.3.6.2 Collaborative projects. Or-ganizations may satisfy the re-quirements of standards 1.3.2 and1.3.5 by collaborating with one an-other, subject to the approval ofHCFA or the State Medicaidagency.


1.4.2.1 Quality indicators are ob-jective, clearly, and unambiguouslydefined, and based on current clini-cal knowledge or health servicesresearch…

(Quality Process)


DMHC Comment

The KKA does not require the Plan tocollect specific data; although this is thepractice in the industry and we expect tosee this as a means to demonstratecompliance with other KKA require-ments.

6.5 QI System

6.5.1.1 (D) (3) Review ofentire range of care

6.5.1.1 (E) Quality ofCare studies

6.5.1.1 (G) The annualQIP report will include asummary of all QIPstudies, trending of clini-cal and service indicators,areas of deficiency andCorrective Actions, anevaluation of overall ef-fectiveness and evidencethat activities contributedto improvements (6.5.1.1)


6.5.2.2 (D) The governingbody reviews the studyresults and actions takenand assesses the QIP forcontinuity, effectivenessand current acceptability.

MMCD Policy Letter00-01 (Relates to medicaland behavioral health QIresponsibilities)

(Quality Process)

6.5.3 (6.5.3.1- 6.5.3.5)Systematic Process of QI

Highly consistent

All four sets of standards require a QIprogram that address a range of clinicalcare and require an assessment of QIactivities. All QI processes requirecollecting data, analyzing data results,implementing interventions, and re-measuring to assess improvement.

NCQA, HCFA and DHS require spe-cific study design, methodology, andanalysis, while DMHC standards areless descriptive.

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1.4.4.2 When a project measuresperformance on quality indicatorsby collecting data on a subset of theunits of analysis (continues to de-scribe quantitative improvementdemonstrated in the repeated meas-urements is statistically significantwith a p value.)

1.4.4.2.1 Samples (describes sam-pling methodology including usingthe same sampling frame and meth-odology)

1.5.1 The system collects data onenrollee and provider characteris-tics, and on services furnished toenrollees, as needed to guide theselection of performance improve-ment project topics and to meet thedata collection requirements forperformance improvement projects

QI 10.1 – At a minimum, theMCO adopts or establishesquantitative measures to assessperformance and to identify andprioritize areas for improvementfor three clinical issues, includ-ing at least one behavioral health



1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurement andintervention, demonstrable andsustained improvement in signifi-

(Quality Process)

Rule 1300.70(a)(1) The QA programmust (be directed by providers andmust) document that the quality of careprovided is being reviewed, that prob-lems are identified, effective action istaken to improve care when deficiencies

6.5.1.1 (G) The annualQIP report will include asummary of all QIPstudies, trending of clini-cal and service indicators,areas of deficiency andCorrective Actions, anevaluation of overall ef-


All four sets of requirements call forthe measurement of performance.


! NCQA requires three clinicalstudies, including one behav-

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issue.

Elements include:

! Relevant to membership

! Objective and quantifi-able

! Based on scientificknowledge

! Established goals andbenchmarks

cant aspects of clinical care andnon-clinical services that can beexpected to have a beneficial effecton health outcomes and enrolleesatisfaction.





1.4.2.1 Quality indicators are ob-jective, clearly, and unambiguouslydefined, and based on current clini-cal knowledge or health servicesresearch. …

1.4.3 Data collection and method-ology. Assessment of the organiza-tion’s performance on the selectedindicators is based on systematic,

are identified, and follow up is plannedwhen indicated

Rule 1300.70(a)(2) This section doesnot set forth a prescriptive approach toQA methodology. Plans are affordedflexibility in meeting the Act’s qualityof care requirements.

fectiveness and evidencethat activities contributedto improvements (6.5.1.1)

(Quality Process)


6.5.3.1 General Require-ments*

6.5.3.2 Quality Perform-ance Measures Report-ing*


6.5.3.4 Internal QualityImprovement Projects(IQIPS)*

DHS Comment

At present DHS does notrequire plans to identifyone behavioral issue fordata collection and qualityimprovement.

EQRO conducts clinicalquality of care studies.

ioral health activity.

! DHS carves out behavioralhealth. Note, however, thatNCQA would hold plan ac-countable for this standard ifthe plan has any responsibilityfor provision of care (e.g.,through PCP).

! DMHC and HCFA do not spe-cifically address behavioralhealth.

! NCQA and HCFA have spe-cific study design require-ments.

! HCFA standards evaluate per-formance against HCFA orState Medicaid agency stan-dards.

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ongoing collection and analysis ofvalid and reliable data. Includessubsections 1.4.3.1 through1.4.3.2.2.


QI 10.2 – The managed careorganization uses appropriatemethods to collect data for eachassessment measure.

Elements include:

! Population based

! Appropriate sampling

! Valid data



1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurement andintervention, demonstrable andsustained improvement in signifi-cant aspects of clinical care andnon-clinical services that can beexpected to have a beneficial effecton health outcomes and enrolleesatisfaction;



(Quality Process)

Rule 1300.70(a)(1) The QA programmust be directed by providers and mustdocument that the quality of care pro-vided is being reviewed, that problemsare identified, effective action is taken toimprove care when deficiencies areidentified, and follow up is plannedwhen indicated

Rule 1300.70(a) (2) This section doesnot set forth a prescriptive approach toQA methodology. Plans are affordedflexibility in meeting the Act’s qualityof care requirements.

6.5.1.1 (G) The annualQIP report will include asummary of all QIPstudies, trending of clini-cal and service indicators,areas of deficiency andCorrective Actions, anevaluation of overall ef-fectiveness and evidencethat activities contributedto improvements.

(Quality Process)





Highly consistent

NCQA, HCFA, and DHS have thesame intent and similar language.

The DMHC is not prescriptive in re-gard to methodology.

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1.4.4.2.1 Sample obtained throughrandom sampling




6.5.3.4 Internal Quality

Improvement Projects(IQIPS)*

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QI 10.3 – The MCO analyzesdata collected for each assess-ment measure.

Elements include:

! Qualitative analysis

! Analysis of cause



1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurement andintervention, demonstrable andsustained improvement in signifi-cant aspects of clinical care andnon-clinical services that can beexpected to have a beneficial effecton health outcomes and enrolleesatisfaction;





1.4.1 Selection of topics. Within

(Quality Process)


6.5.1.1 (G) The annualQIP report will include asummary of all QIPstudies, trending of clini-cal and service indicators,areas of deficiency andcorrective actions, anevaluation of overall ef-fectiveness and evidencethat activities contributedto improvements (6.5.1.1)

(Quality Process)






DHS Comment


Highly consistent

NCQA, HCFA, and DHS have thesame intent and similar language.

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each required focus area, the or-ganization selects a specific topic ortopics to be addressed by a project.Includes subsections 1.4.1.1through 1.4.1.3.


1.4.4.2. When a project measuresperformance on quality indicatorsby collecting data on a subset ofunits of analysis… quantitative im-provement demonstrated in the re-peated measurements is statisticallysignificant with a p value.



QI 11 Intervention and Follow-up for Clinical Issues

QI 11 – The MCO takes actionto improve quality by addressingthe opportunities for improvingperformance identified in QI 10.The managed care organization



1.3.4 Clinical Focus Areas. Clinicalfocus areas applicable to all enrol-

Rule 1300.70(a)(1) The QA programmust be directed by providers, anddocument that the quality of care pro-vided is being reviewed, that problemsare being identified, that effective action



Highly consistent

All of the standards listed have similarlanguage and intent with minor varia-tions.

! NCQA mandates that plans

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also assesses the effectiveness ofthese interventions through sys-tematic follow-up. The intent ofthis standard is for MCOs todesign interventions for QI 11that address the barriers or spe-cific circumstances that wereidentified in the analysis in QI10.3.

Elements include:

! Identifying opportunitiesfor improvement

! Implements interventionswhen it identifies indi-vidual occurrences ofpoor quality


lees. Includes all subsections from1.3.4.1 through 1.3.4.7.


1.4.1 Selection of topics - Withineach required focus area, the or-ganization selects a specific topic ortopics to be addressed by a project.Includes subsections 1.4.1.1through 1.4.1.3.

1.4.4.2 When a project measuresperformance on quality indicatorsby collecting data on a subset ofunits of analysis… quantitative im-provement demonstrated in the re-peated measurements is statisticallysignificant with a p value.

1.4.4.3 The improvement is reason-able attributable to interventionsundertaken by the organization.

1.5.1 The system collects data onenrollee and provider characteris-tics, and on services furnished toenrollees, as needed to guide theselection of performance improve-ment project topics and to meet thedata collection requirements forperformance improvement projects

is taken to improve care where deficien-cies are identified, and that follow-up isplanned where indicated.


6.5.3.4 IQIPs*

DHS Comment


identify opportunities in allthree clinical areas, implementinterventions, and remeasureeffectiveness.

! HCFA standards do not spe-cifically state the implementa-tion of interventions, but creditdemonstrable and sustainedimprovement through the useof such intervention.

! DHS specifies that the EQROwill monitor and evaluate theactivities conducted.

QI 11.1 – The managed careorganization follows up on theopportunities for improvementidentified through assessmentand evaluation activities.

Elements include:

! Identifies opportunities


1.3.4 Clinical Focus Areas. Clinicalfocus areas applicable to all enrol-lees. Includes all subsections from1.3.4.1 through 1.3.4.7.


Rule 1300.70(a)(1) The QA programmust be directed by providers, anddocument that the quality of care pro-vided is being reviewed, that problemsare being identified, that effective actionis taken to improve care where deficien-cies are identified, and that follow-up isplanned where indicated.





All four sets of standards use a QI pro-cess. However, HCFA and DHS re-quire sustained improvement. NCQArequires one remeasurement.

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! Implements timely andappropriate interventions

! Measures effectivenessof interventions


1.3.6.1 HCFA or State Medicaidagency an organization to conductparticular projects that are specificto the organization and that relate totopics and involve quality indica-tors of HCFA’s or the State Medi-caid agency’s choosing.

1.3.6.2 Collaborative projects. Or-ganizations may satisfy the re-quirements of standards 1.3.2 and1.3.5 by collaborating with one an-other, subject to the approval ofHCFA or the State Medicaidagency.


1.4.4.2 When a project measuresperformance on quality indicatorsby collecting data on a subset of theunits of analysis…quantitative im-provement demonstrated in the re-peated measurements is statisticallysignificant with a p value.

1.4.4.3 The improvement is reason-able attributable to interventionsundertaken by the organization.

1.4.5 Sustained improvement. Theorganization sustains the improve-ments in performance described in1.4.4 for at least one year after theimprovement in performance is first

6.5.3.4 IQIPs*

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achieved. Sustained improvement isdocumented through the continuedmeasurement of quality indicatorsfor at least one-year after the per-formance improvement project de-scribed in 1.4.4 is completed.


QI 11.2 – The MCO implementsappropriate interventions when itidentifies individual occurrencesof poor quality.




2.4.4.1 The information is used todevelop activities under the organi-zation’s QAPI program, both toimprove the issue resolution proc-ess itself, and to make improve-ments that address other system

Rule 1300.70(a)(1) The QA programmust be directed by providers, anddocument that the quality of care pro-vided is being reviewed, that problemsare being identified, that effective actionis taken to improve care where deficien-cies are identified, and that follow-up isplanned where indicated

DMHC Comment

NCQA’s evaluation appears morepopulation-based; KKA requires plans toidentify problems on an individual as wellas systemic basis and correct them)


Highly consistent

Although language varies among thesets of standards, the intent in all is thatplans address both systemic and indi-vidual issues of quality.

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issues raised in the issue resolutionprocess.


QI 12 Effectiveness of the QI Program

QI 12 – The MCO evaluates theoverall effectiveness of the QIprogram and demonstrates im-provements in the quality ofclinical and the quality of serviceto its members.

Elements include:

! Annual evaluation of theQI program

! Meaningful improve-ment

- Clinical care

- service

! Makes QI program in-formation available tomembers and practitio-ners






1.4.4 Demonstrable improvement.The organization’s interventionsresult in significant demonstrableimprovement in its performance asevidenced in repeat measurementsof the quality indicators specifiedfor each performance improvementproject undertaken by the organiza-tion. Includes subsections 1.4.4.1through 1.4.4.3.

2.4.4.1 The information is used todevelop activities under the organi-zation’s QAPI program, both to

Rule 1300.70(a)(1) The QA programmust be directed by providers, anddocument that the quality of care pro-vided is being reviewed, that problemsare being identified, that effective actionis taken to improve care where deficien-cies are identified, and that follow-up isplanned where indicated.

Rule 1300.70(a)(3) A plan’s QA pro-gram must address service elements,including accessibility, availability,continuity of care. A plan’s QA programmust also monitor whether the provisionand utilization of services meets profes-sionally recognized standards of prac-tice.

6.5.1.1 (G) The annualQIP report will include asummary of all QIPstudies, trending of clini-cal and service indicators,areas of deficiency andcorrective actions, anevaluation of overall ef-fectiveness and evidencethat activities contributedto improvements

(Quality Process)




6.5.2.2 (D) The governingbody reviews the studyresults and actions takenand assesses the QIP forcontinuity, effectivenessand current acceptability.



6.5.3.2 Quality Perform-

Highly consistent

All four sets of standards require thatplans monitor the effect of their QIactivities.

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improve the issue resolution proc-ess itself, and to make improve-ments that address other systemissues raised in the issue resolutionprocess.

ance Measures Report-ing*



QI 12.1 – There is an annualwritten evaluation of the QI pro-gram.

Elements include:

! A description of com-pleted and ongoing QIactivities

! Trending of measures toassess performance

! An analysis of whetherthere have been demon-strated improvements inthe quality of clinicalcare and quality of serv-ice to members

! An evaluation of theoverall effectiveness ofthe QI program


Does not address

Editorial note

DMHC provided the following refer-ences, however these do not addressthe specificity of this standard.

Rule 1300.70(a)(1) and (a)(3)

6.5.1.1 (G) The annualQIP report will include asummary of all QIPstudies, trending of clini-cal and service indicators,areas of deficiency andcorrective actions, anevaluation of overall ef-fectiveness and evidencethat activities contributedto improvements.


All four sets of requirements call forevaluation of the quality program.

However, NCQA, HCFA, and DHSrequire an annual evaluation.

DMHC indicates that plans must con-tinually evaluate their program, butdoes not require a formal annualevaluation.

QI 12.2 – There is evidence thatQI activities have contributed tomeaningful improvement in thequality of clinical care and qual-ity of service provided to mem-bers.



1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurement andintervention, demonstrable andsustained improvement in signifi-cant aspects of clinical care and


6.5.1 General Require-ment …monitor, evalu-ated and take effectiveaction

6.5.1.1 (G) …an evalua-tion of the overall effec-tiveness of the QIP andevidence that activities

Highly consistent

All sets of standards reflect the sameintent.

NCQA, HCFA, and DHS languagespecifies that there is evidence ofmeaningful improvements in the qual-ity program.

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& COMMENTS


non-clinical services that can beexpected to have a beneficial effecton health outcomes and enrolleesatisfaction.

1.4.4 Demonstrable improvement.The organization’s interventionsresult in significant demonstrableimprovement in its performance asevidenced in repeat measurementsof the quality indicators specifiedfor each performance improvementproject undertaken by the organiza-tion. Includes subsections 1.4.4.1through 1.4.4.3.


DMHC Comment

DMHC is not prescriptive, but requiresthe plan to demonstrate that it has anactive QA program that is successful inidentifying and correcting deficiencies)

have contributed to sig-nificant improvement inthe care delivered tomembers.

DMHC standards provide the plan withthe autonomy to determine how tomeet quality of care requirements.However, DMHC requires effectiveactions resulting in improvement.

QI 12.3 – Upon request theMCO makes available to itsmembers and practitioners in-formation about its QI Program,including a description of the QIprogram and report on theMCOs programs progress inmeeting its goal.

Does not address Does not address Does not address Consistent with variation

Only NCQA mandates providing QIprogram information to members andproviders. The other standards do notaddress this issue.

Quality Improvement


& COMMENTS


QI 13 Delegation of QI Activity

QI 13 – If the MCO delegatesany QI activities, there is evi-dence of oversight of the dele-gated activity.

Elements include:

! A mutually agreed upondocument

! Evidence of delegatedoversight

! Annual review of dele-gate’s work plan

4.1 The organization oversees andis accountable for any functions orresponsibilities that are described inthe standards of Domain 1 through3 that are delegated to other entities.

4.1.1 A written agreement specifiesthe delegated activities and report-ing responsibilities of the entity andprovides for revocation of the dele-gation or other remedies for inade-quate performance

4.1.2 The organization evaluatesthe entity’s ability to perform thedelegated activities prior to delega-tion.

4.1.3 The performance of the entityis monitored on an ongoing basisand formally reviewed by the or-ganization at least annually.

Rule 1300.70 (b)(2)(B) Written docu-ments shall delineate QA authority,function and responsibility, and provideevidence that the plan has establishedquality assurance activities and that theplan’s governing body has approved theQA program. To the extent that plan’sQA responsibilities are delegated withinthe plan or to a contracting provider,the plan’s documents shall provide evi-dence of an oversight mechanism forensuring that delegated QA functionsare adequately performed;

Rule 1300.70(b)(2)(C) In order to meetthese obligations each plan’s QI pro-gram shall meet all of the followingrequirements:

The plan’s governing body, its QAcommittee, if any, and any internal orcontracting providers to whom QA re-sponsibilities have been delegated, shalleach meet on a quarterly basis, or morefrequently if problems have been identi-fied, to oversee their respective QA pro-gram responsibilities. Any delegatedentity must maintain records of its QAactivities and actions, and report to theplan on a appropriate basis and to theplan’s governing body on a regularlyscheduled basis, at least quarterly,which reports shall include findings andactions taken as a result of the QA pro-gram.

The plan is responsible for establishing

3.26.1 Knox-KeeneRegulations

3.26.2 Subcontract Re-quirements

6.5.2.6 Delegation of QIPActivities*

6.5.2.6 (A) Maintain ofpolicies and procedureswhich describe delegatedactivities

6.5.2.6 (B) Establish re-porting standards

6.5.2.6 (C) Continuousmonitoring and evalua-tion of the delegatedfunctions


6.5.2.6 (E) Approve dele-gates QIP

6.5.2.6 (F) Continuouslymonitored and evaluatedQI 13 Delegation of QI Activity

Highly consistent

Although the language differs slightly,all four sets of standards mandate over-sight of delegated activities.

Quality Improvement


& COMMENTS


a program to monitor and evaluate thecare provided by each contracting pro-vider group to ensure that the care pro-vided meets professionally-recognizedstandards of practice; Reports of theplan's governing body shall be suffi-ciently detailed to include findings andactions taken as a result of the QA pro-gram and to identify those internal orcontracting provider components whichthe QA program has identified as pre-senting significant or chronic quality ofcare issues.

Rule 1300.70(b)(2)(G) Medical groupsof other provider entities may have ac-tive quality assurance programs that theplan may use. In all instances, however,the plan must retain responsibility forreviewing the overall quality of caredelivered to plan enrollees. If QA activi-ties are delegated to a participatingprovider to ensure that each providerhas the capacity to perform effectivequality assurance activities.

Rule 1300.70(b)(2)(G)(2) The Planmust ascertain that each provider towhich QA responsibilities have beendelegated has an in-place mechanism tofulfill its responsibilities, including ad-ministrative capacity, technical expertiseand budgetary resources.

Rule 1300.70(b)(2)(G)(3) The Planmust have ongoing oversight proceduresin place to ensure that providers arefulfilling all delegated QA responsibili-ties.

Quality Improvement



& COMMENTS


Rule 1300.70(b)(2)(G)(4) Requiresstandards for evaluating that enrolleesreceive health care consistent with pro-fessionally recognized standards ofpractice.

QI 13.1 – A mutually agreedupon document.

Elements include:

! Responsibilities of theMCO and the delegatedentity

! Delegated activities

! Frequency of reportingto the MCO

! Process by which theMCO evaluates the dele-gated entity’s perform-ance

! Remedies, includingrevocation of the delega-tion, available to theMCO if the delegatedentity does not fulfill itsobligations


Rule 1300.70(b)(2)(B) Written docu-ments shall delineate QA authority,function and responsibility, and provideevidence that the plan has establishedquality assurance activities and that theplan’s governing body has approved theQA program. To the extent that plan’sQA responsibilities are delegated withinthe plan or to a contracting provider,the plan’s documents shall provide evi-dence of an oversight mechanism forensuring that delegated QA functionsare adequately performed;

DMHC Comment

KKA does not specifically address re-voking delegation, although we haveconsidered this an appropriate action totake when there are uncorrected defi-ciencies in performance of delegatedfunctions.

3.19 Sanctions*

3.26.1 KKA and Regula-tions

(cites KKA requirementsthat require writtenagreements)



6.5.2.6 (A) Maintain poli-cies and procedureswhich describe delegatedactivities



Highly consistent

All four sets of standards require writ-ten documents that describe delegationagreements. NCQA’s standards are themost specific requiring a detailed de-scription of the delegation agreement,which is signed and dated by both par-ties.

HCFA requires a detailed agreementbut is less specific about the signatures.

DMHC and DHS both require writtenagreements but are less specific aboutthe required description.

QI 13.2 – There is evidence thatthe MCO:

! Evaluates the delegatedentity’s capacity to per-form the delegated ac-tivities prior to delega-tion

! Approves the delegate’sQI work plan and pro-




The plan’s governing body, its QAcommittee, if any, and any internal orcontracting providers to whom QA re-sponsibilities have been delegated, shalleach meet on a quarterly basis, or more




6.5.2.6 (C) Continuousmaintenance of written

Highly consistent

All four sets of standards are similar inlanguage and intent requiring that theplan conduct oversight of the delegate.Prior to delegation and following dele-gation.

Minor differences include

! NCQA and HCFA standards re-

Quality Improvement



& COMMENTS


gram

! Evaluates regular reportsas specified in QI 13.1.3

! Evaluates annuallywhether the delegatedentity’s activities arebeing conducted in ac-cordance with theMCO’s expectations andNCQA standards

frequently if problems have been identi-fied, to oversee their respective QA pro-gram responsibilities. Any delegatedentity must maintain records of its QAactivities and actions, and report to theplan on a appropriate basis and to theplan’s governing body on a regularlyscheduled basis, at least quarterly,which reports shall include findings andactions taken as a result of the QA pro-gram.

The plan is responsible for establishinga program to monitor and evaluate thecare provided by each contracting pro-vider group to ensure that the care pro-vided meets professionally-recognizedstandards of practice; Reports of theplan's governing body shall be suffi-ciently detailed to include findings andactions taken as a result of the QA pro-gram and to identify those internal orcontracting provider components whichthe QA program has identified as pre-senting significant or chronic quality ofcare issues.

Rule 1300.70(b)(2)(G) Medical groupsof other provider entities may have ac-tive quality assurance programs that theplan may use. In all instances, however,the plan must retain responsibility forreviewing the overall quality of caredelivered to plan enrollees. If QA activi-ties are delegated to a participatingprovider to ensure that each providerhas the capacity to perform effectivequality assurance activities.

procedures and docu-mentation of monitoringand evaluation of thedelegated functions

6.5.2.6 (D) Assurance anddocumentation that sub-contractor has the ad-ministrative capacity,task experience, andbudgetary resources tofulfill its responsibilities

6.5.2.6 (F) Plan ensuresthat actual Q of C pro-vided is continuouslymonitored and evaluated

quire an annual evaluation. DMHCand DHS have on-going evalua-tion, but do not specifically statethat they conduct an annualevaluation

Quality Improvement



& COMMENTS






Utilization ManagementUM 1 Utilization Management Structure

UM 1 Utilization Management Structure


& COMMENTS

UM 1 – The MCO’s UM pro-gram structure and processes areclearly defined.

Elements include:

! Written description

- Structure

- Scope

- Criteria

- Processes

- Delegation and

- UM services

! Designated senior physi-cian

! Evaluated and updatedannually

Editorial Note:

This refers to an annual evalua-tion of the UM program and notto UM criteria.

! In place 12 months

1.6.1.1 The policymaking bodyoversees and is accountable for theQAPI program. (standard describesthe QI program)

3.1.7.2 Policies and procedures,including coverage rules, practiceguidelines, payment policies andutilization management that allowfor individual medical necessitydeterminations.

3.2.1 Use of a health care profes-sional who is formally designatedas having primary responsibility forcoordinating the enrollee’s overallhealth care

Section 1363.5(a) discloses the UMprocesses used by the Plan, contractingprovider groups, or any entity withwhich the plan contracts for servicesthat include utilization review or utili-zation management functions, toauthorize, modify, or deny health carebenefits.

Section 1367(g) the plan shall have theorganizational and administrative ca-pacity to provide services to subscribersand enrollees. The plan shall be able todemonstrate to the department thatqualified medical providers, unhinderedby fiscal and administrative manage-ment, render medical decisions.

Section 1367.01 Process for Review ofRequests by Health Care Service Pro-viders

Section 1367.01(b) requires that theplan have written policies and proce-dures for all UM activities

Section 1367.01(c) (requires that pro-gram identify designated medical di-rector)

Rule 1300.67.3(a) the organization ofeach plan shall provide the capability tofurnish in a reasonable and efficientmanner the health care services forwhich subscribers and enrollees havecontracted.

Rule 1300.70(b)(2)(C) In order to meetthese obligations each plan’s QI pro-

6.5.2.2 (A) GoverningBody (approves the over-all QIP and annual re-port)

6.5.2.2 (D) Annual QIPreport

(describes review of an-nual UM data)


6.5.9 Utilization Man-agement

6.5.9.1 General Require-ments (describes formalUM program)

6.5.9.3 Pre-Authorization/ReviewProcedures (requires thatdecisions be supervisedby qualified medicalprofessionals and physi-cians make denials; re-quires plans to havewritten criteria and up-date criteria regularly)

6.5.9.5 Delegation of UMActivities


All four set of standards require plansto establish a structured UM programthat describes:

! Scope of UM activities

! UM criteria

! Accountability

! Is supervised by health careprofessionals


! NCQA and DHS require veryspecific elements in the de-scription. DMHC and HCFAstandards are less specific.

! NCQA, DHS, and DMHC re-quire that a physician be desig-nated to oversee the UM pro-gram. HCFA accepts oversightby a health care professional.

! NCQA, HCFA and DHS re-quire a formal annual evalua-tion of the QI/UM program.DMHC requires QI quarterlyupdates.

! Only NCQA requires the pro-gram to be in place for 12months.

! DHS and DMHC specify thatthe organization ensures thatUM decisions are not influ-enced by fiscal or administra-tive considerations. NCQA ad-

Utilization Management



& COMMENTS


gram shall meet all of the followingrequirements: A plan must have amechanism to oversee the quality ofcare provided in an inpatient setting toits enrollees which monitors that: Inaddition to the internal quality of carereview system, a plan shall design andimplement reasonable procedures forcontinuously reviewing the performanceof health care personnel, and the utili-zation of services and facilities, andcost. The reasonableness of the proce-dures and the adequacy of the imple-mentation thereof shall be demonstratedto the Department.

DMHC Comment

The Department has considered UMreporting a part of the QI program, andhas applied 1300.70 requirements to UMand QI.

dresses this issue in UM 11.5.

! All sets of standards addressdelegation in their QI or dele-gation standards. However,NCQA requires that a formaldescription of delegation be inthe QI or UM plan.


UM 2 Clinical Criteria for UM Decisions

UM 2 – To make UM decisions,the MCO uses written criteriabased on sound clinical evi-dence, and specifies proceduresfor applying those criteria in anappropriate manner.

Elements include:

! Criteria for determiningmedical necessity Prac-titioner involvement

! Annual review and up-date of criteria

! Criteria in place for 12

3.1.7.2 Policies and procedures,including coverage rules, practiceguidelines, payment policies andutilization management, that allowfor individual medical necessitydeterminations.

3.3.1.2 Criteria for decisions oncoverage and medical necessity areclearly documented, are based onreasonable medical evidence or aconsensus of relevant health careprofessionals, and are regularlyupdated.

Section 1363.5 Authorization or Denialof Services; Process; Disclosures; Crite-ria.

Section 1363.5 Criteria for UM must beevaluated and updated if necessary, atleast annually

Section 1363.5(a) (requires that theplan disclose criteria for authorizing ordenying services)

Section 1363.5(a)(1) (requires that cri-teria be developed with involvementfrom actively practicing health care

6.5.9.3 Pre-Authorization/ReviewProcedures (requires thatdecisions be supervisedby qualified medicalprofessionals and physi-cians make denials; planestablishes written crite-ria; updates criteriaregularly, and applies thecriteria consistently)

DHS Comment

NCQA standards are notspecifically addressed in

Highly consistent

All four sets of standards require thatplans establish written criteria, usingcurrent and sound medical evidence.Although the intent is consistent, lan-guage and details vary.


! NCQA, DMHC and DHS re-quire practitioner participationin developing and adopting thecriteria. HCFA does not requirepractitioner involvement.

! NCQA and DMHC require an




& COMMENTS


months

! Informing practitionershow to obtain criteria

! Consistency across allreviewers

3.3.1 The organization implementswritten policies and procedures,reflecting current standards ofmedical practice, for processingrequests for initial authorization ofservices or requests for continuationof services.

3.3.1.3 Mechanisms are in place toensure consistent application ofreview criteria and compatible de-cisions.

3.3.2 The organization furnishesinformation to all affiliated provid-ers about enrollee benefits.

3.4.1.3 Decisions with respect toutilization management, enrolleeeducation, coverage of services, andother areas to which the guidelinesare applicable are consistent withthe guidelines.UM 2 Clinical Criteria for UM Decisions

providers.)

Section 1365.5(a) A plan shall discloseor provide for the disclosure to thecommissioner and providers under con-tract with the plan the process the planuses to authorize or deny health careservices under the benefits provided bythe plan. A plan shall disclose thoseprocesses to enrollees or persons desig-nated by an enrollee upon request. Thecriteria used by the plans to determinewhether to authorize or deny health careservices shall.

Section 1363.5(b)(2) (requires that cri-teria be developed using sound clinicalprinciples and processes.)

Section 1363.5(b)(4) If used as the basisof a decision to deny services in a speci-fied case under review, be disclosed tothe provider or the enrollee, or both, inthat specified case.


Rule 1300.67.3(a)(3) written proceduresfor the conduct of the business of theplan, including the provision of healthcare services, so as to provide effectivecontrols.

the DHS contract. How-ever, DHS expects plansto incorporate these stan-dards in their UM policiesand procedures.

DHS does not specificallyrequire plans to provideUM criteria to physiciansand non-physicians uponrequest. DHS does pro-vide the criteria to thephysician/non-physicianwhen a service has beendenied or modified

annual evaluation of criteria.HCFA and DHS require onlyregular evaluation.

! DHS does not require the planto address how the practitionercan obtain the plan’s UM crite-ria.

Although all four sets of standards re-quire that the criteria be applied in aconsistent manner, NCQA specificallyassesses the plan’s interrater processesfor both physicians and non- physicianreviewers.




& COMMENTS


DMHC Comment

KKA does not specifically require theplan to review interrater reliability, butdoes require that the quality of care bereviewed.

Section 1367.01(a) and (b) require thatall persons performing UM for plan en-rollees adhere to the plan’s policies andprocedures for UM. Section 1367.01(c)states that the Plan’s medical director isresponsible to ensure that the processby which the plan (or any entity thatperforms UM for the plan) performs UMdecisions based in whole or in part onmedical necessity, complies with therequirements of Section 1367.01. Bylogical progression, these requirementswould require plans to conduct studies ofinterrater reliability in order to demon-strate compliance.


UM 3 Appropriate Professional

UM 3 – Qualified health profes-sionals assess the clinical infor-mation used to support UM deci-sion.

Elements require:

! Professional supervisionof UM decisions

! Physician review of de-nials

- Physician makesmedical denial

- Psychiatrist, Ph.D.,addictionologistmakes behavior

3.3.1.4 A clinical peer reviews alldecisions to deny authorization ongrounds of medical appropriateness.

Section 1367.01(e) No individual otherthan a licensed physician or licensedhealth professional, who is competent toevaluate the specific clinical issues in-volved in the health care services re-quested by the provider, may deny ormodify requests for authorization ofhealth care services for an enrolleebased in whole or in part on reasons ofmedical necessity.

Section 1367(g) the plan shall have theorganizational and administrative ca-pacity to provide services to subscribersand enrollees. The plan shall be able todemonstrate to the department that

6.5.9.3 (A) Pre-Authorization/ReviewProcedures (requires thatreview decisions are su-pervised by qualifiedmedical professional andall denials are made by aqualified physician)

DHS Comment

DHS does not identify theuse of a behavioral healthprofessional to reviewbehavioral health denials


The intent of all four sets of standardsis that appropriate professionals makedecisions, and that physicians or otherappropriate licensed staff make medi-cal necessity denials.

NCQA specifically requires that medi-cal necessity denials be made by physi-cians, and that behavioral health deni-als be made by appropriate personnel.

HCFA, DMHC, and DHS standards arebroader, requiring “qualified medicalprofessionals or physicians, but reflectthe same intent.




& COMMENTS


health denials

! Board certified physi-cians of appropriate spe-cialty assist in makingdecisions on medical ne-cessity.

medical decisions are rendered byqualified medical providers, unhinderedby fiscal and administrative manage-ment.

Only NCQA requires the plan to de-velop and implement a specialty re-view by a board certified physician.

NCQA assesses all levels of UM su-pervision.

The other sets of standards are lessspecific, and address mostly UM deni-als.


UM 4 Timeliness of UM Decisions

UM 4 – The MCO makes utili-zation decisions in a timelymanner to accommodate theurgency of the situation.

Elements Include:

! Timeliness of decisions

! Procedures for expeditedappeals

3.3.1.1 The policies specify timeframes for responding to requestsfor initial and continued determi-nations, specify information re-quired for authorization decisions,provide for consultation with therequesting provider when appropri-ate, and provide for expedited re-sponse to requests for authorizationof urgently needed services.UM4 Timeliness of UM Decisions

Section 1367.01(h)(1) requires that de-cisions be made in a timely fashion ap-propriate to the nature of the enrollee’scondition. If urgent, not to exceed 72hours, if routine, not to exceed fivebusiness days, if concurrent, not to ex-ceed 24 hours, if retrospective, within30 days from the date the Plan receivesthe information reasonably necessaryand requested by the plan.

NCQA Comment:

6.5.9.3 (E) Decisions andappeals are made in atimely manner

Highly consistent

All four sets require that the plan makeUM decisions in a timely manner.

UM 4.1 – The MCO makesutilization decisions in a timelymanner to accommodate theclinical urgency of the situation.

! Precertification of non-urgent care

- Makes decisionswithin working 2days

- Notifies practitionerwithin 1 working day

- Gives members and

3.3.1.1 The policies specify timeframes for responding to requestsfor initial and continued determi-nations, specify information re-quired for authorization decisions,provide for consultation with therequesting provider when appropri-ate, and provide for expedited re-sponse to requests for authorizationof urgently needed services.

3.3.1.5 The requesting provider andthe enrollee are promptly notified ofany decision to deny, limit, or dis-

Section 1367.01(h)(1) requires that de-cisions be made in a timely fashion ap-propriate to the nature of the enrollee’scondition. If urgent, not to exceed 72hours, if routine, not to exceed fivebusiness days, if concurrent, not to ex-ceed 24 hours, if retrospective, within30 days from the date the Plan receivesthe information reasonably necessaryand requested by the plan.


6.9.14 Denial, Deferral,or Modification of PriorAuthorization Requests(requires specific stepsand timeframes)

DHS Comment

DHS does not providespecific time frames forreview and approval ofservices. However, recent


All four include prescriptive time-frames for decision-making processes.


UM4 Timeliness of UM Decisions


& COMMENTS


practitioners writ-ten/electronic deci-sion within 2 workingdays

! Precertification of urgentcare

- Notifies member andpractitioners of denialwithin 1 calendar day

- Provides notificationto member and pro-vider of expeditedappeal process withnotification of denial

- Gives members andpractitioners writ-ten/electronic deci-sion of denials within2 working days

! Concurrent review

- Denials for inpt., in-tensive outpt., andresidential behavioralcare within 1 workingday of getting infor-mation

- Denials of ambula-tory care within 10working days of get-ting information

- Notifies practitionerswithin 1 working day

- Gives members andpractitioners writ-

continue authorization of services.The notice specifies the criteriaused in denying or limiting authori-zation and includes information onhow to request reconsideration ofthe decision pursuant to the proce-dures established under standard2.4.3. The notice to the enrolleemust be in writing.


State legislation (1999)requires Plans to providepain management medi-cations for terminally illmembers within 72 hours.Plans are also required toallow the dispensing of a72-hours supply of cov-ered outpatient drug in anemergency situation

DHS reference plans’compliance with Sections1367.01(h)(1-4)




& COMMENTS


ten/electronic deci-sion of denials within1 working day

- Provides notificationto member and pro-vider of expeditedappeal process withnotification of denial

! Retrospective review

- Makes decisionwithin 30 workingdays of receiving allinformation

- Notifies practitionersand members inwriting within 5 daysof making decision

UM 4.2 – The MCO establishesprocedures for registering andresponding to expedited appeals.

Elements include:

! Expedited appeal may beinitiated by member orpractitioner acting formember

! Decision made no laterthan 3 calendar days af-ter request is made

! Provided written deci-sion within 2 workingdays of decision

3.3.1.1 The policies specify timeframes for responding to requestsfor initial and continued determina-tions, specify information requiredfor authorization decisions, providefor consultation with the requestingprovider when appropriate, andprovide for expedited response torequests for authorization of ur-gently needed services.

Section 1367.10(h)(2) requires that,when the enrollee’s condition is suchthat the enrollee faces an imminent andserious threat to his or her health in-cluding, but not limited to, the potentialloss of life, limb, or major bodily func-tion, or the normal timeframe for deci-sions would be detrimental to the enrol-lees life or health or could jeopardizethe enrollee’s ability to regain maximumfunction, the Plan shall make these de-cisions in a timely fashion appropriatefor the nature of the enrollee’s condi-tion, not to exceed 72 hours after theplan receives the information reasona-bly necessary and requested by the plan.


DHS Comment

DHS requires plans tocomply with Sections1367.01(h)(1-4)

Highly consistent

All four sets of standards require plansto develop and implement an expeditedappeal process and have a 72 hour re-quired decisionmaking timeframe.



& COMMENTS


UM 5 Medical Information

UM 5 – When making a deter-mination of coverage based onmedical necessity, the managedcare organization obtains rele-vant clinical information andconsults with the treating physi-cian.

Elements require:

! Documentation of in-formation used to makethe decision

! Documentation of clini-cal information to makethe decision

! Plan assists the memberto transition care whenbenefits end


3.3.1.5 The requesting provider andthe enrollee are promptly notified ofany decision to deny, limit, or dis-continue authorization of services.The notice specifies the criteriaused in denying or limiting authori-zation and includes information onhow to request reconsideration ofthe decision pursuant to the proce-dures established under standard2.4.3. The notice to the enrolleemust be in writing.

Section 1365.5(a) A plan shall discloseor provide for the disclosure to thecommissioner and providers under con-tract with the plan the process the planuses to authorize or deny health careservices under the benefits provided bythe plan. A plan shall disclose thoseprocesses to enrollees or persons desig-nated by an enrollee upon request.


6.5.9.1 General Require-ments (describes formalUM program, informa-tional sources, and proc-esses)

6.5.9.1 Pre-authorization/review pro-cedures


Medical information documentation

All four sets of standards require plansto make decisions based on medicalinformation.

Only NCQA and DHS specificallyrequires that plans document the deci-sion-making process in UM files.

Only NCQA addresses transition ofcare after benefits end.

UM 5 Medical Information

UM 6 Denial Notices

UM 6 – The MCO clearlydocuments and communicatesthe reasons for each denial.

Elements include:

! Makes a physician re-viewer available to prac-titioner to discuss medi-cal necessity decisions

! Sends written notifica-tion to members andpractitioners that ex-plains decision

2.4.3.1 The organization’s notice toan enrollee and/or provider of itsdecision to deny, limit, or discon-tinue authorization of, or paymentfor, a service includes informationrequired under standard 3.3.1.5,including information about how toobtain a reconsideration of the de-cision. The notice to the enrolleemust be in writing.

3.3.1.5 The requesting provider andthe enrollee are promptly notified ofany decision to deny, limit, or dis-

Section 1367.01(h)(4) requires that re-sponses to deny, delay, or modify healthcare services requested by providersprior to, retrospectively, or concurrentwith the provision of health care serv-ices shall be communicated to the en-rollee in writing and to providers ini-tially be telephone, except that decisionsrendered retrospectively are to be inwriting, and shall include a clear andconcise explanation of the reasons forthe plan’s decision, a description of thecriteria or guidelines used, and the clini-

6.5.9.3 Pre - Authoriza-tions/Review Processes(mandates that plans pro-vide a clear documentedreason for denial and awell-published appealsprocess)

6.9.14 Denial, Referral orModification of PriorAuthorization Requests(includes a reference toTitle 22 Section 53894 --Notice to Members of

Consistent with variations

All four sets of standards require plansto communicate the reason for denial,and the appeal process in writing.

NCQA, DMHC and DHS stress thatthe reason for the denial must be clear.

HCFA states that the reason must atleast cite why the case did not meetcriteria. NCQA will not accept thismore limited explanation.

Only NCQA formally requires that


UM 6 Denial Notices


& COMMENTS


! Includes informationabout the appeal processwith all notifications

UM 6 Denial Notices

continue authorization of services.The notice specifies the criteriaused in denying or limiting authori-zation and includes information onhow to request reconsideration ofthe decision pursuant to the proce-dures established under standard2.4.3. The notice to the enrolleemust be in writing.

cal reasons for the decisions regardingmedical necessity.

Any written communication to a physi-cian or other health care provider of adenial, delay, or modification of a re-quest shall include the name and tele-phone number of the health care profes-sional responsible for the denial, delay,or modification. The telephone numberprovided shall be a direct number of anextension, to allow the physician orhealth care provider easily to contact theprofessional responsible for the denial,delay or modification.

Section 1367.01(h) includes a referenceto Title 22 Section 53894 --Notice toMembers of Plan Action to Deny, Defer,or Modify a Request for Medical Serv-ices. Timeliness and the timeliness ofnotification are addressed in UM 4Contents of notification are discussed inUM 6. Section 51014.1 addresses rightsto a Fair Hearing Related to Denial,Termination or Reduction in MedicalServices (appeals process).

Section 1368(a)(4) states that for griev-ances involving the delay, denial, ormodification of health care services, theplan response shall describe the criteriaused and the clinical reasons for its deci-sion, including all criteria and clinicalreasons related to medical necessity. Ifthe plan denies services on the basis inwhole or in part that they are not coveredbenefits, the plan must state the contractprovisions that exclude coverage.

Plan Action to Deny,Defer, or Modify a Re-quest for Medical Serv-ices. Timeliness and thetimeliness of notificationare addressed in UM 4Contents of notificationare discussed in UM 6.Section 51014.1 ad-dresses rights to a FairHearing Related to De-nial, Termination or Re-duction in Medical Serv-ices (appeals process).

DHS Comment

Plans may allow review-ers to discuss determina-tions with requesting phy-sicians via telephone,although this is not a DHSrequirement

plans provide a discussion with thephysician reviewer regarding the UMdecision.



& COMMENTS


UM 7 Evaluation of New Technology

UM 7 – The MCO evaluates theinclusion of new medical tech-nologies and the new applicationof existing technologies in thebenefit package. This includesmedical procedures, pharmaceu-ticals, and devices.

Elements include:

! Written process includes

- Description of vari-ables used to decideif benefits are cov-ered

- Review of informa-tion from governmentregulatory body aswell as published sci-entific evidence

- Appropriate profes-sionals participate indecision

! Provide examples ofprocess implementation

3.4.2 The organization implementswritten policies and procedures forevaluating new medical technolo-gies and new uses of existing tech-nologies.

Does not address.

Editorial Comment

References provided by DMHC are ad-dressed in NCQA’s Rights and Respon-sibilities RR 3.

Section 1370.4 requires every plan toprovide access to an independent reviewprocess to examine the plan’s coveragedecisions regarding experimental orinvestigation therapies for individualenrollees who meet certain criteria.

DMHC Comment

Effective January 1, 2001, the Depart-ment will provide this independent re-view process to enrollees.

Does not address

DHS Comment

DHS has no provision inthe contract to the use ofnew technologies

Highly consistent

NCQA and HCFA require policies foruse of new technologies.

DHS and DMHC have no provisionsfor the use of new technologies.

UM 7 Evaluation of New Technology

UM 8 Satisfaction with the UM Process

UM 8 – The MCO evaluatesmember and practitioner satis-faction with the UM process.

1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurement andintervention, demonstrable and

Does not address

DMHC Comment

The KKA does not require patient satis-

6.5.6.7 Member Satisfac-tion Surveys

DHS Comment


Only NCQA specifically requires plansto measure member and practitioner




& COMMENTS


Elements include:

! Assessment of membersatisfaction with the UMprogram at least every 2years

! Assessment of providersatisfaction with the UMprogram at least every 2years

! Addresses opportunitiesfor improvement


sustained improvement in signifi-cant aspects of clinical care andnon-clinical services that can beexpected to have a beneficial effecton health outcomes and enrolleesatisfaction;


faction surveys, although we look tothese to demonstrate compliance withother KKA requirements.

DHS requires patient sat-isfaction surveys as partof its Member Rights andResponsibilities contractrequirements (6.5.6.7).The CAHPS® 2.0H sur-vey, which is part of theQI program requirement,can serve as a substitutefor the patient satisfactionsurvey. DHS will onlyrequire the CAHPS® sur-vey to be administeredevery other year. (9/5/00DHS)

satisfaction with the UM process.

HCFA does not state that the plan mustmeasure UM satisfaction. However,general language in the standards pro-vides the plan with the flexibility toselect satisfaction as a topic.

DHS assesses only member satisfaction

DMHC does not address this issue.

UM 9 Emergency Services


UM 9 – The MCO provides,arranges for, or otherwise facili-tates all needed emergencyservices, including appropriatecoverage of costs.

The MCO:

! Covers emergency serv-ices necessary to screenand stabilize memberswithout pre-certificationin cases where a prudentlayperson, acting rea-sonably, would have be-lieved that an emergencymedical condition ex-isted

! Covers emergency serv-

2.2.2.2 The organization ensuresthat enrollees have the right to ac-cess emergency health care serv-ices, consistent with the enrollee’sdetermination of the need for suchservices as a prudent layperson.

Section 1371.4(c) (States that a planmay not deny payment for emergencyservices and care unless the plan deter-mines that the emergency services andcare were never performed. A plan maynot require prior authorization for emer-gency care, but may require priorauthorization for post stabilization care.)

6.6.18 Emergency Serv-ice Providers

(describes the plan’s fi-nancial liability for ERvisits)


Highly consistent

Both NCQA and HCFA require thatplans pay ER charges under the pru-dent layperson rule.

NCQA also requires that plans pay ERcharges if the member is advised to goto the ER by a plan representative.

DMHC and DHS do not allow plans todeny or hold the member responsiblefor ER denials.

CAHPS is a registered trademark of the Agency for Healthcare Research and Quality.




& COMMENTS


ices if a plan representa-tive authorized an emer-gency visit

! Requires that an MD re-view presenting symp-toms as well as dischargediagnosis when making adenial


UM 10 Procedures for Pharmaceutical Management

UM 10 – The managed care or-ganization ensures that its proce-dures for pharmaceutical man-agement, if any, promote theclinically appropriate use ofpharmaceuticals.

Elements require:

! Pharmaceutical proce-dures are based on soundclinical evidence, and theorganization specifieshow to apply the proce-dures in an appropriatemanner based on theneeds of individual pa-tients (refers to openformularies)

! Process to considermedical necessity ex-ceptions for members toobtain coverage of apharmaceutical not onthe formulary (refers toclosed formularies)



Section 1363.01 Plan must provide no-tice in the Evidence of Coverage that ituses a formulary, provide information asto which drugs are on the formularyupon request, shall explain what a for-mulary is, and the process for develop-ing the formulary, and the frequencywith which the Plan evaluates the for-mulary.

Section 1367.20 Plan must make for-mulary available to the public upon re-quest.

Section 1367.21 Plan may not denypayment for a drug prescribed for a usethat is different from the use for whichthe drug has been approved for market-ing by the FDA, providing certain con-ditions are met.

Section 1367.22 Plan may not limit orexclude coverage for a drug for an en-rollee if the drug had previously beenapproved by the plan and the prescribingprovider continues to prescribe the drugfor the patient’s condition.

Section 1367.24 requires plans that of-

3.23 PharmaceuticalServices and PrescribedDrugs

DHS Comment

DHS requires plans tocomply with CaliforniaHealth and Safety Codeand the California Regu-lations consistent withDMHC citations.


NCQA has explicit pharmacy require-ments that address access to both openand closed formularies. These are de-tailed in substandards 10.1-3.

DMHC and DHS standards also re-quire that plans provide formulary in-formation. However, they address thereview of the formulary, the review ofpractitioners who make decisions, andthe timeliness of decisions.

HCFA addresses pharmacy benefits inits regular benefit statements.




& COMMENTS


fer drug coverage to maintain an expe-ditious process for approving medicallynecessary nonformulary drugs. If thePlan denies coverage, the enrollee mayfile a grievance.

UM 10.1 – The managed careorganization procedures forpharmaceutical management, ifany, promote the clinical evi-dence and the organizationspecifies how to apply the pro-cedures in an appropriate man-ner, based on the needs of indi-vidual patients. (refers to openformularies)

Elements include:

! Criteria

! Uses clinical evidencefrom appropriate exter-nal organizations

! Maintains a list of phar-maceuticals, includingrestrictions and prefer-ences

! Describes how to useprocedures

! Explains limitations orquotas

! Describes what informa-tion practitioners mustprovide to request Rx

! Process for Rx substitu-tion

! Reviews procedures an-


Section 1363.01 Plan must provide no-tice in the Evidence of Coverage that ituses a formulary, provide information asto which drugs are on the formularyupon request, shall explain what a for-mulary is, and the process for develop-ing the formulary, and the frequencywith which the Plan evaluates the for-mulary.




Section 1367.24 requires plans that of-fer drug coverage to maintain an expe-ditious process for approving medicallynecessary nonformulary drugs. If thePlan denies coverage, the enrollee mayfile a grievance.


DHS Comment

DHS requires plans tocomply with CA HSC andthe California Regulationsconsistent with DMHCcitations


NCQA is more specific than the othersets of standards.

Comments in UM 10 detail differencesamong the standards.




& COMMENTS


nually

! Involves appropriatepractitioners, includingpharmacists

! Provides practitioners itspharmaceutical man-agement procedures, andprocedure changes

UM 10.2 – Where the managedcare organization restricts phar-macy benefits to a closed for-mulary, it has a process to con-sider medical necessity excep-tions for members to obtain cov-erage of a pharmaceutical not onthe formulary.

Process elements:

! Explains how to requestan exception

! Explains obtainingmedical necessity infor-mation for request

! Use of pharmacists andpractitioners to make de-cision

! Handles requests in atimely manner

! Describes communica-tion of denial appealprocess


Section 1363.01 Plan must provide no-tice in the Evidence of Coverage that ituses a formulary, provides informationas to which drugs are on the formularyupon request, explains what a formularyis, and the process for developing theformulary, and the frequency withwhich the Plan evaluates the formulary.




Section 1367.24 requires plans that of-fer drug coverage to maintain an expe-ditious process for approving medicallynecessary nonformulary drugs. If the


DHS Comment

DHS requires plans tocomply with CaliforniaHealth and Safety Codeand the California Regu-lations consistent withDMHC citations


Only NCQA addresses closed formu-laries.

UM 10 comments detail differencesamong the standards.




& COMMENTS


Plan denies coverage, the enrollee mayfile a grievance.


UM 11 Ensuring Appropriate Service and Coverage

UM 11 – The MCO facilitatesthe delivery of appropriate care,has mechanisms in place to de-tect and correct potential under-and over-utilization of service,and requires distribution of anaffirmative statement regardingincentives.

3.3.1.8 Mechanisms are in effect todetect both underutilization andoverutilization of services.

3.3.1.6 Compensation to persons ororganizations conducting utilizationmanagement activities shall not bestructured so as to provide inappro-priate incentives for denial, limita-tion or discontinuation of authori-zation of services

3.3.1.2 Criteria for decisions oncoverage and medical necessity areclearly documented, are based onreasonable medical evidence or aconsensus of relevant health careprofessions, and are regularly up-dated.

3.3.1.6 Compensation to persons ororganizations conducting utilizationmanagement activities shall not bestructured so as to provide inappro-priate incentives for denial, limita-tion or discontinuation of authori-zation of services.UM 11 Ensuring Appropriate Service and Coverage

Rule 1300.70(b)(2)(H)(2) In order tomeet these obligations, each plan’s QIprogram shall meet all of the followingrequirements: A plan that has capitationfor risk sharing contracts must: Have amechanism to detect and correct under-service by an at-risk provider (as deter-mined by its patient’s mix), includingpossible under-utilization of specialistservices and preventive health careservices.

Rule 1300.70(b)1 To meet the require-ments of the Act which require plans tocontinuously review the quality of careprovided, each plan’s quality assuranceprogram shall be designed to ensurethat: (D) Appropriate care which is con-sistent with professionally-recognizedstandards of practice is not withheld ordelayed for any reason, including a po-tential financial gain and/or incentive tothe plan providers, and/or others. (E)The plan does not exert economic pres-sure to cause institutions to grant privi-leges to health care providers that wouldnot otherwise be granted, or to pressurehealth care providers or institutions torender care beyond the scope of theirtraining experience.

Section 1367(g) The plan shall have theorganizational and administrative ca-pacity to provide services to subscribers

6.5.9.1 General Re-quirements (UM)

6.5.9.2 Under- and Over-utilization -- UM pro-grams must use mecha-nisms to detect both un-der and over-utilization ofservices

6.2.3 Medical Decisions,“…ensure that medicaldecision s are not un-duly influenced by fiscalmanagement”.

6.2.2.A Medical Directorsmust ensure that medicaldecisions rendered byqualified medical person-nel are unhindered byfiscal or administrativemanagement.

Highly consistent

All four sets of requirements state thatorganizations monitor potential over-and under-utilization and prohibit deci-sion making influenced by financialincentives.




& COMMENTS


and enrollees. The plan shall be able todemonstrate to the department thatmedical decisions are rendered byqualified medical providers, unhinderedby fiscal and administrative manage-ment.

Rule 1300.67.3(a)(1) Plan organizationshall be structured to provide separationof medical services from fiscal and ad-ministrative management sufficient toassure the Commissioner that medicaldecisions will not be unduly influencedby fiscal and administrative manage-ment.

Section 1348.6 prohibits plans fromhaving any incentive plan with provid-ers that includes specific payment madedirectly, in any type or form, to a physi-cian, physician group, or other licensedhealth care practitioner as an induce-ment to deny, reduce, limit, or delayspecific, medically necessary and ap-propriate services provided with respectto a specific enrollee or groups of en-rollees with similar medical conditions.


UM 12 Triage and Referral for Behavioral Health Care

UM 12 The MCO has writtenstandards to ensure that anycentralized triage and referralfunctions for behavioral heathdecisions are appropriately im-plemented, monitored and man-aged.

Elements:

3.3.1.4 A clinical peer reviews alldecisions to deny authorization ongrounds of medical appropriateness.

3.1.7.2 Policies and procedures,including coverage rules, practiceguidelines, payment policies andutilization management, that allowfor individual medical necessity

Section 1367.01(e) No individual otherthan a licensed physician or licensedhealth professional, who is competent toevaluate the specific clinical issues in-volved in the health care services re-quested by the provider, may deny ormodify requests for authorization ofhealth care services for an enrolleebased in whole or in part on reasons of

6.5.9.3 (A) Pre-Authorization/ReviewProcedures

(requires that review de-cisions are supervised byqualified medical profes-sional and all denials aremay by a qualified physi-


The intent of all four sets of standardsis that appropriate professionals makedecisions, and that physicians or otherappropriate licensed staff make medi-cal necessity denials. However, NCQAspecifically addresses the behavioralhealth triage and referral process in


UM 12 Triage and Referral for Behavioral Health Care


& COMMENTS


! Protocols that define thelevel of urgency and ap-propriate setting care

! Protocols are re-viewed/revised withinlast two years

! Decisions not requiringclinical judgement madeby appropriate staff

! Decisions requiringclinical judgement madeby licensed practioners

! Staff who make clinicaldecisions are supervisedby a licensed master’slevel practioner with 5years post-mater’s clini-cal experience.

determinations.


medical necessity.

Section 1367(g) the plan shall have theorganizational and administrative ca-pacity to provide services to subscribersand enrollees. The plan shall be able todemonstrate to the department thatmedical decisions are rendered byqualified medical providers, unhinderedby fiscal and administrative manage-ment.

Section 1363.5 Authorization or Denialof Services; Process; Disclosures; Crite-ria.

Section 1363.5(a)(2) (requires that cri-teria be developed using sound clinicalprinciples and processes.)UM 12 Triage and Referral for Behavioral Health Care

cian)

DHS Comment

DHS does not identify theuse of behavioral healthprofessional to reviewbehavioral health denials

6.5.9.3 Pre-Authorization/ReviewProcedures (requires thatdecisions be supervisedby qualified medical pro-fessionals and physiciansmake denials; plan estab-lishes written criteria;updates criteria regularly,and applies the criteriaconsistently)

UM 12. NCQA requires specific triageprotocols, and requires specific staff tomake decisions at each level.

HCFA broadly addresses the level ofstaff required to make behavioralhealth decisions.

DMHC and DHS cover the issues inUM 12 in their general UM statements.

UM 13 Delegation of UM


UM 13 – If the MCO delegatesany UM activities, there is evi-dence of oversight of the dele-gated activity.



4.1.2 The organization evaluatesthe entity’s ability to perform thedelegated activities prior to delega-


Rule 1300.70(b)(2)(C) In order to meetthese obligations each plan’s QI pro-




6.5.2.6 (A) Maintenanceof policies and proce-dures which describedelegated activities


6.5.2.6 (C) Continues

Highly consistent





& COMMENTS


tion.

4.1.3 The performance of the entityis monitored on an ongoing basisand formally reviewed by the or-ganization at least annually.UM 13 Delegation of UM

gram shall meet all of the followingrequirements:

The plan’s governing body, its QA com-mittee, if any, and any internal or con-tracting providers to whom QA responsi-bilities have been delegated, shall eachmeet on a quarterly basis, or more fre-quently if problems have been identified,to oversee their respective QA programresponsibilities. Any delegated entitymust maintain records of its QA activitiesand actions, and report to the plan on aappropriate basis and to the plan’s gov-erning body on a regularly scheduledbasis, at least quarterly, which reportsshall include findings and actions takenas a result of the QA program.


Rule 1300.70(b)(2)(G) Medical groupsof other provider entities may have ac-tive quality assurance programs that theplan may use. In all instances, however,the plan must retain responsibility for

monitoring and evalua-tion of the delegatedfunctions

6.5.2.6 (D) Assuranceand documentation thatsubcontractor has theadministrative capacity,task experience, andbudgetary resources tofulfill its responsibilities

6.5.2.6 (F) Continuouslymonitored and evaluated

6.5.9.5 Delegation UMActivities

DHS Comment

UM is a subset of the QIPProgram

DHS does not have re-quirements for frequencyof reporting.

DHS does not have spe-cific requirements toevaluate delegated en-tity’s performance. How-ever, subcontractors arerequired to comply withcontract sections pertain-ing to subcontracting anddelegation.




& COMMENTS


reviewing the overall quality of caredelivered to plan enrollees. If QA activi-ties are delegated to a participatingprovider to ensure that each providerhas the capacity to perform effectivequality assurance activities.


Rule 1300.70(b)(2)(G)(3) The Plan musthave ongoing oversight procedures inplace to ensure that providers are fulfill-ing all delegated QA responsibilities.


UM 13.1 – A mutually agreedupon document.

Elements include:




! Process by which theMCO evaluates the dele-gated entity’s perform-

4.1.1 A written agreement specifiesthe delegated activities and report-ing responsibilities of the entity andprovides for revocation of the dele-gation or other remedies for inade-quate performance.

Rule 1300.70(b)(2)(B) Written docu-ments shall delineate QA authority,function and responsibility, and provideevidence that the plan has establishedquality assurance activities and that theplan’s governing body has approved theQA program. To the extent that a plan’sQA responsibilities are delegated withinthe plan or to a contracting provider,the plan’s documents shall provide evi-dence of an oversight mechanism forensuring that delegated QA functionsare adequately performed;

3.19 (D) Sanctions*

6.5.2.6 (A) Maintainpolicies and procedureswhich describe delegatedactivities


6.5.2.6 (E) Approvedelegates QIP

Highly consistent



DMHC and DHS both require writtenagreements but are less specific about




& COMMENTS


ance

! Remedies, includingrevocation of the delega-tion, available to theMCO if the delegatedentity does not fulfill itsobligations.

DMHC Comment

KKA does not specifically address re-voking delegation, although we haveconsidered this an appropriate action totake when there are uncorrected defi-ciencies in performance of delegatedfunctions.

the required description.

UM 13.2 – There is evidencethat the MCO evaluates thedelegated entity’s capacity toperform the delegated activitiesprior to delegation.


4.1.3 The performance of the entityis monitored on an ongoing basisand formally reviewed by the or-ganization at least annually.4.1 Theorganization oversees and is ac-countable for any functions or re-sponsibilities that are described inthe standards of Domain 1 through3 that are delegated to other entities.


The plan’s governing body, its QA com-mittee, if any, and any internal or con-tracting providers to whom QA responsi-bilities have been delegated, shall eachmeet on a quarterly basis, or more fre-quently if problems have been identified,to oversee their respective QA programresponsibilities. Any delegated entitymust maintain records of its QA activitiesand actions, and report to the plan on aappropriate basis and to the plan’s gov-erning body on a regularly scheduledbasis, at least quarterly, which reportsshall include findings and actions takenas a result of the QA program.

The plan is responsible for establishinga program to monitor and evaluate thecare provided by each contracting pro-vider group to ensure that the care pro-vided meets professionally-recognizedstandards of practice; Reports of theplan's governing body shall be suffi-ciently detailed to include findings andactions taken as a result of the QA pro-gram and to identify those internal or




6.5.2.6 (C) Continuesmonitoring and evalua-tion of the delegatedfunctions

6.5.2.6 (D) Assuranceand documentation thatsubcontractor has theadministrative capacity,task experience, andbudgetary resources tofulfill its responsibilities


Highly consistent


Minor differences are that

NCQA and HCFA standards require anannual evaluation. DMHC and DHShave on-going evaluation, but do notspecifically state that they conduct anannual evaluation




& COMMENTS


contracting provider components whichthe QA program has identified as pre-senting significant or chronic quality ofcare issues.

Rule 1300.70(b)2(G) Medical groups ofother provider entities may have activequality assurance programs that the planmay use. In all instances, however, theplan must retain responsibility for re-viewing the overall quality of care de-livered to plan enrollees. If QA activitiesare delegated to a participating pro-vider to ensure that each provider hasthe capacity to perform effective qualityassurance activities.







& COMMENTS



Credentialing and RecredentialingCR 1 Credentialing Policies

CR 1 Credentialing Policies


& COMMENTS

CR 1 – The MCO documents themechanism for the credentialingand recredentialing of licensedindependent practitioners withwhom it contracts or employswho treat members outside theinpatient setting and who fallwithin its scope of authority andaction.

Elements include (CR.1-9):

! Scope of credentialedpractitioners

! Criteria

! Decision making process

! Practitioner rights

- Review information

- Notification

- Correct information

- Identification of MR

- Confidentiality of in-formation

3.5 Provider Qualification and Se-lection. The organization imple-ments a documented process forselection and retention of affiliatedproviders.

Section 1367(b) All personnel em-ployed by or under contract to the planshall be licensed or certified by theirrespective board or agency, where licen-sure or certification is required by law.

QA Program Requirements

Rule 1300.70(a)(1) The QA programmust document that the quality of careprovided is being reviewed, that prob-lems are identified, effective action istaken to improve care when deficienciesare identified, and follow up is plannedwhen indicated;

Rule 1300.70(a)(3)

Rule 1300.70(b)(2)(A)(B)

6.5.4 Credentialing andRecredentialing

6.5.4.1 General Require-ments (describes devel-opment of credentialingpolicies and procedures)

6.5.4.5 Disciplinary Ac-tions

Highly consistent

NCQA, HCFA, and DHS have similarcredentialing standards and intent, withminor variations in language.

NCQA mandates more specific practi-tioner rights than either HCFA or DHS.

The DMHC has no distinct Creden-tialing Standards.

The DMHC broadly addresses practi-tioner qualifications stating that “per-sonnel must be licensed or credential asrequired by law and identified qualityissues must be addressed.”

CR 2 Credentialing Committee


CR 2 – The MCO designates acredentialing committee thatmakes recommendations re-garding credentialing decisions.

Elements require the credential-ing committee to

! Include a full range ofparticipating practitio-

3.5.1.3 A process for receiving ad-vice from contracting health careprofessionals with respect to crite-ria for credentialing and recreden-tialing of individual health careprofessionals.

Rule 1300.70(b)(2)(C) QA Committeeto meet quarterly or more frequently ifproblems are identified. Credentialingactivities are part of the QA program.

Editorial CommentSee CR 1 Comments

6.5.4.1 General Require-ments (states that cre-dentialing responsibilityrests with the credential-ing committee)

Highly consistent

NCQA, HCFA, and DHS standardsrequire credentialing or other peer re-view committees be involved in cre-dentialing decisions.

NCQA is more specific, requiring rep-resentatives on the committee includefull range of practitioners who repre-

Credentialing and Recredentialing



& COMMENTS


ners

! Provide substantive ad-vice to MCO

! Document meaningfulconsideration of per-formance at recreden-tialing

sent all significant specialties.

DMHC does not provide specific guid-ance on credentialing.


CR 3 Initial Primary Source Verification

CR 3 – At the time of creden-tialing, the MCO verifies at leastthe following information fromprimary sources.

Elements address:

! Current license †

! Valid DEA or CDS;

! Education and training ofproviders

! Board certification workhistory †

! History of professionalliability

†

† Must be verified within 180days of credentialing decision.

3.1.2 The organization determinesthat all providers are qualifiedthrough the process establishedunder standard 3.5.

3.5.1.1 Procedures for initial cre-dentialing, including: a written ap-plication, verification of licensureand other information (DEA, edu-cation, board certification) fromprimary sources, disciplinary status,eligibility for payment under Medi-care and Medicaid, and site visits asappropriate. The application issigned, dated and includes an at-testation by the applicant of thecorrectness and completeness of theapplication.

(states that information can be nomore than 6 months old on date ofdecision)

Section 1367(b) requires that providersbe licensed at all times. Plan must verifylicense sufficiently frequently to ensurethat license has not lapsed


6.5.4.2 Credentialing (de-scribes verification oflicense, DEA, education,board certification,claims history)

DHS CommentDHS requires primarysource verification andinstructs plans to followNCQAs credentialingstandards.


NCQA, DHS, and HCFA require pri-mary source verification.

NCQA and HCFA will accept onlyinformation that is no more than 180days old.

DHS has no stated time requirement.

CR 3 Initial Primary Source Verification

CR 4 Application and Attestation

CR 4 – The applicant completesan application for membership.The application includes a cur-

3.5.1.1 Procedures for initial cre-dentialing, including: a written ap-plication, verification of licensure

Rule 1300.51(c)(4)(K) Contracts withproviders must demonstrate compliancewith the Act and Rules.

6.5.4.2 (H) Credentialing(describes application)


NCQA, HCFA, and DHS have the




& COMMENTS


rent and signed attestation by theapplicant regarding:

! Inability to perform es-sential functions of theposition

! Lack of present illegaldrug use

! History of loss of license

! History of loss/limitationof privileges

! Current malpractice cov-erage

Application must be signed anddated within 180 days of cre-dentialing decision

and other information (DEA, edu-cation, board certification) fromprimary sources, disciplinary status,eligibility for payment under Medi-care and Medicaid, and site visits asappropriate. The application issigned, dated and includes an at-testation by the applicant of thecorrectness and completeness of theapplication.


Editorial Comment

See CR 1 Comments

same language and intent.

However, NCQA and HCFA requirethat the application be signed no morethan 180 days before the credentialingdecision.


DMHC’s reference does not addressthe specific intent of this standard.


CR 5 Initial Sanction Information

CR 5 – There is evidence thatbefore making a credentialingdecision, the managed care or-ganization has received the fol-lowing information and includesthis information in the creden-tialing files:

Elements require

! NPDB

! Medicare/Medicaidsanctions

! State sanctions

Must be verified within 180 daysof credentialing decision.CR 5 Initial Sanction Information

3.5.1.1 Procedures for initial cre-dentialing, including: a written ap-plication, verification of licensureand other information (standardalso describes obtaining DEA, edu-cation, board certification) fromprimary sources, disciplinary status,eligibility for payment under Medi-care and Medicaid, and site visitsas appropriate.

(also addresses, NPDB, sanction)The application is signed, dated andincludes an attestation by the appli-cant of the correctness and complete-ness of the application. (‘States thatinformation can be no more than 6months old on date of decision)

Rule1300.70((b)(1)(A) and (B)

Editorial Comment

See CR 1 Comments

6.5.4.1 Credentialing

6.5.4.2 Credentialing(sanctions, NPDB)

DHS Comment

Contract does not specify“before making a creden-tialing decision”




NCQA requires that all information bein the credentialing file before the cre-dentialing committee reviews the fileand makes its decision. Although DHSnotes the omission of a specific re-quirement, in practice it is assumedthat the committee would not make adecision without complete information.



& COMMENTS


CR 6 Initial Credentialing Site Visits

CR 6 – The MCO has a processfor ensuring that the offices ofall primary care practitioners,OB/GYNs and high-volume be-havioral health care practitionersmeet the managed care organi-zation’s office site standards.

Elements require the plan:

! Documents site visit andmedical record-keepingreview

! Follows up on deficien-cies

3.5.1.1 Procedures for initial cre-dentialing, including: a written ap-plication, verification of licensureand other information (DEA, edu-cation, board certification) fromprimary sources, disciplinary status,eligibility for payment under Medi-care and Medicaid, and site visits asappropriate. The application issigned, dated and includes an at-testation by the applicant of thecorrectness and completeness of theapplication. (Also site visits)

(states that information can be nomore than 6 months old on date ofdecision).

DMHC CommentAlthough the KKA does not specificallyaddress credentialing and recredential-ing other than requiring providers, facili-ties, and equipment to be appropriatelylicensed in Section 1367(a), (b), and (c),Rule 1300.70 requires the plan to con-duct quality oversight and to identify andcorrect quality deficiencies. It also re-quires the Plan to ensure that care pro-vided to enrollees meets professionallyrecognized standards of practice. [Rule1300.70(b)(1)(A) and (B)]. The Planmust also provide access to specialist,and it is necessary to credential provid-ers to ascertain their qualifications.Therefore, the Department finds a defi-ciency if a plan’s credentialing andrecredentialing are not sufficient or up-to-date.


6.5.4.1 Credentialing (de-scribes site visits to PCPoffices

DHS CommentDHS requires credential-ing site visits only of pri-mary care physicians.However, visits ofOB/GYN physician officesare also done if thesephysicians have desig-nated themselves asPCPs.

DHS does not credentialbehavioral health carepractitioners. Behavioralhealth is carved out.


NCQA, HCFA, and DHS require sitevisits in the initial credentialing proc-ess. NCQA requires site visits forPCPs, OB/GYNs and high volumebehavioral health practitioners.

HCFA requires site visits only to high-volume practitioners.

DHS requires only visits to PCPs.

CR 6 Initial Credentialing Site Visits

CR 7 Recredentialing Primary Source Verification

CR 7 – The MCO formallyrecredentials its practitioners atleast every two years. During therecredentialing process, it veri-fies information from primarysources

Elements include:

! Current license †

! Valid DEA or CDS

! Board certification

3.5.1.2 Procedures for recreden-tialing, at least every two years,through a process that updates in-formation obtained in initial cre-dentialing and considers perform-ance indicators such as those col-lected through the QAPI program,the utilization management system,the grievance system, enrollee satis-faction surveys, and other activitiesof the organization. (also requiresupdate of initial information, re-

See CR 6 6.5.4.3 Recredentialing Consistent with variation

All three sets of standards require re-certification of practitioners every twoyears.






& COMMENTS


! Malpractice history †

! History of professionalliability

! Attestation

† Must be verified within 180 days of

credentialing decision.

verification of licensure, clinicalprivileges, malpractice coverage,board certification, NPDB andsanctions.



CR 8 Recredentialing Sanction Information

CR 8 – There is evidence that,before making a recredentialingdecision, the managed care or-ganization has received the fol-lowing information on the prac-titioner, and includes this infor-mation in the recredentialingfiles:

! National PractitionerData Bank (NPDB)query

! State sanctions informa-tion

! Sanctions activity byMedicare and/or Medi-caid

Must be verified within 180 daysof credentialing decision

3.5.1.2 Procedures for recreden-tialing, at least every two years,through a process that updates in-formation obtained in initial cre-dentialing and considers perform-ance indicators such as those col-lected through the QAPI program,the utilization management system,the grievance system, enrollee satis-faction surveys, and other activitiesof the organization. (also requiresupdate of initial information, reveri-fication of licensure, clinical privi-leges, malpractice coverage, boardcertification, NPDB and sanctions.

(states that information can be nomore than 6 months old on date ofdecision)CR 8 Recredentialing Sanction Information

See CR 6 6.5.4.3 Recredentialing Consistent with variation





& COMMENTS


CR 9 Performance Monitoring

CR 9 – The MCO incorporatesthe following data in its recre-dentialing decision-making pro-cess for primary care practitio-ners and high-volume behavioralhealth care practitioners:

! Member complaints

! Information from QI ac-tivities

! Member satisfaction data(optional)

3.5.1.2 Procedures for recreden-tialing, at least every two years,through a process that updates in-formation obtained in initial cre-dentialing and considers perform-ance indicators such as those col-lected through the QAPI program,the utilization management system,the grievance system, enrollee sat-isfaction surveys, and other activi-ties of the organization.

DMHC CommentThe Department has required plans toconsider performance monitoring whenmaking recredentialing decisions; spe-cifically audit results and complaintsagainst the provider, as part of the plan’squality assurance activities.


6.5.4.3 Recredentialing

MMCD Policy Letter00-01 (Describes MOUwith behavioral healthproviders)

Editorial CommentDHS does not requirecredentialing of behav-ioral health care practitio-ners since this is the re-sponsibility of its associ-ated behavioral healthorganizations.


NCQA, HCFA and DHS require col-lection and review of QI data, satisfac-tion surveys, and other pieces of qual-ity information in the recredentialingprocess.

CR 9 Performance Monitoring

CR 10 Practitioner Appeal Rights

CR 10 – The MCO has policiesand procedures for altering theconditions of the practitioner’sparticipation with the MCObased on issues of quality of careand service. These policies andprocedures define

! The range of actions thatthe MCO may take toimprove performanceprior to termination:

! Procedures for reportingto the authorities

! Appeal process

! Distribution of appealprocess to practitioners

3.5.1.4 Written policies and proce-dures for suspending or terminatingaffiliation with a contracting healthcare professional, including appealsprocess.

DMHC CommentThe Act does not specifically requireplans to notify the Medical Board of seri-ous quality deficiencies. However, if theplan did not do so, the Departmentwould find that the Plan was not in com-pliance with Rule 1300.70. The Depart-ment would find that the plan did nottake an appropriate action in response toa quality of care issue.


6.5.4.5 Disciplinary Ac-tion

Highly consistent

NCQA, HCFA and DHS requirementshave similar language and intent rela-tive to policies and procedures for ter-minating providers.

CR 10.1 – The MCO has proce- 3.5.3 The organization notifies li- Editorial Comment 6.5.4.5 Disciplinary Ac- Highly consistent




& COMMENTS


dures for, and evidence of im-plementation of, as appropriate,reporting of serious quality defi-ciencies that could result in apractitioner’s suspension or ter-mination to appropriate authori-ties.

censing and/or disciplinary bodiesor other appropriate authoritieswhen a health care professional’sor institutional provider or sup-plier’s affiliation is suspended orterminated because of quality defi-ciencies.

See CR 1 Comments tion NCQA, HCFA and DHS require re-porting of quality issues to appropriatebodies.


CR 11 Assessment of Organizational Providers

CR 11.1 – The MCO includes atleast the following medical andbehavioral health providers:

Elements address

! Hospitals, home healthagencies, SNFs, nursinghomes, and free standingsurgical centers

! Behavioral health facilitiesproviding mental health orsubstance abuse services inan inpatient, residential, orambulatory setting

Policies include:

! 3-year cycle

! State and federal re-quirements

! Accreditation

! Site visit if no accredita-tion


3.5.2 For each institutional provideror supplier, the organization deter-mines and redetermines at specifiedintervals (describes license, com-pliance with state and federal re-quirements, reviewed by accredit-ing body).

Does not address credentialing of or-ganizational (facilities) providers

DMHC Comment

DMHC has established general qualityexpectations for all practitioner and pro-vider services and expects any identifiedQI issues to be addressed in the QI pro-cess

The KKA does not specify freestandingsurgical centers or SNFs, and does notspecify residential mental health or sub-stance abuse facilities. However, theKKA requires plans to provide andmonitor accessibility to all covered serv-ices as part of the QA program and totake appropriate action to ensure acces-sibility. The Department has interpretedthis to include recruiting additional pro-viders when necessary to provide rea-sonable access to care. Plans are alsorequired to file changes in their providernetwork as changes to Exhibit H of theirlicense application (Rule 1300.51).

Does not address creden-tialing of organizational(facilities) providers

MMCD Policy Letter00-01 (Describes MOUwith behavioral healthproviders)

DHS Comment

MMCD Policy Letter 00-1,March 16, 20000 - “Medi-Cal Managed Care PlanResponsibilities under theMedi-Cal Specialty MentalHealth Services Consoli-dation Program”. Thepolicy letter also requiresan MOU between thePlan and the local MentalHealth Plans for provisionof mental health services

Highly consistent

NCQA has specific, credentialing re-quirements that must be used to assessvarious organizational providers in-cluding facilities such as hospitals,nursing homes, and SNFs, as well asbehavioral health providers. NCQAassesses the plan’s policies and imple-mentation of the procedures to verify ifthe facility is monitored by an accept-able accreditation process or by theplan’s site visit procedures.

HCFA’s intent is highly similar but isless specific than NCQA.

NCQA requires organizations be recre-dentialed every three years. HCFAstates they are to be credentialed peri-odically.

DMHC and DHS do not specificallyaddress this standard. They have gen-eral expectations that organizationsprovide quality care. The DHS con-ducts a site assessment but it is limitedto such issues as policies and safety.However, neither set of standards pro-vided organizational credentialing




& COMMENTS


standards.

CR 11.2 – The MCO confirmsthat the provider is in goodstanding with state and federalregulatory bodies.

3.5.2.1 Is licensed to operate in thestate, and is in compliance with anyother applicable state or federalrequirements.

3.5.2.3 In the case of a provider orsupplier providing services toMedicare enrollees, is approved forparticipation in Medicare.

Does not address credentialing of or-ganizational providers

Does not address creden-tialing of organizationalproviders

Highly consistent

NCQA and HCFA have the same lan-guage and intent.

CR 11.3 – The MCO confirmsthat the provider has been re-viewed and approved by an ac-crediting body.

3.5.2.2 Is reviewed and approvedby an appropriate accrediting bodyor is determined by the organizationto meet standards established by theorganization itself.


DMHC Comment

KKA does not address review by anotheraccrediting body, except quality of careprograms in hospitals, as stated, andquality programs of medical groups.When a plan delegates QA functions tothese groups, the Plan must performoversight of these delegated functions.


Highly consistent

NCQA and HCFA require the reviewand approval of organizational provid-ers.

NCQA standards apply to various or-ganizational providers, not just inpa-tient settings.

CR 11.4 – If the provider has notbeen approved by an accreditingbody, the MCO develops andimplements standards of partici-pation.

3.5.2.2 Is reviewed and approvedby an appropriate accrediting bodyor is determined by the organiza-tion to meet standards establishedby the organization itself.



Highly consistent

NCQA and QSMIC require the reviewand approval of organizational provid-ers.


CR 12 Delegation of Credentialing

CR 12 – If the MCO delegatesany credentialing and recreden-tialing activities, there is evi-dence of oversight of the dele-gated activity, including:

! Mutually agreed onagreement


4.1.1 A written agreement specifiesthe delegated activities and report-ing responsibilities of the entity and

See CR 1 Comments 3.26.1 Knox-KeeneRegulations



6.5.2.6 (A) Maintain of

Highly consistent

NCQA, HCFA and DHS require over-sight, have similar intent, and havehighly similar language in the require-ments.

Since DMHC does not have specificCR standards, the delegation standard




& COMMENTS


! MCO retains right to ap-prove

! Conducts oversight

provides for revocation of the dele-gation or other remedies for inade-quate performance


4.1.3 The performance of the entityis monitored on an ongoing basisand formally reviewed by the or-ganization at least annually.CR 12 Delegation of Credentialing

policies and procedureswhich describe delegatedactivities






6.5.4.4 Delegated Cre-dentialing

generally does not apply. However, forany general CR regulations, DMHCaddresses oversight in its QI plan –Rule 1300.70(b)(2)(B).

CR 12.1 – A mutually agreedupon document describes:

! Written description of re-sponsibilities of all parties


! Evaluation process

! Remedies for poor perform-ance


See CR 1 Comments. 3.19 Sanctions*

3.26.1 KKA and Regula-tions(cites KKA requirementsthat require writtenagreements)



Highly consistent

All three sets of standards are verysimilar and are supported with formalwritten documents

Minor differences are that NCQA re-quires a mutually agreed upon delega-tion agreement. HCFA and DHS re-quire only polices and procedures thatdescribe the delegation agreement.

Only NCQA requires that the docu-ment include remedies, including revo-




& COMMENTS




cation of the delegation when the dele-gate does not perform.

CR 12.2 – The MCO retains theright, based on quality issues, toapprove new practitioners, pro-viders, and sites and to terminateor suspend individual practitio-ners or providers.

4.2 If the organization delegatesselection of providers to anotherentity, the organization retains theright to approve, suspend, or termi-nate any provider selected by thatentity.

See CR 1 Comments 6.5.4 Credentialing andRecredentialing


Highly consistent

All three requirements state that theorganization retains ultimate rights tosuspend or terminate providers.

CR 12.3 – There is evidence thatthe MCO:


! Evaluates annuallywhether the delegatedentity’s activities arebeing conducted in ac-cordance with theMCO’s expectations andNCQA standards.


4.1.3 The performance of the entityis monitored on an ongoing basisand formally reviewed by the or-ganization at least annually

See CR 1 Comments 3.26.1 Knox-KeeneRegulations







Highly consistent

All three sets of standards are similarin language and intent requiring thatthe plan conduct oversight of the dele-gate. Prior to delegation and followingdelegation.

Minor differences are that NCQA andHCFA standards require an annualevaluation. DHS has on-going evalua-tion, but does not specifically state thatit conducts an annual evaluation.


Members’ Rights and ResponsibilitiesRR 1 Statement of Members’ Rights and Responsibilities

RR 1 Statement of Members’ Rights and Responsibilities


& COMMENTS

RR 1 – The MCO has a writtenpolicy that states the organiza-tion’s commitment to treatingmembers in a manner that re-spects their rights as well as itsexpectations of members’ re-sponsibilities.

! Elements include thefollowing rights (RR 1.1-1.5)

- Information aboutplan

- Dignity and privacy

- Involved in decisionmaking

- Candid discussion ofoptions

- Make complaint/ ap-peal

! Elements include re-sponsibilities (RR 1.6-1.7)

- Providing informa-tion

- Following instruction

! All elements must be inplace for 12 months

2.1. and 2.2 The organization im-plements written policies with re-spect to the enrollee rights specifiedin standard 2.2.

2.2.1 Each enrollee has a right to betreated with respect, dignity, andconsideration for enrollee privacy.

2.2.1.1 The organization imple-ments procedures to ensure theconfidentiality of health and medi-cal records and of other informationabout enrollees. Includes 2.2.1.1.1.

2.2.1.2 The organization imple-ments procedures to ensure thatenrollees are not discriminatedagainst in the delivery of health careservices consistent with the benefitscovered in their policy based onrace, ethnicity, national origin, re-ligion, sex, age, mental or physicaldisability, sexual orientation, ge-netic information, or source ofpayment.

2.2.2.7 To obtain a prompt resolu-tion, through the procedures estab-lished under standard 2.4, of issuesraised by the enrollee, includingcomplaints or grievances and issuesrelating to authorization, coverage,or payment of services.

2.2.3 To choose providers fromamong those affiliated with the or-ganization; including 2.2.3.1 and2.2.3.2.

Section 1368(a) The plan must (1) Es-tablish and maintain a grievance systemapproved by the department underwhich enrollees may submit their griev-ances to the plan. Each system shallprovide reasonable procedures in accor-dance with department regulations thatshall ensure adequate consideration ofenrollee grievances and rectificationwhen appropriate.

Rule 1300.68 Grievance System

Section 1369 Every plan shall establishprocedures to permit subscribers andenrollees to participate in establishingthe public policy of the plan. For pur-poses of this section, public policymeans acts performed by a plan or itsemployees and staff to assure the com-fort, dignity, and convenience of pa-tients who rely on the plan's facilities toprovide health care services to them,their families, and the public.

Rule 1300.69 (describes access to in-formation)

Rule 1300.63.1 Set forth requirementsfor informing enrollees via a disclosureform regarding the plan, its services,and the mechanisms for obtaining care.

DMHC Comment

Effective July 1, 2001 plans are requiredto file a copy of policies and proceduresto protect the security of patient medicalinformation. However this is a profes-sionally recognized standard of practiceeven now, and under the requirements

6.5.1 General requirement(describes policies / pro-cedures)

! Written Policy:Member’s Rights

- Respect

- Provided in-formation

- Participate indecisionmaking

- Voice com-plaints

6.5.6 Members Rightsand Responsibilities

6.5.6.3 Written Policy:

! Member’s Re-sponsibility

- Provide in-formation

- Cooperatingwith providers

6.5.6.5 Members Right toConfidentiality

DHS Comment

Contract does not ad-dress NCQA’s require-ment that “statement ofpatient’s rights” be inplace at least 12 months.


All four sets of standard demonstratethe intent to provide member rights.

NCQA, HCFA and the DHS havesimilar standards and language.DMHC’s list of member rights doesnot include all the rights cited by theother standards


! NCQA and HCFA require thatplans provide members theright to a candid discussion ofmedical options. Neither, theDMHC or the DHS have thisrequirement.

! HCFA and DHS have morecomprehensive member rightsstatements than NCQA.

! DMHC has the least specificmember rights and responsi-bilities. The DMHC providesclear guidelines relative to pro-viding information, dignity,privacy, complaints, and ap-peals. However, other rightsare only implied in generalstatements.

! NCQA, DHS, and HCFAstatements include memberresponsibilities. DMHC doesnot address this issue.

! Only NCQA requires thatmember rights and responsi-bilities be in place for at least

Members’ Rights and Responsibilities


NCQA HCF DMHC DHSDEGREE OF SIMILARITY

& COMMENTS


2.2.4 To participate in decisionmaking regarding his or her healthcare. Includes subsections 2.2.4.1through 2.2.4.2.

2.2.5 Contracts may not limit a pro-vider’s ability to counsel or advisea Medicare or Medicaid enrollee.

2.3.1.13 Information on servicearea.

2.3.1.2 Member responsibilities

of Rule 1300.70 the Department wouldobject if it found a problem in this area.

Some of the member rights are not spe-cifically stated in the KKA, but are basicprofessionally recognized standards ofpractice and the Department would ob-ject if enrollees were not treated in amanner consistent with general qualityexpectations.

12 months.


RR 2 Distribution of Rights Statements to Members and Practitioners

RR 2 – The MCO distributes thepolicy on members’ rights andresponsibilities to members andparticipating practitioners.

Elements require distribution ofmember rights and responsibili-ties to:

! Existing members

! New members

! Existing practitioners

! New practitioners

2.1.1.1 Policies are communicatedto enrollees, in the enrollee state-ment furnished in accordance withstandard 2.3, and to the organiza-tion’s staff and affiliated providers,at the time of initial employment oraffiliation and annually thereafter.

2.3.1.1 Each enrollee receives, atthe time of enrollment and at leastannually thereafter, a writtenstatement including information onenrollee rights;


Rule 1300.68(a)(2) Plan must inform itssubscribers and enrollees upon enroll-ment in the plan and annually thereafterof the procedure for processing andresolving grievances. The informationshall include the location and telephonenumber where grievances may be sub-mitted.

Rule 1300.68(a)(3) Provide forms forgrievances to be given to subscribersand enrollees who wish to register writ-ten grievances. The forms used by planslicensed pursuant to Section 1353 shallbe approved by the commissioner inadvance as to format.

6.5.6.1 Members’ Rightsand Responsibilities /General Requirement

6.9.5 Membership Serv-ices Guide


NCQA, HCFA and DHS have similarlanguage and intent. However, NCQAand HCFA identify the groups thatmust receive the statement and howoften the plan must distribute thestatement. DHS has a more generaldistribution statement.

DMHC addresses and distributes onlya limited number of member rights.

RR 2 Distribution of Rights Statements to Members and Practitioners

RR 3 Policies for Complaints and Appeals

RR 3 The MCO has writtenpolicies and procedures for thethorough, appropriate, andtimely resolution of member

2.2.7 to obtain a prompt resolution,through the procedures establishedunder standard 2.4, of issues raisedby the enrollee, including com-

Section 1368(a)(1) Maintain a griev-ance system

Section 1368(b)(2) Permits enrollee tobe represented to the Department in the

6.5.6.4 Member’s Griev-ance System

(describes complaint /


The intent of all four sets of standardsis to establish a timely system to ad-dress member complaints, appeals, and




& COMMENTS


complaints and appeals.

Standards require that policiesaddress:

! Complaints

! First level appeals

! Second level appeals

! Representative acting onbehalf of member

! Review by practitionerof similar specialty

! External review processRR 3 Policies for Complaints and Appeals

plaints or grievances and issuesrelating to authorization, coverage,or payment of services.

2.4 Resolution of enrollee Issues.The organization has a system forresolving issues raised by enrollees,including: complaints or griev-ances; issues relating to authoriza-tion of, coverage of, or payment forservices; and issues relating to dis-continuation of a service.

2.4.1 The organization followswritten procedures for the receiptand initial processing of all issuesraised by enrollees

2.4.1.5 The organization informsthe enrollee of any applicablemechanism for resolving the issueexternal to the organization’s ownprocesses.

2.4.3.3 Requests for reconsiderationby the organization of a denialbased on lack of medical necessityare reviewed by a physician orhealth care professional who isappropriately credentialed withrespect to the treatment involvedand who is not the individual whomade the initial determination.

3.3.1.7 The organization does notprohibit providers from advocatingon behalf of enrollees within theutilization management process

grievance if the enrollee is a minor, isincompetent or incapacitated.

Section 1370.2 Contains a requirementof review by physician or appropriatelylicensed health professional that iscompetent to evaluate the clinical is-sues, of clinical issues in appeals

Section 1370.4 Requires plans to pro-vide an external, independent reviewprocess to examine the plan’s coveragedecision regarding experimental or in-vestigational therapies for individualenrollees who have a life-threatening orseriously debilitating condition and forwhom standard therapies are not medi-cally appropriate or beneficial

Rule 1300.68(d) At each grievance lo-cation, assistance shall be provided inthe filing of grievances. A “patient ad-vocate” or ombudsperson may be used

Rule 1300.68(g) A plan’s grievancesystem established pursuant to the re-quirement of Section 1368 of the Actshall include at least the following fea-tures: A grievance system shall provide(1) for the acknowledgement of the re-ceipt of a complaint and notice to thecomplainant of who may be contactedwith respect thereto within 20 days, and(2) for notice to the complainant of thedisposition of the complaint, normallywithin 30 days. Where a plan is unableto distinguish between complaints andinquires, they shall be considered com-plaints.

grievance process)

6.9.5 (L) MembershipServices Guide (describesprocess to file complaintsand appeals)

6.9.5 (N) MembershipServices Guide (mandatesa fair hearing process beprovided to members)

6.9.13 Member Com-plaint/Grievance System(describes complaint pro-cess)

6.9.14 Denial, Deferral,or Modification of PriorAuthorization Requests(describes member notifi-cation, right to a fairhearing to contest a de-nial, right to representself or to have an advo-cate represent member)

grievances.

NCQA, HCFA, and the DMHC ad-dress all six sub-standards.

DHS does not require a review by apractitioner of “similar specialty”.

DMHC and DHS have general state-ments describing their appeal processesand required documentation of mem-ber’s complaint files.

NCQA has specific process steps foreach level of complaint or appeal.NCQA also specifically identifies theinformation that must be documentedin each file.

NCQA, DMHC and DHS have pre-scriptive appeal time frames that haveslight variations.

HCFA’s processes are less comprehen-sive than NCQA’s and its timeframesare established by HCFA and StateMedicaid agencies.

Editorial Note: The various sets ofregulations, as well as health care or-ganizations, use different terminologyto describe complaints, appeals, andgrievance. To successfully meet NCQAstandards, refer to the official NCQAdefinitions




& COMMENTS


DMHC Comment

! KKA requires plans to acceptgrievances both orally and inwriting.

! KKA does not address appealprocess, except as generalgrievance, However, grievancein NCQA terminology is thesame thing as an appeal.

RR 3.1 – Procedures for regis-tering and responding to oral andwritten complaints

Procedures must include docu-mentation of:

! Substance of the com-plaint and actions taken

! Full investigation

! Notification to the mem-ber of the disposition ofthe complaint and rightto further appeal

! Timeliness standardswere met

2.2.7 To obtain a prompt resolu-tion, through the procedures estab-lished under standard 2.4, of issuesraised by the enrollee, includingcomplaints

or grievances and issues relating toauthorization, coverage, or paymentof services.

2.4 Resolution of enrollee Issues.The organization has a system forresolving issues raised by enrollees,including: complaints or griev-ances; issues relating to authoriza-tion of, coverage of, or payment forservices; and issues relating to dis-continuation of a service.

2.4.1 The organization followswritten procedures for the receiptand initial processing of all issuesraised by enrollees

2.4.1.1 The organization documentseach issue raised by an enrollee

2.4.1.2 The organization promptlydetermines whether the issue is tobe resolved through: (a) the griev-


Section 1368(a)(4) Provide written re-sponses to members including all clini-cal criteria and reasons for denial

Section 1368(b)(5) The departmentshall send a written notice of the finaldisposition of the grievance.

Rule 1300.68(g) A plan’s grievancesystem established pursuant to the re-quirement of Section 1368 of the Actshall include at least the following fea-tures: A grievance system shall provide(1) for the acknowledgement of the re-ceipt of a complaint and notice to thecomplainant of who may be contactedwith respect thereto within 20 days, and(2) for notice to the complainant of thedisposition of the complaint, normallywithin 30 days. Where a plan is unableto distinguish between complaints andinquires, they shall be considered com-plaints.

Section 1367.01(h) includes a referenceto Title 22 Section 51014.1 addressesrights to a Fair Hearing Related to De-

6.5.6.4 Member’s Griev-ance System

(describes com-plaint/grievance proc-esses)

6.5.6.4 (A) (providescompliant timeframe…plans must acknowledgecomplaints within 5 daysand resolve them within30 days)

6.9.5 (L) MembershipServices Guide (requiresthat plans develop com-plaint/grievance proc-esses)

6.9.13 Member Com-plaint/Grievance System(describes complaint pro-cess).

Highly consistent

All four sets require that plans docu-ment, investigate, and resolve membercomplaints in a timely manner. How-ever, NCQA and HCFA more fullydescribe what plans must document inthe complaint file.

HCFA and DHS do not differentiatebetween verbal and written complaints.




& COMMENTS


ance process established understandard 2.4.2, (b) the process formaking initial determinations oncoverage and payment issues estab-lished under standard 3.3, or (c) theprocess for resolution of disputedinitial determinations establishedunder standard 2.4.3.

2.4.1.3 The organization acknowl-edges receipt of the issue and ex-plains to the enrollee the process tobe followed in resolving his or herissue.

2.4.2 The organization implementsa procedure, with clearly explainedsteps and time limits for each step,for the resolution of a complaint orgrievance. Includes subsections2.4.2.1 through 2.4.2.5

2.4.3.2 The organization’s processcomplies with procedural require-ments and time limits establishedby HCFA or the State Medicaidagency, conforming to HCFA re-quirements.

nial, Termination or Reduction in Medi-cal Services (appeals process).

RR 3.2 – Procedures for regis-tering and responding to oral andwritten first level appeals

Required elements include:

! Notification to the mem-ber of the appeal processwithin five working daysof receiving a request fora first-level appeal

! Documentation of appeal

2.2.7 To obtain a prompt resolu-tion, through the procedures estab-lished under standard 2.4, of issuesraised by the enrollee, includingcomplaints or grievances and issuesrelating to authorization, coverage,or payment of services.

2.4.1 Resolution of enrollee Issues.The organization has a system forresolving issues raised by enrollees,

Section 1368(a)(1 ) Maintain a griev-ance system

Section 1368(a)(4) Provide written re-sponses to members including all clini-cal criteria and reasons for denial


Section 1368.01 Requires that plans

6.9.5 (L) MembershipServices Guide (describesdevelopment of com-plaint/grievance process)

6.9.14(B) Denial, Defer-ral, or Modification ofPrior Authorization Re-quests (addresses mem-ber notification, right tofair hearing to contest a


All four sets of standards reflect theintent to provide the member with theright to appeal an adverse decision.

Editorial Note:

NCQA calls the first request to recon-sider the initial decision an “appeal.”Other organizations, and some MCOs,call this request a “grievance” instead




& COMMENTS


substance

! Documentation of inves-tigation

! Resolution of appealwithin 30 days

- MCO issues a writtendecision within 15working days andprovides notice to themember with the rea-sons for the delay ifnot settled within 30days

- All appeals must besettled within 45 days

! Disposition of the appealand the right to appealfurther

including: complaints or griev-ances; issues relating to authoriza-tion of, coverage of, or payment forservices; and issues relating to dis-continuation of a service.


2.4.1.2 The organization promptlydetermines whether the issue is tobe resolved through: a) the griev-ance process established understandard 2.4.2, b) the process formaking initial determinations oncoverage and payment issues estab-lished under standard 3.3, or c) theprocess for resolution of disputedinitial determinations establishedunder standard 2.4.3.

2.4.1.3 The organization acknowl-edges receipt of the issue and ex-plains to the enrollee the process tobe followed in resolving his or herissue.

2.4.1.4 The organization assists theenrollee as needed in completingforms or taking other necessarysteps to obtain resolution of theissue.


2.4.2 The organization implementsa procedure, with clearly explained

resolve grievances within 30 days

DMHC Comment

KKA does not permit plans to exceed 30days when resolving grievances (Section1368.01).

denial, right to repre-sent self or to have anadvocate representmember) Include a ref-erence to Title 22 Sec-tion 51014.1 addressingrights to a Fair HearingRelated to Denial, Ter-mination or Reductionin Medical Services(appeals process).

DHS Comment

DHS does not requireplans to issue a decisionwithin 15 working dayswhen a decision is notmade within the initial 30working days.

of an appeal.

NCQA’s language includes very spe-cific appeal steps and what informationthe plan must document in the appealfile.

HCFA is less specific about what mustbe documented in the appeal files.However, HCFA is very specific abouthelping the member to continue theappeal process until they resolve theirappeal or exhaust the appeal process.

Timeframes vary among the differentsets of standards.




& COMMENTS


steps and time limits for each step,for the resolution of a complaint orgrievance. Includes subsections2.4.2.1 through 2.4.2.5

2.4.2.1 The grievance is transmittedin a timely manner to staff who haveauthority to take corrective action.A grievance relating to quality ofcare is transmitted to appropriatelyqualified clinical personnel.

2.4.2.2 The organization investi-gates the grievance and notifies theconcerned parties of the results ofthe investigation and the proposedresolution.

2.4.2.3 The organization providesan opportunity for reconsiderationof the proposed resolution.

2.4.2.4 The organization trackseach grievance until its final reso-lution.

2.4.2.5 The organization has anexpedited grievance process forissues requiring immediate resolu-tion.

2.4.3 Reconsideration of Coverageand Payment Determinations. Theorganization implements a proce-dure, with clearly explained stepsand time limits for each step, forreviewing requests for reconsidera-tion of initial decisions not to pro-vide or pay for a service.

2.4.3.2 The organization’s process




& COMMENTS


complies with procedural require-ments and time limits established byHCFA or the State Medicaidagency, conforming with HCFArequirements.

RR 3.3 – Procedures for regis-tering and responding to oral andwritten second level appeals.

Elements include:

! Documentation of sub-stance

! Documentation of inves-tigation, and

! Documentation of reso-lution including

- Review by represen-tative who was notinvolved in previousreview

- Right to appear be-fore panel or com-municate with thepanel by conferencecall or other appro-priate technology

- Review will occurwithin 30 workingdays

- Expedited appealprocess

! Notification to memberwithin 5 working days.

2.2.7 To obtain a prompt resolu-tion, through the procedures estab-lished under standard 2.4, of issuesraised by the enrollee, includingcomplaints or grievances and issuesrelating to authorization, coverage,or payment of services.

2.4.1 Resolution of enrollee Issues.The organization has a system forresolving issues raised by enrollees,including: complaints or grievance;issues relating to authorization of,coverage of, or payment for serv-ices; and issues relating to discon-tinuation of a service.


2.4.1.2 The organization promptlydetermines whether the issue is tobe resolved through: a) the griev-ance process established understandard 2.4.2, b) the process formaking initial determinations oncoverage and payment issues es-tablished under standard 3.3, or c)the process for resolution of dis-puted initial determinations estab-lished under standard 2.4.3.

2.4.1.3 The organization acknowl-edges receipt of the issue and ex-


Section 1368(a)(4) Provide written re-sponses to members, including all clini-cal criteria and reasons for denial

Section 1368(b)(2) Permits enrollee tobe represented to the Department in thegrievance if the enrollee is a minor, isincompetent or incapacitated. This sec-tion also permits enrollee to be repre-sented by a provider.


Section 1368.01 Requires that plansresolve grievances within 30 days

Section 1368.01(b)(1)(a) Grievancesystem shall include a requirement forexpedited plan review of grievances forcases involving an imminent and seriousthreat to the health of the patient, in-cluding, but not limited to, severe pain,potential loss of life, limb, or majorbodily function. When the plan has no-tice of a case requiring expedited re-view, the grievance system shall requirethe plan to immediately inform enrolleesand subscribers in writing of their rightto notify the department of the griev-ance. The grievance system shall also

6.9.5 (L) MembershipServices Guide (mandatesdevelopment of com-plaint/grievance proc-esses)

6.9.14 (B) Denial, Defer-ral, or Modification ofPrior Authorization Re-quests (describes proc-esses for member notifi-cation; the member’sright to fair hearing, tocontest a denial, to repre-sent self or to have anadvocate represent mem-ber) Includes reference toTitle 22 Section 51014.1addresses rights to a FairHearing Related to De-nial, Termination or Re-duction in Medical Serv-ices (appeals process).

DHS Comment

DHS allows member to berepresented by legalcounsel, friend, or otherspokesman. DHS is silentregarding the use of “ap-propriate technology.


All sets of standards require an appealprocess. However, none of the stan-dards require that MCOs provide twolevels of appeal.

NCQA describes a second-level appealprocess. However, NCQA allowsMCOs to bypass the second level ofappeal and proceed directly to a reviewby an external agency.

Under NCQA standards, if the MCOhas only one level of appeal, the ele-ments required in both the first andsecond level processes must be in-cluded in the first level of appeal.

All sets of standards require that theappeal process document the substanceof the complaint, complaint investiga-tion, and resolution; and document thatthe member received notification of thedecision, their right to representation,and their right to have an expeditedreview.

Only NCQA and HCFA require that allreviewers at the next level of appealsbe new.

NCQA requires that the plan providethe member not only the right to appearbefore the appeal committee, but also




& COMMENTS


plains to the enrollee the process tobe followed in resolving his or herissue.

2.4.1.4 The organization assists theenrollee as needed in completingforms or taking other necessarysteps to obtain resolution of theissue.

2.4.2 The organization implementsa procedure, with clearly explainedsteps and time limits for each step,for the resolution of a complaint orgrievance. Includes subsections2.4.2.1 through 2.4.2.5

2.4.2.1 The grievance is transmittedin a timely manner to staff who haveauthority to take corrective action.A grievance relating to quality ofcare is transmitted to appropriatelyqualified clinical personnel.

2.4.2.2 The organization investi-gates the grievance and notifies theconcerned parties of the results ofthe investigation and the proposedresolution.

2.4.2.3 The organization providesan opportunity for reconsiderationof the proposed resolution.

2.4.2.4 The organization trackseach grievance until its final reso-lution.

2.4.2.5 The organization has anexpedited grievance process forissues requiring immediate resolu-

require the plan to provide enrollees,subscribers, and the department with awritten statement on the disposition orpending status of the grievance no laterthan three days from receipt of thegrievance

provide appropriate technology to helpthe member communicate if the mem-ber is unable to appear in person.




& COMMENTS


tion.

2.4.3 Reconsideration of Coverageand Payment Determinations. Theorganization implements a proce-dure, with clearly explained stepsand time limits for each step, forreviewing requests for reconsidera-tion of initial decisions not to pro-vide or pay for a service.

2.4.3.2 The organization’s processcomplies with procedural require-ments and time limits established byHCFA or the State Medicaidagency, conforming with HCFArequirements.


RR 3.4 – A procedure for al-lowing a practitioner or memberrepresentative to act on behalf ofthe member.

3.3.1.7 The organization does notprohibit providers from advocatingon behalf of enrollees within theutilization management process.

Section 1368(b)(2) Permits enrollee tobe represented to the Department in thegrievance if the enrollee is a minor, isincompetent or incapacitated. This sec-tion also permits enrollee to be repre-sented by a provider.

DMHC Comment

The KKA does not address others repre-senting the enrollee to the Plan, howeverdoes not prohibit this.

Rule 1300.68 (d) At each grievance

6.9.14 (B) Denial, Defer-ral, or Modification ofPrior Authorization Re-quests (requires the planprovide member notifica-tion, right to fair hearingto contest a denial, rightto represent self or tohave an advocate repre-sent member) Includes areference to Title 22 Sec-tion 51014.1 addressing

Highly consistent

NCQA, HCFA, and DHS allow mem-bers to have a representative to act ontheir behalf in the appeal process.

DMHC provides the member assis-tance in appealing adverse decisions,but does not explicitly require or pro-hibit member representatives.




& COMMENTS


location, assistance shall be provided inthe filing of grievances. A “patient ad-vocate” or ombudsperson may be used

rights to a Fair HearingRelated to Denial, Termi-nation or Reduction inMedical Services (ap-peals process).

RR 3.5 – In at least one level ofinternal appeal, at least one ofthe people appointed to reviewan appeal involving clinical is-sues is an actively participatingpractitioner in the same or asimilar specialty who typicallytreats the medical condition,performs the procedure or pro-vides the treatment. This indi-vidual did not participate in anyof the managed care organiza-tion’s prior decisions on thecase.


Section 1370.2 Which contains a re-quirement of review by physician orappropriately licensed health profes-sional that is competent to evaluate theclinical issues, of clinical issues in ap-peals

DMHC Comment

The KKA does not require an appealsprocess, but does require the plan tohave a process to review clinical issuesin appeals of denied claims.

Does not address Highly consistent

NCQA, HCFA and DMHC require theprocess described in the far-left col-umn.

DHS does not require a review by aphysician of like specialty.

RR 3.6 – A procedure for pro-viding independent, externalreview of final determinations.

Elements require:

! Eligibility criteria

(see standard for spe-cific review description)

! Notification to member

(see standard for spe-cific review description)

! Conduct of appeal pro-gram (see standard for spe-cific review description)


Section 1370.4 Requires plans to pro-vide an external, independent reviewprocess to examine the plan’s coveragedecision regarding experimental or in-vestigational therapies for individualenrollees who have a life-threatening orseriously debilitating condition and forwhom standard therapies are not medi-cally appropriate or beneficial.


6.9.5 (N) MembershipServices Guide (providesa fair hearing process tomember)

Highly consistent

NCQA, HCFA and DMHC require anexternal review and use similar lan-guage.

DHS has a somewhat general statementbut reflects the same intent.

Note that NCQA RR 3.6 only appliesto plans in states without external re-view laws.



& COMMENTS


RR 4 Appropriate Handling of Complaints and Appeals

RR 4 – The MCO adjudicatesmembers’ complaints and ap-peals in a thorough, appropriateand timely manner. The MCOmeets all of the requirements ofstandard RR 3 and has its ownstandards for handling com-plaints, grievances, and appeals.

(The intent of this standard is toassess implementation of RR 3.)RR 4 Appropriate Handling of Complaints and Ap-peals

2.4.4 Monitoring of Issues Resolu-tion Processes. The organizationmaintains, aggregates and analyzesinformation on the nature of issuesraised by enrollees and on theirresolution.

Section 1368 Grievance System

Rule 1300.68

Section 6.5.6.4 MemberGrievance System

DHS Comment

NCQA requires specificsteps for each level ofcomplaint/appeal, DHSdoes not.


All sets of standards reflect the intentthat plans implement requirements thatare listed in RR3. Requirements areassessed through reports and review ofcomplaint and appeal records.

NCQA assesses implementation ofmore specific steps for each level ofcomplaint and appeal processes.NCQA also systematically reviewsdocumentation of complaint and appealfiles during accreditation surveys toassess the plan’s compliance with pro-cesses described in RR 3.

Since requirements vary between setsof standards, the assessment processalso varies.

RR 5 Subscriber Information


RR 5 – The MCO provides eachsubscriber with the informationneeded to understand benefitcoverage and obtain care

Elements address:

! Benefits and services

! How to obtain primaryand specialty care

! How to voice a com-plaint, appeal, or applyfor new technology

! Continuity of care when

2.3.1.4 Amount, duration, andscope of all benefits and servicesincluded and excluded as a condi-tion of enrollment, including a de-scription of how the organizationevaluates new technology for inclu-sion as a covered benefit.

2.3.3 Enrollee information is read-able and easily understood (2.3.3.1)and available in the language of themajor population groups servedand, as needed, in alternative for-mats for the visually impaired

Section 1363 Disclosure (requires dis-closure of benefits, exclusions, pre-scriptions, co-payments, restrictions,practitioners, obtaining services)

Section 1363.01 Formulary drugs

Section 1363(a)(15) Transition of care

Rule 1300.68 (describes plan’s griev-ance system )

DMHC Comment

Plans are required to provide a copy ofthe Evidence of Coverage and Disclo-sure Form for distribution to enrollees.


6.5.7.1 - 6.5.7.10 (de-scribes access standards)

6.9.7 Distribution ofMember Services Infor-mation


6.9.8 Changes in Avail-ability or Location ofCovered Services

Highly consistent

All four sets of standards require thatplans provide members with writteninformation regarding benefits andchanges that affect the subscriber.

NCQA’s standards are the most pre-scriptive. For example, the other stan-dards require that the plan provide onlythe names and addresses of practitio-ners, while NCQA standards mandatethat the plan also provide the practitio-ner’s professional qualifications.




& COMMENTS


a practitioner terminates (2.3.3.2)

2.3.1.3 The names and locations ofnetwork providers, including infor-mation on which providers are ac-cepting new Medicare or Medicaidpatients and any restrictions on en-rollees’ ability to select from amongnetwork providers

2.3.1.10 Procedures establishedunder standard 2.4 for resolvingenrollee issues, including com-plaints or grievances and issuesrelating to authorization of, cover-age of, or payment for services

2.3.2 The organization notifies en-rollees affected by the terminationof or changes in benefits, services,service sites, or affiliated providers.To the extent practical, enrollees areinformed of such terminations orchanges prior to their effective date

These are reviewed during the licensingprocess and when changes are filed.

RR 5.1.1 The MCO provideswritten information about bene-fits and charges applicable to thesubscriber.

Elements address the followingissues:

! The benefits and servicesincluded in, and ex-cluded from, coverage

! Pharmaceutical man-agement, including howto obtain pharmaceuti-cals and request excep-


(states that the member must re-ceive information regarding phar-maceutical services)

2.3.1.9 Charges to enrollees, if ap-plicable.RR 5 Subscriber Information

Section 1363 Disclosure (describesbenefits, exclusions, prescriptions, co-payments, restrictions, practitioners,obtaining services)

Section 1363(a)(1) Benefits

Section 1363(a)(4) Benefits

Rule 1300.63 Written information cov-ering benefits and services included andexcluded from coverage. Co-paymentsand charges for which member respon-sible.

Section 1363(a)(12) Restrictions on

6.9.3 Disclosure Forms


6.9.7 Distribution ofMember Services Infor-mation

DHS Comment

DHS does not specificallyaddress co-pay.

Highly consistent

All four sets of standards require plansto inform members about benefits andexclusions. However, language variesamong the requirement sets.

NCQA requires plans to provide themember an explanation of benefits,describe co-pays, and explain how tosubmit a claim. NCQA and HCFA arealso very specific about explanationsregarding pharmaceutical benefits. Theother sets of standards contain broaderstatements.




& COMMENTS


tions to the formulary

! Co-payments and othercharges for which themember is responsible

! Benefits that apply toservices obtained outsidethe managed care or-ganization’s system oroutside the MCO’sservice area

! How to submit a claim

benefits outside of MCO’s service areaor system

DHS does not address co-pays.

NCQA’s standards specifically requireplans to explain how a member cansubmit a claim. Although the otherstandards are not this explicit, oftenthis information is provided in writtenmaterial as a matter of doing business.Further, other standards indicate thatplans must provide member servicesand help with appeals, which is con-nected to getting claims resolved.

RR 5.2 – The MCO provideswritten information that instructsmembers about how to obtainprimary and specialty care.

Elements require providing in-formation regarding how to ob-tain:

! Information about prac-titioners

! Primary care services in-cluding points of access

! Specialty care

! After hours care

! Emergency care

! Out of service or net-work care

2.2.3 To choose providers fromamong those affiliated with the or-ganization.

2.3.1.3 The names and locations ofnetwork providers, including in-formation on which providers areaccepting new Medicare or Medi-caid patients and any restrictions onenrollees’ ability to select fromamong network providers.

2.3.1.5 Procedures for obtainingservices, including authorizationrequirements, any special proce-dures for obtaining mental healthand substance abuse services, pro-cedures for obtaining out-of-areacoverage and, in the case of enrol-lees eligible for a point-of-servicebenefit, procedures for obtainingservice through the benefit, includ-ing special conditions or chargesthat may apply.

2.3.1.13 Information on service

Section 1363(a)(13) (disclosure re-garding how to obtain primary and spe-cialty care)

Section 1363(b)(F)(G) (mandates thatplan must explain how to obtain emer-gency care, including policy on when todirectly access emergency care or use911 services)

Rule 1300.63.1(b)(11) (requires plansto explain how a member can obtainprimary and specialty care.



6.5.7.3 Urgent Care

6.5.7.7 After Hours Calls


6.9.9 Primary Care Phy-sician Selection

Highly consistent

All four sets of standards require plansto provide information regarding ac-cess to primary and specialty care, aswell as how to access care after hours,in emergency, and obtain care out ofthe plan’s network.

However, NCQA requires the plan toprovide members with informationregarding practitioner qualifications,and specific language describing howto access behavioral health and hospitalservices. Other sets of standards havebroader statements regarding theseissues.




& COMMENTS


area.

2.3.1.7 Provisions for after-hoursand emergency coverage.

2.3.1.8 Policies on referral for spe-cialty care and other services notfurnished by the enrollee’s primarycare provider.

3.2.1 Use of a health care profes-sional who is formally designatedas having primary responsibility forcoordinating the enrollee’s overallhealth care. Includes subsections3.2.1.1 through .3.2.1.2.

RR 5.3 – The MCO provideswritten information about how:

! To voice a complaint

! To appeal a decision

! The MCO evaluates newtechnology for inclusionas a covered benefit


2.3.1.10 Procedures establishedunder standard 2.4 for resolvingenrollee issues, including com-plaints or grievances and issuesrelating to authorization of, cover-age of, or payment for services.

Section 1368(a)(2) Every plan shallinform its subscribers and enrolleesupon enrollment in the plan and annu-ally thereafter of the procedure for proc-essing and resolving grievances. Suchinformation shall include the locationand telephone number where grievancesmay be submitted.

Section 1368(e) Complaint forms and acopy of the grievance procedure shall bereadily available at each facility of theplan, including facilities of providers,which furnishes services to subscribersand enrollees and shall be furnishedpromptly upon receipt of a requesttherefore by mail or telephone.

Rule 1300.68 A plan’s grievance systemestablished pursuant to the requirementof Section 1368

DMHC Comment

New technology is not specifically ad-

6.9.5 (L) & (N) Member-ship Services Guide


All four sets of requirements state thatmembers will receive information ex-plaining how to submit a complaint.


! NCQA does not specify thetype of complaint form to beused when collecting informa-tion about the complaint orgrievance.

! NCQA and HCFA member re-ceive an explanation describinghow new technology is as-sessed.

! DMHC will implement a simi-lar requirement in 2001.

! DHS does not yet addressmember’s access to new tech-nology.




& COMMENTS


dressed except in Section 1370.4, and inIndependent Medical Review processeffective January 1, 2001.

RR 5.4 – To ensure continuityand coordination of care, themanaged care organizationmakes a good faith effort to no-tify those members affected bythe termination of a practitioneror practice site to assist them inselecting a new practitioner orsite.

Requires notification 30-days(calendar) prior to the actualtermination date.

2.3.2 The organization notifies en-rollees affected by the terminationof or changes in benefits, services,service sites, or affiliated providers.To the extent practical, enrollees areinformed of such terminations orchanges prior to their effective date.

3.1.1.4 Medicare organization in-forms beneficiaries of their right tomaintain access to specialists in thecase of an involuntary terminationof the organization or specialist(s)for a reason other than for cause.Also, a Medicare organization pro-vides the names of other organiza-tions in the area that contract withthe specialists of the beneficiary toreturn to original Medicare.

Section 1373.96 At request of enrolleearrange for the continuation of cover-age services… when provider or prac-tice site terminates

6.9.8 Changes in Avail-ability or Location ofCovered Services

6.9.11 Continuity of Care

Highly consistent

All four sets of standards require thatplans notify members when practitio-ners terminate and provide assistancein finding new providers. However,timeframes differ. For example:

! NCQA requires that membersreceive notification within 14calendar days.

! DHS standards state “themember receives notification30 days prior to the effectivedate or within 14 days prior tounforeseeable changes.”

All four sets of standards allow mem-bers to continue to see practitioners forspecific conditions after the practitio-ner leaves the network.


RR 6 Privacy and Confidentiality

RR 6 – The MCO protects theconfidentiality of member in-formation and records.

Elements address:

! Confidentiality of mem-ber’s medical informa-tion

! Confidentiality of inca-pacitated member medi-cal data

2.2.1.1 The organization imple-ments procedures to ensure theconfidentiality of health and medi-cal records and of other informa-tion about enrollees (standard ad-dress sharing information with em-ployers, special consents, providinginformation regarding minors andprotection of information at all ac-cess sites)

2.2.1.1.1 (Protected data descrip-

Section 1364.5 (requires plan’s on orbefore 7/1/01, to advise enrollees howorganization maintains the confidenti-ality of medical information)

Section 1386(b)(15) Plan protects con-fidentiality of member information andrecords: Plans are required to complywith Confidentiality of Patient Informa-tion Act: Failure to do so is grounds fordisciplinary action.

DMHC Comment

6.5.6.5 Member’s Rightto Confidentiality (proce-dures to guard againstdisclosure of confidentialinformation; counselmembers on confidential-ity rights; insure confi-dentiality of sensitiveservices)

6.5.8.2 Medical RecordsProcedure

Highly Consistent

All four sets of standards require plansto protect the confidentiality of mem-bers’ medical information.

All four sets of standards require plansto develop confidentiality policies andprocedures, obtain members’ consentbefore releasing their medical informa-tion, and acquire “special consent”before providing sensitive medicalinformation.




& COMMENTS


! Statement in practitionercontracts that protectmember confidentialityof medical information

! Information given toemployers

! Member’s right to denyor consent to providingmedical information asallowed by law

! Communicating confi-dentiality policies to po-tential members

! Communicating confi-dentiality policies tomembers, practitioners,and providers

! Implementing internalcommittee to create andreview confidentialitypolicies and practices

tion)

3.6.3 The organization ensures ap-propriate and confidential exchangeof information among providers.

2.2.6 …. to have access to his orher medical records in accordancewith applicable Federal and Statelaws

Plan affords patients the opportunity toconsent to or deny the release of identi-fiable medical or other information by thePlan. Not specifically addressed; butplans are required to comply with stateand federal laws pertaining to confiden-tiality. Plan informs providers of its poli-cies regarding confidentiality of patientinformation. KKA does not specificallyaddress this.

(protect confidentiality ofmedical records; obtain-ing consent)

However, NCQA’s standards are moreextensive, and include more specificrequirements than the other sets ofstandards.

RR 6.1 – The MCO adopts andimplements written confidential-ity policies and procedures toensure the confidentiality ofmember information used forany purpose.

Elements address:

! Routine consent

! Special consent

! Access to medical rec-ords

! Protection of personal

2.2.1.1 The organization imple-ments procedures to ensure the con-fidentiality of health and medicalrecords and of other informationabout enrollees (procedures addressprotecting member medial intermis-sion from employers, obtaining spe-cial consent, protecting minorsmedical information and protectingmedical information at all accesssites)

2.2.1.1.1 (Describes protectingmedical data and who has access tothe information)

Section 1386(b)(15) Plan protects con-fidentiality of member information andrecords: Plans are required to complywith Confidentiality of Patient Informa-tion Act: Failure to do so is grounds fordisciplinary action.

DMHC Comment

Plan affords patients the opportunity toconsent to or deny the release of identi-fiable medical or other information by thePlan. Not specifically addressed; butplans are required to comply with stateand federal laws pertaining to confiden-tiality. Plan informs providers of its poli-

6.5.6.5 Member’s Rightto Confidentiality (de-scribes procedures usedto guard against disclo-sure of confidential in-formation; the need tocounsel members on con-fidentiality rights; andrequires plan insure con-fidentiality of sensitiveservices)



All four sets of standards require thatplans obtain the member’s consentbefore releasing medical information.All sets of standards also, in somemeasure, require over-all protection ofmedical information.


! NCQA and HCFA limit em-ployer access to member medi-cal information. The DMHCand DHS do not require thislevel of protection.




& COMMENTS


health information

- Internally

- Within contracted or-ganizations

- With employer

- For research

- In treatment setting

! Use and protection ofdata for quality meas-urement

! Use of data by self-funded groups or em-ployers

2.2.6 to have access to his or hermedical records in accordance withapplicable Federal and State lawsRR 6 Privacy and Confidentiality

cies regarding confidentiality of patientinformation. KKA does not specificallyaddress this.

(requires plans to protectconfidentiality of medicalrecords; obtain memberconsent before releasinginformation)

! NCQA standards specificallyrequire protection of medicalinformation wherever it isstored, including internal andexternal sites, and protects theconfidentiality of quality data.

! Other sets of standards are lessspecific.

RR 6.2 – The MCO has policiesfor obtaining informed consentwhen the managed care organi-zation is involved in directtreatment of members who lackthe ability to give informed con-sent.

Elements require that policiesidentify people who:

! May authorize release

! May authorize treatment

! Have access to informa-tion


2.2.1.1.1 (describes protection ofmedical information and allowsrelease of information only toauthorized individuals )

Does not address Does not address Consistent with variations

NCQA requires plans to develop a fullrange of polices and procedures thatprotect the confidentiality of medicalinformation when a member is inca-pacitated.

HCFA addresses only the confidential-ity of minors.

Neither the DMHC nor DHS addressthese issues.

RR 6.3 – The managed care or-ganization’s contracts with prac-titioners and providers explicitlystate expectations about the con-fidentiality of member informa-

2.1.1.1 Policies are communicatedto enrollees in the enrollee state-ment, and …to staff and affiliatedproviders at initial affiliation andannually ….material (states that

Section 1386(b)(15) Plan protects con-fidentiality of member information andrecords: Plans are required to complywith Confidentiality of Patient Informa-tion Act: Failure to do so is grounds for


(describes protection ofmedical records; obtain-ing consent)

Highly consistent

All standards express the intent thatplans formally require practitioners andproviders to protect the confidentialityof member medical information.




& COMMENTS


tion and records. information must be included inprovider contracts or manual)


disciplinary action.

DMHC Comment

Plan informs providers of its policiesregarding confidentiality of patient infor-mation. KKA does not specifically ad-dress this.

NCQA and HCFA require that practi-tioner and provider contracts containexplicit statements of expectationsabout the confidentiality of memberinformation and records.

The other sets of standards do not re-quire confidentiality agreements inpractitioner or provider contracts.

RR 6.4 – The managed care or-ganization ensures that datashared with employers, whetherfully insured or self-insured, arenot implicitly or explicitly mem-ber identifiable, unless specificconsent is provided by members.

2.2.1.1 The organization implementsprocedures to ensure the confidenti-ality of health and medical recordsand of other information about en-rollees (procedures address pro-tecting member medial intermissionfrom employers, obtaining specialconsent, protecting minors medicalinformation and protecting medicalinformation at all access sites)

Does not address Does not address Highly consistent

Both NCQA and HCFA limit employerassess to the member medical informa-tion. Neither, DMHC nor DHS addressthe issues described on in the far-leftcolumn.

RR 6.5 – The MCO affords pa-tients the opportunity to consentto or deny the release of identifi-able medical or other informa-tion by the MCO, except whensuch release is required by law.

2.2.1.1 The organization implementsprocedures to ensure the confidenti-ality of health and medical recordsand of other information about en-rollees (procedures address pro-tecting member medial intermissionfrom employers, obtaining specialconsent, protecting minors medicalinformation and protecting medicalinformation at all access sites)

2.2.1.1.1 (Describes what data isprotected and who has access to thedata)

DMHC Comment

Plan affords patients the opportunity toconsent to or deny the release of identi-fiable medical or other information by thePlan. Not specifically addressed; butplans are required to comply with stateand federal laws pertaining to confiden-tiality.

6.5.6.5 Member’s Rightto Confidentiality (proce-dures to guard againstdisclosure of confidentialinformation; counselmembers on confidential-ity rights; insure confi-dentiality of sensitiveservices)


(describes protection of

Highly consistent

NCQA, DMHC, and DHS require theplan to ask for the member’s permis-sion or denial before releasing medicalrecords, unless release is required bylaw.

Although HCFA standard addressesonly obtaining “special consent”, theirintent is to formally protect the mem-ber’s privacy.




& COMMENTS


medical records; obtain-ing consent)

RR 6.6 – The managed care or-ganization communicates to pro-spective members its policiesand practices regarding collec-tion, use, and disclosure ofmedical information.

2.1.1.1 Policies are communicatedto enrollees in the enrollee state-ment, furnished in accordance withstandards 2.3, and to the organiza-tion staff and affiliated providers atinitial affiliation and annually )ma-terial (mandates that informationmust be included in provider con-tacts or manual

Section 1364.5 (requires plan’s on orbefore of 7/1/01, to advise enrollees howorganization maintains the confidenti-ality of medical information)

6.5.6.5 Member’s Rightto Confidentiality (de-scribes procedures toguard against disclosureof confidential informa-tion; counsel members onconfidentiality rights;insure confidentiality ofsensitive services)

Consistent with Variation

NCQA explicitly requires that pro-spective member receive confidential-ity policies and procedures.

The other sets of standards providesuch information to current enrollees,not to prospective members.

RR 6.7 – The MCO informsmembers, practitioners, and pro-viders of its policies and proce-dures on obtaining consents foruse of member medical informa-tion, allowing members access totheir medical records, and pro-tecting access to member medi-cal information.

2.1.1 The organization implementsprocedures to ensure the confidenti-ality of health and medical recordsand of other information about en-rollees (procedures address em-ployer access to information, spe-cial consent, protection of minorsand protection of all access sites)

2.1.1.1 Policies are communicatedto enrollees in the enrollee state-ment, furnished in accordance withstandards 2.3, and to the organiza-tion staff and affiliated providers atinitial affiliation and annually )ma-terial (mandates that informationmust be included in provider con-tacts or manual

Section 1364.5 (requires plan’s on orbefore 7/1/01, to advise enrollees howorganization maintains the confidenti-ality of medical information)

DMHC Comment

Plan affords patients the opportunity toconsent to or deny the release of identi-fiable medical or other information by thePlan. Not specifically addressed; butplans are required to comply with stateand federal laws pertaining to confiden-tiality. Plan informs providers of its poli-cies regarding confidentiality of patientinformation. KKA does not specificallyaddress this.

6.5.6.5 Member’s Rightto Confidentiality (re-quires procedures toguard against disclosureof confidential informa-tion; counsel members onconfidentiality rights;insure confidentiality ofsensitive services)

Highly consistent

All sets of standards reflect the sameintent with minor variations in lan-guage.

RR 6.8 – The managed careorganization designates aninternal committee to create andreview confidentiality policiesand to review practices regardingthe collection, use and disclosureof medical information.

Does not addressRR 6 Privacy and Confidentiality

Does not address Does not address NCQA Only

Only NCQA requires that the planidentify a committee to be responsiblefor developing and overseeing confi-dentiality issues.



& COMMENTS


RR 7 Marketing Information

RR 7 – The managed care or-ganization ensures that commu-nications with prospective mem-bers correctly and thoroughlyrepresent the benefits and oper-ating procedures of the organi-zation.

2.3 Enrollee Information Section 1363 Disclosure Form: (ad-dresses benefits and coverage)

Managed Care Opera-tions Branch Policy Let-ter (MCOB) 93-12

The letter describesDHS’s marketing pro-gram. The program con-tains a standardized mar-keting presentation. Thepresentation includes anexplanation of benefits,exclusions, services, andaccess instructions

Highly consistent

All standards reflect the intent thatprospective members understand theplan’s benefits and covered services.

However, NCQA specifically requiresthat a plan assess new members’ under-standing of benefits.

RR 7.1 – Materials for prospec-tive members contain a summarystatement of how utilizationmanagement procedures work.

2.3.1.14.2 The procedures the or-ganization uses to control utiliza-tion of services and expenditures.

Section 1363 Disclosure Form: (ad-dresses benefits and coverage)


The letter describesDHS’s marketing pro-gram. The program con-tains a standardized mar-keting presentation. Thepresentation includes anexplanation of benefits,exclusions, services, andaccess instructions.

Highly consistent

All sets of standards require plans toprovide prospective members an ex-planation of the utilization process.

RR 7.2 – Materials and presen-tations accurately describe:

! Covered benefits

! Non-covered services

! Availability

! Potential restrictions

! Pharmaceuticalprocedures

2.3.1.4 Amount, duration and scopeof all benefits and services includedand excluded as a condition of en-rollment, Including a description ofhow the organization evaluated newtechnology for inclusion as a cov-ered benefit. (requires that materi-als must include how a member canget information regarding pharma-

Section 1363 Disclose Form: (addressesbenefits and coverage


The letter describesDHS’s marketing pro-gram. The program con-tains a standardized mar-keting presentation. Thepresentation includes an

Highly consistent

The language and intent of all the setsof standards is very similar.




& COMMENTS


ceutical services) explanation of benefits,exclusions, services, andaccess instructions

RR 7.3 – The MCO monitorsnew members’ understanding ofthe MCO’s procedures to ensurethat marketing communicationsare accurate.

2.3.4 The organization evaluates theeffectiveness of its communicationswith enrollees.

Does not address Does not address Consistent with variations

Only NCQA requires that plans assessnew members’ understanding of theplan’s marketing materials.

Other standards either do not addressthis issue or assess only general mem-ber understanding.


RR 8 Delegation of Members’ Rights and Responsibilities

RR 8 – If the MCO delegatesany member services activities,there is:


! Evidence of oversight ofthe delegated activity




4.1.3 The performance of the entityis monitored on an ongoing basisand formally reviewed by the or-ganization at least annually.RR 8 Delegation of Members’ Rights and Responsibilities










6.5.2.6 (D) Assurance anddocumentation that sub-contractor has the ad-ministrative capacity, task

Highly consistent





& COMMENTS




Rule 1300.70(b)(2)(G) Medical groupsof other provider entities may have ac-tive quality assurance programs that theplan may use. In all instances, however,the plan must retain responsibility forreviewing the overall quality of caredelivered to plan enrollees. If QA Ac-tivities are delegated to a participatingprovider to ensure that each providerhas the capacity to perform effectivequality assurance activities.

experience, and budget-ary resources to fulfill itsresponsibilities



6.9.2 Member ServicesEmployee Training: Planensures member servicesstaff are trained on poli-cies, procedures, andscope of benefits




& COMMENTS





RR 8.1.1 – A mutually agreedupon document describes:





! Remedies, includingrevocation of the delega-tion, available to theMCO if the delegatedentity does not fulfill its



DMHC Comment

KKA does not specifically address re-voking delegation, although we haveconsidered this an appropriate action totake when there are uncorrected defi-ciencies in performance of delegated

3.19 Sanctions*







Highly consistent







& COMMENTS


obligations functions.

RR 8.2 – There is evidence thatthe MCO


! Approves the delegate’sQI work plan and pro-gram








Rule 1300.70(b)(2)(G) Medical groups







Highly consistent


Minor differences are that NCQA andHCFA standards require an annualevaluation. DMHC and DHS have on-going evaluation, but do not specifi-cally state that they conduct an annualevaluation




& COMMENTS


of other provider entities may have ac-tive quality assurance programs that theplan may use. In all instances, however,the plan must retain responsibility forreviewing the overall quality of caredelivered to plan enrollees. If QA activi-ties are delegated to a participatingprovider to ensure that each providerhas the capacity to perform effectivequality assurance activities.


Rule 1300.70(b)(2)(G)(3) The Plan musthave ongoing oversight procedures inplace to ensure that providers are fulfill-ing all delegated QA responsibilities.

Rule 1300.70(b)(2)(G)(4) Requires stan-dards for evaluating that enrollees re-ceive health care consistent with profes-sionally recognized standards of practice.


Preventive HealthPH 1 Adoption of Preventive Health Guidelines

PH 1 Adoption of Preventive Health Guidelines


& COMMENTS

PH 1 – The MCO has preventivehealth guidelines for preventionand early detection of illness anddisease.

Elements address:

! All age categories

! Content of guidelines

! Involvement of practi-tioners

! Time in place (at leasttwo years)

! Reviewed and updatedevery two years

Domain 1: Quality Assessment andperformance improvement (QAPI)Program.

1.2.3 Performance Levels

(plans are required to monitor,measure and improve HCFA se-lected measurements which areoften HEDIS measurements relatingto preventive care)

1.3.4.1 Clinical Focus Areas (iden-tifies focus areas that include pri-mary , secondary, tertiary preven-tion of acute conditions and chronicconditions)

1.4.1.3 Selection of topics takes intoaccount: the prevalence of a condi-tion among, or need for a specificservice by, the organization’s en-rollees; enrollee demographiccharacteristics and health risks;and the interest of consumers in theaspect of care or services to be ad-dressed

3.4.1 The organization adopts anddisseminates practice guidelines(standard suggests that the organi-zation have a systematic process toadopt guidelines and involves af-fected practitioners)

3.4.1.1 Guidelines are based onreasonable medical evidence or aconsensus of health care profes-sionals in a particular field, con-sider the needs of the enrolled

Section 1367.3 (standard describes pre-ventive care for children and guidelinecontent)

Section 1367.36 (describes breast can-cer screening)

Rule 1300.67 (states that preventivecare is a basic service and identifies avariety of preventive care services that aplan must cover including mammogra-phy, cervical cancer prenatal and pre-natal care,)

Rule 1300.67(f)(1-8) (addresses pre-ventive services including children, pre-natal care an health education)

Rule 1300.70 (states that providersmust direct QI program; and the pro-gram must address professionally rec-ognized standards of practice)

DMHC Comment

(Rule 1300.76.3 requires the plan tohave written procedures for the provisionof health services, so as to provide ef-fective controls. Therefore, plans arerequired to have written guidelines fortheir preventive health services and thusguidelines for prevention and early de-tection of disease.)

6.5 Quality Improve-ment System

6.5.1.1 (D)(1) Scope ofreview (mandates that thescope includes preventivecare)




6.5.3.2 Quality ReportingMeasures* (describesmonitoring and reportingHEDIS)

6.5.3.5 Standards andGuidelines* (describespreventive care for pedi-atric, adult, obstetricalmembers)

6.7.6 Clinical PreventiveServices

6.7.6.2 (D) Children(Services) (describes pe-riodic health assessmentsand immunizations forunder age21 in accor-dance with AAP guide-lines)

6.7.6.3 - 6.7.6.6 PregnantWomen

Highly consistent

All sets of standards have the sameintent. All require plans to implementpreventive guidelines, support preven-tive health initiatives, and monitor per-formance. All standards require reviewof guideline performance within theplan’s QI program.

Only NCQA requires the guidelines bein place for 2 years and that they mustbe reviewed every 2 years after adop-tion.

NCQA also requires plans to documenthow the guideline is selected, devel-oped, adopted, and reviewed.

HCFA, DMHC, and DHS standardscontain fewer direct plan responsibili-ties than NCQA standards since mostpreventive guidelines are selected, de-veloped, and reviewed by HCFA,DMHC and DHS before they are pre-sented to the plan.

Under the standards of the three or-ganizations above, plans may becharged only with monitoring and im-plementing interventions. However,plans are expected to review guidelineperformance and obtain local practitio-ner input as part of the QI program.

Preventive Health



& COMMENTS


population, are developed in con-sultation with contracting healthcare professionals, and are re-viewed and updated periodically.

6.7.6.7 Adults

PH 1.1 – The MCO guidelinesfor the following categories:

! Preventive care for in-fants up to 24 months

! Preventive care for chil-dren and adolescents, 2-19 years old

! Prenatal and perinatalcare

! Preventive care foradults 20-64 years old

! Preventive care for eld-erly, 65 and older

Elements require:

! Guidelines cover 4 ormore age groups

! Guidelines for any age orrisk group that representsa significant group in theplan’s populations

1.3.4.1 Clinical Focus Areas -(identifies focus areas that includeprimary , secondary, tertiary pre-vention of acute conditions andchronic conditions)

1.4.1.3 Selection of topics takes intoaccount: the prevalence of a condi-tion among, or need for a specificservice by, the organization’s en-rollees; enrollee demographiccharacteristics and health risks;and the interest of consumers in theaspect of care or services to be ad-dressed.






6.5.3.5 Standards andGuidelines* (describespreventive care for pedi-atric, adult, obstetricalmembers)

6.7.6 Clinical PreventiveServices



6.7.6.7 Adults

Highly consistent

All four sets of standards require pre-ventive guidelines that reflect the needsof the plan's population.

PH 1.2 Each guideline describesthe prevention or early detectioninterventions and the recom-mended frequency and condi-tions under which the interven-tions are required. The MCOdocuments the scientific basis orauthority upon which it basedthe preventive health guidelines.

1.2.3 Performance Levels

(plans are required to monitor,measure and improve HCFA se-lected measurements which areoften HEDIS measurements relatingto preventive care)

1.3.4.1 Clinical Focus Areas -(identifies focus areas that include



Rule 1300.67 (states that preventivecare is a basic service and identifies avariety of preventive care services that a


6.5.3.5 Standards andGuidelines* (describespreventive care for pedi-atric, adult, obstetrical

Highly consistent

All four sets of standards require adop-tion and monitoring of preventiveguidelines that are based on nationalstandards or on HEDIS measurements.These national guidelines include earlydetection, frequency of monitoring, andare scientifically based.

Preventive Health



& COMMENTS


Elements require that the guide-lines describe:

! Prevention or early de-tection

! Frequency and condi-tions of interventions

! The scientific basis orauthority upon which theguideline is based

primary , secondary, tertiary pre-vention of acute conditions andchronic conditions)

1.4.1.3 Selection of topics takes intoaccount: the prevalence of a condi-tion among, or need for a specificservice by, the organization’s en-rollees; enrollee demographiccharacteristics and health risks;and the interest of consumers in theaspect of care or services to be ad-dressed

3.4.1.1 Guidelines are based onreasonable medical evidence or aconsensus of health care profes-sionals in a particular field, con-sider the needs of the enrolledpopulation, are developed in con-sultation with contracting healthcare professionals, and are re-viewed and updated periodically.

plan must cover including mammogra-phy, cervical cancer prenatal and pre-natal care,)


members)

6.7.6 Medical Standards– Clinical PreventiveServices



6.7.6.7 Adults

None of the sets of standards restrictsplans from monitoring additional pre-ventive guidelines that may addressissues unique to their populations.

PH 1.3 Practitioners from theMCO who have appropriateknowledge have been involvedin the adoption of the preventivehealth guidelines

Elements include:

! Involvement of practi-tioners from appropriatespecialties who help de-velop guidelines

! Guideline was sharedwith local practitionersbefore adoption

Domain 1: Quality Assessment andperformance improvement (QAPI)Program

3.4.1 The organization adopts anddisseminates practice guidelines(standard suggests that the organi-zation have a systematic process toadopt guidelines and involves af-fected practitioners)

Rule 1300.70 (states that providersmust direct QI program; and the pro-gram must address professionally rec-ognized standards of practice)


6.5.1.1(D)(1) Scope ofreview (mandates that thescope includes preventivecare)



Highly consistent

Although NCQA is very specific aboutpractitioner involvement in developingpreventive care guidelines, the otherstandards reflect the same intent.

All four sets of standards require plansto obtain practitioner input in their QIprograms. Since all QI programs ad-dress preventive health care, practitio-ners provide input into the guidelines.

NCQA specifically requires that pro-viders review and comment beforeguidelines are adopted. The other setsof standards do not address this issue

Preventive Health



& COMMENTS


nor do they appear to allow the plansflexibility in changing preventivestudies.

PH 1.4 The preventive healthguidelines or their predecessorshave been available for use for atleast 2 years

3.4.1 The organization adopts anddisseminates practice guidelines(standard suggests that the organi-zation have a systematic process toadopt guidelines and involves af-fected practitioners

Does not address Does not address Consistent with variation

Only NCQA requires that the preven-tive guidelines be in place for at leasttwo years.

PH. 1.5 For those preventivehealth guidelines that have beenin place for at least 2 years, thereis evidence of review and updateat least once every two years,when appropriate.

3.4.1 The organization adopts anddisseminates practice guidelines(standard suggests that the organi-zation have a systematic process toadopt guidelines and involves af-fected practitioners

Does not address Does not address Consistent with variation

NCQA requires plans to review pre-ventive guidelines at least every twoyears.

HCFA is less prescriptive and onlyrequires a periodic review.

DMHC requires a formal review ofUM guidelines but does not addresspreventive care guidelines.

Plans may review guidelines as part ofthe assessment of their QI programs.However, NCQA requires plans toestablish a systematic guideline reviewprocess.


PH 2 Distribution of Guidelines to Practitioners

PH 2 – The managed care or-ganization distributes the pre-ventive guidelines and any up-dates to practitioner. Including:

! Guidelines to all appro-priate existing practitio-ners

! Revised guidelines to

3.4.1 The organization adopts anddisseminated practice guidelines.

Does not address distribution of preven-tive care guidelines in cited standards.

Does not address distri-bution of preventive careguidelines in cited stan-dards.


Only NCQA and HCFA standardsformally require distribution of guide-lines.

However, DMHC and DHS are likelyto distribute guidelines as part of theirQI program implementation, even iftheir standards do not specifically

Preventive Health



& COMMENTS


existing practitioners

! Existing guidelines tonew practitioners

make this a requirement.


PH 3 Health Promotion with Members

PH 3 – The managed care or-ganization regularly encouragesits members to use preventivehealth services.

Elements include:

! Distribution of guide-lines annually

! Encouraging prevention

! Targeting at least two at-risk member groups

1.2.3 The organization meets anygoals for performance improvementto specific measures that may beestablished for that organization byHFCA (Medicare) or the StatesMedicaid agency (Medicaid).

(These measurers often relate topreventive care and may be HEDISmeasurers.

1.4.1.3 Selection of topics takes intoaccount: the prevalence of a condi-tion among, or need for a specificservice by, the organization’s en-rollees; enrollee demographiccharacteristics and health risks;and the interest of consumers in theaspect of care or services to be ad-dressed.

3.4.1 The organization adopts anddisseminates practice guidelines.

Section 1300.80(B) Medical SurveyProcess (states that plans must adviseenrollees how to obtain care and pro-vide the types of care including preven-tive care)


Rule 1300.67(f)(1-8) (addresses pre-ventive services including children, pre-natal care and health education)

DMHC Comment

Plan informs members of health promo-tion, health education, and preventivehealth services

Plan identifies specific members whomay be at risk for specific health prob-lems and urges these members to useappropriate health promotion and pre-ventive services.PH 3 Health Promotion with Members

6.5.3.5 Standards andGuidelines* (new stan-dards prevention for pe-diatric, adult, obstetrics

6.7.1 Heath Education

6.7.7.1 Implement clini-cal services

6.7.7.3 Individual HealthEducation

(Behavioral Assessments)

6.7.7.7 Group Needs As-sessment

6.7.6 Medical Standards –Clinical Preventive Serv-ices

6.7.6.1 Initial Health As-sessment

6.7.6.2 Children

6.7.6.2 (B) (Addressesnotification of availabilityof preventive healthservices for at-risk chil-dren and adolescents)

6.7.6.3 – 6.7.6.6 Pregnantwomen

6.7.6.7 Adults

Highly consistent

All fours sets of standards require theplan to assess members’ needs andencourage members to seek preventivecare. However, the language varies.

NCQA, DMHC, and DHS languagestates that the organization will providehealth education to members. HCFAlanguage states that plan must establishprocedures to help members obtainpreventive services.

HCFA does not require plans to spe-cifically encourage health education fortargeted at-risk members.

DHS standards mandate assessmenttime frames. However, NCQA stan-dards do not specify a timeframe forassessment of medical or behavioralhealth problems.

Preventive Health



& COMMENTS


6.9.5 (B), (E), & (P)Membership ServicesGuide

DHS Comment

NCQA requires MCO toidentify members whomay be at risk and thentarget specific services tothem. Contract requiresMCO conduct groupneeds assessment todetermine needs.


PH 4 Delegation of Preventive Health

PH 4 – If the MCO delegatesany preventive health activities,there is evidence of oversight ofthe delegated activity.

Elements include:


! Evidence of delegatedoversight






Rule 1300.70 (b)(2)(C) In order to meetthese obligations each plan’s QI pro-gram shall meet all of the followingrequirements:








6.5.2.6 (D) Assurance anddocumentation that sub-contractor has the ad-ministrative capacity, task

Highly consistent


Preventive Health



& COMMENTS





Rule 1300.70(b)(2)(G) Medical groupsof other provider entities may have ac-tive quality assurance programs that theplan may use. In all instances, however,the plan must retain responsibility forreviewing the overall quality of caredelivered to plan enrollees. If QA Ac-tivities are delegated to a participatingprovider to ensure that each providerhas the capacity to perform effectivequality assurance activities.

experience, and budget-ary resources to fulfill itsresponsibilities



Preventive Health



& COMMENTS





PH 4.1 – A mutually agreedupon document that describes


! Delegated activities;

! Frequency of reportingto the MC


! Remedies, includingrevocation of the delega-tion, available to theMCO if the delegatedentity does not fulfill its

4.1.1 A written agreement specifiesthe delegated activities and report-ing responsibilities of the entity andprovides for revocation of the dele-gation or other remedies for inade-quate performance.


DMHC Comment

KKA does not specifically address re-voking delegation, although we haveconsidered this an appropriate action totake when there are uncorrected defi-ciencies in performance of delegated

3.19 Sanctions*







Highly consistent




Preventive Health



& COMMENTS


obligations functions.

PH 4.2 – There is evidence thatthe MCO:


! Approves the delegate’sQI work plan and pro-gram








Rule 1300.70(b)(2)(G) Medical groups







Highly consistent


Minor differences include:

! NCQA and HCFA standardsrequire an annual evaluation.DMHC and DHS have on-going evaluation, but do notspecifically state that they con-duct an annual evaluation

Preventive Health



& COMMENTS


of other provider entities may have ac-tive quality assurance programs that theplan may use. In all instances, however,the plan must retain responsibility forreviewing the overall quality of caredelivered to plan enrollees. If QA activi-ties are delegated to a participatingprovider to ensure that each providerhas the capacity to perform effectivequality assurance activities.






Medical Records

MR 1 Medical Record Documentation Standards


& COMMENTS

MR 1 – The MCO requiresmedical records to be main-tained in a manner that is cur-rent, detailed and organized,and permits effective and confi-dential patient care and qualityreview.

Elements include:

! Medical record confi-dentiality

! Distribution of medicalrecord standards topractice sites

! Established medical re-cord keeping systemsand availability ofmedical records

! Established process toassess and improvemedical record keeping

1.1.2 Conducts performance im-provement projects that achieve,through ongoing measurementand intervention, demonstrableand sustained improvement insignificant aspects of clinical careand non-clinical services that canbe expected to have a beneficialeffect on health outcomes andenrollee satisfaction.

1.1.3 Corrects significant sys-temic problems that come to itsattention through internal sur-veillance, complaints, or othermechanisms.

2.2.1.1 The organization imple-ments procedures to ensure theconfidentiality of health andmedical records and of other in-formation about enrollees. In-cludes 2.2.1.1.1.

3.6.2 The organization ensuresthat each provider furnishingservices to enrollees maintains anenrollee health record in accor-dance with standards establishedby the organization that takes intoaccount professional standards.

3.6.2.1 The organization enforcesstandards for health record con-tent and organization.

3.6.3 The organization ensuresappropriate and confidential ex-change of information amongproviders specifications of basic

Rule 1300.80(b)(4) Medical recordsmaintained in a current, detailed, andorganized manner

Rule 1300.80(b)(5)(J) the handlingand adequacy of medical record sys-tems including filing procedures, pro-cedures for maintenance of confiden-tiality, the efficiency of procedures forretrieve and transmittal, and the utili-zation of filing techniques for medicalrecords audits and quality of carereviews.

Rule 1300.70(a)(1) (describes QIprocess)

DMHC Comment

Plan has a means to assess and im-prove the quality of medical recordkeeping.

Plan has confidentiality procedures.Plans are required to abide by federaland state confidentiality laws.

Plan has MR documentation standardsthat are distributed to providers.

3.27.2 Contractor’sDuty to Maintain Con-fidentiality

6.5.8.2 Medical Rec-ords Procedures (de-scribes the processesmandated for storing,filing; confidentiality;legible, current, de-tailed organized andcomprehensive rec-ords.)

6.5.8.3 On-site MedicalRecords (requires theplan to identify “anindividual be delegatedthe responsibility ofmedical records “onsite.”)

Highly consistent

All four sets of standards requiremedical record standards, medicalrecord-keeping standards, and confi-dentiality processes.

All sets of requirements mandate aprocess to assess and improve medi-cal records.

Medical Records


& COMMENTS


MR 2 Compliance with NCQA Medical Records Standards

MR 2 – File review of criticalcriteria

Element require that medicalrecords document:

! Problem list

! Allergies

! History

! Diagnosis

! Treatment Plans

! Appropriate treatment

(As of January 1, 2001 NCQAwill no longer require this stan-dard, however will continue toperform medical record reviewin states that mandate it.)

3.6.2.1 The organization enforcesstandards for health record con-tent and organization.

(Including problems lists, aller-gies, history, treatment plan, di-agnosis

3.6.2.2 (describes assessment ofmedical record)

Rule 1300.80(b)(4)…entries establishthe diagnosis stated and appropriatehistory and physical find-ing….allergists, therapies

DMHC Comment

KKA does not evaluate compliancewith NCQA standards, but with profes-sionally recognized standards of prac-tice.

6.5.8.4 Shall reflect allaspects of patient careMember Medical Rec-ord

(mandates that the rec-ord includes:

! Problem list

! Allergies

! Diagnosis

! Treatment plan)

6.5.8.5 Medical RecordReview …system toreview record compli-ance


NCQA recently restricted its medicalreview to six critical elements.

The other standards still review manyof the elements formally reviewed inNCQA surveys.

DHS does not state that it reviewsmedical records for medical history.

DMHC does not state that it reviewsmedical records for the problem list.


Appendix

NCQA MCO Accreditation Program – Performance Measurement Requirement

This Crosswalk does not include all NCQA accreditation requirements. Specifically, NCQA ac-creditation requires plans to annually report selected measures from the Health Plan EmployerData and Information Set (HEDIS®) and Consumer Assessment of Health Plan Satisfaction(HEDIS/CAHPS® 2.0H) survey. As part of NCQA’s vision of being the best source of datadriving improvements in health care quality, we score plans on the measurement of actual per-formance in our accreditation program. Health plans must annually submit measures for each ofthe products they wish to have accredited (commercial, Medicare, and/or Medicaid). The re-quired measures include the Effectiveness of Care domain of the HEDIS Technical Specifica-tions (Vol. 2), and measures collected in the CAHPS® 2.0H survey (Vol. 3).

A health plan’s HEDIS score is based on its performance relative to other plans for that sameproduct. NCQA calculates regional and national benchmarks each year for the commercial,Medicare, and Medicaid products. Individual plan performance is assessed against those bench-marks and a score is created. Each year, an accredited plan has its product accreditation statusreassessed based upon changes in relative performance.

Performance measurement comprises 25 percent of a health plan’s total accreditation score,while the review against the standards comprises the remaining 75 percent. (In the 2001 MCOAccreditation Standards, the performance measurement component will increase to 27.5 per-cent.) Accreditation status is updated annually to reflect the most current performance data. In2000, this resulted in a change in accreditation status for roughly 10 percent of plans. Plan use ofperformance data, including member satisfaction information, is reinforced throughout theNCQA standards; however, it is the annual re-evaluation using HEDIS that enables NCQA tograde plans on their actual results. For more information on the accreditation process, pleasecontact NCQA.

CAHPS®

is a registered trademark of the Agency for Healthcare Research and Quality.

Medi-Cal Audit Crosswalk · Medi-Cal Policy Institute 476 Ninth Street Oakland, CA 94607 Tel: (510)...

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