Performance Metrics Program Clause Samples
Performance Metrics Program. A. Quality Initiative and Improvement Program (QIP) The TPA and HCO must execute the QHPP through the management of protocols. The TPA and HCO must have in place a Quality Initiative and Improvement Program to address those activities regarding the quality of healthcare services according to the mandatory activities described in 42 CFR §§ 438.358, 438.240 and 438.204 and will measure and report to ADMINISTRATION on an annual basis the. The components of the QIP are as follows:
1. Performance Improvement Projects (PERIP) The TPA and HCO must design, conduct, and report a PERIP in a methodologically sound manner as specified by the ADMINISTRATION. The ADMINISTRATION will require one or more PERIPs according to the GHIP population needs. The PERIP will be focused on clinical or non-clinical areas as stipulated on 42 CFR §§ 438.240 and §438.358(b)(1), and Law No. 72 of September 7, 1993, as amended. In addition, the ADMINISTRATION will require, on an annual basis, of the TPA and/or HCO, an Enrollee/Provider Annual Satisfaction Survey (EPASS) as a compulsory PERIP, which may be a CAHPS or any other type of survey provided by the TPA.
2. Quality Performance Measures The ADMINISTRATION will require of the TPA and/or the HCO that: 1) HEDIS be the quality performance measures to use as determined by the Puerto Rico Department of Health; 2) the specifications and methodology to be followed in calculating the measures, and the format and mechanisms for reporting these measures to the State must be according to the National Committee for Quality Assurance (NCQA) Guidelines. In addition, the TPA and HCO must comply with the following activities:
a) The TPA and HCO Information Systems must have the capability for collecting and integrating data from all components of its network, in order to enable valid measurement of its performance on dimensions of care specified by the ADMINISTRATION.
b) Validate the measurement of the TPA and HCO performance using a hybrid methodology (administrative plus medical record review data) in collecting the data to compute the HEDIS performance measures selected for each measurement year.
c) The data will be retroactive up to the previous three- year period, or up to the date when the previous MCO initiated operations in the region, including the termination date of the contract, using the service date field in the formats specified/agreed with the Administration.
d) The MCO leaving the Health Region will not be responsible for the HEDIS’...
Performance Metrics Program. (PMP)
1. The TPA shall submit all (100%) of the quarterly reports by the 15th day of the month after the corresponding reporting quarter, except where a different submission date has been stated herein.
2. The TPA and the HCO shall solve at least 95% of any filed enrollee complaints within thirty-days (30) of receipt, through the corresponding notification letter.
3. The TPA must provide through the HCO’s Providers Education Program (PEP) at least five (5) hours of workshops, seminars, and conferences as well as any other type of similar activity on a quarterly basis regarding any GHIP clinical and/or non-clinical topics, with a minimum of 70% participation of the HCO’s PCPs.
4. The TPA must provide through the HCO’s PEP at least one workshop, seminar, conference and any other similar activity, every six (6) months, related to mental health topics, regarding the GHIP managed care model, with a minimum of 70% participation of the HCO’s PCPs.
5. The ADMINISTRATION will require from the TPA a compliance target of at least seventy percent (70%) for the provision of preventive services from each PCP.
6. The TPA guarantees that the enrollee/provider satisfaction rate (EPSR) for each policy period must be 95% or greater, and shall be executed on a policy year basis.
a. The EPASS Response Rate must be greater than 70%. The response rate means the number of enrollees/providers responding to the survey.
b. The ADMINISTRATION must provide timely approvals of survey materials and methodology 60 calendar days prior to the execution of a survey.
c. The sampling size will be randomly chosen and not less than 400 in the case of the enrollees, and 30% of the providers participating in the region.
d. The submission of the survey results to the ADMINISTRATION will be ninety-days (90) after the end of the fiscal year.
e. The TPA must make available a toll-free customer service telephone number for use by beneficiaries. The TPA guarantees that the target Average Speed of Answer (ASA) of this toll-free customer service telephone line each quarter must be no greater than thirty-seconds (30) ASA means the time elapsed between a caller choosing the option to speak with a customer service agent and the agent attending the phone call.
7. The TPA guarantees that the customer service lines for a GHIP enrollee must have an Abandon Rate (AR) no greater than 5% out of all incoming calls per policy year. AR means the percent of calls where the caller chooses the option to speak with an ag...