Common use of Performance Metrics Program Clause in Contracts

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’ process, except for assuming responsibility of the historical/utilization data, providing it during the transition term. The HEDIS’ will be assumed by the MCO entering the Health Region, on an operational and administrative basis according to NCQA guidelines and schedule. e) Timeliness in reporting to the ADMINISTRATION the specified performance measures in the NCQA defined format. 3. Plan Compliance Evaluation Program (PCEP) The TPA and HCO must demonstrate their capability to fulfill the following standards sets forth in 42 CFR §§ 438.206 to 424 that includes, without limitation: a. Enrollee Rights and Protections (42 CFR § 438.100) b. Availability of Services (42 CFR § 438.206) c. Coordination of Continuity of Care (42 CFR § 438.208) d. Coverage and Authorization of Services (42 CFR § 438.210) e. Provider Selection (42 CFR § 438.214) f. Enrollee Information (42 CFR § 438.218) g. Confidentiality (42 CFR § 438.224) h. Enrollment and Disenrollment (42 CFR §§ 438.226, 438. 56)

Performance Metrics Program. A. Quality Initiative and Improvement Program (QIP) The TPA INSURER and HCO must execute the QHPP HCO, through the management of protocolsprotocols must execute the QHPP. The TPA INSURER 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§438.204. The components of the QIP are as follows: 1. Performance Improvement Projects (PERIP) The TPA INSURER 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, §§ 438.240 and §438.358(b)(1), 438.358 (b)(1) and Law No. 72 of September 7, 1993, as amended. In addition, the ADMINISTRATION will require, require on an annual basis, of basis to the TPA INSURER and/or HCO, an Enrollee/Provider Annual Satisfaction Survey (EPASS) as a compulsory PERIP, which it may be a CAHPS or any other type of survey provided by the TPAINSURER. 2. Quality Performance Measures The ADMINISTRATION will require of to the TPA INSURER and/or the HCO that: 1) HEDIS will 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 INSURER and HCO must comply with the following activities: a) a. The TPA INSURER 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) b. Validate the measurement of the TPA INSURER 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’ process, except for assuming responsibility of the historical/utilization data, providing it during the transition term. The HEDIS’ will be assumed by the MCO entering the Health Region, c. Timeliness on an operational and administrative basis according to NCQA guidelines and schedule. e) Timeliness in reporting to the ADMINISTRATION the specified performance measures in the NCQA defined format. 3. Plan Compliance Evaluation Program (PCEP) The TPA INSURER and HCO must demonstrate their capability to fulfill the following standards sets forth in 42 CFR §§ 438.206 to 424 that includes, without limitationbut are not limited to: a. Enrollee Rights and Protections (42 CFR § 438.100) b. Availability of Services (42 CFR § 438.206) c. Coordination of Continuity of Care (42 CFR § 438.208) d. Coverage and Authorization of Services (42 CFR § 438.210) e. Provider Selection (42 CFR § 438.214) f. Enrollee Information (42 CFR § 438.218) g. Confidentiality (42 CFR § 438.224) h. Enrollment and Disenrollment (42 CFR §§ 438.226, 438. 56) i. Grievances and Appeals system (42 CFR § 438.402 to 438.424) j. Sub contractual Relationships and Delegation (42 CFR § 438.230) k. Practice Guidelines (42 CFR § 438.236) l. Quality Assessment and Performance Improvement Program (42 CFR § 438.240) m. Health Information Systems (42 CFR § 438.242) 4. An External Quality Review Organization (EQRO) will be performing at a minimum the evaluation to the extent specified in 42 CFR 438.358. 5. The ADMINISTRATION reserves the right to add any other compliance standards, HEDIS performance measure or PERIP as it may deemed necessary and in accordance to the GHIP population needs.