Common use of Quality Management and Improvement Clause in Contracts

Quality Management and Improvement. The process for conducting outcome reviews, data analysis, policy evaluation, and technical assistance internally and externally to improve the quality of care to Enrollees. Quarterly Business Review or QBR – Quarterly in-person meetings between Covered California and Contractor at Covered California headquarters to report and review program performance results including all Services and components of the program, i.e., clinical, financial, contractual reporting requirements, customer service, appeals and any other program recommendations. Regulations – The regulations adopted by Covered California Board. (California Code of Regulations, Title 10, Chapter 12, § 6400, et seq.) Risk-Adjusted Premiums – Actuarially calculated premiums utilizing risk adjustment. Risk-Based Capital or RBC – The approach to determine the minimum level of capital needed for protection from insolvency based on an organization’s size, structure, and retained risk. Factors in the Risk Adjustment – An actuarial tool used to calibrate premiums paid to Health Benefits Plans or Health Insurance Issuers based on geographical differences in the cost of health care and the relative differences in the health risk characteristics of enrollees enrolled in each plan. Risk adjustment establishes premiums, in part, by assuming an equal distribution of health risk among Health Benefits Plans in order to avoid penalizing enrollees for enrolling in a Health Benefits Plan with higher than average health risk characteristics. Run-Out Claims – All claims presented and adjudicated after the end of a specified time period where the health care service was provided before the end of the specified time period.