Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix A. Arizona Long-term CARE System

The MCO is required to have the following key staff positions for quality oversight/reporting:

• The Medical Director/CMO is a state licensed physician who:
  • Is actively involved in all major clinical and QM components of the contract.
  • Oversees the QM/PI program monitoring and evaluation activities.
  • Serves as chair to quality oversight committees.
• The QM Coordinator is a state-licensed RN, physician or physician's assistant or is a CPHQ by the NAHQ and/or CHCQM by the American Board of Quality Assurance and Utilization Review Providers. The QM Coordinator must have experience in QM and QI. The primary functions of the QM Coordinator position are to:
  • Ensure individual and systemic quality of care.
  • Integrate quality throughout the organization.
  • Implement process improvement.
  • Resolve, track and trend quality of care grievances.
  • Ensure a credentialed provider network.
• The Performance/QI Coordinator has a minimum qualification as a CPHQ or CHCQM or comparable education and experience in data and outcomes measurement. The primary functions of the Performance/QI Coordinator are to:
  • Focus organizational efforts on improving clinical quality performance measures.
  • Develop and implement PIPs.
  • Utilize data to develop intervention strategies to improve outcomes.
  • Report QI/performance outcome.

The MCO must ensure that the QM/QI Unit within the organizational structure is separate and distinct from any other units or departments (e.g., Medical Management or Case Management units).

MCOs are required to demonstrate that providers are credentialed and reviewed through the MCO's Credentialing Committee chaired by the MCO's Medical Director. The provider monitoring shall follow a documented process for provisional credentialing, initial credentialing, re-credentialing and organizational credential verification of providers who have signed contracts or participation agreements with the MCO. The MCO must submit a Credentialing Quarterly Report.

MCOs shall provide an annual Case Management Plan which outlines how all case management and administrative standards will be implemented and monitored by the MCO. The administrative standards shall include but not be limited to a description of the MCO's systematic method of monitoring its case management program. The plan shall also include an evaluation of the MCO's Case Management Plan from the prior year to include lessons learned and strategies for improvement.

The MCO shall implement a systematic method of monitoring its case management program to include but not be limited to conducting quarterly case file audits and quarterly reviews of the consistency of member assessments/service authorizations (inter-rater reliability). The MCO shall compile reports of these monitoring activities to include an analysis of the data and a description of the continuous improvement strategies the MCO has taken to resolve identified issues. The MCO shall ensure adequate staffing to meet case management requirements. The MCO's case management plan shall also describe their methodology for assigning and monitoring case management caseloads.

The MCO must have a health information system that integrates member demographic data, case management information, provider information, service provision, claims submission and reimbursement and be capable of collecting, storing and producing information for the purposes of financial, medical and operational management. The MCO shall develop and maintain a HIPAA compliant claims processing and payment system capable of processing, cost avoiding and paying claims and must be adaptable to updates to meet changing policies as-needed.

The MCO must include nationally recognized methodologies to correctly pay claims, able to assess and/or apply data related edits, and produce remittance advice related to payments and/or denials to providers. To record and track placement history and cost effectiveness studies, the MCO must have a CATS. MCOs are not required to enter service authorizations into the CATS. However, the MCO is expected to maintain a uniform tracking system in each member chart documenting the beginning and end date of services inclusive of renewal of services and the number of units authorized for services.

The MCO is required to track and trend member and provider issues which include investigation and analysis of quality of care issues, abuse, neglect and unexpected deaths. The resolution process must include:

• Acknowledgement letter to the originator of the concern.
• Documentation of all steps utilized during the investigation and resolution process.
• Follow-up with the member to assist in ensuring immediate health care needs are met.
• Closure/resolution letter that provides sufficient detail to ensure that the member has an understanding of the resolution of their issue, any responsibilities they have in ensuring all covered, medically necessary care needs are met, and an MCO contact name/telephone number to call for assistance or to express any unresolved concerns.
• Documentation of implemented corrective action plan(s) or action(s) taken to resolve the concern.
• Analysis of the effectiveness of the interventions taken.

None specified.

MCOs are required to have a written grievance system process for subcontractors, enrollees and non-contracted providers which define their rights regarding disputed matters with the MCO. The MCO's grievance system for enrollees includes a grievance process (procedures for addressing enrollee grievances), an appeals process, and access to the state's fair hearing process. The MCO shall also ensure that it timely provides written information to both enrollees and providers which clearly explain the grievance system requirements. The MCO will provide reports on the grievance system to the state.

None specified.

• Measurement of performance using objective quality indicators.
• Implementation of system interventions to achieve improvement in quality.
• Evaluation of the effectiveness of the interventions.
• Planning and initiation of activities for increasing or sustaining improvement.

PIPs are mandated but MCOs may select additional projects based on opportunities for improvement identified by internal data and information. Each PIP must be completed in a reasonable time period so as to generally allow information on the success of PIPs in the aggregate to produce new information on quality of care every year. MCO must submit PIP baseline, re-measurement and final reports to the state.

The MCO case manager must complete a UAT based on information from the strengths/needs assessment to determine the member's current LOC.

Each case manager's caseload may not exceed a weighted value of 96 base on the following formula:

• Number of HCBS members x 2.0.
• Number of ALF members x 1.6.
• Number of ACO members x 1.0.
• Plus number of NF members x 0.8.

MCOs may assign a weighted value lower than those outlined.

The MCO is required to initiate a SP for each member at the time of enrollment. The SP shall identify the immediate health care needs of each newly enrolled member with an action plan. The comprehensive SP must be developed within 60 calendar days from date of the initial medical service and contain all the required elements. The MCO case manager modifies and updates the SP when there is a change in the member's condition or recommended services. This will occur periodically as determined by the member, family, or provider.

MCOs must identify and facilitate coordination of care for all members during changes or transitions between MCOs, as well as changes in service areas, subcontractors, and/or health care providers. Members with special circumstances may require additional or distinctive assistance during a period of transition. Policies or protocols must be developed to address these situations. Special circumstances include members designated as having "special health care needs".

If a member is referred to and approved for long-term care, the MCO must coordinate the transition with the assigned long-term care facility provider to assure that applicable protocols are followed for any special circumstances of the member, and that continuity and quality of care is maintained during and after the transition.

None specified.

The MCO's QM program shall be designed to achieve, through ongoing measurements and intervention, significant improvement sustained over time in the areas of clinical care and non-clinical care expected to have a favorable effect on health outcomes and member satisfaction. The MCO must:

• Measure and report to the state its performance using standard measures required by the state by CMS.
• Submit to the state data specified by the state that enables the state to measure the MCO's performance.

CHCQM = Certified in Health Care Quality and Management
CI = critical incident
CMO = Chief Medical Officer
CMS = Centers for Medicare and Medicaid Services
CPHQ = Certified Professional in Healthcare Quality

DD = developmental disability
EQRO = external quality review organization
HCBS = home and community-based services
HIPAA = Health Insurance Portability and Accountability Act
IT = information technology

LOC = level of care
LTSS = long-term services and supports
MCO = managed care organization
NAHQ = National Association of Health Care Quality
NF = nursing facility

PCP = primary care provider/physician
PIP = performance improvement project
QI = quality improvement
QM = quality management
RN = registered nurse

SP = service plan
UAT = Uniform Assessment Tool