(1) To assure that managed care enrollees receive quality health care services, the agency requires managed care organizations (MCOs) to comply with quality improvement standards detailed in the agency's managed care contract. MCO's must:
(a) Have a clearly defined quality organizational structure and operation, including a fully operational quality assessment, measurement, and improvement program;
(b) Have effective means to detect over and under utilization of services;
(c) Maintain a system for provider and practitioner credentialing and recredentialing;
(d) Ensure that MCO subcontracts and the delegation of MCO responsibilities are in accordance with the agency standards and regulations;
(e) Ensure MCO oversight of delegated entities responsible for any delegated activity to include:
(i) A delegation agreement with each entity describing the responsibilities of the MCO and the entity;
(ii) Evaluation of the entity prior to delegation;
(iii) An annual evaluation of the entity; and
(iv) Evaluation or regular reports and follow-up on issues out of compliance with the delegation agreement or the agency's managed care contract specifications.
(f) Cooperate with an agency-contracted, qualified independent external review organization (EQRO) conducting review activities as described in 42 C.F.R. 438.358;
(g) Have an effective mechanism to assess the quality and appropriateness of care furnished to enrollees with special health care needs;
(h) Assess and develop individualized treatment plans for enrollees with special health care needs which ensure integration of clinical and nonclinical disciplines and services in the overall plan of care;
(i) Submit annual reports to the agency on performance measures as specified by the agency;
(j) Maintain a health information system that:
(i) Collects, analyzes, integrates, and reports data as requested by the agency;
(ii) Provides information on utilization, grievances and appeals, enrollees ending enrollment for reasons other than the loss of medicaid eligibility, and other areas as defined by the agency;
(iii) Collects data on enrollees, providers, and services provided to enrollees through an encounter data system, in a standardized format as specified by the agency; and
(iv) Ensures data received from providers is adequate and complete by verifying the accuracy and timeliness of reported data and screening the data for completeness, logic, and consistency.
(k) Conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care outcomes and services, and that involve the following:
(i) Measuring performance using objective quality indicators;
(ii) Implementing system changes to achieve improvement in service quality;
(iii) Evaluating the effectiveness of system changes;
(iv) Planning and initiating activities for increasing or sustaining performance improvement;
(v) Reporting each project status and the results as requested by the agency; and
(vi) Completing each performance improvement project timely so as to generally allow aggregate information to produce new quality of care information every year.
(l) Ensure enrollee access to health care services;
(m) Ensure continuity and coordination of enrollee care; and
(n) Maintain and monitor availability of health care services for enrollees.
(2) The agency may:
(a) Impose intermediate sanctions in accordance with 42 C.F.R. 438.700 and corrective action for substandard rates of clinical performance measures and for deficiencies found in audits and on-site visits;
(b) Require corrective action for findings for noncompliance with any contractual state or federal requirements; and
(c) Impose sanctions for noncompliance with any contractual, state, or federal requirements not corrected.
[Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. 13-02-010, § 182-538-140, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as § 182-538-140, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-140, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-140, filed 1/12/06, effective 2/12/06; 03-18-111, § 388-538-140, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510,[74.08.]522 , 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-140, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-140, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-140, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 93-17-039 (Order 3621), § 388-538-140, filed 8/11/93, effective 9/11/93.]