WAC 388-538-0140 Quality of care.

1. In order to assure that managed care enrollees receive quality health care and services, the medical assistance administration (MAA) requires managed care organizations (MCOs) to comply with quality improvement standards as stated in the medical assistance administration (MAA) managed care contract as follows:

   1. Have a clearly defined quality organizational structure and operation, including a fully operational quality assessment, measurement, and improvement program;

   2. Have effective means to detect both underutilization and overutilization of services;

   3. Maintain a grievance system that includes a process for enrollees to file grievances and appeals according to the requirements of WAC 388-538-0110;

   4. Maintain a system for provider and practitioner credentialing and recredentialing;

   5. Ensure that MCO subcontracts and the delegation of MCO responsibilities are in accordance with MAA standards and regulations;

   6. Cooperate with an MAA-contracted qualified independent external review organization (EQRO) conducting review activities as described in 42 C.F.R. 438.358;

   7. Have an effective means to assess the quality and appropriateness of care furnished to enrollees with special health care needs;

   8. Submit annual reports to MAA, including HEDIS performance measures, specified by MAA;

   9. Maintain a health information system that:

      1. Collects, analyzes, integrates, and reports data as requested by MAA;

      2. 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 MAA;

      3. Collects data on enrollees, providers, and services provided to enrollees through an encounter data system, in a standardized format as specified by MAA; and

      4. 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.

   10. Conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care outcomes and services, and that involve the following:

       1. Measuring performance using objective quality indicators;

       2. Implementing system changes to achieve improvement in service quality;

       3. Evaluating the effectiveness of system changes;

       4. Planning and initiating activities for increasing or sustaining performance improvement;

       5. Reporting each project status and the results as requested by MAA; and

       6. Completing each performance improvement project timely so as to generally allow aggregate information to produce new quality of care information every year.

   11. Ensure enrollee access to health care services;

   12. Ensure continuity and coordination of enrollee care; and

   13. Ensure the protection of enrollee rights and the confidentiality of enrollee health information.

2. MAA may 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..