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2006 Impact of the RFQ and other New State Requirements on Quality Management at NSMHA

2006 Impact of the RFQ and other New State Requirements on Quality Management at NSMHA. 2006 Impact of the RFQ and other New State Requirements on Quality Management at NSMHA. NSMHA passed with a score of 83% Corrective action is required in three areas Clinical Guidelines Access

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2006 Impact of the RFQ and other New State Requirements on Quality Management at NSMHA

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  1. 2006 Impact of the RFQ and other New State Requirements on Quality Management at NSMHA

  2. 2006 Impact of the RFQ and other New State Requirements on Quality Management at NSMHA • NSMHA passed with a score of 83% • Corrective action is required in three areas • Clinical Guidelines • Access • Title XIX Special Information Requirements • We do not have any other details except our scores on the sections

  3. The RFQ adds many new requirements and expands others • MHD has also added new and expanded requirements in our current contract and we anticipate more changes based on the draft contracts provided with the RFQ

  4. Three contracts (Medicaid, State-funded and Federal Block Grant) to monitor instead of one More audits (EQRO, MHD, etc.) to prepare for Greater emphasis on policies and procedures

  5. Care Coordination • EPSDT • High Risk Consumers(Adults, Child/Adolescents) • Frequent Users of Crisis, Emergency Room and Inpatient Services

  6. Customer Service • NSMHA (and our designee VOA) must provide a customer service line from 8-5 M-F (excluding holidays) • Must answer calls within 5 rings with an average speed of 30 seconds and less than 3% abandonment • Respond to benefit, claim and other inquiries or complaints, log all calls and resolutions • Monitor the performance of customer service staff

  7. Delegated functions • Cannot be done by a CMHA, thus inpatient certification and Access are moving to Volunteers of America • Extensive requirements for NSMHA to develop a delegation plan and monitor these areas closely

  8. Authorization • Now NSMHA must authorize Intakes as well as ongoing services • Inpatient Denials require NSMHA to issue a Notice of Action • NSMHA must have a process for a review of treatment plans

  9. Care Management • Includes Authorization, Re-authorization at all levels of care • Includes Utilization Management • Includes Resource Management • Includes High Risk Case Tracking and Follow-up • Cannot be delegated to a network CMHA

  10. Expanded Areas • Critical Incidents definitions and MHD reporting requirements have been increased • Grievance System has been expanded to include expedited grievances as well as appeals, increased reporting • Increased Utilization Review and Utilization Management requirements • Provider Network Sufficiency and Capacity monitoring • Provider Profiling reports • Annual Provider Formal Audits

  11. Increased Allied System Coordination • Evidence-Based Practices • Focus on State Plan Modalities • Contracting and billing for Community Hospital Care

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