5101:3-26-07 Managed health care programs: annual external quality review survey.

(A) ODJFS will select an external quality review organization (EQRO) to provide for an annual, external, and independent review of the quality, outcomes, timeliness of and access to services provided by MCPs.

(B) The external quality review (EQR) will include but not be limited to the following components for MCPs:

(1) A review of the MCP’s administrative quality functions including internal QAPI activities as described in rule 5101:3-26-07.1 of the Administrative Code.

To avoid duplication of the federally required administrative review conducted every three years to determine compliance with standards established by ODJFS in accordance with 42 C.F.R. 438.360 and 438.362 (2003), information about the MCP may be obtained from a private accreditation or medicare review in place of a review by the EQRO and must be comparable to federal standards and ODJFS’ program requirements. An MCP must meet all the requirements outlined in the federal regulations and the standards for exemption established by ODJFS. A recommendation for exemption is subject to prior approval by ODJFS.

(2) A performance review and outcome assessment of the MCP’s care management system and other internal administrative programs.

(3) Encounter data studies.

(4) Validation of performance measurement data and a comprehensive review of information systems.

(5) Validation of performance improvement projects (PIPs).

(6) A member satisfaction survey.

(C) MCPs must timely submit at no cost to the member or ODJFS data and information, including member medical records, as requested by ODJFS or its designee for the annual external quality review.

(D) MCPs must develop and implement corrective action plans (CAPs), performance improvement projects, or quality improvement directives that are prior-approved by ODJFS and address EQR survey deficiencies cited by the EQRO.

Effective: 09/15/2008

R.C. 119.032 review dates: 04/14/2009 and 04/01/2014

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17

Rule Amplifies: 5111.01, 5111.02, 5111.16, 5111.17

Prior Effective Dates: 4/1/85, 5/2/85, 10/1/87, 2/15/89 (Emer), 5/8/89, 11/1/89 (Emer), 2/1/90, 5/1/92, 5/1/93, 11/1/94, 7/1/96, 7/1/97 (Emer), 9/27/97, 7/1/01, 7/1/02, 7/1/03, 7/1/04, 10/31/05, 6/1/06, 1/1/07, 1/1/08