Letter to CMS - Medicaid Managed Care Policies - Agency for ...

Standard VIII: Quality Improvement Program
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
12. Strategic Direction in the
QI Plan
CC-VIII.A.2.a
13. QI Program Committee
CC-VIII.A.2.b
14. QI Program Committee
Chairperson
CC-VIII.A.2.b
15. Staff Representation on
QI Program Committee
CC-VIII.A.2.b
The written QI Plan clearly describes the
mechanism within the health plan for
strategic direction from the governing
body to be provided to the QI Program
and for the QI Program committee to
communicate with the governing body.
The health plan has a QI Program
Committee.
The health plan’s Medical Director
serves as either the Chairman or Co-
Chairman of the QI Program Committee.
Appropriate health plan staff
representing the various departments of
the organization are members of the
Committee:
a. Quality Director.
b. Grievance Coordinator.
c. Utilization Review Manager.
d. Credentialing Manager.
e. Risk Manager/Infection Control.
f. Advocate Representative (if
applicable).
g. Provider Representation (providers or
a person from the network
management department).
Individual staff members may serve in
multiple roles on the committee if they
also serve in multiple positions within
the health plan.
Yes
No
Yes
No
Yes
No
a. Yes
No
b. Yes
No
c. Yes
No
d. Yes
No
e. Yes
No
f. Yes
No
N/A
g. Yes
No
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_VIII_F2_07_11
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