Qlarant performed External Quality Review Organization (EQRO) services for the North Dakota Medicaid MCO.
Mandatory Regulatory Requirements included:
Assessment of the MCO’s strengths and weakness with respect to quality, timeliness, and access to health care services furnished to ND Medicaid Expansion recipients; recommendations for improving quality of health care services furnished by the MCO; assessment of the degree to which the MCO has effectively addressed the recommendations for quality improvement made by the EQRO during the previous year’s review; and independent assessment per State’s 1915(b) waiver requirements.
Technical Report Activities included:
- Validation of MCO’s Performance Improvement Projects (PIPs) in accordance with CMS Protocols.
- Validation of MCO’s reported Performance Measures (PMs)
- Compliance Review and Assessment to determine MCO’s compliance with standards for conduct of PIPs and calculations of PMs.
Additional Annual EQRO Activities included:
- validation of the MCO’s encounter data, methods of data collection/analysis, description of data obtained; and conclusions drawn from data.
- Administration or validation of consumer or provider surveys of quality of care
- Calculation of PMs in addition to those reported by an MCO and validated by the EQRO
- conducting PIPs in addition to those calculated by an MCO and validated by the EQRO
- conducting studies on quality that focus on a particular aspect of clinical or nonclinical services at a point in time
- review of the MCO’s plan for identifying non-English languages spoken by members.
- Monitoring of how the MCO is striving to improve the quality of health care for multicultural populations by ensuring that services are available, accessible, and provided in a culturally and linguistically appropriate manner.
- Review of the adequacy of the MCO’s network and the MCO’s plans to pay for and coordinate care or services if the MCO is unable to provide necessary covered services in a timely manner.
- Review of information to beneficiaries, grievances, and provider selection during the EQRO’s onsite review.
- Assessment of program measures, including program impact, timely access, quality, cost effectiveness, beneficiary choice, and provider selection and other areas of service or service delivery of the health plan.
- recommendations for quality improvement and cost containment initiatives.
- Providing technical assistance and guidelines to the managed care contractors.
- Performing State-directed quality and/or performance ad hoc review activities.
Performing other duties as assigned, specifically relative to the State’s 1915(b) waiver.
