N.M. Admin. Code § 8.308.21.9 - QUALITY MANAGEMENT
A HSD managed care organization (MCO) quality management program includes a philosophy, a method of management, and a structured system designed to improve the quality of services; includes both quality assurance and quality improvement activities; and is incorporated into the health care delivery and administrative systems.
A. Quality management (QM) program structure:
The MCO shall have QM structure and processes as detailed in the medicaid
managed care services agreement or the medical assistance division (MAD)
managed care policy manual.
B. QM
program description: The MCO shall develop a written QM and a quality
improvement (QI) program description that includes the requirements described
in the medicaid managed care services agreement or the managed care policy
manual.
C. QM and QI program
principles: The MCO QM and QI programs are based on principles of continuous
quality improvement (CQI) and total quality management (TQM). Such an approach
will:
(1) recognize clinical and non-clinical
opportunities are unlimited;
(2) be
data driven;
(3) use real-time
input from members and MCO contracted providers to develop CQI activities;
and
(4) require on-going
measurement of effectiveness and improvement.
D. QM program evaluation: The MCO will have a
written QM and QI program evaluation as described in the medicaid managed care
services agreement or the managed care policy manual.
Notes
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