Ariz. Admin. Code § 9-22-522

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-22-522 - Quality Management/Utilization Management (QM/UM) Requirements

A. A contractor shall comply with Quality Management/Utilization Management (QM/UM) requirements specified in this Section and in contract. The contractor shall ensure compliance with QM/UM requirements that are accomplished through delegation or subcontract with another party.

B. In addition to any requirements specified in contract, a contractor shall:

1. Submit to the Administration a written QM/UM plan that includes a description of the systems, methodologies, protocols, and procedures to be used in:

a. Monitoring and evaluating the types of services provided,

b. Identifying the numbers and costs of services provided,

c. Assessing and improving the quality and appropriateness of care and services,

d. Evaluating the outcome of care provided to members, and

e. Determining the actions necessary to improve service delivery;

2. Submit the QM/UM plan to the Administration on an annual basis within timelines specified in contract. If the QM/UM plan is changed during the year, the contractor shall submit the revised plan to the Administration before implementation;

3. Receive approval from the Administration before implementing the initial or revised QM/UM plan;

4. Ensure that a QM/UM committee operates under the control of the contractor's medical director and includes representation from medical and executive management personnel. The committee shall:

a. Oversee the development, revision, and implementation of the QM/UM plan; and

b. Ensure that there are qualified QM/UM personnel and sufficient resources to implement the contractor's QM/UM activities; and

5. Ensure that the QM/UM activities include at least:

a. Prior authorization for non-emergency or scheduled hospital admissions;

b. Concurrent review of inpatient hospitalization;

c. Retrospective review of hospital claims;

d. Program and provider audits designed to detect over- or under-utilization, service delivery effectiveness, and outcome;

e. Medical records audits;

f. Surveys to determine satisfaction of members;

g. Assessment of the adequacy and qualifications of the contractor's provider network;

h. Review and analysis of QM/UM data;

i. Measurement of performance using objective quality indicators;

j. Ensuring individual and systemic quality of care;

k. Integrating quality throughout the organization;

l. Process improvement;

m. Credentialing a provider network;

n. Resolving quality of care grievances; and

o. Quality improvement activities focused on improving the quality of care and the efficient, cost-effective delivery and utilization of services.

C. A member's primary care provider shall maintain medical records that:

1. Conform to professional medical standards and practices for documentation of medical diagnostic and treatment data;

2. Facilitate follow-up treatment; and

3. Permit professional medical review and medical audit processes.

D. Within 30 days following termination of the contract between a subcontractor and a contractor, the subcontractor or the subcontractor's designee shall forward to the primary care provider medical records or copies of medical records of all members assigned to the subcontractor or for whom the subcontractor has provided services.

E. The Administration shall monitor each contractor and the contractor's providers to ensure compliance with Administration QM/UM requirements and adherence to the contractor's QM/UM plan.

1. A contractor and the contractor's providers shall cooperate with the Administration in the performance of the Administration's QM/UM monitoring activities; and

2. A contractor and the contractor's providers shall develop and implement mechanisms for correcting deficiencies identified through the Administration's QM/UM monitoring.

Ariz. Admin. Code § R9-22-522

Adopted as an emergency effective May 20, 1982, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-522 adopted as an emergency adopted, amended and renumbered as Section R9-22-520, former Section R9-22-524 adopted as an emergency now adopted and renumbered as Section R9-22-522 as a permanent rule effective August 30, 1982 (Supp. 82-4). Former Section R9-22-522 renumbered and amended as Section R9-22-515, new Section R9-22-522 adopted effective October 1, 1985 (Supp. 85-5). Amended under an exemption from the provisions of the Administrative Procedure Act, effective March 1, 1993 (Supp. 93-1). Amended effective December 13, 1993 (Supp. 93-4). Amended effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 11 A.A.R. 4277, effective December 5, 2005 (Supp. 05-4). Amended by final rulemaking at 14 A.A.R. 4330, effective January 3, 2009 (Supp. 08-4).