WAC 182-538-0140 Quality of care.

1. To assure that managed care enrollees receive quality healthcare services, the department requires managed care organizations (MCOs) to comply with quality improvement standards detailed in the department's managed care contract. MCO's must:

     a. Have a clearly defined quality organizational structure and operation, including a fully operational quality assessment, measurement, and improvement program;

     b. Have effective means to detect over and under utilization of services;

     c. Maintain a system for provider and practitioner credentialing and recredentialing;

     d. Ensure that MCO subcontracts and the delegation of MCO responsibilities are in accordance with the department standards and regulations;

     e. Ensure MCO oversight of delegated entities responsible for any delegated activity to include:

i. A delegation agreement with each entity describing the responsibilities of the MCO and the entity;

ii. Evaluation of the entity prior to delegation;

iii. An annual evaluation of the entity; and

iv. Evaluation or regular reports and follow-up on issues out of compliance with the delegation agreement or the department's managed care contract specifications.

    f. Cooperate with a department-contracted, qualified independent external review organization (EQRO) conducting review activities as described in 42 C.F.R. 438.358;

    g. Have an effective mechanism to assess the quality and appropriateness of care furnished to enrollees with special healthcare needs;

    h. Assess and develop individualized treatment plans for enrollees with special healthcare needs which ensure integration of clinical and nonclinical disciplines and services in the overall plan of care;

    i. Submit annual reports to the department on performance measures as specified by the department;

    j. Maintain a health information system that:

i. Collects, analyzes, integrates, and reports data as requested by the department; 

ii. Provides information on utilization, grievances and appeals, enrollees ending enrollment for reasons other than the loss of medicaid eligibility, and other areas as defined by the department; 

iii. Collects data on enrollees, providers, and services provided to enrollees through an encounter data system, in a standardized format as specified by the department; and 

iv. Ensures data received from providers is adequate and complete by verifying the accuracy and timeliness of reported data and screening the data for completeness, logic, and consistency.

    k. Conduct performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care outcomes and services, and that involve the following: 

i. Measuring performance using objective quality indicators; 

ii. Implementing system changes to achieve improvement in service quality;

iii. Evaluating the effectiveness of system changes; 

iv. Planning and initiating activities for increasing or sustaining performance improvement; 

v. Reporting each project status and the results as requested by the department; and 

vi. Completing each performance improvement project timely so as to generally allow aggregate information to produce new quality of care information every year. 

     l. Ensure enrollee access to healthcare services; 

     m. Ensure continuity and coordination of enrollee care; and

     n. Maintain and monitor availability of healthcare services for enrollees.

2. The department may:

     i. Impose intermediate sanctions in accordance with 42 C.F.R. 438.700 and corrective action for substandard rates of clinical performance measures and for deficiencies found in audits and on-site visits;

     ii. Require corrective action for findings for noncompliance with any contractual state or federal requirements; and

     iii. Impose sanctions for noncompliance with any contractual, state, or federal requirements not corrected.