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

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

B.       In addition to any requirements specified in contract, a con- tractor 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 pro- vided,

b.        Identifying the numbers and costs of services pro- vided,

c.         Assessing and improving the quality and appropri- ateness of care and services,

d.        Evaluating the outcome of care provided to mem- bers, and

e.         Determining the actions necessary to improve ser- vice 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 imple- menting the initial or revised QM/UM plan;

4.        Ensure that a QM/UM committee operates under the con- trol of the contractor’s medical director and includes rep- resentation from medical and executive management personnel. The committee shall:

a.         Oversee the development, revision, and implementa- tion of the QM/UM plan; and

b.        Ensure that there are qualified QM/UM personnel and sufficient resources to implement the contrac- tor’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 effective- ness, 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 qual- ity 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 improv- ing the quality of care and the efficient, cost-effec- tive 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 sub- contractor’s designee shall forward to the primary care pro- vider medical records or copies of medical records of all members assigned to the subcontractor or for whom the sub- contractor has provided services.

E.       The Administration shall monitor each contractor and the con- tractor’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 cooper- ate 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 monitor- ing.

Historical Note

Adopted as an emergency effective May 20, 1982, pursu- ant 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 per- manent rule effective August 30, 1982 (Supp. 82-4). For- mer 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, effec- tive December 5, 2005 (Supp. 05-4). Amended by final

rulemaking at 14 A.A.R. 4330, effective January 3, 2009

(Supp. 08-4).