Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-62 - REGIONAL CARE ORGANIZATIONS › Section 560-X-62-.09 - Provider Standards Committee

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Each regional care organization shall
			 create a provider standards committee which shall review and develop the
			 performance standards and quality measures required of a provider by the
			 regional care organization.
(2) The
			 performance standards reviewed and developed by a provider standards committee
			 shall include, but not be limited to, provider performance benchmarks relating
			 to the efficiency and management of care provided to Medicaid beneficiaries.
			 Performance standards shall not include office hours, terms of reimbursement or
			 the application of such standards in a contract between a regional care
			 organization and a provider. The quality measures reviewed and developed by a
			 provider standards committee shall include, but not be limited to, numeric
			 quantification of results or outcomes of high-quality care experienced by
			 Medicaid beneficiaries.
(3) The
			 regional care organization shall promptly publish and distribute to its
			 providers and the Medicaid Agency all performance standards and quality
			 measures developed by the provider standards committee.
(4) The performance standards and quality
			 measures shall be subject to the approval of the Medicaid Quality Assurance
			 Committee established in Section
			 22-6-154 of the Code of Ala. 1975.
(a) If the regional care organization or a
			 provider is dissatisfied with any performance standard or quality measure
			 developed or approved by the provider standards committee, the regional care
			 organization or provider who is dissatisfied may within 30 calendar days of
			 publication of the performance standard or quality measure make a written
			 request for review of the performance standard or quality measure to the
			 Medicaid Quality Assurance Committee.
(b) Upon receipt of the request for review,
			 the Medicaid Quality Assurance Committee shall request any information and
			 documents to review the performance standard or quality measure at issue and
			 the regional care organization or the provider shall have 10 business days to
			 provide the Medicaid Quality Assurance Committee with the requested information
			 and documents and any additional supporting information and documents that the
			 regional care organization or provider wishes to present to the Medicaid
			 Quality Assurance Committee. In addition, the chairperson of the provider
			 standards committee shall have 10 business days to provide the Medicaid Quality
			 Assurance Committee with requested information and documents concerning the
			 basis, supporting studies and rationale for the performance standard or quality
			 measure.
(c) The Medicaid Quality
			 Assurance Committee shall either approve or disapprove the performance standard
			 or quality measure at issue and shall promptly notify the regional care
			 organization, the provider and the provider standards committee of its
			 determination. Upon request by the Medicaid Quality Assurance Committee, the
			 provider standards committee shall review any such approved performance
			 standard or quality measure within six months after such approval and the
			 provider standards committee shall provide the Medicaid Quality Assurance
			 Committee a written report detailing the efficacy of said performance standard
			 or quality measure. The Medicaid Quality Assurance Committee may withdraw its
			 approval of the performance standard or quality measure based upon the findings
			 of the provider standards committee's report.
(d) No member of the Medicaid Quality
			 Assurance Committee who also served on the provider standards committee which
			 developed the performance standard or quality measure at issue shall vote or
			 participate in the Medicaid Quality Assurance Committee's review of that
			 performance standard or quality measure.
(e) No performance standard or quality
			 measure reviewed or developed by the regional care organization's provider
			 standards committee and/or by the Medicaid Quality Assurance Committee shall be
			 subject to review pursuant to Section
			 22-6-153(g) or
			 Rule No. 560-X-62-.11. The contractual
			 application of these standards and measures shall be subject to review but not
			 the performance standards or quality measures themselves.