Q7: Can the state confirm the number of PMs that must be validated annually for each MCO? Of the number of PMs that must be validated, can the state indicate how many use hybrid versus administrative data collected? Q8: How many of the Performance Measures that require validation follow HEDIS specifications? Q9: Do the MCOs contract with a licensed HEDIS audited organization to conduct an audit of their HEDIS measure reporting? R7: See R3 and R5 above R8: All 9 (nine) of the Performance Measures follow HEDIS specification. R9: Unknown if all do Specifications: A. Detailed Scope of Work, Deliverables, 3. Validation of Performance Improvement Projects 24 Q1: How many PIPs are required for validation per MCO: Q2: How many PIPs per MCO will require annual validation? R1: There are 5 (five) Performance Improvements to be validated per MCO. Please refer to Centennial Care 2.0 Managed Care Contract. Section 4.12.4.10 R2: See R1. Specifications: A, Detailed Scope of Work, Deliverables, 4. Validation of Network Adequacy 24-25 Q1: The RFP states that annual validation activities must adhere to the protocols upon CMS development. Please confirm the EQRO will be expected to start the activities using the HSD/MAD standards in advance of the release of the CMS protocol. Q2: Can the State provide the current network adequacy requirements? Q3: What are HSD/MAD’s anticipated sources of data for the evaluation? R1: Yes the EQRO will be expected to start the Validation of Network Adequacy in advance of the release of the CMS protocol. Please refer to Centennial Care 2.0 Managed Care Contract. Section 4.8 Provider Network R2: Please refer to CFR cited for in this section and to the Centennial Care 2.0 Managed Care Contract. Section 4.8 Provider Network R3: Submissions by the MCO of Policy and Procedures and possibly documents supporting adherence to internal Policy and Procedures. R4: The data should be provided by the MCOs directly to the EQRO.
Q13: Does the audit include NF LOC for waivers such as PACE or other home and community based waiver services: Or is it just those members need Nursing Facility placement? Q14: Will the EQRO be responsible for reviewing the PASSR? Q15: For NF LOC determinations that were denied, does a Physician attest to this and subsequently testify in a Fair Hearing? Medical Social Worker with a minimum of 1 year of relevant experience. Physical, Occupational, or Rehab Therapists with a minimum of 1 year relevant experience. Please refer the NM Medicaid NF LOC Criteria and Instruction: Search: Providers/Manuals and Guides. R13: See R2 R14: No R15: The MCO is required to have a Medical director review denials, and would testify if requested to do so during a Fair Hearing. Specifications: A. Detailed Scope of Work, Deliverables 8. Communications and Meetings 27-28 Q1: We believe there is a typo and this section should be numbered 8. Q2: Is this section (1. Communications and Meetings) part of the deliverables section and thus subject to the 25-page limit? Q3: What is the anticipated frequency of on-site meetings with HSD/MAD vs. telephone or video conferences? R1: Yes, this should be 8, not 1. Please see amendment 2. R2: Yes R3: At a minimum the EQRO should plan to attend quarterly on-site meetings. Specifications: B. Mandatory Specifications 28- 29 Q1: Would the State consider an EQRO without CMS certification as a QIO (-like) entity, if the EQRO maintained a subcontractor relationship with a QIO R1: No