The One Care plan avoided or eliminated all double-counted members or numerator events. Met Met The One Care plan adhered to any parameters required by PM specifications (i.e., the measure occurred during the time period that the PM specified or defined). Met Met The One Care plan made substitutions for properly excluded records and documented the percentage of substituted records. Met Met The One Care plan properly collected medical record data extracted for inclusion in the numerator. The One Care plan carried out medical record reviews and abstractions in a manner that facilitated the collection of complete, accurate, and valid data. NA NA Record review staff were properly trained and supervised for the task. NA NA Record abstraction tools required the appropriate notation that the measure event occurred. NA NA Record abstraction tools required notation of the results or findings of the measured event, as applicable. NA NA Data in the record extract files were consistent with data in the medical records as evidenced by a review of a sample of medical records for applicable PMs. NA NA The process of integrating administrative and medical record data for the purpose of determining the numerator was consistent and valid. NA NA Data and Processes to Calculate and Report Performance Measures Review Element CCA THPP The One Care plan has measurement plans and policies stipulating and enforcing documentation of data requirements, issues, validation efforts, and results. The One Care plan documented data file and field definitions for each PM. Met Met The One Care plan documented maps to standard coding if not used in the original data collection. Met Met The One Care plan conducted statistical testing of results and made any correction or adjustments processing. Met Met The One Care plan has complete documentation of programming specifications (either as a schematic diagram or in narrative form) for each PM. The One Care plan documented all data sources, including external data (whether from a vendor, public registry, or other outside source), and any prior years’ data, if applicable. Met Met The One Care plan documented detailed medical record review methods and practices, including the qualifications of record review supervisors and staff persons; training materials; tools, including completed copies of each record-level reviewer determination; all case-level critical PM data elements to determine either a positive or negative event, or exclusion; and inter-rater reliability testing procedures and results. Met Met
KEPRO uses the mandatory compliance validation protocol to determine, in a manner consistent with standard industry practices, the extent to which Medicaid managed care entities are in compliance with Federal quality standards mandated by the Balanced Budget Act of 1997 (BBA). This validation process is conducted triennially. The 2017 compliance reviews were structured based on program requirements as outlined in 42 CFR 438. In addition, compliance with provisions in contracts as they relate to 42 CFR 438 between MassHealth and each One Care plan were assessed. Appropriate provisions in the Code of Massachusetts Regulations (CMR) were included in the reviews as indicated. The most stringent of the requirements were used to assess for compliance when State and Federal requirements differed. One Care activity and services occurring for calendar year 2016 were subject to review. Based on regulatory and contract requirements, compliance reviews were divided into the following 14 standards: Enrollee Rights and Protections; Enrollee Information; Availability and Accessibility of Services; Coordination and Continuity of Care; Coverage and Authorization of Services;