c. Identify the stakeholders involved and give an opinion as to why you think there is a mandate in the contract to include these stakeholders d. Identify the sections where performance improvement tools are recommended for the patient safety guidelines and describe the tools
e. Identify the sections where data sources are recommended for the patient safety guidelines and describe the sources
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Get Help Now!f. Identify the sections and describe two performance measures used
iii. (9 points) Utilization Management
a. Identify the section(s) and describe the utilization review guidelines
b. Identify the sections and describe 2 of the following:
– the performance measures and standards used
– benchmarks used
– tools used
c. Identify the section and definition of the utilization management program
d. Identify one section where continuous improvement is required and describe the improvement
e. How and where is medical necessity defined?
f. Identify and describe one section of the contract that mandates
– prospective medical necessity review
– concurrent medical necessity review
– retrospective medical necessity review
g. Identify the section and describe the medical conditions for which clinical practice guidelines and best practices are required
h. Identify the section and describe the organizations and committees used to establish the basis for the clinical practice guidelines
iv. (1 point) Identify the sections of the contract where the Medicaid agency is demanding that the contractor address issues in Medicaid recipients access transportation and use of telemedicine. Describe the contractual requirements.
v. (1 point) Identify two sections of the contract where there are environmental requirements of the contractor related to state and federal environmental protection agencies. Give an opinion as to why these requirements exist.
vi. (1 point) Identify the section of the contract and the organization(s) responsible for accrediting the managed care plans.
4. Conduct an internet search for the following quality models for improving patient safety: Failure Mode and Effects Analysis (FMEA) and Root Cause Analysis (RCA).
a. Find an example of each model. For each model, identify the internet site and the date.
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