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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 408. Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees
11/23/2024

12VAC5-408-300. Clinical performance evaluation systems.

A. The MCHIP licensee shall have a system for the evaluation of the outcomes and processes of clinical care services delivered to the MCHIP's covered persons.

B. The MCHIP licensee shall adopt a nationally recognized clinical performance evaluation system, such as the Health Plan Employer Data and Information Set (HEDIS), that analyzes data based upon selected performance factors or shall establish a clinical performance evaluation system that uses data collection, quantitative measures, and analysis to monitor quality improvement activities.

C. The MCHIP licensee shall notify the department regarding its adoption of a nationally recognized clinical performance evaluation system, such as HEDIS, or that it has chosen to establish its own performance measurement system.

MCHIP licensees that choose not to adopt a nationally recognized system shall provide justification to the department of their choice of performance measurement selections for the department's approval.

D. The MCHIP licensee shall annually evaluate its performance in at least three of the areas of clinical care shown below:

1. Primary care services;

2. High volume specialty services;

3. Behavioral health services; and

4. Institutional health services including inpatient hospital care, home health services, skilled nursing facility services and ambulatory surgery.

If HEDIS measures are used to assess clinical performance, the MCHIP licensee shall substitute the HEDIS "Effectiveness of Care" measures for those areas listed in subdivisions 1 through 4 of this subsection.

E. The performance measurement indicators chosen by the MCHIP licensee shall:

1. Be objective and quantifiable;

2. Be based upon current and reliable scientific information;

3. Have an established goal or benchmark;

4. Effectively measure performance indicators; and

5. Have priority areas for measuring outcomes of clinical care and be reflective of industry-wide performance measurement goals.

F. The MCHIP licensee shall implement ways to improve its performance based on an analysis of its clinical performance measurements.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 16, Issue 7, eff. January 20, 2000; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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