Tuesday, October 16, 2018       
     
 
Members

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Providers
 
     
     
 
Future Clients
 
     
  Available Reports  

Access

  • Members with emergent needs who are seen within 6 hours
  • Members with urgent needs who are seen within 24 hours
  • Members with routine needs who are seen within 10 business days
  • Member access to psychological testing
  • Average speed of telephone answer (ASA)
  • Telephone call abandonment rate

Availability

  • Members with appropriate facility availability
  • Members with appropriate practitioner availability
  • Members with appropriate practitioner ratio 

Care of Members

  • Patients admitted for mental illness who complete a follow-up visit within 30 days of hospital discharge
  • Patients admitted for Depressive Disorders who complete a follow-up visit within 30 days of hospital discharge
  • Patients admitted for detox who complete a follow-up visit within 30 days of hospital discharge
  • Patients under 18 years of age who complete one family therapy or evaluation session within 30 days of initial outpatient assessment

Information Management

  • Claims: Rate of Provider Claims Payment
  • Credentialing and Recredentialing Activities
  • Completeness of practitioner treatment records 

Quality Improvement

  • Member satisfaction
  • Provider satisfaction
  • Treatment consistent with Bipolar Disorder Practice Guideline
  • Outpatient treatment plans consistent with Depression Practice Guideline

Member Rights and Responsibilities

  • Non-certified days overturned on appeal
  • Cases with non-certified days resulting in partial or complete overturn on appeal
  • Appeal resolution timelines

Risk Management

  • Complaints
  • Complaint resolution timeliness
  • Requests to change provider
  • Patient Safety Monitoring
  • Sentinel events

Utilization Management

  • Inpatient days per 1000 members per year
  • Partial hospital visits per 1000 members per year
  • Outpatient visits per 1000 members per year
  • Average length of hospital stay
  • Patients readmitted to inpatient care within 90 days of inpatient discharge
  • Readmission episodes within 90 days of inpatient discharge
  • Patients readmitted to inpatient care within 30 days of inpatient discharge
  • Readmission episodes within 30 days of inpatient discharge
  • Pended cases resolved within 24 hours
  • Consistency of application of medical necessity criteria (inter-rater reliability) 

Measurement Requirements

  • Continuity and coordination of care within behavioral health
  • Continuity and coordination with medical care
  • Clinical issue identified in collaboration with relevant medical delivery system (Region specific)
  • Timeliness of UM decisions
  • Clinical information consistently supports UM decisions
  • Assessment of preventive health programs
  • Quality and utilization improvement program evaluations
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