N.M. Admin. Code § 8.308.21.14

Current through Register Vol. 35, No. 20, October 22, 2024

Section 8.308.21.14 - EXTERNAL QUALITY REVIEW ORGANIZATION (EQRO)

An EQRO will conduct independent reviews of the MCO's external quality review (EQR) activities as detailed in the medicaid managed care services agreement or the managed care policy manual.

A. The MCO shall fully cooperate with the following mandatory EQRO activities, such as:

(1) the validation of required performance improvement projects (PIP) as detailed in the medicaid managed care services agreement or the managed care policy manual;

(2) the validation of plan performance measures reported by the MCO as defined in the medicaid managed care services agreement or the managed care policy manual;

(3) a review to determine the MCOs' compliance with state standards for access to care, structure and operations, and QM and QI requirements; and

(4) the validation of network adequacy.

B. The MCO shall fully cooperate with the following EQRO optional activities:

(1) the validation of encounter data reported by the MCO;

(2) the administration or validation of member and provider surveys on the quality of care;

(3) the calculation of additional performance measures;

(4) conducting additional PIPs validations;

(5) conducting studies on quality focused on a particular aspect of clinical or nonclinical services at a specific point in time;

(6) assist with the quality rating of MCOs; and

(7) all other optional activities as deemed appropriate.

C. The EQRO may, at the direction of MAD, provide technical guidance to the MCO to assist in conducting activities related to mandatory and optional EQR activities.

N.M. Admin. Code § 8.308.21.14

8.308.21.14 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018