[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.364]



[Page 236-237]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

                    Subpart E_External Quality Review

 

Sec.  438.364  External quality review results.



    (a) Information that must be produced. The State must ensure that 

the EQR produces at least the following information:

    (1) A detailed technical report that describes the manner in which 

the data from all activities conducted in accordance with Sec.  438.358 

were aggregated and analyzed, and conclusions were drawn as to the 

quality, timeliness, and access to the care furnished by the MCO or 

PIHP. The report must also include the following for each activity 

conducted in accordance with Sec.  438.358:

    (i) Objectives.

    (ii) Technical methods of data collection and analysis.

    (iii) Description of data obtained.

    (iv) Conclusions drawn from the data.

    (2) An assessment of each MCO's or PIHP's strengths and weaknesses 

with respect to the quality, timeliness, and access to health care 

services furnished to Medicaid recipients.

    (3) Recommendations for improving the quality of health care 

services furnished by each MCO or PIHP.

    (4) As the State determines, methodologically appropriate, 

comparative information about all MCOs and PIHPs.

    (5) An assessment of the degree to which each MCO or PIHP has 

addressed effectively the recommendations for quality improvement made 

by the EQRO during the previous year's EQR.

    (b) Availability of information. The State must provide copies of 

the information specified in paragraph (a) of this section, upon 

request, through print or electronic media, to interested parties such 

as participating health care providers, enrollees and potential 

enrollees of the MCO or PIHP, recipient advocacy groups, and members of 

the general public. The State must make this information available in 

alternative formats for persons with sensory impairments, when 

requested.

    (c) Safeguarding patient identity. The information released under 

paragraph



[[Page 237]]



(b) of this section may not disclose the identity of any patient.