Attachment_J-10_Annual_and_54th_Month_Evaluation_Criteris_Measures_Table_Revised_Amendment_1_12-24-2013.docx
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Attachment J-10 Annual and 54th Month Evaluation Criteris Measures Table Revised Amendment 1 12-24-2013
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Attachment J-10 Annual and 54th Month Evaluation Criteria Measures Table Revised per Amendment Number 1 as of December 24, 2013
| 5 Year Assessment Period (54 months) |
| Measure |
| Num/Den (Inclusion & Exclusions |
| Data Source |
| Data Lag |
| Annual Assessment: Target End of Year 1 |
| Annual Assessment: Target End of Year 2 |
| Annual Assessment: Sustain Target Years 3- 5 |
(Year 5 time period ending January 31, 2019)
| Quality of Review: Inter-Rater Reliability |
| Numerator: Number of IRR reviewer agreements |
Denominator: Total number of cases selected for IRR review Inclusion: Quality of Care, Discharge/Service Termination Reviews, HWDRG Reviews, Medical Necessity Reviews, Readmission Reviews Exclusion: Technical Denials, EMTALA; Cases selected for IRR in one time period cannot be selected for IRR again.
CMS-designated case review system(s)
(IRR Contractor TBD) Data lag is 4 days after the end of each year.
| TBD once the methodology for IRR has been defined |
| TBD once the methodology for IRR has been defined |
| TBD once the methodology for IRR has been defined |
| 4-day Data Entry Compliance |
| Numerator: Total number of completed case reviews (Quality of Care reviews, Discharge/Service Termination Reviews, HWDRG Reviews, EMTALA Reviews and Beneficiary Helpline calls) where data entry was completed on time (within 4 calendar days of case completion). |
Denominator: Total number of completed case reviews (Quality of Care, Discharge/Service Termination Reviews, HWDRG Reviews, EMTALA Reviews and Beneficiary Helpline calls).
| CMS-designated case review system(s) |
| Data lag is 4 days after the end of each year. |
| 80% |
| 90% |
| 90% |
Timeliness of Beneficiary Complaints and Other Quality of Care Reviews
Numerator: Total number of quality of care reviews completed in established timeframes Denominator: Total number of completed quality of care reviews in the CMS-designated case review system. Inclusion: Quality of care reviews conducted based on beneficiary complaints, referred to QIOs and identified during other case review types.
Exclusions: Technical Denials Assessment Time Period:
Year 1 with rolling 4 quarters
| CMS-designated case review system(s) |
| Data lag is 4 days after the end of each year. |
| 90% |
| 95% |
| 95% |
Timeliness of Discharge/ Service Termination Reviews
Numerator: Total number of discharge/service termination reviews completed in established timeframes.
Denominator: Total number of discharge/service termination reviews in the CMS-designated case review system. Inclusions: BIPA, Grijalva and Weichardt reviews. Exclusions: Technical Denial
| CMS-designated case review system(s) |
| Data lag is 4 days after the end of each year. |
| 95% |
| 98% |
| 98% |
Timeliness of EMTALA and HWDRG Reviews
Numerator: Total number of EMTALA and HWDRG reviews completed during in established timeframes.
Denominator: Total number of EMTALA and HWDRG reviews completed in the CMS-designated case review system.
Exclusions: Technical Denial
| CMS-designated case review system(s) |
| Data lag is 4 days after the end of each year. |
| 90% |
| 95% |
| 95% |
| Complainant Agreement to Complete Survey |
| Percentage of beneficiaries/representatives complainants agreeing to complete a satisfaction survey from a completed complaint case or appeal review |
Numerator: Number of beneficiaries/representatives agreeing to complete a satisfaction survey from a completed complaint case or appeal review
Denominator: Number of beneficiaries receiving an invitation to complete a satisfaction survey from a completed complaint case or appeal review Report from Survey contractor
| 65% of complainants beneficiaries/representatives with a completed complaint case or appeal review agree to complete the satisfaction survey |
| 65% of complainants beneficiaries/representatives with a completed complaint case or appeal review agree to complete the satisfaction survey. |
This measure includes completed cases during the assessment year. A rolling 4-quarter approach will be used if QIO has at least ten eligible cases. If there are less than ten eligible cases the contractor will be assessed August 1, 2014 through current evaluation period.
65% of complainants beneficiaries/representatives with a completed complaint case or appeal review agree to complete the satisfaction survey.
This measure includes completed cases during the assessment year. A rolling 4-quarter approach will be used if at least ten eligible cases. If less than ten eligible cases the contractor will be assessed August 1, 2014 through current evaluation period.
| Beneficiary Experience with Quality of Care Complaints |
| Numerator: Number of completed surveys for beneficiary complaints reviews with a positive experience score. |
Denominator: Number of completed surveys for beneficiary complaints reviews. Inclusions: Total number of surveys conducted for beneficiary complaints reviews.
Exclusions: Referred Quality of Care reviews, QIO-initiated quality of care reviews and Technical Denials.
| Report from survey contractor |
| Data lag is 30 days after the end of the year. |
| 70% |
| 75% |
This measure includes completed cases during the assessment year. If there are less than ten eligible cases the contractor will be assessed August 1, 2014 through current evaluation period.
75% This measure includes completed cases during the assessment year. A rolling 4-quarter approach will be used if at least ten eligible cases. If less than ten eligible cases the contractor will be assessed August 1, 2014 through current evaluation period.
| Beneficiary Experience with Appeal Reviews |
| Numerator: Number of completed surveys for discharge/services termination reviews with positive experience score. |
Denominator: Number of completed surveys for discharge/services termination reviews. Inclusions: Total number of surveys conducted for BIPA, Grijalva, and Weichardt reviews.
Exclusions: Technical Denials.
| Report from Survey contractor. |
| Data lag is 30 days after the end of the year. |
| 70% |
| 75% |
This measure includes completed cases during the assessment year. If there are less than ten eligible cases the contractor will be assessed August 1, 2014 through current evaluation period.
75% This measure includes completed cases during the assessment year. A rolling 4-quarter approach will be used if at least ten eligible cases. If less than ten eligible cases the contractor will be assessed August 1, 2014 through current evaluation period.
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