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MCO External Quality Review Annual Technical Reports

The Code of Federal Regulations (42 CFR §438.350) requires states contracting with Managed Care Organizations (MCOs) to conduct annual, independent reviews of the Medicaid managed care program. To meet these requirements, DHCF contracts with Qlarant, an independent External Quality Review Organization (EQRO), which evaluates the quality, accessibility, and timeliness of healthcare services furnished by the MCOs through a variety of mandatory and optional activities in accordance with the Centers for Medicare and Medicaid Services (CMS)-developed EQRO Protocols. Qlarant completed the following External Quality Review (EQR) activities in the current measurement year:

  • Compliance Review, known as the Operational Systems Review (OSR)
  • Performance Improvement Project (PIP) Review
  • Performance Measure Validation (PMV)
  • Network Adequacy Validation (NAV)
  • Encounter Data Validation (EDV)

In addition to completing federally mandated EQR activities, 42 CFR §438.364(a) requires the EQRO to produce a detailed technical report that describes the manner in which data from all activities conducted were aggregated and analyzed, and conclusions drawn as to the quality, accessibility, and timeliness of the care furnished by the MCOs. This document is Qlarant’s report to DHCF on the assessment of MCO performance as evaluated during the measurement year (MY), January 1 through December 31. Notations will be added in the respective reports to reflect any EQR activities completed outside of the normal 12 month review cycle.

The Managed Care Program encompasses DC Healthy Families Program, Child and Adolescent Supplemental Security Income Program and District Dual Choice Program. The associated health plans participating in the respective programs are noted in the attached table.

The Annual Technical Report (ATR) describes EQR methodologies for completing activities; provides MCO performance measure results; summarizes compliance results; and includes an overview of the quality, access, and timeliness of healthcare services provided to the District’s Medicaid managed care beneficiaries. Recommendations for improvement are made, and if acted upon, may positively impact beneficiary outcomes.

MCO External Quality Review Annual Technical Reports