Kev Tshawb Fawb Txog Kev Kho Mob thiab Kev Npaj Kho Kom Zoo
Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) ua haujlwm nrog Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv Tswj (DMHC) los ua cov kev soj ntsuam kev kho mob niaj hnub ntawm Medi-Cal Managed Care Health Plans (MCPs) rau cov pej xeem xaiv txhua xyoo. Daim ntawv ntsuam xyuas kev kho mob yog kev ntsuam xyuas dav dav ntawm MCP txoj kev ua raws li Txoj Cai Kev Kho Mob Tswj Xyuas Lub Sijhawm (Knox-Keene Health Care Service Plan Act).
DHCS’ Managed Care Quality and Monitoring Division (MCQMD) is responsible for ensuring overall monitoring and oversight of MCPs. MCQMD designates the Contract & Enrollment Review Division (CERD) of DHCS’ Audits and Investigations (A&I) to perform the mandated audits.
MCQMD thiab A&I tau koom tes ua ke los tsim Cov Lus Qhia Txog Kev Pab Txuj Ci (TAG) rau txhua rau pawg kev tshuaj xyuas. Cov TAGs yog tsim los txheeb xyuas cov ntsiab lus tseem ceeb uas yuav raug soj ntsuam kom qhia rau MCPs txog cov txheej txheem kev tshuaj xyuas thiab ua kom pom tseeb dua.
DHCS makes a finding of fact with respect to the ability of the MCPs to provide quality health care services, the effectiveness of peer review, and utilization control mechanisms, and the overall performance in providing health care benefits to its enrollees. These audits assist DHCS with its overall monitoring effort, and identify areas of non-compliance, which form the basis for corrective actions.
MCPs are required to provide a Corrective Action Plan (CAP) upon the completion of a DHCS Medical Audit or any other monitoring activity where findings are identified. DHCS conducts CAP submission evaluations and provides technical assistance to ensure compliance.
Daim Ntawv Ceeb Toom Txog Kev Kho Mob thiab Cov Kev Npaj Kho Kom Zoo:
Saib hauv qab no rau Daim Ntawv Tshaj Qhia Kev Tshawb Fawb tsis ntev los no thiab cov phiaj xwm kho kom raug
Tshaj tawm
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Txoj Kev Npaj Kho Kom Zoo tau ua tiav
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