Partners Health Management (Partners) is responsible for assuring the quality of services delivered by the Provider Network. Likewise, Partners is accountable to the Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMHDDSAS) and the Division of Health Benefits in the management of both state and Medicaid services.
In addition to state requirements, Medicaid Waiver quality requirements are extensive and include the following:
- Health and safety of enrollees
- Rights protection
- Provider qualifications
- Enrollee satisfaction
- Management of complaints
- Incident investigation and monitoring
- Assessment of outcomes to determine the efficacy of care
- Management of care for special needs populations
- Preventive health initiatives
- Clinical best practice
The Quality Management department (QM) maintains a schedule of monitoring reviews. Post-Payment monitoring of Medicaid-funded providers will no longer occur every two years but will occur on an as-needed basis when a request for a targeted review is made via complaint, grievance, quality of care concern or as requested by other internal/external entities. State-funded providers will continue to be monitored every two years or may occur as the result of a request for a targeted review. A member of the QM monitoring team will contact the provider agency to schedule and coordinate a review.
Monitoring reviews use standardized tools that were created by the N.C Department of Health and Human Services Local Management Entity/Managed Care Organization (NCDHSS-LME/MCO) Provider Collaboration Workgroup. These tools have been adopted by Partners for use in the Behavioral Health and Intellectual/Developmental Disabilities Tailored Plan.
More details regarding monitoring are available in the Provider Operations Manual.
Health & Safety Site Review
Effective June 9, 2022, Partners no longer requires initial credentialing or re-credentialing applications from providers, including agencies, LIPs and associated clinicians. Site visits are no longer required from the Monitoring department.
Unlicensed Alternative Family Living (UAFL) homes are required to have a Health and Safety Review by the Partners Quality Management Monitoring department upon entry into the network and annually thereafter, per Clinical Coverage Policy 8P and the 1915 (c) Home and Community Based Services Waiver. AFL reviews must be conducted within 30 days of the annual review due date. The review of an unlicensed AFL includes the completion of the Partners’ UAFL review tool, recently adopted from the former NCDHHS Unlicensed AFL Review Tool for Providers. The reviews occur virtually with plans to continue this process as Partners becomes a Tailored Plan.
Employer of Record (EOR) reviews are conducted annually by the Partners Quality Management department. The reviews occur during or near the member’s birth month. The EOR reviews are conducted utilizing an EOR review tool developed by Partners Quality Management department.