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  • Quality Improvement > Delegation Oversight

    Delegation Oversight Committee

    Purpose: The Delegation Oversight Committee assesses and oversees all delegated activities performed by contracted delegates. The Delegation Oversight Committee monitors the delegates’ compliance with EmblemHealth’s policies and procedures, accreditation standards, and applicable laws, rules, regulations and stipulations, thereby ensuring that all members receive equitable access to care and services.

    Responsibilities: The responsibilities of the Delegation Oversight Committee include but are not limited to:

    • Responding to and addressing the concerns of the EmblemHealth operational departments in a process-oriented manner as it relates to the performance/non-performance of delegated entities.
    • Using objective criteria/metrics to evaluate the measures/processes of performance of the delegated entities against EmblemHealth’s and the health care industry’s standards and benchmarks to identify areas of success and areas in need of improvement. Metrics help to ensure that the Delegation Oversight Committee’s decisions concerning delegated activities and processes are based on objectively measured outcomes and results. It is the Delegation Oversight Committee’s responsibility to provide oversight of the audit tools and metrics used to measure delegate performance in the context of frequently changing regulatory and accreditation requirements and changes in industry practice. Audit tools are reviewed and, if applicable, revised on a periodic basis to assure the tools remain sensitive and specific to assess delegate compliance.
    • Reviewing all applicable pre-delegation materials and annual audit materials against established protocols.
    • Making recommendations to the Quality Improvement Committee regarding delegation activities including, but not limited to, a potential delegate being approved as a delegate, adding functions and/or lines of business to an established delegate, rescinding the delegate status of delegate to that of a vendor, rescinding the contract of a delegate and/or pursuing recommendations that impact the delegate.
    • Establishing time frames and protocols for auditing and reporting the functionality of delegated entities to the Delegation Oversight Committee. Delegation audits are completed as frequently as necessary to evaluate compliance, but no less than annually, started and completed within 10 months to 14 months of the prior year’s audit.
    • Recommending the decisions regarding the delegates to the Quality Improvement Committee in a manner that allows the Quality Improvement Committee to act within timely and appropriate time frames. The Delegation Oversight Committee communicates with all affected and concerned customers in a confidential manner.
    • Overseeing statements of deficiencies and improvement action plans to ensure completion of recognized deficiencies and compliance with CMS, NYS, the NYC Department of Health, and other state and federal regulatory and accreditation bodies. If serious problems cannot be corrected, the Relationship Manager and Subject Matter Experts present the unresolved issues to the Delegation Oversight Committee. The Delegation Oversight Committee may recommend to the Quality Improvement Committee partial or full revocation of delegated activities.

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    Glossary terms found on this page:

    An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    The government agency responsible for administering the Medicare and Medicaid programs.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    The process by which the organization permits another entity to perform functions and assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.

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