NY Manual
SHP Manual

SHP Provider Manual
6.2 Appeals of Benefit and Service Determination | 7.1 Quality Assurance, Performance Improvement (QAPI) Plan and Compliance

6.3 Quality Review and Oversight

  • Records of complaints and appeals are stored, tracked ,and reviewed by the Vice President of Clinical Excellence or designee.
  • Providers may be asked to investigate individual or aggregate complaints and may be asked to define action improvement plans, as necessary.
  • Results of activities are reported to the Quality Utilization and Management (QUM) Committee to determine ongoing issues, trends, and opportunities for improvement.
  • Recommendations may also be made to limit a provider’s participation in the network.
  • The results of the review and analysis are also reported to the Quality Management Committee.