Providers

The CMAC adopts evidence and approves clinical criteria on an annual basis. The specific functions and responsibilities of the committee are as follows:

• Provide regular clinical measurement oversight
• Identify and monitor key quality indicators that measure performance against clinical practice guidelines, external benchmarks and internal targets (HEDIS)
• Assist with review of clinical aspects of the Quality Improvement (QI) program, work plan, and the Care Management program
• Recommend new opportunities or changes in current programs and interventions to improve clinical care and service
• Assist with development, review and maintenance of clinical policies and procedures
• Review and analyze potential quality of care issues if required
• Review, assess, and recommend internal utilization management practices
• Approve the criteria used to review authorization decisions at least annually
• Review and approve the Utilization Management (UM) program description
• Evaluate utilization functions including the assessment and analysis of utilization statistics, management guidelines, referral trends, ambulatory treatment patterns, inpatient monitoring processes and the effectiveness of discharge planning programs

Committee Structure

The membership is comprised of the following:

• Chair: VP of Clinical Integration and Senior Medical Director
• Chief Medical Officer (CMO)
• Director of Behavioral Health Care
• Behavioral Health Medical Director
• VP of Care Management
• AVP of Quality Improvement (QI)
• Director of Care Management
• Regional Quality Managers (2)
• Clinical Quality Analysts
• Community Practitioners—These practitioners are selected to represent primary care and high volume specialties per region. It is recommended to appoint at least three (3) outside practitioners to the committee.

Quorum

Committee meetings are held a minimum of quarterly. All members have voting rights and a majority of the membership constitutes a quorum. Meeting minute reflect decisions made and are signed and dated. Meeting minute are confidential, approved prior to the next meeting, and stored in a secured area.