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Medicaid External Quality Review

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Health Services Advisory Group (HSAG) is the largest External Quality Review Organization (EQRO) in the nation and provides quality review services for states that operate Medicaid managed care programs and fee-for-service programs. As an EQRO, HSAG evaluates managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs), as required by the code of federal regulations 42 CFR Part 438, Subpart E1, and aggregates information on the timeliness, access, and quality of healthcare services furnished to Medicaid enrollees. HSAG provides EQR-related services in 17 states and serves as the designated EQRO in 15 states. HSAG's quality review services affect more than 33 million Medicaid recipients, or approximately 46 percent of the nation's Medicaid population.

The EQR process currently consists of three mandatory activities and five optional activities, in addition to producing an annual EQR technical report and providing technical assistance, as needed. Each of the mandatory and optional activities has a corresponding EQR protocol, which HSAG follows when performing each EQR activity.

Mandatory EQR Activities

Optional EQR Activities

HSAG customizes quality review services based on each state's needs and can provide quality review technical assistance to states that do not operate managed care programs but wish to monitor the healthcare delivery and health outcomes of the population served in the Medicaid program. HSAG also provides quality improvement development and administration to enable states to monitor and achieve their strategic quality-related goals.

Features unique to HSAG:

  • With our extensive experience, HSAG is the only EQRO that is also a National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) Certified Survey Vendor and NCQA Licensed Organization with the capability of conducting certified HEDIS®2 Compliance Audits3.
  • Staffs its contracts with highly skilled and credentialed professionals such as Certified HEDIS Compliance Auditors, Certified Professionals in Healthcare Quality, registered nurses, Master's-prepared social workers, statisticians, biostatisticians, and epidemiologists.
  • Has extensive experience with Medicaid managed care programs being implemented for the first time in their state (Hawaii, Florida, Nevada, New Hampshire, Arizona, California, and Colorado).
  • Has the capacity to compare a large volume of data and create customized reports that assist states in monitoring their Medicaid programs.
  • Has proven success in developing and implementing innovative electronic tools and websites for states to use. In some states, HSAG has become an extension of the state's data staff members, providing accurate and timely training, support, and help-desk service for all hours of business.
  • Develops a customized EQR strategy for each state that is designed to achieve the state's specific quality goals and objectives. This customized approach has proven effective in helping HSAG's customers achieve higher quality services in their managed care programs.

For more information about HSAG's external quality review services, please contact Gretchen Thompson, Executive Director, State & Corporate Services, at

1In June 2015, the Centers for Medicare & Medicaid Services (CMS) issued a set of proposed regulations that would modernize the Medicaid managed care regulations in the usage of managed care delivery systems. The proposed regulations extended many of the external quality review activities to prepaid ambulatory health plans (PAHPs). HSAG has performed external quality review of PAHPs in the past. HSAG is prepared to assist states with implementing changes that affect their Medicaid managed care programs once the regulations are made final.
2HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
3NCQA HEDIS® Compliance Audit is a trademark of the National Committee for Quality Assurance (NCQA).