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External Quality Review - Washington Medicaid


As Washington's Medicaid external quality review organization (EQRO), Qualis Health provides external quality review and supports quality improvement for enrollees of Washington Apple Health managed care programs and the Behavioral Health Organization (BHO) network. Our work supports the Washington State Health Care Authority (HCA) and Department of Social and Health Services (DSHS) Division of Behavioral Health and Recovery (DBHR).


Services We Provide

State of Washington Health Care Authority (HCA)

Qualis Health reviews services provided by Apple Health managed care organizations (MCOs) through the following annual activities:

  • Evaluating Consumer Assessment of Healthcare Providers and Systems (CAHPS®) customer satisfaction surveys distributed among MCO enrollees
     
  • Validating MCO performance measures on important dimensions of care and service through audits of the MCOs’ Healthcare Effectiveness Data and Information Set (HEDIS®) measures
     
  • Conducting a comparative analysis of MCO performance measure performance


Department of Social and Health Services (DSHS) Division of Behavioral Health and Recovery (DBHR)

Qualis Health reviews mental health and substance use disorder treatment services provided by the state’s Behavioral Health Organizations (BHOs)—formerly Regional Support Networks (RSNs)—through the following annual activities:

  • Reviewing performance improvement projects (PIPs)
     
  • Conducting an Information Systems Capabilities Assessment (ISCA) or a follow-up of the previous year’s assessment
     
  • Reviewing compliance with federal regulatory and State contractual standards
     
  • Validating encounter data submitted by BHOs to the State


In addition, Qualis Health conducts yearly in-person trainings and educational sessions for MCO and BHO staff, and publishes annual technical and analytic reports presenting the results of the above activities and analyses. You can find more information about these activities on the Events and Publications pages.

Questions or Concerns

We understand how important it is to receive quality healthcare services.

As the external quality review organization, Qualis Health's role is to assess the quality of care Medicaid recipients receive.

If you have a concern about the care you or a family member has received, please contact the Washington State Health Care Authority.

»Washington State Health Care Authority