The health maintenance organization shall have a written quality assurance plan that includes the following:
goals and objectives;
staffing and contractual arrangements;
a system for communicating information regarding quality assurance activities;
the scope of the quality assurance program activities; and
a description of peer review activities.
Quality assurance authority, function, and responsibility shall be delineated in specific documents, including documents such as bylaws, board resolutions, and provider contracts. These documents shall demonstrate that the health maintenance organization has assumed ultimate responsibility for the evaluation of quality of care provided to enrollees, and that the health maintenance organization's governing body has periodically reviewed and approved the quality assurance program activities.
The governing body shall designate a quality assurance entity that may be a person or persons to be responsible for operation of quality assurance program activities. This entity shall maintain records of its quality assurance activities and shall meet with the governing body at least quarterly.
A physician or physicians designated by the governing body shall advise, oversee, and actively participate in the implementation of the quality assurance program.
There must be sufficient administrative and clinical staff with knowledge and experience to assist in carrying out quality assurance activities. In determining what is sufficient staff support, the commissioner shall consider the number of enrollees, types of enrollees, numbers of providers, the variety of health care services offered by the health maintenance organization, the organizational structure of the health maintenance organization, and the quality assurance staffing levels used by other health care organizations that perform similar health care functions.
The health maintenance organization may delegate performance of quality assurance activities to other entities. The health maintenance organization shall retain responsibility for performance of all delegated activities. If the health maintenance organization delegates performance of quality assurance activities, the health maintenance organization shall develop and implement review and reporting requirements to ensure that the delegated entity performs all delegated quality assurance activities.
The data collection and reporting system shall support the information needs of the quality assurance program activities. The quality assurance program shall have prompt access to necessary medical record data including data by diagnoses, procedure, patient, and provider.
An evaluation of the overall quality assurance program shall be conducted at least annually. The results of this evaluation shall be communicated to the governing body. The written quality assurance plan shall be amended when there is no clear evidence that the program continues to be effective in improving care.
Effective July 1, 1999, a health maintenance organization shall conduct ongoing evaluation of all enrollee complaints as defined in part 4685.0100, subpart 4, including complaints filed with participating providers. Ongoing evaluations must be conducted according to the steps in part 4685.1120.
Evaluation methods must permit a health maintenance organization to track specific complaints, assess trends, and establish that corrective action is implemented and effective in improving the identified problem.
The quality assurance program shall conduct ongoing evaluation of enrollee complaints that are related to quality of care. The evaluations shall be conducted according to the steps in part 4685.1120. The data on complaints related to quality of care must be reported to and evaluated by the appointed quality assurance entity at least quarterly.
The data from the health maintenance organization's utilization review activities shall be reported to the quality assurance program for analysis at least quarterly.
The health maintenance organization shall have policies and procedures for provider selection, credentialing, and recredentialing that, at a minimum, are consistent with accepted community standards.
Any health maintenance organization staff or contractees conducting quality assurance activities must be qualified by virtue of training and experience.
The quality assurance entity appointed under subpart 3 shall conduct ongoing evaluation of medical records.
The health maintenance organization shall implement a system to assure that medical records are maintained with timely, legible, and accurate documentation of all patient interactions. Documentation must include information regarding patient history, health status, diagnosis, treatment, and referred service notes.
The health maintenance organization shall maintain a medical record retrieval system that ensures that medical records, reports, and other documents are readily accessible to the health maintenance organization.
14 SR 903; 23 SR 1238
October 11, 2007
Official Publication of the State of Minnesota
Revisor of Statutes