Minnesota Administrative Rules

4685.1115 ACTIVITIES.

Subpart 1.

Ongoing quality evaluation.

The health maintenance organization, through the health maintenance organization staff or contracting providers, shall conduct quality evaluation activities according to the steps in part 4685.1120. The quality evaluation activities must address each of the components of the health maintenance organization described in subpart 2.

Subp. 2.

Scope.

The components of the health maintenance organization subject to evaluation include the following:

A.

Clinical components that include the following services:

(1)

acute hospital services;

(2)

ambulatory health care services;

(3)

emergency services;

(4)

mental health services;

(5)

preventive health care services;

(6)

pharmacy services;

(7)

chemical dependency services;

(8)

other professional health care services provided to enrollees, such as chiropractic, occupational therapy, and speech therapy;

(9)

home health care, as applicable;

(10)

durable medical equipment, as applicable; and

(11)

skilled nursing care, as applicable.

B.

Organizational components which are the aspects of the health plan that affect accessibility, availability, comprehensiveness, and continuity of health care, and which include the following:

(1)

referrals;

(2)

case management;

(3)

discharge planning;

(4)

appointment scheduling and waiting periods for all types of health care services;

(5)

second opinions, as applicable;

(6)

prior authorizations, as applicable;

(7)

provider reimbursement arrangements; and

(8)

other systems, procedures, or administrative requirements used by the health maintenance organization that affect delivery of care.

C.

Consumer components that are the enrollees' perceptions regarding all aspects of the quality of the health plan's services, and that include:

(1)

enrollee satisfaction surveys, which must meet validity standards in the following areas:

(a)

assessment of enrollee health care experiences;

(b)

statistical methodology for population sampling and analysis of the results, with a focus on membership affected by the issue being researched; and

(c)

ease of completion and interpretation by enrollees;

(2)

enrollee complaints; and

(3)

enrollee written or verbal comments or questions.

Statutory Authority:

MS s 62D.03; 62D.04; 62D.11; 62D.20

History:

14 SR 903; 17 SR 2858; 23 SR 1238

Published Electronically:

October 11, 2007