1.The health maintenance organization shall establish procedures to assure that the
health care services provided to enrollees will be rendered under reasonable
standards of quality of care consistent with prevailing professionally recognized
standards of medical practice. The procedures must include mechanisms to assure
availability, accessibility, and continuity of care.
2.The health maintenance organization must have an ongoing internal quality assurance
program to monitor and evaluate its health care services, including primary and
specialist physician services, and ancillary and preventive health care services, across
all institutional and noninstitutional settings. The program must include, at a minimum,
the following:
a.A written statement of goals and objectives which emphasizes
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1. The health maintenance organization shall establish procedures to assure that the
health care services provided to enrollees will be rendered under reasonable
standards of quality of care consistent with prevailing professionally recognized
standards of medical practice. The procedures must include mechanisms to assure
availability, accessibility, and continuity of care.
2. The health maintenance organization must have an ongoing internal quality assurance
program to monitor and evaluate its health care services, including primary and
specialist physician services, and ancillary and preventive health care services, across
all institutional and noninstitutional settings. The program must include, at a minimum,
the following:
a. A written statement of goals and objectives which emphasizes improved health
status in evaluating the quality of care rendered to enrollees.
b. A written quality assurance plan which describes the following:
(1) The health maintenance organization's scope and purpose in quality
assurance.
(2) The organizational structure responsible for quality assurance activities.
(3) Contractual arrangements, when appropriate, for delegation of quality
assurance activities.
(4) Confidentiality policies and procedures.
(5) A system of ongoing evaluation activities.
(6) A system of focused evaluation activities.
(7) A system for credentialing providers and performing peer review activities.
(8) Duties and responsibilities of the designated physician responsible for the
quality assurance activities.
c. A written statement describing the system of ongoing quality assurance activities,
including:
(1) Problem assessment, identification, selection, and study.
(2) Corrective action, monitoring, evaluation, and reassessment.
(3) Interpretation and analysis of patterns of care rendered to individual patients
by individual providers.
d. A written statement describing the system of focused quality assurance activities
based on representative samples of the enrolled population which identifies
method of topic selection, study, data collection, analysis, interpretation, and
report format.
e. Written plans for taking appropriate corrective action whenever, as determined by
the quality assurance program, inappropriate or substandard services have been
provided or services which should have been furnished have not been provided.
3. The organization shall record proceedings of formal quality assurance program
activities and maintain documentation in a confidential manner. Quality assurance
program minutes must be available to the commissioner.
4. The organization shall ensure the use and maintenance of an adequate patient record
system which will facilitate documentation and retrieval of clinical information for the
purpose of the health maintenance organization evaluating continuity and coordination
of patient care and assessing the quality of health and medical care provided to
enrollees.
5. Enrollee clinical records must be available to the commissioner or an authorized
designee for examination and review to ascertain compliance with this section, or as
deemed necessary by the commissioner. The clinical records are confidential and are
not subject to section 44-04-18, except upon written consent for disclosure by the
enrollee or the enrollee's authorized representative.
6. The organization shall establish a mechanism for periodic reporting of quality
assurance program activities to the governing body, providers, and appropriate
organization staff.