§ 26-24-130 — 26-34-108. Quality assurance program

Wyoming § 26-24-130

• Jurisdiction: Wyoming
• Title 26: Insurance Code
• Ch. 34: HEALTH MAINTENANCE ORGANIZATIONS

Text

(a) The health maintenance organization shall establish
procedures to assure that the health care services provided to
enrollees are rendered under reasonable standards of quality of
care consistent with prevailing professionally recognized
standards of medical practice. The procedures shall include
mechanisms to assure availability, accessibility and continuity
of care.
(b) The health maintenance organization shall 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 shall include, at a
minimum, the following:
(i) A written statement of goals and objectives which
emphasizes improved health status in evaluating the quality of
care rendered to enrollees;
(ii) A written quality assurance plan which describes
the following:
(A) The health maintenance organization's scope
and purpose in quality assurance;
(B) The organizational structure responsible for
quality assurance activities;
(C) Contractual arrangements, where appropriate,
for delegation of quality assurance activities;
(D) Confidentiality policies and procedures;
(E) A system of ongoing evaluation activities;
(F) A system of focused evaluation activities;
(G) A system for credentialing providers and
performing peer review activities; and
(H) Duties and responsibilities of the
designated physician responsible for the quality assurance
activities.
(iii) A written statement describing the system of
ongoing quality assurance activities including:
(A) Problem assessment, identification,
selection and study;
(B) Corrective action, monitoring, evaluation
and reassessment; and
(C) Interpretation and analysis of patterns of
care rendered to individual patients by individual providers.
(iv) 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; and
(v) Written plans for taking appropriate corrective
action whenever, as determined by the quality assurance program,
inappropriate or substandard care or services have been
provided, or care or services which should have been furnished
have not been provided.
(c) The organization shall record proceedings of formal
quality assurance program activities and maintain documentation
in a confidential manner. Quality assurance program minutes
shall be available to the administrator. Contents of the minutes
shall be confidential to the extent confidentiality is provided
under the provisions of W.S. 16-4-203(d)(i) and (vii), 26-34-
129, 26-34-130, 35-2-910 or 35-17-105.
(d) 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.
(e) Enrollee clinical records shall be available to the
administrator or an authorized designee for examination and
review to ascertain compliance with this section, or as deemed
necessary by the administrator.
(f) The organization shall establish a mechanism for
periodic reporting of quality assurance program activities to
the governing body, providers and appropriate organization
staff.