(a) An issuer must establish and maintain procedures
to assure that the health care services provided to insureds are rendered
under reasonable standards of quality of care consistent with prevailing
professionally recognized standards of medical practice. These procedures
must include:
(1) mechanisms to assure availability, accessibility,
quality, and continuity of care;
(2) an ongoing internal quality improvement program
to monitor and evaluate its health care services, including primary
and specialist physician services, and ancillary and preventive health
care services, in all institutional and non-institutional contexts;
(3) a record of formal proceedings of quality improvement
program activities and a means for maintaining documentation in a
confidential manner. Quality improvement program minutes must be made
available to the commissioner;
(4) a physician review panel to assist in reviewing
medical guidelines or criteria and to assist in determining the prescription
drugs to be covered by the EPP, if the plan contains a prescription
drug benefit;
(5) an adequate patient record system that will facilitate
documentation and retrieval of clinical information for the purpose
of the issuer's evaluation of continuity and coordination of patient
care and assessment of the quality of health care services provided
to insureds;
(6) a mechanism for making available to the commissioner
the clinical records of insureds for examination and review. Such
records are confidential and privileged, and are not subject to Government
Code, Chapter 552, Public Information, or to subpoena, except to the
extent necessary to enable the commissioner to enforce this title;
and
(7) a mechanism for the periodic reporting of quality
improvement program activities to its governing body, providers, and
appropriate organization staff. An issuer is also subject to the same
quality improvement requirements as outlined in §11.1901 of this
title (relating to Quality Improvement Structure).
(b) An issuer must establish a mechanism for utilizing
independent review organizations as outlined in Insurance Code Chapter
4201.
|