Ala. Admin. Code r. 420-5-6-.13

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-6-.13 - External Quality Improvement Assessment

(1) When the Department may direct for cause, each health maintenance organization shall have an external quality improvement assessment performed.

(2) The assessment shall study the quality of care being provided to plan enrollees and the effectiveness of the quality improvement program established according to 420-5-6-.07.

(3) The assessment shall be conducted by an expert experienced in health maintenance organization review activities.

(a) The expert shall be hired by the health maintenance organization and not involved in the operation or direction of the health maintenance organization or in the delivery of health care services to its enrollees.

(b) The expert must be an individual or organization with recognized experience in the appraisal of medical practice and quality improvement in a health maintenance organization setting.

(c) The expert shall be approved by the Department.

(d) The expert shall review, at least, a statistically significant sample of medical records.

(e) The expert shall issue a written report of his findings to the health maintenance organization's governing body.

(4) A copy of the expert's report shall be submitted to the Department within 10 business days of its receipt by the health maintenance organization.

Author: Department of Public Health

Ala. Admin. Code r. 420-5-6-.13

Filed September 1, 1982. Repealed and New Rule adopted in lieu thereof: Filed March 31, 1987. Amended: Filed January 20, 1999; effective February 24, 1999.

Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.