S.D. Admin. R. 44:18:01:03

Current through Register Vol. 51, page 67, December 16, 2024

Section 44:18:01:03 - Quality of services

The quality of health care provided by an HMO shall be evaluated by methods that include the following:

(1) Provisions for meeting the standards of quality review set forth in the Social Security Amendments of 1972, United States code, title 42, sections 1320c to 1320c-19;

(2) Written or on-site examinations of the HMO and providers with whom the HMO has contracts and agreements. The department of health shall make the examinations as often as the department considers necessary, but at least once every three years. In lieu of the examination, the department may accept the report from the director, the state department of health of another state or jurisdiction, the federal government or its designee agency, or contract with an outside organization to assess the quality of care being provided by the HMO;

(3) An ongoing internal peer review quality assurance program, supervised by a physician in the HMO and involving a broad spectrum of health professionals in the organization. The objectives of the internal quality assurance program shall be to assure that health care services meet the patient's needs in a quality manner and to assure that the organization and administration support the timely provision of quality care;

(4) A defined set of criteria and procedures used by the HMO in selecting providers to serve enrollees and the retention of the records revealing the method used to scrutinize and screen individual provider applications for consideration of contractual arrangement with the HMO; and

(5) To ascertain enrollee satisfaction as part of the overall quality evaluation program, provision to the secretary, upon request, of individual or family enrollee names, where applicable, and respective addresses for the purpose of conducting surveys.

S.D. Admin. R. 44:18:01:03

12 SDR 50, effective 9/29/1985.

General Authority: SDCL 58-41-12, 58-41-67.

Law Implemented: SDCL 58-41-12, 58-41-13, 58-41-70, 58-41-71.