W. Va. Code R. § 114-53-3

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-53-3 - Goals of a Quality Assurance Program

3.1. The goals of a health maintenance organization's quality assurance program shall be to:

a. Assure the provision of appropriate medical services delivered to members, while simultaneously addressing the effectiveness of quality of care;

b. Monitor, evaluate and improve the quality of health care;

c. Provide a systematic process that promotes the delivery of medically appropriate care in a timely, effective and efficient manner, while maintaining the quality of health care;

d. Direct members and providers toward the goal of quality, cost effective health care.

3.2. A health maintenance organization's quality assurance program shall include a mechanism for identifying potential utilization management issues and linking them to the HMO's utilization management program.

W. Va. Code R. § 114-53-3