28 CA ADC § 1300.70
28 CCR s 1300.70
Cal. Admin. Code tit. 28, s 1300.70
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 8. SELF-POLICING PROCEDURES
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.70. Health Care Service Plan Quality Assurance Program.
(a) Intent and Regulatory Purpose.
(1) The QA program must be directed by providers and must document that
the quality of care provided is being reviewed, that problems are being
identified, that effective action is taken to improve care where
deficiencies are identified, and that follow-up is planned where
indicated.
(2) This section is not intended to set forth a prescriptive approach to
QA methodology. This section is intended to afford each plan flexibility
in meeting Act quality of care requirements.
(3) A plan's QA program must address service elements, including
accessibility, availability, and continuity of care. A plan's QA program
must also monitor whether the provision and utilization of services meets
professionally recognized standards of practice.
(4) The Department's assessment of a plan's QA program will focus on:
(A) the scope of QA activities within the organization;
(B) the structure of the program itself and its relationship to the plan's
administrative structure;
(C) the operation of the QA program; and
(D) the level of activity of the program and its effectiveness in
identifying and correcting deficiencies in care.
(b) Quality Assurance Program Structure and Requirements.
(1) Program Structure.
To meet the requirements of the Act which require plans to continuously
review the quality of care provided, each plan's quality assurance program
shall be designed to ensure that:
(A) a level of care which meets professionally recognized standards of
practice is being delivered to all enrollees;
(B) quality of care problems are identified and corrected for all provider
entities;
(C) physicians (or in the case of specialized plans, dentists,
optometrists, psychologists or other appropriate licensed professionals)
who provide care to the plan's enrollees are an integral part of the QA
program;
(D) appropriate care which is consistent with professionally recognized
standards of practice is not withheld or delayed for any reason, including
a potential financial gain and/or incentive to the plan providers, and/or
others; and
(E) the plan does not exert economic pressure to cause institutions to
grant privileges to health care providers that would not otherwise be
granted, nor to pressure health care providers or institutions to render
care beyond the scope of their training or experience.
(2) Program Requirements.
In order to meet these obligations each plan's QA program shall meet all
of the following requirements:
(A) There must be a written QA plan describing the goals and objectives of
the program and organization arrangements, including staffing, the
methodology for on-going monitoring and evaluation of health services, the
scope of the program, and required levels of activity.
(B) Written documents shall delineate QA authority, function and
responsibility, and provide evidence that the plan has established quality
assurance activities and that the plan's governing body has approved the
QA Program. To the extent that a plan's QA responsibilities are delegated
within the plan or to a contracting provider, the plan documents shall
provide evidence of an oversight mechanism for ensuring that delegated QA
functions are adequately performed.
(C) The plan's governing body, its QA committee, if any, and any internal
or contracting providers to whom QA responsibilities have been delegated,
shall each meet on a quarterly basis, or more frequently if problems have
been identified, to oversee their respective QA program responsibilities.
Any delegated entity must maintain records of its QA activities and
actions, and report to the plan on an appropriate basis and to the plan's
governing body on a regularly scheduled basis, at least quarterly, which
reports shall include findings and actions taken as a result of the QA
program. The plan is responsible for establishing a program to monitor and
evaluate the care provided by each contracting provider group to ensure
that the care provided meets professionally recognized standards of
practice. Reports to the plan's governing body shall be sufficiently
detailed to include findings and actions taken as a result of the QA
program
and to identify those internal or contracting provider components which
the QA program has identified as presenting significant or chronic quality
of care issues.
(D) Implementation of the QA program shall be supervised by a designated
physician(s), or in the case of specialized plans, a designated
dentist(s), optometrist(s), psychologist(s) or other licensed professional
provider, as appropriate.
(E) Physician, dentist, optometrist, psychologist or other appropriate
licensed professional participation in QA activity must be adequate to
monitor the full scope of clinical services rendered, resolve problems and
ensure that corrective action is taken when indicated. An appropriate
range of specialist providers shall also be involved.
(F) There must be administrative and clinical staff support with
sufficient knowledge and experience to assist in carrying out their
assigned QA activities for the plan and delegated entities.
(G) Medical groups or other provider entities may have active quality
assurance programs which the plan may use. In all instances, however, the
plan must retain responsibility for reviewing the overall quality of care
delivered to plan enrollees.
If QA activities are delegated to a participating provider to ensure that
each provider has the capability to perform effective quality assurance
activities, the plan must do the following:
(1) Inform each provider of the plan's QA program, of the scope of that
provider's QA responsibilities, and how it will be monitored by the plan.
(2) Ascertain that each provider to which QA responsibilities have been
delegated has an in-place mechanism to fulfill its responsibilities,
including administrative capacity, technical expertise and budgetary
resources.
(3) Have ongoing oversight procedures in place to ensure that providers
are fulfilling all delegated QA responsibilities.
(4) Require that standards for evaluating that enrollees receive health
care consistent with professionally recognized standards of practice are
included in the provider's QA program, and be assured of the entity's
continued adherence to these standards.
(5) Ensure that for each provider the quality assurance/utilization review
mechanism will encompass provider referral and specialist care patterns of
practice, including an assessment of timely access to specialists,
ancillary support services, and appropriate preventive health services
based on reasonable standards established by the plan and/or delegated
providers.
(6) Ensure that health services include appropriate preventive health care
measures consistent with professionally recognized standards of practice.
There should be screening for conditions when professionally recognized
standards of practice indicate that screening should be done.
(H) A plan that has capitation or risk-sharing contracts must:
1. Ensure that each contracting provider has the administrative and
financial capacity to meet its contractual obligations; the plan shall
have systems in place to monitor QA functions.
2. Have a mechanism to detect and correct under-service by an at-risk
provider (as determined by its patient mix), including possible under
utilization of specialist services and preventive health care services.
(I) Inpatient Care.
1. A plan must have a mechanism to oversee the quality of care provided in
an inpatient setting to its enrollees which monitors that:
a. providers utilize equipment and facilities appropriate to the care; and
b. if hospital services are fully capitated that appropriate referral
procedures are in place and utilized for services not customarily provided
at that hospital.
2. The plan may delegate inpatient QA functions to hospitals, and may rely
on the hospital's existing QA system to perform QA functions. If a plan
does delegate QA responsibilities to a hospital, the plan must ascertain
that the hospital's quality assurance procedure will specifically review
hospital services provided to the plan's enrollees, and will review
services provided by plan physicians within the hospital in the same
manner as other physician services are reviewed.
(c) In addition to the internal quality of care review system, a plan
shall design and implement reasonable procedures for continuously
reviewing the performance of health care personnel, and the utilization of
services and facilities, and cost. The reasonableness of the procedures
and the adequacy of the implementation thereof shall be demonstrated to
the to the Department.
Note: Authority cited: Sections 1344 and 1370, Health and Safety Code.
Reference: Section 1370, Health and Safety Code.
HISTORY
1. Amendment filed 12-20-90; operative 1-19-91 (Register 91, No. 6).
2. Editorial correction of printing error (Register 91, No. 17).
28 CA ADC s 1300.70
END OF DOCUMENT
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