420-J:9 Quality Assessment, Quality Improvement, and Reporting. –
I. A health carrier shall:
(a) Establish and maintain a written quality assessment program designed to collect and evaluate information regarding the quality of the health care processes used by the health carrier and the health outcomes of its covered persons.
(b) Establish and maintain a written quality improvement program structured to identify opportunities to improve care, practices that result in improved health care outcomes, problematic utilization patterns, and those providers who may be responsible for either exemplary or problematic patterns of utilization.
II. The quality improvement program shall at a minimum include: a statement of the objectives of the program; a description of how the health carrier will conduct its quality improvement program; the lines of authority and accountability including data collection responsibilities; evaluation tools; performance improvement activities; and an annual effectiveness review.
III. The chief medical officer or clinical director of the health carrier shall have primary responsibility for the quality assessment and quality improvement activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter relative to quality assessment and quality improvement are met.
IV. A health carrier shall:
(a) Assure that participating providers have an opportunity to participate in developing, implementing, and evaluating the quality assessment and quality improvement programs.
(b) Maintain at its principal office a copy of the quality assessment program and the quality improvement program which shall be available for inspection by the commissioner or designee at any time during the health carrier's regular business hours.
(c) Certify to the commissioner on or before March 1 of each year that its quality assessment program and its quality improvement program meet the requirements of this chapter and any applicable rules.
(d) Notify the commissioner on or before March 1 of each year of its accreditation by any external accrediting agencies and shall provide a contact person and a phone number for consumer phone calls.