Current through Register Vol. 48, No. 12, March 22, 2024
a) The application for an HMO Certificate of
Authority shall contain a description of the actions that will be taken by the
HMO to:
1) Monitor, on an ongoing basis, the
quality, availability and accessibility of care delivered under the auspices of
the HMO, and
2) Implement change,
where necessary, based on problem identification, analysis and identification
of corrective action.
b)
The application for an HMO Certificate of Authority shall contain a description
of the quality assessment program adopted by the HMO, which shall meet the
following requirements:
1) The quality
assessment program shall address both the medical and administrative aspects of
the provision and delivery of health care services, such as availability,
accessibility and continuity of care.
2) The HMO shall have a written quality
assessment plan that:
A) Establishes goals,
timeframes and objectives for the quality assessment program;
B) Outlines the organizational structure that
will be utilized in implementing the quality assessment monitoring activities
and the recommendations that result from the quality assessment monitoring
activities; and
C) Describes the
methodology and criteria that will be used to evaluate the health care services
provided under the auspices of the HMO.
3) Quality assessment monitoring activities
shall include the following:
A) Problems or
concerns relative to the care rendered to enrollees shall be identified.
Enrollees' accessibility to health care providers, appropriateness of
utilization, and concerns identified by the HMO's medical or administrative
staff and enrollees shall be considered.
B) Problems or concerns identified by the
quality assessment activities shall be evaluated in accordance with the written
plan's methodology and criteria to determine whether problems or concerns do
indeed exist, and what the causes of the problems or concerns are.
C) An action plan shall be developed and
implemented to correct the problems or concerns that have been verified. The
action plan shall include an educational component for providers included in
the action plan.
D) Follow-up
measures shall be implemented to evaluate the effectiveness of the action
plan.
E) The HMO shall have an
ongoing process for monitoring the continued effectiveness of action plans in
preventing problems from reoccurring, and in preventing problems from
developing.
4) The
quality assessment program shall include physician participation, and all
medical decisions shall be made by the medical director or the HMO's peer
review body.
5) Reports of quality
assessment activities shall be made to the governing board of the HMO on a
quarterly basis, at a minimum.
A) Records and
minutes shall be kept on meetings that pertain to quality assessment
activities.
B) Copies of reports of
quality assessment activities shall be forwarded to the administrators of the
HMO.
C) The HMO shall make records
and reports of quality assessment activities available for review by the
Department, and the HMO shall submit the records to the Department upon
request. In accordance with Sections 8-2101 and 8-2102 of the Code of Civil
Procedure [735 ILCS 5 ], these records and reports shall be used solely for the
purpose of evaluating and improving the quality of care rendered to enrollees
through the HMO, and shall therefore not be admissible as evidence, nor
discoverable in any action of any kind in any court or before any tribunal,
board, agency or person. (Section 8-2102 of the Code of Civil
Procedure)
c)
The application for an HMO Certificate of Authority shall contain a description
of the medical record review program adopted by the HMO, which shall meet the
following requirements:
1) A written medical
record review program shall:
A) Establish
minimum chart standards that shall be consistent with the medical record
standards contained in this Part (see Section
240.90
);
B) Provide for a review and
evaluation of the medical record documentation of primary care physicians
pursuant to the HMO medical record review program, demonstrating that the HMO
has assessed medical record practices; and
C) Include a program of correction and
education that will be implemented when deficiencies relative to chart
documentation are found. Such a program shall include a means for the follow-up
and correction of deficiencies.
2) Reports of medical record review
activities shall be made, at a minimum, on a quarterly basis.
A) Records and minutes shall be kept on
meetings that pertain to medical record review activities.
B) Copies of reports of medical record review
activities shall be forwarded to the administrators of the HMO.
C) The HMO shall make records and reports of
medical record review activities available for review by the Department, and
the HMO shall submit the records to the Department upon request. In accordance
with Sections 8-2101 and 8-2102 of the Code of Civil Procedure, these records
and reports shall be used solely for the purpose of evaluating and improving
the quality of care rendered to enrollees through the HMO, and shall therefore
not be admissible as evidence, nor discoverable in any action of any kind in
any court or before any tribunal, board, agency or person. (Section 8-2102 of
the Code of Civil Procedure)
3) The HMO shall provide an outline of the
organizational structure that will be used in implementing the medical record
review activities and the recommendations that result from the medical record
review activities.
d)
The application for an HMO Certificate of Authority shall contain a description
of the utilization review program adopted by the HMO, which shall meet the
following requirements:
1) The utilization
review program shall include procedures for the compilation of statistics that
relate to health services information.
2) The utilization review program shall
review and evaluate health related statistical information, such as hospital
admissions, ambulatory encounters, and the level of care utilized.
3) The HMO shall outline the organizational
structure that will be used in implementing the utilization review program
activities and the recommendations that result from the utilization review
activities.
4) Reports of
utilization review activities shall be made to the governing board of the HMO
at a minimum, on a quarterly basis.
A)
Records and minutes shall be kept on meetings that pertain to utilization
review activities.
B) Copies of
reports of utilization review activities shall be forwarded to the
administrators of the HMO.
C) The
HMO shall make records and reports of utilization review activities available
for review by the Department, and the HMO shall submit the records to the
Department upon request. In accordance with Sections 8-2101 and 8-2102 of the
Code of Civil Procedure, these records and reports shall be used solely for the
purpose of evaluating and improving the quality of care rendered to enrollees
through the HMO, and shall therefore not be admissible as evidence, nor
discoverable in any action of any kind in any court or before any tribunal,
board, agency or person. (Section 8-2102 of the Code of Civil
Procedure)