Minnesota Administrative Rules
Agency 144 - Health Department
Chapter 4685 - HEALTH MAINTENANCE ORGANIZATIONS
QUALITY ASSURANCE
Part 4685.1115 - ACTIVITIES
Universal Citation: MN Rules 4685.1115
Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1. Ongoing quality evaluation.
The health maintenance organization, through the health maintenance organization staff or contracting providers, shall conduct quality evaluation activities according to the steps in part 4685.1120. The quality evaluation activities must address each of the components of the health maintenance organization described in subpart 2.
Subp. 2. Scope.
The components of the health maintenance organization subject to evaluation include the following:
A. Clinical components that include the
following services:
(1) acute hospital
services;
(2) ambulatory health
care services;
(3) emergency
services;
(4) mental health
services;
(5) preventive health
care services;
(6) pharmacy
services;
(7) chemical dependency
services;
(8) other professional
health care services provided to enrollees, such as chiropractic, occupational
therapy, and speech therapy;
(9)
home health care, as applicable;
(10) durable medical equipment, as
applicable; and
(11) skilled
nursing care, as applicable.
B. Organizational components which are the
aspects of the health plan that affect accessibility, availability,
comprehensiveness, and continuity of health care, and which include the
following:
(1) referrals;
(2) case management;
(3) discharge planning;
(4) appointment scheduling and waiting
periods for all types of health care services;
(5) second opinions, as applicable;
(6) prior authorizations, as
applicable;
(7) provider
reimbursement arrangements; and
(8)
other systems, procedures, or administrative requirements used by the health
maintenance organization that affect delivery of care.
C. Consumer components that are the
enrollees' perceptions regarding all aspects of the quality of the health
plan's services, and that include:
(1)
enrollee satisfaction surveys, which must meet validity standards in the
following areas:
(a) assessment of enrollee
health care experiences;
(b)
statistical methodology for population sampling and analysis of the results,
with a focus on membership affected by the issue being researched;
and
(c) ease of completion and
interpretation by enrollees;
(2) enrollee complaints; and
(3) enrollee written or verbal comments or
questions.
Statutory Authority: MS s 62D.03; 62D.04; 62D.11; 62D.20
Disclaimer: These regulations may not be the most recent version. Minnesota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
