New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 24 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter 7 - CONTINUOUS QUALITY IMPROVEMENT
Section 11:24-7.2 - External quality audit

(a) Each HMO shall submit, as part of the comprehensive assessment review process, evidence of the most recent external quality audit that has been conducted within three years of the date of the comprehensive assessment review. Such audit shall be performed by an external quality review organization (EQRO) approved by the Department.

(b) The report shall describe in detail the HMO's conformance to performance standards established by the (EQRO), other national standard-setting bodies for HMOs, and/or the rules within this chapter. The report shall also describe in detail any corrective actions proposed and/or undertaken and approved by the (EQRO). The report shall be submitted to the Department within 60 days of its receipt in final form by the HMO.

(c) The HMO shall not be required to receive "accreditation" or "certification" or other such status granted by the (EQRO). If the HMO attains "accreditation" or "certification" or other such status granted by the (EQRO) within the 12 months prior to the Department's comprehensive assessment review, the HMO shall be exempted from examination by the Department in any area in which the Commissioner determines that the (EQRO's) review demonstrated specific compliance with standards substantially equivalent to those contained in this chapter.

(d) The Commissioner may grant an HMO a deferral of the above requirement for an external quality audit for a 12-month period if it is in the initial three years of start-up operations, and it demonstrates a financial or operational hardship.