A. A health maintenance organization shall establish procedures to assure that the health care services provided to enrollees shall be rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. Such procedures shall include mechanisms to assure availability, accessibility and continuity of care.
B. A health maintenance organization shall have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and non-institutional settings. The program shall include, at a minimum, the following:
(1) a written statement of goals and objectives that emphasizes improved health status in evaluating the quality of care rendered to enrollees;
(2) a written quality assurance plan that describes the following:
(a) the health maintenance organization's scope and purpose in quality assurance;
(b) the organizational structure responsible for quality assurance activities;
(c) contractual arrangements, where appropriate, for delegation of quality assurance activities;
(d) confidentiality policies and procedures;
(e) a system of ongoing evaluation activities;
(f) a system of focused evaluation activities;
(g) a system for credentialing providers and performing peer review activities; and
(h) duties and responsibilities of the designated physician responsible for the quality assurance activities;
(3) a written statement describing the system of ongoing quality assurance activities, including:
(a) problem assessment, identification, selection and study;
(b) corrective action, monitoring, evaluation and reassessment; and
(c) interpretation and analysis of patterns of care rendered to individual patients by individual providers;
(4) a written statement describing the system of focused quality assurance activities based on representative samples of the enrolled population that identifies method of topic selection, study, data collection, analysis, interpretation and report format; and
(5) written plans for taking appropriate corrective action whenever, as determined by the quality assurance program, inappropriate or substandard services have been provided or services that should have been furnished have not been provided.
C. A health maintenance organization shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes shall be available for examination by the superintendent and by the secretary of health if requested by the superintendent but shall not be disclosed to third parties except as permitted by the provisions of Chapter 59A, Article 46 NMSA 1978.
D. A health maintenance organization shall ensure the use and maintenance of an adequate patient record system that will facilitate documentation and retrieval of clinical information for the purpose of the health maintenance organization evaluating continuity and coordination of patient care and assessing the quality of health and medical care provided to enrollees.
E. Except as otherwise restricted or prohibited by state or federal law, enrollee clinical records shall be available to the superintendent or an authorized designee for examination and review to ascertain compliance with this section or as deemed necessary by the superintendent.
F. A health maintenance organization shall establish a mechanism for periodic reporting of quality assurance program activities to the governing body, providers and appropriate organization staff.
History: 1978 Comp., § 59A-46-7, enacted by Laws 1993, ch. 266, § 7.
ANNOTATIONSRepeals and reenactments. — Laws 1993, ch. 266, § 43 repealed former 59A-46-7 NMSA 1978, as enacted by Laws 1984, ch. 127, § 854, related to fiduciary responsibilities, and Laws 1993, ch. 266, § 7 enacted a new section, effective January 1, 1994.