Ga. Comp. R. & Regs. R. 120-2-80-.08 - Quality Assurance
(1) A managed care entity shall disclose the
quality assurance program in effect with documentation specified in Form GID
PPA-1.
(2) The managed care entity
must demonstrate, to the satisfaction of the Commissioner, that its quality
assurance program includes organizational arrangements and ongoing procedures
for the identification, evaluation, resolution and follow up of potential and
actual problems in health care administration and delivery to enrollees. The
program should include, but not be limited to procedures to:
(a) monitor and resolve complaints;
(b) monitor provider performance;
(c) monitor patient satisfaction;
(d) establish appropriate quality indicators
based on current standards of the relevant health care profession;
(e) meet reasonable thresholds with regard to
quality indicators;
(f) credential
network providers according to established standards;
(g) ensure access to network providers by
maintaining sufficient numbers of primary care physicians and other types of
providers within the managed care entity's service area; and
(h) detect both under utilization and over
utilization of services.
Notes
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