Ohio Admin. Code 4123-6-53 - Employer participation in the QHP system - QHP quality assurance program required
(A) Each QHP shall have a quality assurance
program that monitors the operation and measures the effectiveness of peer
review, utilization review, and dispute resolution within the QHP. Data
collected from the quality assurance program shall be used to assist an
employer in determining the quality, efficiency and effectiveness of the
employer's QHP and the QHP system in accordance with division
(D)
(A) of
section 4121.442 of the Revised
Code.
(B) Each quality assurance
program shall include a mechanism for monitoring and the methodology for
measuring and improving the QHP's compliance with each of the following eleven
elements:
(1) Peer review and evaluation of
clinical performance;
(2)
Credentialing and recredentialing and use of provider profiling;
(3) Utilization management to determine the
appropriateness of care;
(4)
Evaluation of employee and provider dispute resolution procedures and
outcomes;
(5) Evaluation of
outcomes of care based on clinical data;
(6) Procedures for remedial action for
inappropriate or substandard services;
(7) Evaluation of employee satisfaction with
the plan;
(8) Evaluation of
provider satisfaction with the plan;
(9) Evaluation of employer satisfaction with
the plan;
(10) Periodic evaluation
of medical records and office procedures; and
(11) Practice patterns compared to accepted
medical criteria.
(C)
The quality assurance program shall include a quality assurance committee or
other mechanism adequate to evaluate the outcomes of each of the eleven
elements listed in paragraph (B) of this rule.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Prior Effective Dates: 9/5/96
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) Each QHP shall have a quality assurance program that monitors the operation and measures the effectiveness of peer review, utilization review, and dispute resolution within the QHP. Data collected from the quality assurance program shall be used to assist an employer in determining the quality, efficiency and effectiveness of the employer's QHP and the QHP system in accordance with division (D) (A) of section 4121.442 of the Revised Code.
(B) Each quality assurance program shall include a mechanism for monitoring and the methodology for measuring and improving the QHP 's compliance with each of the following eleven elements:
(1) Peer review and evaluation of clinical performance;
(2) Credentialing and recredentialing and use of provider profiling;
(3) Utilization management to determine the appropriateness of care;
(4) Evaluation of employee and provider dispute resolution procedures and outcomes;
(5) Evaluation of outcomes of care based on clinical data;
(6) Procedures for remedial action for inappropriate or substandard services;
(7) Evaluation of employee satisfaction with the plan;
(8) Evaluation of provider satisfaction with the plan;
(9) Evaluation of employer satisfaction with the plan;
(10) Periodic evaluation of medical records and office procedures; and
(11) Practice patterns compared to accepted medical criteria.
(C) The quality assurance program shall include a quality assurance committee or other mechanism adequate to evaluate the outcomes of each of the eleven elements listed in paragraph (B) of this rule.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Prior Effective Dates: 9/5/96