Statutes, codes, and regulations
Colorado Administrative Code
Department 700 - Department of Regulatory AgenciesDivision 702 - Division of InsuranceRule 3 CCR 702-4 - LIFE, ACCIDENT AND HEALTHSection 3 CCR 702-4 Series 4-7 - LIFE, ACCIDENT AND HEALTH, Series 4-7 Health Maintenance Organizations
Regulation Regulation 4-7-03 - STANDARDS FOR HEALTH MAINTENANCE ORGANIZATIONS
Section 3 CCR 702-4-7-03-6 - Quality Assurance

3 Colo. Code Regs. § 702-4-7-03-6

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Current through Register Vol. 47, No. 16, August 25, 2024
Section 3 CCR 702-4-7-03-6 - Quality Assurance
A. Each HMO shall establish and maintain an ongoing program for quality assurance accountable to the HMO's governing body. The quality assurance program shall systematically monitor and evaluate the quality and appropriateness of health care services; shall develop and implement methods to resolve identified problems; and shall monitor the implementation of corrective measures to ensure their effectiveness. The evaluation of the quality and appropriateness of health care services shall be prospective, concurrent, and retrospective. The program shall be designed to improve the delivery of health care services and outcomes.
B. The quality assurance program shall implement a written plan that is evaluated at least annually and updated as necessary. The plan shall describe:
1. The program's mission, philosophy, goals and objectives;
2. The program's organizational structure and the job titles of the personnel responsible;
3. Specific diagnoses, conditions or treatments targeted for review by the program and focused studies designed to improve health care services and health outcomes;
4. Mechanisms to evaluate the health of enrollees and the results of treatment and outcomes of health care services in relation to reference data bases, such as current medical research, knowledge, standards and practice guidelines;
5. Mechanisms by which the findings generated by the quality assurance program, including preventive services, shall be used on a continuing basis by providers and other staff to improve the health of enrollees;
6. Mechanisms for the evaluation of the clinical performance of providers; and
7. Confidentiality policies and procedures for enrollee health information considered under the quality assurance program.
C. The quality assurance program shall be directed by a licensed physician or alternatively there shall be substantial input from one or more licensed physicians. The clinical elements of the quality assurance program shall be under the direction of a licensed physician.
D. The quality assurance program shall include preventive services for enrollees that are designed to reduce the rate of occurrence or the likelihood of morbidity, disability or mortality resulting from illness or injury. The program shall strive to meet public and community health goals as well as to improve the health of the plan's enrollees. Programs may include, but are not limited to:
1. Prevention, screening and treatment of environmental diseases;
2. Prevention and treatment of communicable diseases, including vaccine preventable diseases and tuberculosis;
3. Prevention and treatment of tobacco, alcohol or drug addictions;
4. Prevention and treatment of injuries; and
5. Prevention and treatment of chronic diseases and disabilities, and the prevention of complications directly caused thereby.
E. In order for the HMO to conduct effective quality assurance and utilization review programs, each HMO shall develop written medical record policies and procedures and implement a medical records monitoring system that requires the maintenance of medical records by providers that are current, organized, and detailed. Such medical records monitoring system shall facilitate documentation and retrieval of clinical information. The HMO shall institute procedures to safeguard the confidentiality of individual enrollee medical records. Such records shall include, at a minimum, the following information:
1. The enrollee's name, identification number, date of birth, gender and place of residence;
2. Services delivered, including when, where and by whom services were provided; and
3. Medical diagnoses, treatments and therapies prescribed, medications administered or prescribed, referrals and follow-up arrangements.
F. New, amended, and extended contracts between the HMO and providers managed, owned, under contract with or employed by the HMO shall include provisions requiring the sharing between providers, who are treating or who have treated the same enrollee, of medical record information which facilitates the continuity of health care services, consistent with state and federal statutes and regulations.
G. The quality assurance program shall foster the provision of enrollee education relating to the prevention of illness and injury and the management of chronic illnesses and disabilities.
H. Each HMO shall coordinate the quality assurance program with the utilization review and the credentialing functions conducted by the HMO.
I. Each HMO shall make available to the Commissioner, upon request and in the form prescribed, documentation demonstrating the capacity to implement and/or the implementation of the quality assurance program including, but not limited to, the quality assurance plan, policies and procedures, program minutes, annual summary reports of quality assurance activities and evaluations, and focused or special studies.

3 CCR 702-4-7-03-6

37 CR 11, June 10, 2014, effective 7/1/2014
37 CR 12, June 25, 2014, effective 7/15/2014
Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/2014
37 CR 23, December 10, 2014, effective 1/1/2015
38 CR 03, February 10, 2015, effective 3/15/2015
38 CR 06, March 25, 2015, effective 4/30/2015
38 CR 09, May 10, 2015, effective 6/1/2015
38 CR 13, July 10, 2015, effective 7/30/2015
38 CR 19, October 10, 2015, effective 11/1/2015
38 CR 21, November 10, 2015, effective 1/1/2016
38 CR 23, December 10, 2015, effective 1/1/2016
39 CR 01, January 10, 2016, effective 2/1/2016
39 CR 05, March 10, 2016, effective 4/1/2016
39 CR 08, April 25, 2016, effective 5/15/2016
39 CR 19, October 10, 2016, effective 11/1/2016
39 CR 20, October 25, 2016, effective 1/1/2017
39 CR 22, November 25, 2016, effective 1/1/2017
39 CR 23, December 10, 2016, effective 1/1/2017
39 CR 23, December 25, 2016, effective 1/1/2017
40 CR 03, February 10, 2017, effective 3/15/2017
40 CR 09, May 10, 2017, effective 6/1/2017
40 CR 15, August 10, 2017, effective 9/1/2017
40 CR 17, September 10, 2017, effective 10/1/2017
40 CR 21, November 10, 2017, effective 12/1/2017
41 CR 04, February 25, 2018, effective 4/1/2018
41 CR 05, March 10, 2018, effective 6/1/2018
41 CR 08, April 25, 2018, effective 6/1/2018
41 CR 09, May 10, 2018, effective 6/1/2018
41 CR 11, June 10, 2018, effective 7/1/2018
41 CR 15, August 10, 2018, effective 9/1/2018
41 CR 17, September 10, 2018, effective 10/1/2018
41 CR 18, September 25, 2018, effective 10/15/2018
41 CR 21, November 10, 2018, effective 12/1/2018
41 CR 23, December 10, 2018, effective 1/1/2019
42 CR 01, January 10, 2019, effective 2/1/2019
41 CR 19, October 10, 2018, effective 3/1/2019
42 CR 03, February 10, 2019, effective 4/1/2019
42 CR 04, February 25, 2019, effective 4/1/2019
42 CR 06, March 25, 2019, effective 6/1/2019
42 CR 08, April 10, 2019, effective 6/1/2019
42 CR 15, August 10, 2019, effective 9/1/2019
42 CR 17, September 10, 2019, effective 10/1/2019
43 CR 02, January 25, 2020, effective 12/20/2019
43 CR 02, January 25, 2020, effective 12/23/2019
42 CR 23, December 10, 2019, effective 1/1/2020
43 CR 01, January 10, 2020, effective 2/1/2020
42 CR 24, December 25, 2019, effective 2/2/2020
43 CR 06, March 25, 2020, effective 4/15/2020
43 CR 10, May 25, 2020, effective 8/1/2020
43 CR 14, July 25, 2020, effective 8/15/2020
43 CR 17, September 10, 2020, effective 10/1/2020
43 CR 18, September 25, 2020, effective 11/1/2020
43 CR 22, November 25, 2020, effective 12/15/2020
43 CR 24, December 25, 2020, effective 1/15/2021
44 CR 03, February 10, 2021, effective 3/15/2021
44 CR 08, April 25, 2021, effective 5/15/2021
44 CR 09, May 10, 2021, effective 6/1/2021
44 CR 10, May 25, 2021, effective 6/14/2021
44 CR 10, May 25, 2021, effective 6/15/2021
44 CR 13, July 10, 2021, effective 8/1/2021
44 CR 15, August 10, 2021, effective 9/1/2021
44 CR 19, October 10, 2021, effective 11/1/2021
44 CR 21, November 10, 2021, effective 12/1/2021
44 CR 23, December 10, 2021, effective 12/30/2021
44 CR 21, November 10, 2021, effective 1/1/2022
44 CR 23, December 10, 2021, effective 1/15/2022
44 CR 24, December 25, 2021, effective 1/15/2022
45 CR 03, February 10, 2022, effective 3/2/2022
45 CR 08, April 25, 2022, effective 5/30/2022
45 CR 09, May 10, 2022, effective 5/30/2022
45 CR 10, May 25, 2022, effective 6/14/2022
45 CR 11, June 10, 2022, effective 6/30/2022
45 CR 11, June 10, 2022, effective 7/15/2022
45 CR 19, October 10, 2022, effective 11/1/2022
45 CR 20, October 25, 2022, effective 11/14/2022
45 CR 21, November 10, 2022, effective 11/30/2022
45 CR 24, December 25, 2022, effective 1/14/2023
46 CR 01, January 10, 2023, effective 2/14/2023
46 CR 06, March 25, 2023, effective 2/15/2023
46 CR 03, February 10, 2022, effective 3/2/2023
46 CR 04, February 25, 2023, effective 3/17/2023
46 CR 05, March 10, 2023, effective 4/15/2023
46 CR 09, May 10, 2023, effective 5/30/2023
46 CR 09, May 10, 2023, effective 6/1/2023
46 CR 10, May 25, 2023, effective 6/15/2023
46 CR 11, June 10, 2023, effective 6/30/2023