Rule 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.Ga. Comp. R. & Regs. R. 120-2-80-.08
O.C.G.A. Secs. 33-2-9, 33-20A-2, 33-20A-4, 33-20A-5.
Original Rule entitled "Quality Assurance" adopted. F. Mar. 20, 1998; eff. Apr. 9, 1998.