(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 (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.
Five Year Review (FYR) Dates: 08/26/2015 and 08/25/2020
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