IC 27-13-6-1 Procedures; establishment
Sec. 1. (a) A health maintenance organization shall establish
procedures based on professionally recognized standards to assess
and monitor the health care services provided to enrollees of the
organization.
(b) The procedures established under this section must include
mechanisms to implement corrective action when necessary and to
assess the availability, accessibility, and continuity of care. As added by P.L.26-1994, SEC.25.
IC 27-13-6-2 Internal quality management program required
Sec. 2. A health maintenance organization shall have an ongoing
internal quality management program to monitor and evaluate the
health care services it provides, including:
(1) primary and specialist physician services; and
(2) ancillary and preventive health care services;
across all institutional and noninstitutional settings. As added by P.L.26-1994, SEC.25.
IC 27-13-6-3 Quality management program requirements
Sec. 3. The quality management program required by section 2 of
this chapter must include at least the following:
(1) A written statement of the scope and purpose of the health
maintenance organization's quality management program,
including a written statement of goals and objectives that
emphasizes improved health status in evaluating the quality of
care rendered to enrollees.
(2) The organizational structure responsible for quality
management activities.
(3) Any contractual arrangements, when appropriate, for
delegation of quality management activities.
(4) Confidentiality of policies and procedures.
(5) A system of ongoing evaluation activities.
(6) A system of focused evaluation activities.
(7) A system for credentialing providers and performing peer
review activities.
(8) Duties and responsibilities of the designated physician
responsible for the quality management activities. As added by P.L.26-1994, SEC.25.
IC 27-13-6-4 Written statement of quality management activities
Sec. 4. The quality management program required by section 2 of
this chapter must contain a written statement describing the system
of ongoing quality management activities, including the following:
(1) Problem assessment, identification, selection, and study.
(2) Corrective action, monitoring, evaluation, and reassessment.
(3) Interpretation and analysis of patterns of care rendered to
individual patients by individual providers.
(4) Comparison between patterns of care, including outcomes,
rendered to patients by providers and the cost to the health
maintenance organization of that care.
(5) A written statement describing the system of focused quality
assurance activities based on representative samples of the
enrolled population that identifies method of topic selection,
study, data collection, analysis, interpretation, and report
format. As added by P.L.26-1994, SEC.25.
IC 27-13-6-5 Written plans for correcting insufficient service
Sec. 5. The quality management program required by section 2 of
this chapter must contain written plans for taking appropriate
corrective action whenever the quality management program
determines that:
(1) inappropriate or substandard services have been provided;
or
(2) services that should have been provided were not provided. As added by P.L.26-1994, SEC.25.
IC 27-13-6-6 Patient record system
Sec. 6. A health maintenance organization shall ensure the use and
maintenance of an adequate patient record system that will facilitate:
(1) documentation and retrieval of clinical information to
enable the health maintenance organization to evaluate
continuity and coordination of patient care; and
(2) the assessment of the quality of health and medical care
provided to enrollees. As added by P.L.26-1994, SEC.25.
IC 27-13-6-7 Reporting quality management program activities
Sec. 7. A health maintenance organization shall establish a
mechanism for periodic reporting of quality management program
activities to the governing body, providers, and appropriate staff of
the organization. As added by P.L.26-1994, SEC.25.
IC 27-13-6-8 Records of proceedings; confidentiality
Sec. 8. A health maintenance organization shall:
(1) record the proceedings of formal quality management
program activities; and
(2) maintain its documentation of the quality management
program in a confidential manner. As added by P.L.26-1994, SEC.25.
IC 27-13-6-9 Inspection of records by commissioner
Sec. 9. The commissioner may inspect the records of a health
maintenance organization's quality management program. The health
maintenance organization shall cooperate with the inspections by
making available to the commissioner the records requested by the
commissioner, while protecting the confidentiality of enrollee
medical records. As added by P.L.26-1994, SEC.25.
IC 27-13-6-10 Hospital accreditation
Sec. 10. (a) A health maintenance organization may not refuse to
enter into an agreement with a hospital solely because the hospital
has not obtained accreditation from an accreditation organization
that:
(1) establishes standards for the organization and operation of
hospitals;
(2) requires the hospital to undergo a survey process for a fee
paid by the hospital; and
(3) was organized and formed in 1951.
(b) This section does not prohibit a health maintenance
organization from using performance indicators or quality standards
that:
(1) are developed by private organizations; and
(2) do not rely upon a survey process for a fee charged to the
hospital to evaluate performance. As added by P.L.259-1995, SEC.3.
IC 27-13-6-1 Procedures; establishment
Sec. 1. (a) A health maintenance organization shall establish
procedures based on professionally recognized standards to assess
and monitor the health care services provided to enrollees of the
organization.
(b) The procedures established under this section must include
mechanisms to implement corrective action when necessary and to
assess the availability, accessibility, and continuity of care. As added by P.L.26-1994, SEC.25.
IC 27-13-6-2 Internal quality management program required
Sec. 2. A health maintenance organization shall have an ongoing
internal quality management program to monitor and evaluate the
health care services it provides, including:
(1) primary and specialist physician services; and
(2) ancillary and preventive health care services;
across all institutional and noninstitutional settings. As added by P.L.26-1994, SEC.25.
IC 27-13-6-3 Quality management program requirements
Sec. 3. The quality management program required by section 2 of
this chapter must include at least the following:
(1) A written statement of the scope and purpose of the health
maintenance organization's quality management program,
including a written statement of goals and objectives that
emphasizes improved health status in evaluating the quality of
care rendered to enrollees.
(2) The organizational structure responsible for quality
management activities.
(3) Any contractual arrangements, when appropriate, for
delegation of quality management activities.
(4) Confidentiality of policies and procedures.
(5) A system of ongoing evaluation activities.
(6) A system of focused evaluation activities.
(7) A system for credentialing providers and performing peer
review activities.
(8) Duties and responsibilities of the designated physician
responsible for the quality management activities. As added by P.L.26-1994, SEC.25.
IC 27-13-6-4 Written statement of quality management activities
Sec. 4. The quality management program required by section 2 of
this chapter must contain a written statement describing the system
of ongoing quality management activities, including the following:
(1) Problem assessment, identification, selection, and study.
(2) Corrective action, monitoring, evaluation, and reassessment.
(3) Interpretation and analysis of patterns of care rendered to
individual patients by individual providers.
(4) Comparison between patterns of care, including outcomes,
rendered to patients by providers and the cost to the health
maintenance organization of that care.
(5) A written statement describing the system of focused quality
assurance activities based on representative samples of the
enrolled population that identifies method of topic selection,
study, data collection, analysis, interpretation, and report
format. As added by P.L.26-1994, SEC.25.
IC 27-13-6-5 Written plans for correcting insufficient service
Sec. 5. The quality management program required by section 2 of
this chapter must contain written plans for taking appropriate
corrective action whenever the quality management program
determines that:
(1) inappropriate or substandard services have been provided;
or
(2) services that should have been provided were not provided. As added by P.L.26-1994, SEC.25.
IC 27-13-6-6 Patient record system
Sec. 6. A health maintenance organization shall ensure the use and
maintenance of an adequate patient record system that will facilitate:
(1) documentation and retrieval of clinical information to
enable the health maintenance organization to evaluate
continuity and coordination of patient care; and
(2) the assessment of the quality of health and medical care
provided to enrollees. As added by P.L.26-1994, SEC.25.
IC 27-13-6-7 Reporting quality management program activities
Sec. 7. A health maintenance organization shall establish a
mechanism for periodic reporting of quality management program
activities to the governing body, providers, and appropriate staff of
the organization. As added by P.L.26-1994, SEC.25.
IC 27-13-6-8 Records of proceedings; confidentiality
Sec. 8. A health maintenance organization shall:
(1) record the proceedings of formal quality management
program activities; and
(2) maintain its documentation of the quality management
program in a confidential manner. As added by P.L.26-1994, SEC.25.
IC 27-13-6-9 Inspection of records by commissioner
Sec. 9. The commissioner may inspect the records of a health
maintenance organization's quality management program. The health
maintenance organization shall cooperate with the inspections by
making available to the commissioner the records requested by the
commissioner, while protecting the confidentiality of enrollee
medical records. As added by P.L.26-1994, SEC.25.
IC 27-13-6-10 Hospital accreditation
Sec. 10. (a) A health maintenance organization may not refuse to
enter into an agreement with a hospital solely because the hospital
has not obtained accreditation from an accreditation organization
that:
(1) establishes standards for the organization and operation of
hospitals;
(2) requires the hospital to undergo a survey process for a fee
paid by the hospital; and
(3) was organized and formed in 1951.
(b) This section does not prohibit a health maintenance
organization from using performance indicators or quality standards
that:
(1) are developed by private organizations; and
(2) do not rely upon a survey process for a fee charged to the
hospital to evaluate performance. As added by P.L.259-1995, SEC.3.
IC 27-13-6-1 Procedures; establishment
Sec. 1. (a) A health maintenance organization shall establish
procedures based on professionally recognized standards to assess
and monitor the health care services provided to enrollees of the
organization.
(b) The procedures established under this section must include
mechanisms to implement corrective action when necessary and to
assess the availability, accessibility, and continuity of care. As added by P.L.26-1994, SEC.25.
IC 27-13-6-2 Internal quality management program required
Sec. 2. A health maintenance organization shall have an ongoing
internal quality management program to monitor and evaluate the
health care services it provides, including:
(1) primary and specialist physician services; and
(2) ancillary and preventive health care services;
across all institutional and noninstitutional settings. As added by P.L.26-1994, SEC.25.
IC 27-13-6-3 Quality management program requirements
Sec. 3. The quality management program required by section 2 of
this chapter must include at least the following:
(1) A written statement of the scope and purpose of the health
maintenance organization's quality management program,
including a written statement of goals and objectives that
emphasizes improved health status in evaluating the quality of
care rendered to enrollees.
(2) The organizational structure responsible for quality
management activities.
(3) Any contractual arrangements, when appropriate, for
delegation of quality management activities.
(4) Confidentiality of policies and procedures.
(5) A system of ongoing evaluation activities.
(6) A system of focused evaluation activities.
(7) A system for credentialing providers and performing peer
review activities.
(8) Duties and responsibilities of the designated physician
responsible for the quality management activities. As added by P.L.26-1994, SEC.25.
IC 27-13-6-4 Written statement of quality management activities
Sec. 4. The quality management program required by section 2 of
this chapter must contain a written statement describing the system
of ongoing quality management activities, including the following:
(1) Problem assessment, identification, selection, and study.
(2) Corrective action, monitoring, evaluation, and reassessment.
(3) Interpretation and analysis of patterns of care rendered to
individual patients by individual providers.
(4) Comparison between patterns of care, including outcomes,
rendered to patients by providers and the cost to the health
maintenance organization of that care.
(5) A written statement describing the system of focused quality
assurance activities based on representative samples of the
enrolled population that identifies method of topic selection,
study, data collection, analysis, interpretation, and report
format. As added by P.L.26-1994, SEC.25.
IC 27-13-6-5 Written plans for correcting insufficient service
Sec. 5. The quality management program required by section 2 of
this chapter must contain written plans for taking appropriate
corrective action whenever the quality management program
determines that:
(1) inappropriate or substandard services have been provided;
or
(2) services that should have been provided were not provided. As added by P.L.26-1994, SEC.25.
IC 27-13-6-6 Patient record system
Sec. 6. A health maintenance organization shall ensure the use and
maintenance of an adequate patient record system that will facilitate:
(1) documentation and retrieval of clinical information to
enable the health maintenance organization to evaluate
continuity and coordination of patient care; and
(2) the assessment of the quality of health and medical care
provided to enrollees. As added by P.L.26-1994, SEC.25.
IC 27-13-6-7 Reporting quality management program activities
Sec. 7. A health maintenance organization shall establish a
mechanism for periodic reporting of quality management program
activities to the governing body, providers, and appropriate staff of
the organization. As added by P.L.26-1994, SEC.25.
IC 27-13-6-8 Records of proceedings; confidentiality
Sec. 8. A health maintenance organization shall:
(1) record the proceedings of formal quality management
program activities; and
(2) maintain its documentation of the quality management
program in a confidential manner. As added by P.L.26-1994, SEC.25.
IC 27-13-6-9 Inspection of records by commissioner
Sec. 9. The commissioner may inspect the records of a health
maintenance organization's quality management program. The health
maintenance organization shall cooperate with the inspections by
making available to the commissioner the records requested by the
commissioner, while protecting the confidentiality of enrollee
medical records. As added by P.L.26-1994, SEC.25.
IC 27-13-6-10 Hospital accreditation
Sec. 10. (a) A health maintenance organization may not refuse to
enter into an agreement with a hospital solely because the hospital
has not obtained accreditation from an accreditation organization
that:
(1) establishes standards for the organization and operation of
hospitals;
(2) requires the hospital to undergo a survey process for a fee
paid by the hospital; and
(3) was organized and formed in 1951.
(b) This section does not prohibit a health maintenance
organization from using performance indicators or quality standards
that:
(1) are developed by private organizations; and
(2) do not rely upon a survey process for a fee charged to the
hospital to evaluate performance. As added by P.L.259-1995, SEC.3.
