1. The health maintenance organization shall establish procedures to assure that the health care services provided to enrollees will be rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. The procedures must include mechanisms to assure availability, accessibility, and continuity of care. 2. The health maintenance organization must have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, across all institutional and noninstitutional settings. The program must include, at a minimum, the following: a. A written statement of goals and objectives which emphasizes improved health status in evaluating the quality of care rendered to enrollees. b. A written quality assurance plan which describes the following: (1) The health maintenance organization's scope and purpose in quality assurance. (2) The organizational structure responsible for quality assurance activities. (3) Contractual arrangements, when appropriate, for delegation of quality assurance activities. (4) Confidentiality 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 assurance activities. c. A written statement describing the system of ongoing quality assurance activities, including: (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. d. A written statement describing the system of focused quality assurance activities based on representative samples of the enrolled population which identifies method of topic selection, study, data collection, analysis, interpretation, and report format. e. Written plans for taking appropriate corrective action whenever, as determined by the quality assurance program, inappropriate or substandard services have been provided or services which should have been furnished have not been provided. 3. The organization shall record proceedings of formal quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes must be available to the commissioner. 4. The organization shall ensure the use and maintenance of an adequate patient record system which will facilitate documentation and retrieval of clinical information for the purpose of the health maintenance organization evaluating continuity and coordination
of patient care and assessing the quality of health and medical care provided to enrollees. 5. Enrollee clinical records must be available to the commissioner or an authorized designee for examination and review to ascertain compliance with this section, or as deemed necessary by the commissioner. The clinical records are confidential and are not subject to section 44-04-18, except upon written consent for disclosure by the enrollee or the enrollee's authorized representative. 6. The organization shall establish a mechanism for periodic reporting of quality assurance program activities to the governing body, providers, and appropriate organization staff.
26.1-18.1-07. Requirements for group contract, individual contract, and evidence of coverage. 1. a. Every group and individual contractholder is entitled to a group or individual contract. b. The contract may not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by chapter 26.1-04. c. The contract must contain a clear statement of the following: (1) Name and address of the health maintenance organization. (2) Eligibility requirements. (3) Benefits and services within the service area. (4) Emergency care benefits and services. (5) Out-of-area benefits and services, if any. (6) Copayments, deductibles, or other out-of-pocket expenses. (7) Limitations and exclusions. (8) Enrollee termination. (9) Enrollee reinstatement, if any. (10) Claims procedures. (11) Enrollee grievance procedures. (12) Continuation of coverage. (13) Conversion. (14) Extension of benefits, if any. (15) Coordination of benefits, if applicable. (16) Subrogation, if any. (17) Description of the service area. (18) Entire contract provision. (19) Term of coverage. (20) Cancellation of group or individual contractholder. (21) Renewal. (22) Reinstatement of group or individual contractholder, if any. (23) Grace period. (24) Conformity with state law. An evidence of coverage may be filed as part of the group contract to describe the provisions required in this subdivision. 2. In addition to those provisions required in subdivision c of subsection 1, an individual contract must provide for a ten-day period to examine and return the contract and have the premium refunded. If services were received during the ten-day period, and the person returns the contract to receive a refund of the premium paid, the person must pay for the services. 3. a. Every subscriber shall receive an evidence of coverage from the group contractholder or the health maintenance organization. b. The evidence of coverage may not contain provisions or statements which are unfair, unjust, inequitable, misleading, deceptive, or which encourage misrepresentation as defined by chapter 26.1-04.
c. The evidence of coverage must contain a clear statement of the provisions required in subdivision c of subsection 1. 4. The commissioner may adopt rules establishing readability standards for individual contract, group contract, and evidence of coverage forms. 5. No group or individual contract, evidence of coverage, or amendment thereto may be delivered or issued for delivery in this state, unless its form has been filed with and approved by the commissioner, as provided by sections 26.1-30-19 and 26.1-30-20. 6. The provisions set forth in sections 26.1-30-20 and 26.1-30-21 govern the approval and disapproval of forms required to be filed under this section. 7. The commissioner may require the submission of whatever relevant information the commissioner deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.