N.J. Admin. Code § 11:24A-3.8

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:24A-3.8 - Continuous quality improvement

(a) Carriers shall have or employ a CQI program to monitor the quality of their UM program under the direction of the carrier's medical director.

(b) A carrier shall set forth its system for its CQI program in a plan reviewable upon request by the Department specifying the following:

1. The scope and purpose of the program;

2. The organizational structure of quality improvement activities;

3. The duties and responsibilities of the medical director (or designee);

4. Contractual arrangements, if any, for delegation of quality improvement activities;

5. Confidentiality policies and procedures;

6. Specifications of standards for the assessment of the adequacy and appropriateness of health care resources utilized;

7. A system of on-going evaluation activities;

8. A system of monitoring satisfaction of covered persons; and

9. A system for evaluation of the effectiveness of the CQI program.

(c) The carrier shall establish a multidisciplinary CQI committee to be responsible for the implementation and operation of the CQI program, which shall be composed of representatives of the carrier's medical, nursing and administrative staff, with substantial involvement of the carrier's medical director.

1. The committee shall maintain minutes of its meetings, and such minutes shall be reviewable, upon request, by the Department.

2. The committee shall monitor provider and member access to utilization management services including waiting times to respond to phone requests for service authorization, member urgent care inquiries, and other services required for the carrier's UM program.

3. The committee shall prepare an annual report on the carrier's CQI activities, which shall be available for review upon request by the Department, delineating quality improvements, performance measures used and their results, and demonstrated improvements in service quality, corrective action recommendations, including corrections to policies and procedures of the carrier, and educational activities for covered persons.

(d) The carrier shall follow-up on the findings of its CQI committee to assure that recommendations made are implemented effectively, and shall document the corrective actions taken and the results of their outcome, which documentation shall be reviewable upon request by the Department.

(e) The carrier shall coordinate its CQI activities with other performance monitoring activities it may have, if any.

(f) The Department's review of a carrier's health benefits plan that has been approved as a selective contracting arrangement is not intended to be duplicative of, but complementary to, the review of the carrier's utilization review program and quality assurance program made pursuant to N.J.A.C. 11:4-37.4(c)6 and 7.

N.J. Admin. Code § 11:24A-3.8

Amended by 50 N.J.R. 985(a), effective 3/5/2018