Quality assurance standards - 28 Pa. Code § 9.674

A managed care plan must have an ongoing quality assurance program that includes review, analysis and assessment of the access, availability and provision of health care services; the plan must meet the following standards for its program:1

•         Document all quality assurance activities and quality improvement accomplishments;
•         Ensure that all participating health care providers maintain current and comprehensive medical records which conform to standard medical practice;
•         Include consideration of clinical aspects of care, access, availability and continuity of care in the review of quality;
•         Provide mechanisms for the sharing of results with health care providers in an educational format to solicit input and promote continuous improvement;
•         Annually present to its board of directors a report of the plan’s activities documenting studies undertaken, evaluation of results, subsequent actions recommended and implemented, and aggregate data; and
•         Include regularly updated standards for the following:

o       Health promotion;

o       Early detection and prevention of disease;

o       Injury prevention for all ages;

o       Systems to identify special chronic and acute care needs as early as possible; and

o       Access to routine, urgent and emergent appointments.