(1) STANDARDS; OTHER THAN PREFERRED PROVIDER PLANS. A defined network plan that is not a preferred provider plan shall develop comprehensive quality assurance standards that are adequate to identify, evaluate, and remedy problems related to access to, and continuity and quality of, care. The standards shall include at least all of the following: (a) An ongoing, written internal quality assurance program. (b) Specific written guidelines for quality of care studies and monitoring. (c) Performance and clinical outcomes-based criteria. (d) A procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action. (e) A plan for gathering and assessing data. (f) A peer review process. (1m) PROCEDURE FOR REMEDIAL ACTION; PREFERRED PROVIDER PLANS. A preferred provider plan shall develop a procedure for remedial action to address quality problems, including written procedures for taking appropriate corrective action. (2) SELECTION AND EVALUATION OF PROVIDERS. (a) A defined network plan shall develop a process for selecting participating providers, including written policies and procedures that the plan uses for review and approval of providers. After consulting with appropriately qualified providers, the plan shall establish minimum professional requirements for its participating providers. The process for selection shall include verification of a provider’s license or certificate, including the history of any suspensions or revocations, and the history of any liability claims made against the provider. (b) A defined network plan shall establish in writing a formal, ongoing process for reevaluating each participating provider within a specified number of years after the provider’s initial acceptance for participation. The reevaluation shall include all of the following: 1. Updating the previous review criteria. 2. Assessing the provider’s performance on the basis of such criteria as enrollee clinical outcomes, number of complaints and malpractice actions. (c) A defined network plan may not require a participating provider to provide services that are outside the scope of his or her license or certificate.
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