(2) FUNCTIONS.—A quality improvement pro-
gram established pursuant to paragraph (1) shall—
(A) assess the performance of the organi-
zation and its participating health care profes-
sionals and providers and report the results of
such assessment to purchasers, participating
health care professionals and providers, and ad-
ministrative personnel;
(B) demonstrate measurable improvements
in clinical outcomes and plan performance
measured by identified criteria, including those
specified in paragraph (1)(A); and
(C) analyze quality assessment data to de-
termine specific interactions in the delivery sys-
tem (both the design and funding of the health
care coverage and the clinical provision of care)
that have an adverse impact on the quality of
care.
(b) UTILIZATION REVIEW.—The utilization review
program of a managed care organization shall—
(1) be developed (including any screening cri-
teria used by such program) with the involvement of
participating health professionals and providers;
(2) to the extent consistent with the protection
of proprietary business information (as defined for
purposes of section 552 of title 5, United States
Code) release, upon request, to affected health pro-
fessionals, providers, and enrollees the screening cri-
teria, weighting elements, and computer algorithms
used in reviews and a description of the method by
which they were developed;
(3) uniformly apply review criteria that are
based on sound scientific principles and the most re-
cent medical evidence;
(4) use licensed, accredited, or certified health
professionals to make review determinations (and for
services requiring specialized training for their deliv-
ery, use a health professional who is qualified
through equivalent specialized training and experi-
ence);
(5) subject to reasonable safeguards, disclose to
health professionals and providers, upon request, the
names and credentials of individuals conducting uti-
lization review;
(6) not compensate individuals conducting utili-
zation review for denials of payment or coverage of
benefits;
(7) comply with the requirement of section
4(d)(1) that prior authorization not be required for
emergency and related services furnished in a hos-
pital emergency department;
(8) make prior authorization determinations—
(A) in the case of services that are urgent
care services described in section 4(d)(2)(C),
within 30 minutes of a request for such deter-
mination, and
(B) in the case of other services, within 24
hours after the time of a request for determina-
tion;
(9) include in any notice of such determination
an explanation of the basis of the determination and
the right to an immediate appeal;
(10) treat a favorable prior authorization review
determination as a final determination for purposes
of making payment for a claim submitted for the
item or service involved unless such determination
was based on false information knowingly supplied
by the person requesting the determination;
(11) provide timely access, as defined by the
applicable State authority, to utilization review per-
sonnel and, if such personnel are not available,
waives any prior authorization that would otherwise
be required; and
(12) provide notice of an initial determination
on payment of a claim within 30 days after the date
the claim is submitted for such item or service, and
include in such notice an explanation of the reasons
for such determination and of the right to an imme-
diate appeal.
SEC. 12. MINIMUM LOSS RATIOS; GENERAL CONSUMER
PROTECTIONS.
(a) MINIMUM LOSS RATIO.—The loss-ratio (as de-
fined by the Secretary) for a managed care organization
shall not be less than 85 percent with respect to managed
care plans it offers.
(b) PARTICIPATION IN POLICY DEVELOPMENT.—A
managed care organization shall have a procedure whereby
enrollees may participate in the development of policies of
the organization.
(c) NEEDS OF NON-ENGLISH PROFICIENT ENROLL-
EES.—A managed care organization shall have procedures
for addressing the needs of enrollees who are not pro-
ficient in English.
Æ