HARRY HUGHES, Governor

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(IV)  REVIEW AND UPDATE CONTINUING EDUCATION
PROGRAMS FOR HEALTH PROFESSIONALS PROVIDING SERVICES TO ITS
MEMBERS;

(V)  IDENTIFY NEEDED CHANGE AND PROPOSED
MODIFICATIONS TO IMPLEMENT THE CHANGE; AND

(VI)  MAINTAIN WRITTEN RECORDS OF THE INTERNAL
PEER REVIEW PROCESS.

(F) (1) THE DEPARTMENT SHALL CONDUCT AN EXTERNAL REVIEW OF
THE QUALITY OF THE HEALTH SERVICES OF THE HEALTH MAINTENANCE
ORGANIZATION IN A MANNER THAT THE DEPARTMENT CONSIDERS TO BE
APPROPRIATE.

(2)  THE EXTERNAL REVIEW SHALL BE CONDUCTED BY:

(I)  A PANEL OF PHYSICIANS AND OTHER HEALTH
PROFESSIONALS THAT CONSISTS OF PERSONS WHO:

1.  HAVE BEEN APPROVED BY THE DEPARTMENT;

2.  HAVE SUBSTANTIAL EXPERIENCE IN THE
DELIVERY OF HEALTH CARE IN A HEALTH MAINTENANCE ORGANIZATION
SETTING, BUT WHO ARE NOT MEMBERS OF THE HEALTH MAINTENANCE
ORGANIZATION STAFF OR PERFORMING PROFESSIONAL SERVICES FOR THE
HEALTH MAINTENANCE ORGANIZATION; AND

3.  RESIDE OUTSIDE THE AREA SERVICED BY
THE HEALTH MAINTENANCE ORGANIZATION;

(II)  THE DEPARTMENT; OR

(III)  A FEDERALLY APPROVED PROFESSIONAL
STANDARDS REVIEW ORGANIZATION.

(3)  THE FINAL DECISION ON THE TYPE OF EXTERNAL REVIEW
THAT IS TO BE EMPLOYED RESTS SOLELY WITH THE DEPARTMENT.

(4)  THE EXTERNAL REVIEW SHALL CONSIST OF A REVIEW AND
EVALUATION OF:

(I)  AN INTERNAL PEER REVIEW SYSTEM AND REPORTS;

(II)  THE PROGRAM PLAN OF THE HEALTH MAINTENANCE
ORGANIZATION TO DETERMINE IF IT IS ADEQUATE AND BEING FOLLOWED;

(III)  THE PROFESSIONAL STANDARDS AND PRACTICES
OF THE HEALTH MAINTENANCE ORGANIZATION IN EVERY AREA OF SERVICES
PROVIDED;

(IV)  THE GRIEVANCES RELATING SPECIFICALLY TO
THE DELIVERY OF MEDICAL CARE, INCLUDING THEIR FINAL DISPOSITION;

(V)  THE PHYSICAL FACILITIES AND EQUIPMENT; AND