Section R2-6-205. Performance Standards for Health, Dental, and Vision Insurance Plans

As required under A.R.S. § 38-651, the Department establishes and shall require that a plan provider comply with the following mini- mum performance standards:

1.        Cost competitiveness. A plan provider shall offer the Department a discount from full-billed charges that is sig- nificant and an administrative fee that is reasonable when compared with the discount and administrative fee of other potential plan providers.

2.        Utilization review. A plan provider of medical manage- ment services shall employ utilization review standards that are generally accepted in the industry and specified by the Department in contract.

3.        Network development and access. A plan provider of a medical network shall comply with the access and avail- ability requirements that the Department develops based on the location of participants and specifies in contract.

4.        Conversion and implementation. A plan provider shall fully perform in accordance with all requirements that the Department specifies in contract from the date on which the contract begins until the date on which the contract ends or is terminated after giving proper notice.

5.        Report accuracy and timeliness. A plan provider shall ensure that all reports are complete, accurate, and submit- ted as specified in contract.

6.        Quality outcomes. A plan provider shall comply with the quality-outcome standards that the Department specifies in contract. The Department may offset expenses, costs, or damages incurred as a result of the plan provider fail- ing to comply with the specified quality-outcome stan- dards against any sums due to the plan provider.

7.        Customer satisfaction. The Department shall annually measure the extent to which participants are satisfied with a plan provider’s services.

Historical Notes

Adopted effective July 27, 1983 (Supp. 83-4). Former Section R2-6-205 repealed, new Section R2-6-205 renumbered from R2-6-105 effective September 16, 1997 (Supp. 97-3). Section repealed; new Section adopted by final rulemaking at 5 A.A.R. 2514, effective July 15,

1999 (Supp. 99-3). Section expired under A.R.S. § 41-

1056(E) at 8 A.A.R. 5017, effective September 30, 2002 (Supp. 02-4). New Section made by final rulemaking at 15 A.A.R. 258, effective March 7, 2009 (Supp. 09-1).