Title 31A Insurance Code Chapter 8 Health Maintenance Organizations and Limited Health Plans Section 104 Determination of ability to provide services.
31A-8-104.Determination of ability to provide services.
(1) The commissioner may not issue a certificate of authority to an applicant for a
certificate of authority under this chapter unless the commissioner has determined that the
applicant has:
(a) demonstrated the willingness and potential ability to furnish the proposed health care
services in a manner to assure both availability and accessibility of adequate personnel and
facilities and continuity of service;
(b) arrangements for an ongoing quality of health care assurance program concerning
health care processes and outcomes, established in accordance with rules adopted by the director
of the Department of Health based upon prevailing standards for quality assurance for other forms
of health care delivery in this state; and
(c) a procedure, established in accordance with rules of the director of the Department of
Health, to develop, compile, evaluate, and report statistics relating to the cost of its operations,
the pattern of utilization of its services, the availability and accessibility of its services, and such
other matters as may be reasonably required by the director of the Department of Health.
(2) Upon receipt of an application for a certificate of authority under this chapter, the
commissioner shall transmit a copy of the application and accompanying documents to the
director of the Department of Health. Upon receipt of the application, the director of the
Department of Health shall review the application, investigate the surrounding facts and
circumstances, and make a finding concerning whether the applicant satisfies the requirements of
Subsection (1). The director of the Department of Health is considered to have found the
applicant to comply with Subsection (1) unless he delivers to the commissioner a finding of
noncompliance within 90 days after receiving the application from the commissioner.
(3) In determining whether the requirements of Subsection (1) are satisfied, the
commissioner shall rely on the findings of the director of the Department of Health delivered to
the commissioner in accordance with Subsection (2).
(4) A finding of noncompliance with Subsection (1) shall specify in what respects the
applicant is deficient in meeting the requirements of Subsection (1).
(5) An organization's certificate of authority issued under this chapter is conclusive
evidence of compliance with Subsection (1), as to the services authorized to be performed under
the certificate of authority, except in a proceeding by the state against the organization. Licensing
under this chapter does not exempt an organization from any licensing requirement applicable
under Title 26, Chapter 21.
Amended by Chapter 185, 1997 General Session
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