DEPARTMENT OF REGULATORY AGENCIES Colorado Medical Board Rule 360 - DESIGNATION OF HEALTH MAINTENANCE ORGANIZATIONS AUTHORIZED TO ESTABLISH PROFESSIONAL REVIEW COMMITTEES 3 CCR 713-27 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] INTRODUCTION A. BASIS: The authority for promulgation of rules and regulations by the Colorado Medical Board (“Board” ) is set forth in Sections 24-4-103, 12-36-104 (1)(a) and 12-36.5-104(5), C.R.S.

B. PURPOSE: These rules have been adopted by the Board to:

1. Establish standards for the designation of a professional review committee composed of physicians by a health maintenance organization as authorized by the Board to establish professional review committees in order that such committee and health maintenance organization will be entitled to the immunities and confidentiality provided by Section 12- 36.5-101, et seq. , C.R.S.;

2. Effectuate the legislative policy set forth in Section 12-36.5-101, et seq. , C.R.S., by encouraging members of a professional review committee established by a health maintenance organization to openly, honestly and effectively study and review the conduct of practice by physicians who contract with a health maintenance organization and subject themselves to the authority of the professional review committee, including the quality of service rendered by those physicians; and 3. Enable the Board to more effectively regulate the conduct of the practice of medicine by encouraging the prompt, accurate and complete reporting or instances of unprofessional conduct by peers in the medical profession.

RULES AND REGULATIONS REGARDING THE DESIGNATION OF HEALTH MAINTENANCE ORGANIZATION PROFESSIONAL REVIEW COMMITTEES AND THE CORRESPONDING GRANT OF IMMUNITY In order for a health maintenance organization to be authorized to establish a professional review committee pursuant to Section 12-36.5-104(5), C.R.S., and to be entitled to the immunities provided by Section 12-36.5-101, et seq. , C.R.S., such health maintenance organization and committee must comply with the following:

1. The health maintenance organization must be federally qualified or state qualified, and must have a certificate of authority to operate as a health maintenance organization in the State of Colorado.

2. Except as set forth below with regard to a medical director of the health maintenance organization, the professional review committee established by the health maintenance organization must be composed only of physicians who are licensed to practice medicine in the State of Colorado and who have entered into a contract or subcontract to provide medical services to enrollees of the health maintenance organization. A medical director of the health maintenance organization may be a non-voting member of the professional review committee.

3. The committee shall have jurisdiction to review only physicians and licensed health care providers (a) who have entered into a contract or subcontract to provide medical services to enrollees of the health maintenance organization; and (b) who have agreed to be subject to the authority of such committee.

4. Any professional review action taken by the professional review committee and the health maintenance organization affecting the affiliation of a physician with the health maintenance organization will be taken in conformity with state and federal law, including the procedures set forth in the Colorado Peer Review Statutes, Section 12-36.5-101, et seq. , C.R.S.

5. Upon issuing its recommendation to the health maintenance organization’s governing board for final action, the professional review committee shall also forward a copy of its recommendation to the Board in accordance with Section 12-36.5-104(7)(f). If the Board determines, after initial review, consideration or investigations that the alleged conduct of the physician does not involve a violation of the Colorado Medical Practice Act, Section 12-36-101, et seq. , C.R.S., the reports of information submitted by the professional review committee and related documents or proceedings of the Board shall be confidential and not subject to public inspection or disclosure.

6. Records submitted to the Board by a peer review committee of a designated health maintenance organization shall be entitled to protection against release or disclosure consistent with state and federal law.

Effective: 9/30/98; REVISED 11/13/2003; EFFECTIVE 12/31/2003; Revised 08/19/10; Effective 10/15/10 _____________________________________________________ Editor’s Notes History Entire Rule eff. 10/15/2010.