California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 7 - Standards › Section 1300.67.2.3 - Timely Access Quality Assurance for Measurement Year 2022

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Quality
				  Assurance Processes for Measurement Year 2022. Each plan shall have written
				  quality assurance systems, policies and procedures designed to ensure that the
				  plan's network is sufficient to provide accessibility, availability and
				  continuity of covered health care services as required by the Knox-Keene Act
				  and this section. In addition to the requirements established by Rule 1300.70,
				  a plan's quality assurance program shall address:
(1) Standards for the provision of covered
				  services in a timely manner consistent with the requirements of this
				  section.
(2) Compliance monitoring
				  policies and procedures, filed for the Department's review and approval,
				  designed to accurately measure the accessibility and availability of contracted
				  providers, which shall include:
(A) Tracking
				  and documenting network capacity and availability with respect to the standards
				  set forth in Rule 1300.67.2.2(c);
(B) Conducting an annual enrollee experience
				  survey, which shall be conducted in accordance with a valid and reliable survey
				  methodology and designed to ascertain compliance with the standards set forth
				  at Rule 1300.67.2.2(c);
(C)
				  Conducting an annual provider survey, which shall be conducted in accordance
				  with a valid and reliable survey methodology and designed to solicit, from
				  physicians and non-physician mental health providers, perspective and concerns
				  regarding compliance with the standards set forth at Rule
				  1300.67.2.2(c);
(D) Reviewing and
				  evaluating, on not less than a quarterly basis, the information available to
				  the plan regarding accessibility, availability and continuity of care,
				  including but not limited to information obtained through enrollee and provider
				  surveys, enrollee grievances and appeals, and triage or screening services;
				  and
(E) Verifying the advanced
				  access programs reported by network providers, medical groups and independent
				  practice associations to confirm that appointments are scheduled consistent
				  with the definition of advanced access in Rule 1300.67.2.2(b)(1).
(F) A plan that provides services through a
				  preferred provider organization network may, for that portion of its network,
				  demonstrate compliance with subsections (a)(2)(A) and (D) of this Rule by
				  monitoring, on not less than an annual basis the following: the number of PPO
				  primary care and specialty physicians under contract with the plan in each
				  county of the plan's network service area; enrollee grievances and appeals
				  regarding timely access; and the rates of compliance with the time-elapsed
				  standards established in Rule 1300.67.2.2, subsection
				  (c)(5).
(3) A plan shall
				  implement prompt investigation and corrective action when compliance monitoring
				  discloses that the plan's network is not sufficient to ensure timely access as
				  required by this section, including taking all necessary and appropriate action
				  to identify the cause(s) underlying identified timely access deficiencies and
				  to bring its network into compliance. Plans shall give advance written notice
				  to all network providers affected by a corrective action, and shall include a
				  description of the identified deficiencies, the rationale for the corrective
				  action, and the name and telephone number of the person authorized to respond
				  to provider concerns regarding the plan's corrective
				  action.