Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.03 - Maryland Medicaid Managed Care Program: MCO Application › Section 10.67.03.09 - Quality Assurance System - General

Current through Register Vol. 51, No. 14, July 12, 2024
An applicant shall include in its application the following
					 information or descriptions:
A. The
				  applicant's proposed quality assurance plan, that contains, at a minimum, all
				  elements specified by Health-General Article, §15-103(b)(9)(i), Annotated
				  Code of Maryland;
B. A description
				  of any written procedures or protocols regarding physician and nursing care
				  practice the applicant intends to use;
C. A description of the applicant's peer
				  review committee structure and process;
D. A copy of the applicant's case management
				  plan;
E. A description of all
				  mechanisms to be used to ensure the quality of any services, including
				  administrative and clinical, that the applicant intends to delegate to
				  subcontractors;
F. The name and a
				  description of the published standards or guidelines for maintenance of medical
				  records the applicant will follow;
G. A description of how providers will be
				  apprised of medical records, utilization review, and case management
				  requirements;
H. A description of
				  the applicant's system for ensuring inclusion in the medical record of reports
				  of health care services or diagnostic testing performed in a referral
				  setting;
I. A written description
				  of the applicant's internal review system for the handling, monitoring, and
				  resolution of provider complaints, grievances, and appeals;
J. Evidence of an adequate system for medical
				  record retention and retrieval that meets, at minimum, all requirements of
				  Health-General Article, §15-103(b)(9)(xiv), Annotated Code of
				  Maryland;
K. Documentary evidence
				  that the applicant requires school-based clinics to provide information
				  concerning health care services provided to their enrollees;
L. A copy of the applicant's practice
				  guidelines used to assist practitioners in approaching health care issues in a
				  systematic, appropriate manner;
M.
				  A copy of the applicant's health education plan;
N. A written description of the applicant's
				  complaint resolution protocol, which shall, at minimum:
(1) Include an internal grievance procedure
				  by which an enrollee who is dissatisfied with the applicant or its providers
				  may seek recourse within the applicant;
(2) Specify what constitutes a
				  grievance;
(3) Provide for prompt
				  resolution of complaints;
(4)
				  Require participation in the grievance process by individuals within the MCO
				  who have the authority to require corrective action;
(5) Specify how the MCO will handle formal
				  appeals by enrollees;
(6) Include a
				  form that enrollees will use when filing a grievance, including foreign
				  language versions for any substantial minorities in the applicant's proposed
				  MCO service area;
(7) Identify the
				  steps in the grievance process, and what personnel will be responsible for
				  receiving, processing, monitoring, and responding to grievances;
(8) Specify how the enrollee will be informed
				  that the enrollee's grievance is being investigated, and the protocols by which
				  grievances will be resolved;
(9)
				  Describe what methods will be used to inform enrollees about the operation of
				  the grievance procedure; and
(10)
				  Describe whether manual or automated processes will be used to track enrollees'
				  complaints, determine any patterns of complaints, and report findings to the
				  proposed MCO's quality assurance or quality improvement system; and