Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 657 - Certified Workplace Medical Plans › Subchapter 5 - Quality Assurance › Section 310:657-5-4 - Inspections

Current through Vol. 41, No. 20, July 1, 2024
(a) For purposes of conducting the site
				visit, the Department may inspect any person, or the business of any person,
				insofar as such inspection is necessary or material to the investigation of the
				Plan.
(b) The refusal of any Plan
				by its officers, directors, employees or agents to submit to the inspection or
				to comply with any reasonable written request of the inspectors shall be
				grounds for suspension, revocation or nonrenewal of any certification or
				authority held by the Plan to engage in business subject to the Department's
				jurisdiction.
(c) In the case of a
				annual site visit, the Department may provide advance notice of not longer than
				15 working days to the Plan by telephone and/or written means of communication.
(1) Such notification may include a request
				for the Plan to provide case, dispute and/or grievance listings to the
				Department to allow Department consideration and possible selection of samples
				prior to arriving at the Plan's office.
(2) In advance of an announced site visit or
				upon arrival of an unannounced site visit, the Department may request to have
				Plan materials and personnel available which includes, but not limited to the
				following:
(A) Current Organizational
				Chart;
(B) Listing of current
				personnel and those person's direct-dial telephone numbers or
				extensions;
(C) Assignment of a
				single Plan representative to serve as the Department's primary contact during
				the course of the on-site inspection;
(D) Current Master Client Report, or other
				comprehensive listing of contracts currently or previously in place, including
				counts of CWMP participants;
(E)
				Current listing of contracted Insurers and/or Insureds; and
(F) Assignment of one or more persons to:
(i) Conduct a preliminary walk-through tour
				of the offices;
(ii) Explain to the
				Department staff how physical files are arranged;
(iii) Explain to the Department staff what
				files are electronic only and will require a Department request to the Plan's
				primary contact person for printing or visual inspection;
(iv) Explain the process for entering or
				leaving the Plan's office;
(v)
				Explain how case management is assigned;
(vi) Explain how the Plan monitors
				caseloads;
(vii) Explain how the
				Plan receives cases from the payer.
(G) Provision for Departmental file reviews,
				of any written:
(i) Case management policies
				and procedures;
(ii) Utilization
				review policies and procedures;
(iii) Case management forms;
(iv) Utilization review forms;
(v) Case management form letters;
(vi) Utilization review letters;
(vii) Communication standards;
(viii) Account specific
				instructions;
(ix) List of all
				routine audits or other QA procedures; and
(x) List of the prior periods' explicit
				Medical Director or Peer Reviews.
(H) Specific personnel, by title, that the
				Department initially anticipates interviewing during the course of the site
				visit to ensure that those persons will be available.
(I) Such other material that the Department
				requires to be assembled for inspection such as Policies and Procedures changed
				since the last application for certification or renewal.