reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 405 - RULES GOVERNING PRIVATE REVIEW AGENTS › Section 12VAC5-405-100 - Access to and confidentiality of medical records and information

Current through Register Vol. 40, No. 24, July 15, 2024
A. Private review
				agents who have been granted a certificate by the department shall have
				reasonable access to patient-specific medical records and
				information.
B. The private review
				agent's procedures shall specify that specific information exchanged for the
				purpose of conducting review will be considered confidential, be used by the
				private review agent solely for the purposes of utilization review, and shared
				by the private review agent with only those parties who have authority to
				receive such information, such as the claim administrator. The private review
				agent's process shall specify that procedures are in place to assure
				confidentiality and that the private review agent agrees to abide by any
				federal and state laws governing the issue of confidentiality. Summary data
				which does not provide sufficient information to allow identification of
				individual patients or providers need not be considered confidential.
C. When consistent with subsection B of this
				section and federal and state statutes and regulations, patient-specific data
				gathered by the private review agent which raises questions of deficiencies in
				quality may be shared with the hospital's or other facility's Quality Assurance
				Committee. Prior to the sharing of such information, a private review agent may
				require the hospital or other facility to assure compliance with
				confidentiality requirements, to assure the appropriate review and follow-up
				within that hospital's or other facility's Quality Assurance Committee, and to
				indemnify the private review agent from inappropriate use of such
				information.
D. Chapter 6 (§
				38.2-600 et seq.) of Title 38.2 and § 32.1-127.1:03 of the Code of
				Virginia shall apply to private review agents. Prior to the release of
				patient-specific information to a private review agent, a patient shall provide
				written consent for the release of such information. If the patient will not
				authorize the release of information, or has refused to sign the release of
				information forms, the private review agent may then follow its own policy or
				that of the insurer regarding that refusal.
E. Medical records and patient-specific
				information shall be maintained by the private review agent in a secure area
				with access limited to essential personnel only.
F. Information generated and obtained by
				private review agents in the course of utilization review shall be retained for
				at least five years if the information relates to a case for which an adverse
				decision was made at any point or if the information relates to a case which
				may be reopened.
Statutory Authority
§§ 32.1-138.7 and 32.1-138.15 of the Code of
					 Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 405 - RULES GOVERNING PRIVATE REVIEW AGENTS › Section 12VAC5-405-110 - Accessibility

Current through Register Vol. 40, No. 24, July 15, 2024
A. A private review
				agent shall provide free telephone access to patients and providers at least 40
				hours per week during normal business hours. Private review agents must have a
				mechanism for informing patients and providers of the eastern time zone hours
				during which those agents are accessible; such eastern time zone hours shall be
				no less than 40 hours per week during normal business hours.
B. It is the responsibility of the private
				review agent to install and maintain an adequate telephone system that accepts
				and records messages or accepts and provides recorded business hour information
				for incoming calls outside of normal business hours.
C. The department may determine, upon written
				request, that other telephone systems are adequate in special
				circumstances.
Statutory Authority
§§ 32.1-138.7 and 32.1-138.15 of the Code of
					 Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 405 - RULES GOVERNING PRIVATE REVIEW AGENTS › Section 12VAC5-405-120 - Examination of private review agents

Current through Register Vol. 40, No. 24, July 15, 2024
A. The department may conduct reviews of the
				operations of private review agents operating in this Commonwealth to determine
				if the private review agent is operating in compliance with this chapter and
				Article 2.1 (§ 32.1-138.6 et seq.) of Chapter 5 of Title 32.1 of the Code
				of Virginia. The reviews may include telephone audits to determine if the
				private review agents are accessible as required by this chapter.
B. The department may investigate any
				complaint from a health care provider or patient regarding the compliance of a
				private review agent with the requirements of this chapter or Article 2.1 of
				Chapter 5 of Title 32.1 of the Code of Virginia.
C. The investigation of private review agents
				shall not include individual determinations of medical necessity or appropriate
				charges for covered services. If there is evidence which indicates an alleged
				pattern of misconduct with respect to utilization review performed by a private
				review agent, the department may take such action it deems appropriate to
				correct such pattern of misconduct.
Statutory Authority
§§ 32.1-138.7 and 32.1-138.15 of the Code of
					 Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 405 - RULES GOVERNING PRIVATE REVIEW AGENTS › Form - FORMS (12VAC5-405)

Current through Register Vol. 40, No. 24, July 15, 2024
Application for Certification as a Private Review Agent
				  (eff. 7/99).
Renewal Application for Recertification as a Private Review
				  Agent (eff. 7/99).
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part I - Definitions and General Information › Section 12VAC5-407-10 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter
					 shall have the following meanings unless the context clearly indicates
					 otherwise:
"Board" means State Board of Health.
"Commissioner" means the State Health Commissioner.
"Consumer" means any person (i) whose occupation is other
					 than the administration of health activities or the provision of health
					 services; (ii) who has no fiduciary obligation to a health care institution or
					 other health agency or to any organization, public or private, whose principal
					 activity is an adjunct to the provision of health services; or (iii) who has no
					 material financial interest in the rendering of health services.
"Department" means the Virginia Department of
					 Health.
"Health maintenance organization" or "HMO" means any person
					 who undertakes to provide or to arrange for one or more health care plans
					 pursuant to Chapter 43 (§ 38.2-4300 et seq.) of Title 38.2 of the Code of
					 Virginia.
"HEDIS" means the Health Employer Data and Information Set,
					 also known as the Healthcare Effectiveness Data and Information Set, a set of
					 standardized performance measures collected and maintained by the National
					 Committee for Quality Assurance.
"NCQA" means the National Committee for Quality
					 Assurance.
"Nonprofit organization" means a nonprofit, tax-exempt
					 health data organization with the characteristics, expertise, and capacity to
					 execute the powers and duties set forth for such entity in Chapter 7.2 (§
					 32.1-276.2 et seq.) of Title 32.1 of the Code of Virginia and that enters into
					 a contract for the compilation, storage, analysis, and evaluation of data
					 pursuant to Chapter 7.2 of Title 32.1.
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part I - Definitions and General Information › Section 12VAC5-407-20 - Applicability

Current through Register Vol. 40, No. 24, July 15, 2024
This chapter shall apply to all HMOs with an active license
					 to operate in this Commonwealth.
Statutory Authority
§§ 32.1-12 and 32.1-276.6 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part II - Quality of Care Data Reporting › Section 12VAC5-407-30

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part II - Quality of Care Data Reporting › Section 12VAC5-407-40

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part II - Quality of Care Data Reporting › Section 12VAC5-407-50 - Reporting methods and exemption from reporting

Current through Register Vol. 40, No. 24, July 15, 2024
A. Every HMO with an active license in the
				  Commonwealth shall be required to submit the HEDIS or any other quality of care
				  or performance information set approved by the board unless granted a written
				  exemption by the commissioner.
B.
				  The following methods shall be used for data submission:
1. If the HMO submits data to NCQA, the
				  commissioner may purchase HEDIS data or any other quality of care or
				  performance information set from NCQA.
2. If the HMO does not submit data to NCQA,
				  or the commissioner elects not to purchase HEDIS data from the NCQA, then the
				  HMO shall submit the performance information sets approved by the board to the
				  nonprofit organization in accordance with the timeframes established in
				  12VAC5-407-70.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part II - Quality of Care Data Reporting › Section 12VAC5-407-60 - Audited data required

Current through Register Vol. 40, No. 24, July 15, 2024
HMOs shall submit HEDIS or other quality of care or
					 performance information set approved by the board that has been verified by an
					 independent auditing organization with no financial interest in or managerial
					 association with the HMO. The HMO shall submit an audit report with the
					 data.
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part II - Quality of Care Data Reporting › Section 12VAC5-407-70 - Process for data submission

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Before January 1 of each year, the commissioner shall submit to each HMO in
				  writing the process required for data submission, the fee associated with data
				  submission, and the process for obtaining a waiver. HMOs providing HEDIS or any
				  other quality of care or performance information set directly to the nonprofit
				  organization shall submit the data by September 15 of each year.
B. The board shall direct the nonprofit
				  organization to publish annually the quality information data before December
				  31.
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part II - Quality of Care Data Reporting › Section 12VAC5-407-80 - Fees

Current through Register Vol. 40, No. 24, July 15, 2024
A. For each HMO
				  required to provide information pursuant to this chapter, the board shall
				  prescribe a reasonable fee to cover the cost of collecting and making available
				  such data. The commissioner may purchase HEDIS data or other quality of care or
				  performance information set on behalf of all the actively licensed HMOs in the
				  Commonwealth that are participating in HEDIS and divide the cost among the
				  HMOs. Each HMO shall pay an equal share of the cost to the board for purchase
				  of the HEDIS data directly from NCQA. The remainder of the cost associated with
				  making the data available shall be divided among the participating HMOs in a
				  tiered format based on the number of enrollees per HMO.
B. Fees described in subsection A of this
				  section shall not exceed $3,000 per HMO per year.
C. The payment of such fees shall be on
				  September 15 of each year or later if determined by an agreement between the
				  board and the nonprofit organization. The nonprofit organization shall be
				  authorized to charge and collect the fees prescribed by the board in subsection
				  A of this section when the data are provided directly to the nonprofit
				  organization. Such fees shall not exceed the amount authorized by the
				  board.
D. The nonprofit
				  organization shall be authorized to charge and collect reasonable fees approved
				  by the board for making available to any individual or entity who requests the
				  HEDIS data or other approved quality of care data; however, the commissioner,
				  the State Corporation Commission, and the Commissioner of Behavioral Health and
				  Developmental Services shall be entitled to receive relevant and appropriate
				  data from the nonprofit organization at no charge.
E. The board shall direct the nonprofit
				  organization to solicit input from the HMO industry to determine relevant and
				  appropriate data that the industry shall receive at no charge.
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part II - Quality of Care Data Reporting › Section 12VAC5-407-90 - Late charge

Current through Register Vol. 40, No. 24, July 15, 2024
A. A late charge
				  of $25 per working day shall be paid to the board by an HMO that has not
				  received an exemption from the commissioner as provided for in
				  12VAC5-407-50 and that has not
				  paid the assessed fees by September 15 or later if determined by an agreement
				  between the board and the nonprofit. The late charge may not be assessed until
				  completion of a 30-day grace period for submitting the data.
B. Late charges may be waived by the board,
				  in its discretion, if an HMO can show that an extenuating circumstance exists.
				  Examples of an extenuating circumstance may include, but are not limited to,
				  the installation of a new computerized system, a bankruptcy proceeding, or
				  change of ownership in the HMO.
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part III - Duties of the Board and the Nonprofit Organization › Section 12VAC5-407-100 - Duties of the nonprofit organization

Current through Register Vol. 40, No. 24, July 15, 2024
The contract entered into by the board and the nonprofit
					 organization pursuant to Chapter 7.2 (§ 32.1-276.2 et seq.) of Title 32.1
					 of the Code of Virginia shall provide:
1. The nonprofit organization shall compile,
				  store, and make available to consumers the data submitted by HMOs.
2. The nonprofit organization shall assist
				  the board in developing a summary plan and budget to collect and make available
				  HMO HEDIS or any other quality of care performance information set results for
				  consumers. The nonprofit organization shall present the summary plan and budget
				  on a biennial basis to the board for approval. The commissioner, at his
				  discretion, shall also review the summary plan on a periodic basis to determine
				  its effectiveness.
3. The nonprofit
				  organization shall collect the HEDIS data in the most cost-effective manner
				  available.
4. The nonprofit
				  organization shall prepare a biennial summary plan in identifying the measures
				  selected for reporting. The summary plan shall include:
a. The rationale for selecting each measure
				  to be made available to consumers;
b. The goal of reporting each
				  measure;
c. The cost and benefit of
				  collecting the measures and making them available to consumers; and
d. The scope of dissemination of information
				  in paper or electronic format and the target audience.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part III - Duties of the Board and the Nonprofit Organization › Section 12VAC5-407-110 - Biennial evaluation

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  board shall evaluate biennially the impact and effectiveness of collecting and
				  making available HEDIS or any other quality of care or performance information
				  set and the appropriateness of the fee structure. This evaluation shall be
				  completed by January 15.
B. As part
				  of the biennial evaluation, the board may consult with the HMOs and the
				  nonprofit organization to determine whether changes should be made to the HEDIS
				  or any other quality of care or performance information set
				  requirements.
Statutory Authority
§§ 32.1-12 and 32.1-276.6 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 407 - PROCEDURES FOR THE SUBMISSION OF HEALTH MAINTENANCE ORGANIZATION QUALITY OF CARE PERFORMANCE INFORMATION › Part III - Duties of the Board and the Nonprofit Organization › Section 12VAC5-407-120

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§ 32.1-12 and 32.1-276.5
						of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-20 - Responsibility of the department

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The Code of Virginia allows the Board of Health to adopt regulations for the
				  certification of quality assurance for managed care health insurance plans
				  licensees. The Department of Health is charged with the responsibility for
				  examining the quality of health care services provided by, arranged for, paid
				  for, or reimbursed by managed care health insurance plan licensees according to
				  regulations adopted by the board and any additional requirements that may be
				  specified by the Code of Virginia. The Center for Quality Health Care Services
				  and Consumer Protection acts as agent for the department for certifying managed
				  care health insurance plans, which includes investigating complaints made
				  against an MCHIP licensee.
B. In
				  developing or revising these regulations, the department adheres to the
				  requirements of the Administrative Process Act (§ 2.2-4000 et seq. of the
				  Code of Virginia) and the public participation process. The department solicits
				  input from MCHIPs, associations of MCHIPs, providers, experts in related
				  fields, advocacy organizations, consumers and the general public in the
				  development or revision of this chapter through informal and formal comment
				  periods and public hearings.
C. The
				  department shall coordinate its activities with the Bureau of Insurance to
				  ensure an appropriate level of regulatory oversight and to avoid undue
				  duplication of effort or regulation.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-40 - Fees

Current through Register Vol. 40, No. 24, July 15, 2024
A. The center shall
				  collect a fee for each initial application and each renewal application. MCHIP
				  licensees with multiple plans wishing to submit a separate application for each
				  plan must include the appropriate fee for each application. Fees shall
				  accompany the application and are not refundable.
B. Fees shall be sufficient to cover
				  reasonable costs for the administration of the quality assurance
				  program.
C. Fees shall be based
				  upon a percentage, not to exceed 1/10 of 1.0%, of the proportion of direct
				  gross premium income on business done in this Commonwealth attributable to the
				  operation of managed care health insurance plans in the preceding biennium not
				  to exceed $10,000 per plan submitted by the licensee for separate
				  certification.
After July 2000, applicants proposing to offer MCHIP plans
					 in the Commonwealth shall be assessed a flat fee of $5,000 for the initial
					 application for a certificate of quality assurance.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-50 - Compliance provisions appropriate for type of plan

Current through Register Vol. 40, No. 24, July 15, 2024
A. Managed care health insurance plan
				  licensees that offer one or more PPO plans as defined in this chapter must
				  require their PPO plans to only comply with the following sections:
1. Parts I (12VAC5-408-10 et seq.) and II
				  (12VAC5-408-160 et seq.) of this
				  chapter;
2. Part III (12VAC5-408-220 et seq.) of this
				  chapter except for subdivision 1 of
				  12VAC5-408-220 and subdivisions 2
				  and 10 of 12VAC5-408-240;
3.
											12VAC5-408-260 through
				  12VAC5-408-280 of this chapter
				  except subsection E of
				  12VAC5-408-260, subsections D and
				  E of 12VAC5-408-270 and subsection G of
				  12VAC5-408-280; and
4. Parts VI (12VAC5-408-320 et seq.) and VII
				  (12VAC5-408-360 ) of this chapter.
The MCHIP licensee may comply with
					 12VAC5-408-170,
					 12VAC5-408-200, as well as
					 subdivisions A 2 through A 4 of this section, by demonstrating it operates a
					 PPO plan in conformity with the standards of a nationally recognized
					 accrediting body applicable to preferred provider organizations and acceptable
					 to the department. While such demonstration shall be considered reasonable and
					 adequate compliance for purposes of initial and renewal MCHIP certification,
					 the department may employ a checklist to identify and determine compliance with
					 specific statutory or regulatory requirements that are more stringent than the
					 nationally recognized accrediting body standards.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-60 - General examination process

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The commissioner shall cause MCHIP licensees to be examined or reviewed by the
				  department according to Article 1.1 (§ 32.1-137.1 et seq.) of Chapter 5 of
				  Title 32.1 of the Code of Virginia to:
1.
				  Verify that an MCHIP qualifies for an initial or renewal certificate of quality
				  assurance;
2. Investigate a
				  complaint filed against an MCHIP licensee;
3. Determine compliance with this chapter and
				  applicable law; and
4. Determine if
				  the MCHIP licensee has successfully implemented corrective action following an
				  examination, or as a result of disciplinary action or sanction.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-70 - Administrative review

Current through Register Vol. 40, No. 24, July 15, 2024
A. The initial
				  examination shall be an administrative review of the application for
				  certificate of quality assurance and supporting documentation that includes:
1. The items listed in subsections F, G, H,
				  and I of 12VAC5-408-160, except that if the
				  MCHIP is accredited by a nationally recognized accrediting body appropriate for
				  the type of MCHIP and approved by the department, it shall not be required to
				  include in its application the items listed in subdivisions F 5, G 2, G 3, G 7
				  and subsection I;
2. A copy of the
				  most recent accreditation report executive summary, as applicable issued to the
				  MCHIP or to the MCHIP's licensee from a nationally recognized accrediting body
				  that evaluates quality assurance programs, with the written corrective action
				  response, if any;
3. For MCHIP
				  licensees that have been cited by another state or the District of Columbia
				  concerning their quality assurance program, a copy of the most recent report of
				  an examination of the quality of health care provided by the MCHIP under
				  similar laws and regulations of another state, with a copy of the written
				  corrective action response, if any;
4. The most recent report of any examination
				  of the quality assurance program provided by the MCHIP issued by a federal
				  regulatory agency with similar laws and regulations. Submission of this report
				  shall not be necessary if the MCHIP provides a copy of the report required by
				  subdivision 2 of this subsection with the written corrective action plan, if
				  any; and
5. The department may
				  coordinate with the Bureau of Insurance to obtain information that may assist
				  its review.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-80 - Renewal application

Current through Register Vol. 40, No. 24, July 15, 2024
A. Every
				  MCHIP licensee shall request renewal of its certificate of quality assurance
				  biennially with the department. The purpose of the renewal examination shall be
				  to determine if the MCHIP has maintained compliance with applicable laws and
				  regulations since the last certificate of quality assurance was issued or
				  renewed, and whether the MCHIP is using its best efforts to meet its quality
				  assurance goals as set forth in its quality assurance plan.
B. The renewal examination shall include an
				  administrative review of the renewal application and supporting documentation
				  that includes:
1. The items listed in
				  subsections F, G, H, and I of
				  12VAC5-408-160, except that if the
				  MCHIP is accredited by a nationally recognized accrediting body appropriate for
				  the type of MCHIP and acceptable to the department, it shall not be required to
				  include in its application the items listed in subdivisions F 5, G 2, G 3, G 7
				  and subsection I;
2. The annual
				  complaint reports;
3. The MCHIP's
				  formal written evaluations of its quality assurance program expectations for
				  the time period since the MCHIP's last application for a certificate of quality
				  assurance;
4. A copy of the most
				  recent accreditation report executive summary, as applicable, issued to the
				  MCHIP or to the licensee from a nationally recognized accrediting body that
				  evaluates quality assurance programs if the report was issued after the
				  issuance of the current certificate from the department, provided that
				  resubmission of the most recent accreditation report previously submitted in
				  the prior initial or renewal application shall not be required, unless there
				  has been a completed accreditation survey since that time that has led to
				  renewal, suspension, or denial of accreditation and the written corrective
				  action plan in response to the report, if applicable, shall also be
				  submitted;
5. For MCHIP licensees
				  that have been cited by another state or the District of Columbia concerning
				  the quality of health care provided or administered, a copy of the most recent
				  report of an examination of the quality of health care provided by the MCHIP
				  under similar laws and regulations of another state or the District of
				  Columbia, and a copy of the written corrective action response; and
6. A copy of the report of any examination of
				  the MCHIP by a federal regulatory body with similar laws and regulations issued
				  since the certificate of quality assurance was last issued or renewed, provided
				  that submission of this report shall not be necessary if the MCHIP licensee
				  submits a copy of the report required by subdivision 4 of this
				  subsection.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-90 - Comprehensive onsite examination

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The comprehensive onsite examination represents a periodic quality assurance
				  evaluation process designed to ensure that the MCHIP licensee has in place the
				  appropriate systems and processes to meet the requirements set forth in this
				  chapter.
B. A comprehensive onsite
				  examination shall be conducted triennially except for MCHIPs that meet the
				  criteria specified in
				  12VAC5-408-100 pertaining to
				  nationally recognized accreditation.
C. The comprehensive onsite examination shall
				  take place:
1. At a time established by the
				  department with 90 days advance notification to the MCHIP licensee;
2. In conjunction with a Bureau of Insurance
				  market conduct examination of the licensee; or
3. At the request of the MCHIP licensee in
				  agreement with the department following the completion of an initial
				  administrative review examination for certification in order to document any
				  corrective action taken in response to the initial examination.
At the department's discretion and in response to
					 complaints against the MCHIP licensee or the MCHIP, the department may expand a
					 complaint investigation to a comprehensive examination to determine compliance
					 with the MCHIP laws and regulations if it appears that covered person's health
					 and safety may be jeopardized.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-100 - Examination by a nationally recognized accreditation organization

Current through Register Vol. 40, No. 24, July 15, 2024
A. The department
				  shall accept the accreditation of an MCHIP licensee or MCHIP by a nationally
				  recognized accrediting body appropriate to the type of MCHIP and approved by
				  the department in lieu of the triennial comprehensive onsite examination
				  described in
				  12VAC5-408-90 under the following
				  conditions:
1. Conditional or provisional
				  accreditation may be considered acceptable for meeting the requirements of this
				  chapter provided that a second examination by a nationally recognized
				  accrediting body is scheduled and completed within 15 to 18 months of the date
				  a decision for conditional or provisional accreditation is made by the
				  accrediting body, and that the second examination leads to an accreditation
				  status that is not conditional or provisional.
2. The MCHIP licensee shall release to the
				  department a copy of a report or document from a nationally recognized
				  accrediting body containing that body's final report, or evaluation of the
				  MCHIP's compliance with accreditation standards. The department may, at its
				  discretion and on a case-by-case basis, request from the licensee any and all
				  reports, letters and memoranda issued by the nationally recognized accrediting
				  body to the licensee regarding the licensee's accreditation application or its
				  evaluation for accreditation. In the event a licensee is granted only
				  conditional or provisional accreditation, any written materials generated by
				  the licensee regarding corrective or remedial action to be taken for achieving
				  compliance with the accreditation standards shall also be released to the
				  department at the same time the nationally recognized accrediting body is
				  notified. The MCHIP licensee shall forward copies of the executive summary of
				  its accreditation report to the department within 10 days of receipt by the
				  MCHIP licensee, unless otherwise directed by the department.
3. The MCHIP licensee notifies the department
				  of the date of its accreditation examination.
The department reserves the right to conduct a
					 comprehensive examination of an accredited MCHIP when it appears that the
					 health and safety of the covered persons may be jeopardized.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-110 - Corrective action procedures

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Within 30 business days of the conclusion of the examination, the department
				  shall provide the MCHIP licensee with a written summary of violations of the
				  regulations or laws and any factual findings used as a basis to determine that
				  a violation has occurred.
B. The
				  department shall require the MCHIP licensee to submit a written plan of
				  correction specifying how each violation will be corrected along with the time
				  frames for completion of each corrective action. A single plan of correction
				  shall address all events associated with a given violation. The plan of
				  correction, when required, shall be submitted by the MCHIP licensee within 20
				  business days of receipt of the notice of violation, or sooner, if the
				  department determines that the violations jeopardize the safety of covered
				  persons.
C. The plan of correction
				  shall be approved when the MCHIP licensee demonstrates to the satisfaction of
				  the department that compliance will be achieved. If the plan of correction is
				  not approved, the department may request that an amended plan of correction be
				  submitted within 10 business days, or sooner, if the department determines that
				  the violations jeopardize the safety of covered persons.
D. The summary of violations and the plan of
				  correction shall not be released as public information until the department has
				  approved the plan of correction or, in the event no plan of correction is
				  required, after 20 business days of receipt of the summary of violations by the
				  MCHIP licensee, whichever is sooner.
E. Unless otherwise documented, the
				  department will presume receipt of the summary of violations by the MCHIP
				  licensee by the seventh business day when mailed return receipt
				  requested.
F. Failure of the MCHIP
				  licensee to successfully implement the written plan of correction within a
				  specified time period may result in an administrative sanction.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-120 - Changes to geographic service areas

Current through Register Vol. 40, No. 24, July 15, 2024
A. No MCHIP shall operate in a manner that
				  varies in a material manner with the geographic service area information
				  submitted pursuant to this chapter. Any changes in such information which would
				  result in operational changes that vary in a material manner with the
				  information currently on file with the department shall be subject to the
				  department's prior approval.
B. The
				  request for a material change in a geographic service area shall include:
1. A description of the current geographic
				  service area including a map of the current service area, a list of current
				  primary care and specialty physicians and other providers, and the number of
				  covered persons by service area.
2.
				  An explanation as to whether the MCHIP is requesting an expansion or a
				  reduction in its service area.
3.
				  Notification that the MCHIP licensee has inquired of the Bureau of Insurance as
				  to whether or not the service area request constitutes a material change and
				  the bureau's determination, if available.
4. If a service area expansion is proposed,
				  then the following is required:
a. A
				  description of the service area that includes a map of the geographic service
				  area expansion, projections of new enrollment, a listing of new primary care
				  and specialty providers and other providers and their locations, and physician
				  capacity to accept the anticipated enrollment;
b. Information necessary to determine if the
				  MCHIP licensee will be capable of conforming to the access, availability, and
				  travel requirements of
				  12VAC5-408-260 and
				  12VAC5-408-270; and
c. The methodology used to determine that the
				  current health care system in the proposed service area can support the
				  expansion.
5. If an
				  MCHIP is reducing or eliminating a service area, the following information is
				  required:
a. A description of the service
				  area being reduced or eliminated;
b. The reason for the reduction or
				  elimination of the service area and the effective date on which health care
				  services will no longer be available through the MCHIP; and
c. Any information required by the department
				  to determine that MCHIP covered persons are ensured continuity of care during
				  the transition.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-130 - Complaint system, complaint examination and investigation

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each MCHIP
				  licensee shall establish and maintain for each of its MCHIPs a complaint system
				  approved by the department and the Bureau of Insurance to provide reasonable
				  procedures for the resolution of complaints.
B. The department, on behalf of the
				  commissioner and in cooperation with the Bureau of Insurance, shall examine the
				  complaint system for compliance of the system with applicable statutes and
				  regulations and shall require corrections or modifications as necessary. The
				  effectiveness of the complaint system in allowing covered persons, or their
				  duly authorized representatives, to have issues regarding quality assurance
				  appropriately resolved shall be assessed by the department.
C. The department has the responsibility to
				  investigate complaints regarding quality of care violations filed by or on
				  behalf of covered persons.
D. Every
				  person from whom information is sought in an investigation of a complaint
				  against an MCHIP licensee shall cooperate in producing, or allowing reasonable
				  access during regular business hours to, the books, records, files, accounts,
				  papers, documents, and any or all computer or other recordings of the licensee
				  being examined or those of any person or delegated services entity delivering
				  health care services under contract, affiliation, delegation or other
				  arrangement. Information shall be limited to that which is relevant to the
				  investigation in question.
E.
				  Deficiencies found during a complaint investigation shall be corrected as
				  required in
				  12VAC5-408-110.
F. When the investigation is complete, the
				  MCHIP licensee and the complainant will be notified of the findings of the
				  investigation.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-140 - Administrative sanctions

Current through Register Vol. 40, No. 24, July 15, 2024
A. Nothing
				  in this part shall prohibit the department from exercising its responsibility
				  and authority to enforce applicable law and this chapter including proceeding
				  directly to imposition of administrative sanctions.
B. The department, in consultation with the
				  Bureau of Insurance, may impose such administrative sanctions or take such
				  actions as are appropriate for violation of any of the regulations or laws.
				  Such sanctions include:
1. Imposing civil
				  monetary penalties, which shall not exceed $1,000 per incident of
				  noncompliance, to a maximum of $10,000 for a series of related incidents of
				  noncompliance;
2. Placing a
				  certificate holder on probation;
3.
				  Temporarily suspending a certificate of quality assurance;
4. Temporarily restricting or prohibiting,
				  with the concurrence of the Bureau of Insurance, new enrollments into an
				  MCHIP;
5. Revoking or not renewing
				  a certificate of quality assurance and certifying to the Bureau of Insurance
				  that an MCHIP licensee or its managed care health insurance plan is unable to
				  fulfill its obligations to furnish quality health care services; or
6. Other remedies as provided by state or
				  federal law.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part I - Definitions and General Information › Section 12VAC5-408-150 - Surrender of certificate

Current through Register Vol. 40, No. 24, July 15, 2024
A. Upon
				  revocation or suspension of a certificate or loss of license, the MCHIP
				  licensee must surrender its certificate to a representative of the
				  center.
B. In the event an MCHIP
				  licensee voluntarily ceases operation, it shall provide at least 90 business
				  days advance written notice to all covered persons, employers, providers, the
				  department, and the Bureau of Insurance. The notice shall identify the storage
				  location of business and medical records, where applicable, and procedures for
				  obtaining copies of such records.
Statutory Authority
§ 32.1-137.1 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part II - Administrative Services › Section 12VAC5-408-160 - Management and administration

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  No person shall establish or operate a managed care health insurance plan in
				  Virginia without first obtaining a license from the Bureau of Insurance and a
				  certificate of quality assurance from the department.
B. The MCHIP licensee must comply with:
1. This chapter;
2. Other applicable federal, state or local
				  laws and regulations; and
3. The
				  MCHIP licensee's own policies and procedures.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part II - Administrative Services › Section 12VAC5-408-170 - Provider credentialing and recredentialing

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCHIP
				  licensee shall establish and maintain a comprehensive credentialing
				  verification program to ensure its providers meet the minimum standards of
				  professional licensure or certification. Written supporting documentation for
				  providers who have completed their residency or fellowship requirements for
				  their specialty area more than 12 months prior to the credentialing decision
				  shall include:
1. Current valid license and
				  history of licensure or certification;
2. Status of hospital privileges, if
				  applicable;
3. Valid DEA
				  certificate, if applicable;
4.
				  Information from the National Practitioner Data Bank, as available;
5. Education and training, including post
				  graduate training, if applicable;
6. Specialty board certification status, if
				  applicable;
7. Practice or work
				  history covering at least the past five years; and
8. Current, adequate malpractice insurance
				  and malpractice history of at least the past five years.
Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 408 - CERTIFICATE OF QUALITY ASSURANCE OF MANAGED CARE HEALTH INSURANCE PLAN LICENSEES › Part II - Administrative Services › Section 12VAC5-408-180 - Complaint system

Current through Register Vol. 40, No. 24, July 15, 2024
A. Every MCHIP
				  licensee shall establish and maintain a system for the resolution of complaints
				  brought by covered persons, or by providers acting on behalf of an covered
				  person and with the covered person's consent, including complaints regarding
				  availability, delivery, or quality of health care services, or any other matter
				  pertaining to the covered person's contractual relationship or status as a
				  third party beneficiary with the MCHIP.
The system shall include:
1. Written notification to all covered
				  persons of the procedures, including telephone numbers and addresses, for
				  contacting the MCHIP with a complaint and telephone numbers and addresses of
				  the complaint unit of the center and the Office of the Managed Care Ombudsman
				  to help with complaints or appeals;
2. A description of the process used to
				  investigate and resolve complaints, including specific time lines for each step
				  in the complaint process; and
3. A
				  description of the process used to document and track the status of all
				  complaints and compile the complaint information required to be reported to the
				  department under § 32.1-137.6C of the Code of Virginia.