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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 408. Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees
11/21/2024

12VAC5-408-100. Examination by a nationally recognized accreditation organization.

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.

B. Accreditation by a nationally recognized accrediting body will not be accepted in lieu of the comprehensive onsite examination unless the accreditation standards are appropriate for the type of plan seeking exemption from the department's comprehensive onsite examination.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 16, Issue 7, eff. January 20, 2000; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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