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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
6/22/2024

12VAC5-408-230. Program requirements.

A. The MCHIP licensee shall be structured operationally to administer the quality assurance program. The quality assurance operations shall include, but not be limited to:

1. Establishing performance goals designed to improve the quality of health care services provided by the MCHIP licensee and governed by the certificate;

2. Developing a quality assurance plan to implement the goals;

3. Measuring and assessing the MCHIP licensee's performance in meeting the goals;

4. Implementing activities based upon the assessments to improve and maintain performance;

5. Integrating the quality assurance activities of appropriate organizational units, providers, delegated service providers, and the governing body into the quality assurance program and providing feedback to those entities;

6. Enlisting covered person input through sources such as satisfaction surveys, reviews of complaints, appeals, and requests to change providers;

7. Maintaining and documenting the licensee's compliance with state and federal laws, as well as private accreditation requirements, if applicable, that govern the MCHIP licensee's quality assurance program; and

8. Ensuring that the MCHIP licensee's quality assurance goals are communicated to all appropriate organizational units of the MCHIP licensee and delegated health service entities and made available to covered persons and providers upon request.

B. The quality assurance program shall be managed by professional personnel qualified by training and experience to implement the MCHIP licensee's program goals. The organizational relationship and responsibilities for quality assurance shall be clearly defined.

C. The quality assurance program shall be structured to include:

1. Operations accountable for the quality assurance program;

2. A quality assurance program advisory committee whose members include covered persons and representatives from the operations responsible for quality assurance, utilization management, provider affairs, credentialing, complaints and appeals, customer service, medical records, and data management; and

3. A designated physician or clinical professional appropriate to the type of the MCHIP licensee.

D. The MCHIP licensee shall designate a board-certified physician or clinical professional appropriate to the type of MCHIP to serve as the designated physician or clinical professional.

E. The designated physician, or clinical professional as appropriate to the type of MCHIP licensee, must have substantial involvement in the quality assurance program. Substantial involvement may be evidenced by:

1. Defining the responsibilities and interrelationships for professional services;

2. Coordinating, supervising and overseeing the functioning of professional services;

3. Providing input into the medical performance of providers;

4. Overseeing the continuing in-service education of the MCHIP's professional staff;

5. Providing clinical direction and leadership to the continuous quality assurance program;

6. Establishing policies and procedures covering all health care services provided to covered persons; and

7. Ensuring review of provider credentials including, but not limited to:

a. Delineating qualifications for participating in the MCHIP;

b. Establishing a system for verification of providers' credentials, recredentialing, performance reviews; and

c. Obtaining information about any disciplinary action against a provider.

F. The quality assurance program advisory committee shall:

1. Recommend policies for quality assurance;

2. Review and approve the quality assurance program;

3. Evaluate the results of the quality assurance program;

4. Initiate quality assurance activities; and

5. Ensure implementation of the quality assurance program.

G. All determinations and actions made by the committee shall be recorded in minutes that are dated, approved and current.

H. The quality assurance program operations shall maintain written descriptions of the responsibilities of each of the operational units of the licensee and the governing body in the planning, development, implementation and evaluation of the MCHIP licensee's quality assurance program. The descriptions shall include an organizational chart.

I. A written report shall be issued annually by quality assurance operations to the MCHIP licensee's executive management and to the governing body. The purpose of the report shall be to evaluate the MCHIP licensee's quality assurance program activities including, at a minimum:

1. The MCHIP licensee's achievements in meeting its quality assurance expectations;

2. Those areas where expectations were not met or where improvements are still needed;

3. The impact of the MCHIP licensee's quality assurance program, including specific programmatic initiatives, on the quality of care received by covered persons as assessed using reasonable indicators; and

4. New areas identified through the quality assurance assessment process that will be incorporated in the next annual quality assurance program plan.

J. The quality assurance program is accountable to the governing body. Documentation shall be maintained by the MCHIP licensee that the governing body has reviewed the annual quality assurance program report and has provided direction to the program and, as necessary, other operational units in response to the report.

K. A summary of the program shall be provided to appropriate managers, providers and staff members of the MCHIP licensee, and shall be available to covered persons of the MCHIP upon request.

L. There shall be a mechanism in place to inform covered persons, providers, and employers of the MCHIP licensee's annual performance results each year, upon request.

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; Errata, 16:7 VA.R. 831 December 20, 1999; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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