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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
6/20/2024

12VAC5-408-240. Quality assurance plan.

Each MCHIP licensee shall have a written quality assurance plan. The plan shall include:

1. The quality assurance performance expectations for the MCHIP licensee for the year and an explanation as to the rationale for targeting these expectations;

2. Delineation of the expected outcomes for the performance expectations;

3. The performance activities to implement the plan and the specific lines of authority and accountability for implementation;

4. The data collection and analysis methodologies to be used to evaluate the quality of services;

5. For MCHIP licensees that have access to clinical data, clinical studies, applicable to the type of MCHIP, that target clinical diagnosis and treatments with the requirement that those diagnoses focused upon are pertinent to a substantial number of its covered persons, or have been identified as major public health risks. The plan shall also include studies that are pertinent to the covered persons of the product lines that the MCHIP manages or that address major public health risks;

6. Strategies to evaluate provider performance and systems, request corrective action when patterns are identified, and act when corrective action has not been taken;

7. Methods to assess covered person satisfaction so as to identify opportunities for improvement and set improvement goals;

8. For MCHIP licensees that have access to clinical data, evaluations of the actual outcomes of care provided to selected groups of covered persons with an analysis of variations in care;

9. For MCHIP licensees that have access to clinical data, amendment of treatment protocols and clinical practice guidelines, as necessary, to make them current and the development of new protocols and clinical practice guidelines, as necessary, to address clinical conditions;

10. Strategies to evaluate the continuity of care that covered persons receive; and

11. Analysis of the accessibility of covered person services including emergency services and after-hour care within the licensee's geographic service area. Compliance may be demonstrated by evidence of contract language with providers stipulating after-hour care, customer satisfaction surveys, and complaint reviews.

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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