Administrative Code

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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

12VAC5-408-340. Exchange of information.

A. If the delegated services are health care services, then the delegated services entity or the MCHIP licensee shall make the following information available if requested by the MCHIP's covered persons:

1. The procedures for filing complaints and appeals;

2. The utilization management decision process;

3. The process for appealing claims denials;

4. How to access emergency and urgent care;

5. How to obtain services not covered in the delegated health services' benefit package;

6. The process for changing from one practitioner to another;

7. Orientation process for new covered persons;

8. Covered person participation opportunities; and

9. Participating practitioners and providers.

B. If the delegated services are health care services, then the delegated service entity or the MCHIP licensee shall also inform the MCHIP's providers of at least the following:

1. Opportunities for provider involvement;

2. MCHIP licensee expectations of providers in achieving quality assurance program goals;

3. Provider credentialing process;

4. Procedures for complaints and appeals;

5. Process for utilization management decisions; and

6. Procedures to approve covered person access to emergency and urgent care.

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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