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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
7/24/2024

12VAC5-408-60. General examination process.

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.

B. Examinations may be conducted onsite at an MCHIP licensee's office and at the site of any delegated service provider. At its discretion, the department may choose to conduct an administrative review to evaluate the MCHIP for compliance with applicable law and this chapter. The MCHIP's examination may also include contractors with whom the licensee has agreements, contracts, or other arrangements to provide health care services for the MCHIP.

C. Any examiner authorized by the department shall, so far as necessary for the purposes of the examination or review, have access during regular business hours to the premises and to any books, records, files, or property of the licensee as far as they directly relate to this regulation and Articles 1.1 (§ 32.1-137.1 et seq.) and 1.2 (§ 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 of the Code of Virginia.

All material copied, recorded, or received by the department from the MCHIP licensee shall be privileged and confidential and shall not be subject to subpoena.

D. The MCHIP licensee shall be responsible for ensuring that all examination materials are submitted to the department at the time specified for submission and that they are complete. Failure to submit all of the examination materials as required may delay processing or result in the denial of the issuance or renewal of the quality assurance certificate.

E. A summary report of an MCHIP licensee's examination shall become part of the department's public file on the MCHIP. A copy of the summary report shall be provided to the Bureau of Insurance.

F. The department shall consider an MCHIP licensee's initial examination for a certificate of quality assurance as an evaluation of the MCHIP's quality assurance program in order to determine if it has the structure, organization, and policies and procedures in place to provide and support quality improvement activities.

G. Information provided during any examination conducted regarding compliance with this chapter shall be accurate and truthful. The MCHIP licensee shall not provide the department with falsified information during any aspect of the examination process. The department shall construe any effort to provide falsified information as violation of the statute, and the MCHIP licensee shall be subject to disciplinary action. Falsification is defined for the purpose of this chapter as fabrication, in whole or in part, of any information provided by the MCHIP or the MCHIP licensee.

H. The refusal of any MCHIP licensee, by its officers, directors, employees or agents, to submit to examination or review or to comply with any reasonable written request of the examiners shall be grounds for suspension, revocation, denial, or nonrenewal of a certificate of quality assurance held by the licensee.

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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