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
6/14/2024

12VAC5-408-70. Administrative review.

A. The initial examination shall be an administrative review of the application for certificate of quality assurance and supporting documentation that includes:

1. The items listed in subsections F, G, H, and I of 12VAC5-408-160, except that if the MCHIP is accredited by a nationally recognized accrediting body appropriate for the type of MCHIP and approved by the department, it shall not be required to include in its application the items listed in subdivisions F 5, G 2, G 3, G 7 and subsection I;

2. A copy of the most recent accreditation report executive summary, as applicable issued to the MCHIP or to the MCHIP's licensee from a nationally recognized accrediting body that evaluates quality assurance programs, with the written corrective action response, if any;

3. For MCHIP licensees that have been cited by another state or the District of Columbia concerning their quality assurance program, a copy of the most recent report of an examination of the quality of health care provided by the MCHIP under similar laws and regulations of another state, with a copy of the written corrective action response, if any;

4. The most recent report of any examination of the quality assurance program provided by the MCHIP issued by a federal regulatory agency with similar laws and regulations. Submission of this report shall not be necessary if the MCHIP provides a copy of the report required by subdivision 2 of this subsection with the written corrective action plan, if any; and

5. The department may coordinate with the Bureau of Insurance to obtain information that may assist its review.

B. The administrative review examination shall be conducted within 45 business days of the receipt of all the documentation required by the department. The MCHIP licensee shall be notified in writing if additional information is needed to clarify the information submitted and the specific time period in which to submit the materials. Accreditation by a nationally recognized accrediting body appropriate to the type of MCHIP and acceptable to the department shall be sufficient to demonstrate compliance with state requirements pursuant to 12VAC5-408-50. Nothing in the preceding sentences shall preclude the department from imposing further requirements if the regulatory requirements are more stringent than the nationally recognized accrediting body's standards.

C. The MCHIP licensee shall be notified of the results of the administrative review examination within 60 business days from the receipt by the department of all of the required documents and related information.

The department, at its discretion, may extend, for up to an additional 30 days, the period of time within which to approve or disapprove the information submitted. Licensees shall be notified in writing of any such extension.

D. The department, at its discretion, may conduct an onsite examination of the MCHIP licensee's quality assurance program if, for example, during its conduct of the administrative review examination, the department determines that an onsite examination is warranted in order to determine the MCHIP licensee's compliance with applicable laws or this chapter.

E. Licensees with MCHIPs that successfully complete the examination shall be issued a certificate of quality assurance. Licensees with MCHIPs that do not successfully complete the examination shall be denied a certificate of quality assurance. Licensees with more than one MCHIP requesting separate certificates for each MCHIP shall file a separate certificate of quality assurance application for any of their MCHIPs with an accompanying fee. Each of the licensee's MCHIPs that were filed with separate applications that successfully complete the examination shall be issued a certificate of quality assurance. Each of the licensee's MCHIPs that were filed with separate applications that do not successfully complete the examination shall be denied a certificate of quality assurance.

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. 823 December 20, 1999; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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