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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
6/18/2024

12VAC5-408-80. Renewal application.

A. Every MCHIP licensee shall request renewal of its certificate of quality assurance biennially with the department. The purpose of the renewal examination shall be to determine if the MCHIP has maintained compliance with applicable laws and regulations since the last certificate of quality assurance was issued or renewed, and whether the MCHIP is using its best efforts to meet its quality assurance goals as set forth in its quality assurance plan.

B. The renewal examination shall include an administrative review of the renewal application 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 acceptable to 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. The annual complaint reports;

3. The MCHIP's formal written evaluations of its quality assurance program expectations for the time period since the MCHIP's last application for a certificate of quality assurance;

4. A copy of the most recent accreditation report executive summary, as applicable, issued to the MCHIP or to the licensee from a nationally recognized accrediting body that evaluates quality assurance programs if the report was issued after the issuance of the current certificate from the department, provided that resubmission of the most recent accreditation report previously submitted in the prior initial or renewal application shall not be required, unless there has been a completed accreditation survey since that time that has led to renewal, suspension, or denial of accreditation and the written corrective action plan in response to the report, if applicable, shall also be submitted;

5. For MCHIP licensees that have been cited by another state or the District of Columbia concerning the quality of health care provided or administered, 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 or the District of Columbia, and a copy of the written corrective action response; and

6. A copy of the report of any examination of the MCHIP by a federal regulatory body with similar laws and regulations issued since the certificate of quality assurance was last issued or renewed, provided that submission of this report shall not be necessary if the MCHIP licensee submits a copy of the report required by subdivision 4 of this subsection.

C. In addition, the department shall consider the following in its renewal examination:

1. The report of any comprehensive onsite examination of the MCHIP or licensee if one was conducted during the renewal period; and

2. Any disciplinary actions or sanctions issued by the department pursuant to § 32.1-137.5 of the Code of Virginia or this chapter, or by the Bureau of Insurance in keeping with § 32.1-137.2 E of the Code of Virginia.

D. The department may consider a summary report of the analysis of any data required to be reported by state law or regulation to the Health Care Data Reporting System in its renewal examination.

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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