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
9/27/2023

12VAC5-408-90. Comprehensive onsite examination.

A. The comprehensive onsite examination represents a periodic quality assurance evaluation process designed to ensure that the MCHIP licensee has in place the appropriate systems and processes to meet the requirements set forth in this chapter.

B. A comprehensive onsite examination shall be conducted triennially except for MCHIPs that meet the criteria specified in 12VAC5-408-100 pertaining to nationally recognized accreditation.

C. The comprehensive onsite examination shall take place:

1. At a time established by the department with 90 days advance notification to the MCHIP licensee;

2. In conjunction with a Bureau of Insurance market conduct examination of the licensee; or

3. At the request of the MCHIP licensee in agreement with the department following the completion of an initial administrative review examination for certification in order to document any corrective action taken in response to the initial examination.

At the department's discretion and in response to complaints against the MCHIP licensee or the MCHIP, the department may expand a complaint investigation to a comprehensive examination to determine compliance with the MCHIP laws and regulations if it appears that covered person's health and safety may be jeopardized.

D. The MCHIP licensee shall be notified in writing at least 90 days in advance of the comprehensive onsite examination and shall be provided with information regarding the parameters of the examination.

The final determination of when a comprehensive onsite examination shall be conducted rests with the department. However, the department will take into consideration mitigating circumstances presented by the MCHIP licensee.

E. The MCHIP licensee or the department may request a preexamination conference for the purpose of discussing preparations for the examination. The conference shall not be used for determining whether a plan needs to be examined or the frequency of an onsite comprehensive examination.

F. Prior to the comprehensive onsite examination, the MCHIP licensee shall make available to the department the results of a member satisfaction survey or other initiative conducted to obtain member input regarding the MCHIP licensee. If the MCHIP licensee did not conduct a member satisfaction survey or initiative, then the MCHIP licensee will publish public notice soliciting comments from the MCHIP's covered persons regarding satisfaction with the MCHIP.

G. The MCHIP shall be notified of the results of the comprehensive onsite examination within 60 business days of the final day of the examination. The department may choose to notify the MCHIP earlier than 60 days and require immediate corrective action or initiate administrative disciplinary hearings for findings of serious or substantial noncompliance with the law or the regulations that could jeopardize covered persons' health or safety.

H. Depending on the examination findings, the department shall:

1. Require a corrective action plan as specified in 12VAC5-408-110 with a time frame in which corrective action shall be completed and verified by the department;

2. Proceed with disciplinary action or sanctions as specified in 12VAC5-408-140; or

3. Notify the MCHIP licensee that it is fully and completely in compliance with all applicable regulations.

I. If the MCHIP licensee applicant has achieved accreditation from a nationally recognized accreditation entity acceptable to the department, it will be exempt from the comprehensive on-site examination following receipt of all accreditation findings.

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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