Part VI. Delegated Services
12VAC5-408-320. Delegated services.
A. If the MCHIP licensee contracts for any of the following services, it shall retain accountability for the oversight of those services:
1. Quality assurance activities;
2. Credentialing and recredentialing;
3. Covered person education, communication and satisfaction;
4. Utilization management;
5. Health promotion;
6. Records management;
7. Data management;
8. Providers and provider networks;
9. Claims administration; or
10. Pharmacy benefits.
B. The MCHIP licensee shall establish and implement written procedures to evaluate the effectiveness of any delegated service.
C. The MCHIP licensee shall require the delegated service entity to maintain documentation of its compliance with this chapter, its agreement with the MCHIP licensee to provide services, and any applicable state and federal laws.
D. Data and information exchanged between the delegated service entity and the plan shall be accomplished in a manner that is timely, efficient, and effective.
E. The MCHIP licensee shall require the delegated service entity to provide for timely and efficient access by state examiners to data, records, and personnel necessary to determine compliance with this chapter.
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.
12VAC5-408-330. Written agreement.
A. There shall be a written agreement signed by the MCHIP licensee and the delegated service entity that describes the:
1. Delegated service or services;
2. Responsibilities of the MCHIP and the delegated service entity and the remedies available to the MCHIP if the delegated service entity does not fulfill its obligations; and
3. Frequency of reporting to the MCHIP licensee and the process by which the MCHIP will evaluate the delegated service entity's performance.
B. The MCHIP licensee shall ensure that the covered persons' continuity of care is not disrupted because of changes made in the written agreement between the MCHIP licensee and the delegated service entity or because the relationship, as provided for in the agreement, is terminated.
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.
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.
12VAC5-408-350. Quality assurance program.
A. As it pertains to the covered persons, the MCHIP licensee shall integrate monitoring of the delegated service entity with respect to the following activities within its quality assurance program:
1. Quality assurance program activities;
2. Quality assurance plan measures; and
3. Complaint and appeals processes.
B. When the MCHIP's licensee's expectations have not been met, the MCHIP licensee shall require the delegated service entity to provide:
1. A corrective action plan that addresses areas where performance expectations have not been met; and
2. Evidence that corrective action was taken in keeping with corrective action plans.
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.