D.C. Mun. Regs. tit. 29, r. 29-5603

Current through Register Vol. 71, No. 43, October 25, 2024

Rule 29-5603 - REQUIRED INFORMATION

5603.1

The managed care provider shall submit the following to the Department with its application for a Medicaid managed care provider agreement:

(a) A copy of the basic organizational documents of the managed care provider, including an organizational chart and current articles of incorporation;

(b) A copy of the by-laws or any other documents that regulate the conduct of the internal affairs of the managed care provider;

(c) A description of the organization's ownership structure and a list of major owners, including stockholders who own or control five percent (5%) or more of the organization's outstanding shares;

(d) A list of board members and each member's business affiliations, interests in, and ownership of, other health care providers or related services or providers;

(e) A statement of the managed care provider's policies and procedures governing payment of claims to health care providers;

(f) A statement of the managed care provider's policies and procedures governing the distribution of revenues to owners (distribution of revenues may include bonuses, dividends, stock options, and other incentives);

(g) A list of the name, address and specialty of each physician who participates in the managed care provider's plan and a copy of their licenses and evidence of board certification;

(h) A roster of key personnel and the qualifications and job descriptions of each;

(i) A written description of the managed care provider's credentialing procedures;

(j) The number of clinical, administrative, and marketing employees who will provide services to eligible children enrolled in the managed care provider's plan;

(k) The form of evidence of coverage to be issued to enrolled children and their families or representatives;

(l) Pro forma operating statements and balance sheets and written documentation of sources of working capital, other sources of funding, and documentation that the managed care provider has ready access to these funds;

(m) A written description of the proposed marketing plan;

(n) A written description of the service delivery record and statistical reporting systems;

(o) A copy of the proposed process for addressing enrolled children's grievances;

(p) A copy of the managed care provider's proposed plan for handling out-of-plan and out-of-area emergency coverage;

(q) A copy of any agreement with any hospital located in the District and a copy of the inpatient care admission policies, which shall ensure that each enrolled child shall receive inpatient care in a hospital located in the District;

(r) A list of subcontractors that will provide services to enrolled children and a copy of each subcontract;

(s) The address of each site at which services will be provided to enrolled children;

(t) A description of the procedures and programs that ensure the availability and accessibility of urgent and emergency services on a twenty-four (24) hour, seven (7) day per week basis;

(u) A copy of the managed care provider's plan to ensure that the services provided are effective and of a consistently high quality; and

(v) A written description of the enrollment process.

5603.2

The managed care provider shall provide to the Department written notice of the termination of any agreement between the provider and a hospital to provide inpatient care, or any other significant change in the agreement between the managed care provider and the hospital, not less than thirty (30) calendar days prior to the effective date of the change.

5603.3

The managed care provider shall notify the Department, in writing, within thirty (30) days of any material modification of the information in § 5603.1.

5603.4

The managed care provider shall make available to the Department for inspection and copying, all standards, protocols, manuals, and other documents used to arrive at care provision decisions for eligible children enrolled in the managed care provider's plan.

5603.5

At the beginning of each quarter, the managed care provider shall provide to the Department a list of the names and qualifications of each physician enrolled or disenrolled in the provider's plan during the previous quarter.

5603.6

Except as provided in § 5603.5, the managed care provider shall notify the Department, in writing, within thirty (30) days of any material change in the information required in this section.

D.C. Mun. Regs. tit. 29, r. 29-5603

Final Rulemaking published at 43 DCR 4833, 4837 (September 6, 1996)