Md. Code Regs. 10.67.03.09

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.03.09 - Quality Assurance System - General

An applicant shall include in its application the following information or descriptions:

A. The applicant's proposed quality assurance plan, that contains, at a minimum, all elements specified by Health-General Article, §15-103(b)(9)(i), Annotated Code of Maryland;

B. A description of any written procedures or protocols regarding physician and nursing care practice the applicant intends to use;

C. A description of the applicant's peer review committee structure and process;

D. A copy of the applicant's case management plan;

E. A description of all mechanisms to be used to ensure the quality of any services, including administrative and clinical, that the applicant intends to delegate to subcontractors;

F. The name and a description of the published standards or guidelines for maintenance of medical records the applicant will follow;

G. A description of how providers will be apprised of medical records, utilization review, and case management requirements;

H. A description of the applicant's system for ensuring inclusion in the medical record of reports of health care services or diagnostic testing performed in a referral setting;

I. A written description of the applicant's internal review system for the handling, monitoring, and resolution of provider complaints, grievances, and appeals;

J. Evidence of an adequate system for medical record retention and retrieval that meets, at minimum, all requirements of Health-General Article, §15-103(b)(9)(xiv), Annotated Code of Maryland;

K. Documentary evidence that the applicant requires school-based clinics to provide information concerning health care services provided to their enrollees;

L. A copy of the applicant's practice guidelines used to assist practitioners in approaching health care issues in a systematic, appropriate manner;

M. A copy of the applicant's health education plan;

N. A written description of the applicant's complaint resolution protocol, which shall, at minimum:

(1) Include an internal grievance procedure by which an enrollee who is dissatisfied with the applicant or its providers may seek recourse within the applicant;

(2) Specify what constitutes a grievance;

(3) Provide for prompt resolution of complaints;

(4) Require participation in the grievance process by individuals within the MCO who have the authority to require corrective action;

(5) Specify how the MCO will handle formal appeals by enrollees;

(6) Include a form that enrollees will use when filing a grievance, including foreign language versions for any substantial minorities in the applicant's proposed MCO service area;

(7) Identify the steps in the grievance process, and what personnel will be responsible for receiving, processing, monitoring, and responding to grievances;

(8) Specify how the enrollee will be informed that the enrollee's grievance is being investigated, and the protocols by which grievances will be resolved;

(9) Describe what methods will be used to inform enrollees about the operation of the grievance procedure; and

(10) Describe whether manual or automated processes will be used to track enrollees' complaints, determine any patterns of complaints, and report findings to the proposed MCO's quality assurance or quality improvement system; and

O. A copy of the MCO's provider education plan.

Md. Code Regs. 10.67.03.09

Regulations .09 recodified from 10.09.64.09 effective 46:22 Md. R. 976, eff. 11/1/2019