Okla. Admin. Code § 310:657-5-4

Current through Vol. 41, No. 19, June 17, 2024

Section 310:657-5-4 - Inspections

(a) For purposes of conducting the site visit, the Department may inspect any person, or the business of any person, insofar as such inspection is necessary or material to the investigation of the Plan.

(b) The refusal of any Plan by its officers, directors, employees or agents to submit to the inspection or to comply with any reasonable written request of the inspectors shall be grounds for suspension, revocation or nonrenewal of any certification or authority held by the Plan to engage in business subject to the Department's jurisdiction.

(c) In the case of a annual site visit, the Department may provide advance notice of not longer than 15 working days to the Plan by telephone and/or written means of communication.

(1) Such notification may include a request for the Plan to provide case, dispute and/or grievance listings to the Department to allow Department consideration and possible selection of samples prior to arriving at the Plan's office.

(2) In advance of an announced site visit or upon arrival of an unannounced site visit, the Department may request to have Plan materials and personnel available which includes, but not limited to the following:

(A) Current Organizational Chart;

(B) Listing of current personnel and those person's direct-dial telephone numbers or extensions;

(C) Assignment of a single Plan representative to serve as the Department's primary contact during the course of the on-site inspection;

(D) Current Master Client Report, or other comprehensive listing of contracts currently or previously in place, including counts of CWMP participants;

(E) Current listing of contracted Insurers and/or Insureds; and

(F) Assignment of one or more persons to:

(i) Conduct a preliminary walk-through tour of the offices;

(ii) Explain to the Department staff how physical files are arranged;

(iii) Explain to the Department staff what files are electronic only and will require a Department request to the Plan's primary contact person for printing or visual inspection;

(iv) Explain the process for entering or leaving the Plan's office;

(v) Explain how case management is assigned;

(vi) Explain how the Plan monitors caseloads;

(vii) Explain how the Plan receives cases from the payer.

(G) Provision for Departmental file reviews, of any written:

(i) Case management policies and procedures;

(ii) Utilization review policies and procedures;

(iii) Case management forms;

(iv) Utilization review forms;

(v) Case management form letters;

(vi) Utilization review letters;

(vii) Communication standards;

(viii) Account specific instructions;

(ix) List of all routine audits or other QA procedures; and

(x) List of the prior periods' explicit Medical Director or Peer Reviews.

(H) Specific personnel, by title, that the Department initially anticipates interviewing during the course of the site visit to ensure that those persons will be available.

(I) Such other material that the Department requires to be assembled for inspection such as Policies and Procedures changed since the last application for certification or renewal.

(d) The Department is not required to provide advance notice of a site visit to a Plan in an instance where the Department has reason to believe that the Plan is either:

(1) Not operating in accordance with its application, the Act, or OAC 310:657; or

(2) Not adequately providing a claimant(s) with medical services or medical management.

(e) Upon the completion of the site visit and review of the findings, the Department shall prepare a report with a determination that a Plan is or is not operating in accordance with its latest application. This report may also include recommendations for follow-up and/or corrective actions.

(f) The Plan shall not issue marketing or solicitation materials that advertise, identify or judge the results of an investigation completed by the Department.

Okla. Admin. Code § 310:657-5-4

Added at 12 Ok Reg 2977, eff 6-16-95 (emergency); Added at 13 Ok Reg 2127, eff 6-13-96; Amended at 23 Ok Reg 2404, eff 6-25-06