Ala. Admin. Code r. 420-5-6-.06

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-6-.06 - Assurance Of Access To And Continuity Of Care

(1) A health maintenance organization shall have available sufficient personnel to meet the standards set forth in this Chapter and its contractual obligations.

(2) When health care services are not provided directly, a health maintenance organization shall develop and maintain written executed contracts for the provision of the health services contracted for by its enrollees.

(3) The Department may grant a waiver from the requirement for executed provider contracts in certain areas of health care, if the Department determines that:

(a) The specific services are services which, because of an emergency, it was medically necessary to provide to the enrollee other than through contracted providers; or

(b) The specific service or services being reviewed are unusual or infrequently used health services.

(4) In those specialities which are generally available and frequently utilized in the geographic area served by the health maintenance organization, services of qualified specialty practitioners shall be provided through executed provider contracts between the health maintenance organization and the practitioner, assuring enrollee access to medically necessary specialty care.

(5) Medically necessary specialty services other than those described in paragraphs (3) and (4) shall be provided by participating or nonparticipating specialists.

(6) A health maintenance organization may expand the service area approved in the Certificate of Authority process at any time through submission of information validating the ability to provide "basic health care services," "frequently utilized specialty services" and any other covered benefit. Service area expansions require the approval of the Alabama Department of Public Health and the Department of Insurance.

(7) A health maintenance organization may require that all health care services be coordinated and supervised by a primary care provider. In such circumstances, a health maintenance organization may either assign, or each enrollee may select, a primary care provider to supervise and coordinate the health care of the enrollee. An enrollee who is dissatisfied with the assigned or selected primary care provider shall be allowed to select another primary care provider. However, the health maintenance organization may impose a reasonable waiting period to accomplish this transfer. A list of primary care providers and enrollees assigned to each shall be maintained.

(8) All health maintenance organizations shall have a system in place to ensure that enrollees receive medically necessary referrals. Referrals, except in emergency situations, shall be made by the enrollee's primary care provider (if the primary care provider concept is utilized by the health maintenance organization) or by a physician under contract or other arrangement with the health maintenance organization. If a requested referral is denied, the provider or enrollee may seek referral from the medical director who may, after consultation with appropriate providers, grant or deny the referral.

(a) The health maintenance organization shall have a process to ensure requests for referrals are processed in a timely fashion with appropriate medical director oversight, as well as a process for expedited referrals.

(b) In those cases in which a health condition of ongoing or chronic status has been established and the need for specialized care has been determined, the referring physician may authorize in advance a number of visits to a specialty physician so that the enrollee may proceed directly to the specialty physician without first meeting with the referring physician.

(9) Utilization decisions shall be made within seven (7) calendar days of receipt of all necessary information, unless the attending physician indicates that the enrollee's life, health or ability to regain maximum function could be seriously jeopardized, in which event the decision shall be expedited. Each health maintenance organization shall have policies and procedures addressing these processes and will communicate the policies and procedures to providers through the provider manual.

(a) All decisions shall be communicated to the provider within a time period reasonably calculated to accommodate the clinical urgency of the situation.

(b) In the event of DENIAL based on medical necessity, the health maintenance organization must give the provider initiating the request for authorization, and the enrollee if he or she requests it, a written denial response that identifies by name, title and telephone number the medical director or other physician who made the denial decision and the name of the person, address and telephone number to whom a request for an informal complaint, formal complaint, or expedited formal complaint may be made.

In the event of DENIAL based on reasons other than medical necessity, such as non covered services, the health maintenance organization must give the provider initiating the request for authorization, and the enrollee if he or she requests it, a written denial response that indicates where to initiate a request for an informal complaint or a formal complaint. The written denial response shall include the address, telephone number and title of the individual or the specific department within the health maintenance organization to whom the request may be made.

(c) An expedited formal complaint may be requested verbally or in writing by the enrollee or the provider. For a request made or supported by a physician, the health maintenance organization must provide an expedited response if the physician indicates that applying standard response time provided in paragraph (9) above could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. The expedited formal complaint process is described at Rule 420-5-6-.08(6)(h).

(10) The health maintenance organization shall have in effect an adequate system of documentation of services requested by providers which shall include:

(a) A log shall be kept of all medical necessity requests from participating providers where reimbursement for requested services was denied. The log shall include the name of the enrollee, name and address of the requesting provider, type of service requested, date of the request, date of the denial, and the name of the health maintenance organization medical director who made the decision. Sufficient documentation must exist to establish a clear picture of the process and outcome. The log may be maintained through a backed-up automated system.

(11) The health maintenance organization shall have in effect an adequate system of documentation of referrals to noncontracted providers which shall include:

(a) A log which includes all referrals by contracted physicians to noncontracting providers and hospitals. The log shall include the name of the enrollee, name and address of the referring contracting physician, an authorization number, and the date of referral. The log may be maintained through an automated system; and

(b) Transfer of adequate information from the health maintenance organization to the referral physician with assigned responsibility for follow-up.

(12) When an enrollee is referred by a health maintenance organization or by a health maintenance organization physician to a nonparticipating specialist for covered services, the enrollee shall incur no financial liability above that which he would have incurred had he been referred to a participating specialist except when such referral occurs pursuant to noncontractual provider arrangements as defined by Code of Ala. 1975, § 27-21A-29(b).

(13) To insure that claims payments are not a barrier to accessibility of health care, claims shall be paid as follows:

(a) All health maintenance organizations issuing contracts to employers, unions, trustees, or other organizations and individuals within this State shall consider claims made thereunder and, if found to be valid and proper, shall pay such claims within 45 days after the health maintenance organization receives reasonable proof of the fact and amount of loss sustained. If reasonable proof is not supplied as to the entire claim, the amount supported by reasonable proof shall be considered overdue if not paid within 45 days after such proof is received by the health maintenance organization. Any part or all of the remainder of the claim that is later supported by reasonable proof shall be considered overdue if not paid within 45 days after such proof is received by the health maintenance organization. For the purposes of calculating if any benefits are overdue, payment shall be treated as made on the date a draft or other valid instrument was placed in the United States mail to the last known address of the claimant or beneficiary in a properly addressed, postpaid, envelope, or, if not so posted, on the date of delivery period. When the claim is overdue or denied, the health maintenance organization must provide written justification within five days of the overdue or denial date to any providers involved and to the enrollee if the enrollee is financially liable for the denied claim.

(b) The above required payment time period of 45 days is not applicable if the health maintenance organization has executed provider contracts in which the health maintenance organization and the provider have agreed to a different schedule of payment in which case, all other stipulations in (a) will be applicable with the exception that the time payment period will be in accordance with the contract between the health maintenance organization and the provider.

(14) A health maintenance organization shall have written procedures governing the availability of frequently utilized services contracted for by enrollees, including at least the following:

(a) Service protocols by type of maintenance visit;

(b) Well child and adult examinations and immunizations;

(c) Emergency telephone consultation on a 24-hour a day, 7-day a week basis including qualified physician coverage for emergency services;

(d) Treatment of acute emergencies including ambulance and transport services;

(e) Treatment of acute minor illness;

(f) Treatment of chronic illness;

(g) Hours of operation of delivery sites including appointment systems;

(h) Distribution to enrollees of information concerning enrollee rights and patient education;

(i) List of referral sources; and

(j) Medical records establishment and review.

(15) Each health maintenance organization shall have a written procedure describing coverage for emergency health services received by an enrollee outside of the health maintenance organization's service area.

(a) The health maintenance organization's coverage for emergency health services shall be clearly described in enrollee contracts and shall include disclosure of any restrictions regarding emergency services.

(16) Each health maintenance organization shall pay the provider or reimburse its enrollees for the payment of emergency services, as defined in these Rules in 420-5-6-.06(13).

(a) Each health maintenance organization shall adopt procedures to review promptly all claims for reimbursement for the provision of emergency services, including a procedure for the determination of the medical necessity for obtaining these services other than through the health maintenance organization.

(b) Emergency services shall include payment to the nearest 24-hour emergency facility and ambulance services when appropriate.

(17) The health maintenance organization shall provide coordinated discharge planning including the planning of such continuing care as may be necessary, both medically and as a means of preventing possible rehospitalization.

(18) If a health maintenance organization fails to become operational within twelve months after receiving a Certificate of Authority, the Alabama Department of Public Health may request the Department of Insurance to issue a Show Cause Order why the health maintenance organization should be authorized to retain the Certificate of Authority.

(19) If at any time a formerly operational health maintenance organization ceases to provide covered services for a period of ten months, the Alabama Department of Public Health may request the Department of Insurance to issue an Order for the health maintenance organization to document why the health maintenance organization should be authorized to retain the Certificate of Authority.

(20) The distance from the health maintenance organization's geographic service area boundary to the nearest primary care delivery site and to the nearest institutional service site shall be a radius of no more than 30 miles. Frequently utilized specialty services shall be within a radius of no more than 60 miles. The Department may waive this requirement if the distance limit is not feasible in a particular geographic area.

After notification to the health maintenance organization and a reasonable opportunity to cure, the Alabama Department of Public Health may recommend to the Department of Insurance the withdrawal of a previously approved service area if required provider access is not maintained.

(21) The health maintenance organization shall insure that it has access to the medical records of enrollees upon request for review by the health maintenance organization and the Department.

Author: Department of Public Health

Ala. Admin. Code r. 420-5-6-.06

Filed September 1, 1982. Repealed and New Rule adopted in lieu thereof: Filed March 31, 1987. Amended: Filed January 20, 1999; effective February 24, 1999.

Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.