Ala. Admin. Code r. 420-5-6-.11

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

Section 420-5-6-.11 - Professional Staffing of Health Maintenance Organizations

(1) Professional staff standards.

(a) A health maintenance organization shall have a sufficient number of physicians to adequately cover the health care needs of enrollees.

1. The health maintenance organization shall conduct an annual affirmative capacity analysis of availability of providers required to render covered services.

(b) For purposes of these Rules, the following definitions apply:

1. "Credentials" means certificates, diplomas, licenses, and other written documentation that establishes proof of training, education, and experience in a field of expertise based on national and state standards.

2. "Credentialing" means the process by which the health maintenance organization reviews and evaluates the qualifications of licensed independent practitioners and other providers of health care services to its enrollees. Eligibility is determined by the extent to which applicants meet defined requirements for education, licensure, professional standing, service availability, and accessibility, as well as for conformity to a health maintenance organization or applicant organization's quality and utilization management requirements.

3. "Credential Verification Organization" means an organization that has demonstrated the capability to perform primary source verification for any physician/provider on behalf of a health maintenance organization or applicant organization.

4. "Delegated Credentialing Organization" means a hospital, health care delivery network (for example, vision care, mental health, chiropractic), or independent practice association (IPA) of physicians that has demonstrated the capability to perform credentialing as defined above for a limited network of providers.

(c) There shall be established a credentials committee charged with the responsibility of reviewing each provider prior to contracting with the provider to determine that each provider is properly credentialed in Alabama. The credentials committee shall conduct annual reviews of each contracted provider for state licensure/controlled substance certificate; and conduct a complete credentialing review every 3 years. All providers shall be recredentialed every 3 years.

1. The credentials committee shall assure appropriate licensure and certification of providers.

2. The health maintenance organization may delegate primary source verification to Alabama Department of Public Health approved credentialing verification organizations, delegated credentialing organizations, or both.

3. The health maintenance organization may rely upon the credentialing of approved delegates, with oversight, which must also be approved by the Alabama Department of Public Health.

4. Expired drug enforcement agency certificates and malpractice insurance should be updated between cycles as necessary.

(2) Medical director standards.

(a) A health maintenance organization shall identify a physician who shall serve as medical director of the Alabama health maintenance organization. A medical director must have a current license to practice medicine granted by the Medical Licensure Commission of Alabama. Alternately, an HMO may employ, for no longer than 12 months, an individual as medical director provided that the individual is eligible in all respects for licensure as an Alabama physician and the individual has a current active application for licensure on file with the Medical Licensure Commission of Alabama.

(b) The medical director shall be responsible for, at a minimum, the following:

1. General coordination of the medical care of the health maintenance organization on behalf of the health maintenance organization;

2. Implementation and oversight of protocols for quality improvement;

3. Implementation and oversight of quality improvement programs and continuing education requirements; and

4. Implementation and oversight of protocols for the credentials committee.

5. Oversight of medical necessity determinations.

(c) The time spent by the medical director in performing medical director functions shall not be counted in the physician-enrollee ratio required in (1)(a) above.

(3) The health maintenance organization shall define procedures for taking corrective action against any provider whose conduct is detrimental to public safety or the delivery of care, or disruptive to the operation of the health maintenance organization.

Ala. Admin. Code r. 420-5-6-.11

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.

Amended by Alabama Administrative Monthly Volume XXXVII, Issue No. 12, September 30, 2019, eff. 11/14/2019.

Author: Department of Public Health

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