Ala. Admin. Code r. 420-5-6-.14

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

Section 420-5-6-.14 - Annual And Quarterly Reports

(1) Any person which has received a Certificate of Authority to operate a health maintenance organization shall submit before March 1 of each year a detailed report of its activities during the preceding calendar year. The report shall include, at least, the following:

(a) A copy of the annual financial report submitted to the Commissioner;

(b) Copies of the quality improvement and utilization review reports submitted to the governing body according to 420-5-6-.07;

(c) A copy of the complaint resolution system established according to 420-5-6-.08, including a summary of total number of complaints handled, a compilation of causes underlying the complaints, and the resolution of complaints;

(d) A statement of number of providers leaving the health maintenance organization and the number of providers replacing them and total number of providers; and

(e) A summary of enrollment and disenrollment rates during the year.

(2) Any health maintenance organization shall submit to the Department quarterly reports which shall contain, at least, the following;

(a) A copy of any quarterly financial report required by the Commissioner;

(b) A summary of total number of grievances handled, a compilation of causes underlying the grievances, and the resolution of grievances;

(c) A statement of number of providers leaving the health maintenance organization and the number of providers replacing them and total number of providers;

(d) A summary of enrollment and disenrollment rates during the quarter; and

(e) Utilization statistics containing the following minimum data:

1. The hospitalization experience in terms of the number of days of inpatient hospitalization experienced per 1,000 enrollees on a quarterly basis, year-to-date basis, and annualized basis; and

2. The average number of physician inpatient and outpatient visits per enrollee on a quarterly basis, year-to-date basis, and annualized basis.

(f) Quarterly reports shall be submitted according to the following schedule:

1. The report for the first quarter, January 1 to March 31, shall be submitted no later than May 15;

2. The report for the second quarter, April 1 to June 30, shall be submitted no later than August 15.

3. The report for the third quarter, July 1 to September 30, shall be submitted no later than November 15; and

4. The report for the last quarter, October 1 to December 31, shall be submitted concurrently with the annual report required in Subsection 1.

(3) The Department may add or delete information required on an annual and quarterly basis upon written notification to each health maintenance organization.

(4) Federally qualified health maintenance organizations may submit copies of reports submitted to federal authorities which contain substantially the same information required in (2) and (3).

Author: Department of Public Health

Ala. Admin. Code r. 420-5-6-.14

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.