18 Del. Admin. Code § 1403-11.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1403-11.0 - Quality Assurance and Operations

11.1 Medical Director's Duties. The medical director shall be responsible for the direction, provision and quality of health care services provided to enrollees, including but not limited to the following:

11.1.1 Establishing policies and procedures covering all health care services provided to enrollees;

11.1.2 Coordinating, supervising and overseeing the functioning of professional services;

11.1.3 Providing clinical direction and leadership to the continuous quality improvement and utilization management programs;

11.1.4 Providing clinical direction to physicians responsible for utilization management determinations;

11.1.5 Establishing a committee responsible for delineating qualifications of participating providers and reviewing and verifying credentials of participating providers;

11.1.6 Evaluating the medical aspects of provider contracts; and

11.1.7 Overseeing the continuing in-service education of professional staff.

11.2 Health Care Professional Credentialing

11.2.1 General Responsibilities. An MCO shall:

11.2.1.1 Establish written policies and procedures for credentialing verification of all health care professionals with whom the MCO contracts and apply these standards consistently;

11.2.1.2 Verify the credentials of a health care professional before entering into a contract with that health care professional;

11.2.1.3 Make available for review by the applying health care professional upon written request all application and credentialing verification policies and procedures;

11.2.1.4 Retain all records and documents relating to a health care professional's credentialing verification process for not less than four years; and

11.2.1.5 Keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.

11.2.2 Selection standards for participating providers shall be developed for primary care professionals and each health care professional discipline. The standards shall be used in determining the selection of health care professionals by the MCO, its intermediaries and any provider networks with which it contracts. Selection criteria shall not be established in a manner:

11.2.2.1 That would allow an MCO to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations or providers presenting a risk of higher than average claims, losses or health services utilization; or

11.2.2.2 That would exclude providers because they treat or specialize in treating populations presenting a risk of higher than average claims, losses or health services utilization.

11.2.3 Nothing in these regulations shall be construed to require an MCO to select a provider as a participating provider solely because the provider meets the MCO's credentialing verification standards, or to prevent the MCO from utilizing separate or additional criteria in selecting the health care professionals with whom it contracts.

11.2.4 Verification Responsibilities. An MCO shall:

11.2.4.1 Obtain primary verification of at least the following information about the applicant:

11.2.4.1.1 current license, certification, or registration to render health care in Delaware and history of same;

11.2.4.1.2 current level of professional liability coverage, if applicable;

11.2.4.1.3 status of hospital privileges, if applicable;

11.2.4.1.4 specialty board certification status, if applicable; and

11.2.4.1.5 current Drug Enforcement Agency (DEA) registration certificate, if applicable.

11.2.4.2 Obtain, subject to either primary or secondary verification:

11.2.4.2.1 the health care professional's record from the National Practitioner Data Bank; and

11.2.4.2.2 the health care professional's malpractice history.

11.2.4.3 Not less than every three years obtain primary verification of a participating health care professional's:

11.2.4.3.1 current license or certification to render health care in Delaware;

11.2.4.3.2 current level of professional liability coverage, if applicable;

11.2.4.3.3 status of hospital privileges, if applicable;

11.2.4.3.4 current DEA registration certificate, if applicable; and

11.2.4.3.5 specialty board certification status, if applicable.

11.2.4.4 Require all participating providers to notify the MCO of changes in the status of any of the items listed in this section 11.2.4 at any time and identify for participating providers the individual to whom they should report changes in the status of an item listed in this section 11.2.4.

11.2.5 Health Care Professional's Right to Review Credentialing Verification Information. An MCO shall provide a health care professional the opportunity to review and correct information submitted in support of that health care professional's credentialing verification application.

11.3 Provider Network Adequacy

11.3.1 Primary, Specialty and Ancillary Providers

11.3.1.1 The MCO shall maintain an adequate network of primary care providers, specialists, and other ancillary health care resources to serve enrollees at all times.

11.3.1.2 If a plan has an insufficient number of providers that are geographically accessible and available within a reasonable period of time to provide covered health services to enrollees, the MCO shall cover non-network providers, and shall prohibit balance billing.

11.3.1.3 The MCO shall allow referral to a non-network provider, upon the request of a network provider, when medically necessary covered health services are not available through network providers, or the network providers are not available within a reasonable period of time. The MCO shall make acceptable service arrangements with the provider and enrollee, and shall prohibit balance billing.

11.3.2 Facility and Ancillary Health Care Services

11.3.2.1 The MCO shall maintain contracts or other arrangements acceptable to the Department with institutional providers which have the capability to provide covered health services to enrollees and are geographically accessible.

11.3.2.2 The MCO shall make acceptable service arrangements with the provider and enrollee, and shall prohibit balance billing, if the appropriate level of service is not geographically accessible. These services will not be limited to the State of Delaware. These services could include but are not limited to tertiary services, burn units and transplant services.

11.3.3 Emergency and Urgent Care Services

11.3.3.1 The MCO shall establish written policies and procedures governing the provision of emergency and urgent care which shall be distributed to each enrollee at the time of initial enrollment and after any revisions are made. These policies shall be easily understood by a layperson.

11.3.3.2 When emergency care services are performed by non-network providers, the MCO shall make acceptable service arrangements with the provider and enrollee, and shall prohibit balance billing. In those cases where the MCO and the provider cannot agree upon the appropriate charge, the provider may petition the Department for arbitration.

11.3.3.3 Enrollees shall have access to emergency care 24 hours per day, seven days per week. The MCO shall cover emergency care necessary to screen and stabilize an enrollee and shall not require prior authorization of such services if a prudent lay person acting reasonably would have believed that an emergency medical condition existed.

11.3.3.4 Emergency and urgent care services shall include but are not limited to:

11.3.3.4.1 medical and psychiatric care, which shall be available 24 hours a day, seven days a week;

11.3.3.4.2 trauma services at any designated Level I or II trauma center as medically necessary. Such coverage shall continue at least until the enrollee is medically stable, no longer requires critical care, and can be safely transferred to another facility, in the judgment of the treating physician. If the MCO requests transfer to a hospital participating in the MCO network, the patient must be stabilized and the transfer effected in accordance with federal regulations at 42 CFR 489.20 and 42 CFR 489.24;

11.3.3.4.3 out of area health care for urgent or emergency conditions where the enrollee cannot reasonably access in-network services;

11.3.3.4.4 hospital services for emergency care; and

11.3.3.4.5 upon arrival in a hospital, a medical screening examination, as required under federal law, as necessary to determine whether an emergency medical condition exists.

11.3.3.5 When an enrollee has received emergency care from a non-network provider and is stabilized, the enrollee or the provider must request approval from the MCO for continued post-stabilization care by a non-network provider. The MCO is required to approve or disapprove coverage of post-stabilization care as requested by a treating physician or provider within the time appropriate to the circumstances relating to the delivery of services and the condition of the enrollee, but in no case to exceed one hour from the time of the request.

11.3.4 The MCO shall submit evidence of network adequacy to the Department upon request. If the Department receives a complaint regarding an MCO's network adequacy, the burden shall be on the MCO to prove network adequacy to the satisfaction of the Department.

11.4 Utilization Management

11.4.1 The MCO shall establish and implement a comprehensive utilization management program to monitor access to and appropriate utilization of health care and services. The program shall be under the direction of a designated physician and shall be based on a written plan that is reviewed at least annually.

11.4.2 Utilization management determinations shall be based on written clinical criteria and protocols reviewed and approved by practicing physicians and other licensed health care providers within the network. These criteria and protocols shall be periodically reviewed and updated, and shall, with the exception of internal or proprietary quantitative thresholds for utilization management, be readily available, upon request, to affected providers and enrollees.

11.4.3 All materials including internal or proprietary materials for utilization management shall be available to the Department upon request.

11.4.4 Compensation to persons providing utilization review services for an MCO shall not contain incentives, direct or indirect, for these persons to make inappropriate review decisions. Compensation to any such persons may not be based, directly or indirectly, on the quantity or type of adverse determinations rendered.

11.4.5 Utilization Management Staff Availability

11.4.5.1 At a minimum, appropriately qualified staff shall be immediately available by telephone, during routine provider work hours, to render utilization management determinations for providers.

11.4.5.2 The MCO shall provide enrollees with a toll free telephone number by which to contact customer service staff on at least a five day, 40 hours a week basis.

11.4.5.3 The MCO shall supply providers with a toll free telephone number by which to contact utilization management staff on at least a five day, 40 hours a week basis.

11.4.5.4 The MCO must have policies and procedures addressing response to inquiries concerning emergency or urgent care when a PCP or his authorized on call back up provider is unavailable.

11.4.6 Utilization Management Determinations

11.4.6.1 All determinations to authorize services shall be rendered by appropriately qualified staff.

11.4.6.2 All determinations to deny or limit an admission, service, procedure or extension of stay shall be rendered by a physician. The physician shall be under the clinical direction of the medical director responsible for medical services provided to the MCO's Delaware enrollees. Such determinations shall be made in accordance with clinical and medical criteria and standards and shall take into account the individualized needs of the enrollee for whom the service, admission, procedure or extension is requested.

11.4.6.3 All determinations shall be made on a timely basis as required by the exigencies of the situation.

11.4.6.4 An MCO may not retroactively deny reimbursement for a covered health service provided to an enrollee by a provider who relied upon the written or verbal authorization of the MCO or its agents prior to providing the service to the enrollee, except in cases where the MCO can show that there was material misrepresentation, fraud or the patient was found not to have coverage.

11.4.6.5 An enrollee must receive written notice of all determinations to deny coverage or authorization for services required and the basis for the denial.

11.5 Quality Assessment and Improvement

11.5.1 Continuous Quality Improvement

11.5.1.1 Under the direction of the Medical Director or his designated physician, the MCO shall have a system-wide continuous quality improvement program to monitor the quality and appropriateness of care and services provided to enrollees. This program shall be based on a written plan which is reviewed at least semi-annually and revised as necessary.

11.5.1.2 The MCO shall assure that participating providers have the opportunity to participate in developing, implementing and evaluating the quality improvement system.

11.5.1.3 The MCO shall provide enrollees the opportunity to comment on the quality improvement process.

11.5.1.4 The MCO shall follow up on findings from the program to assure that effective corrective actions have been taken, including at least policy revisions, procedural changes and implementation of educational activities for enrollees and providers.

11.5.1.5 The MCO shall make documentation regarding the quality improvement program available to the Department upon request.

11.5.2 External Quality Audit

11.5.2.1 Each MCO shall submit, as a part of its annual report due June 1, evidence of its most recent external quality audit that has been conducted or of acceptable accreditation status.

11.5.2.2 The report of the external quality audit must describe in detail the MCO's conformance to performance standards and the rules within this regulation. The report shall also describe in detail any corrective actions proposed and/or undertaken by the MCO.

11.5.2.3 External quality audits must be completed no less frequently than once every three years. Such audit shall be performed by a nationally known accreditation organization or an independent quality review organization acceptable to the Department.

11.5.2.4 In lieu of the external quality audit, the Department may accept evidence that an MCO has received and has maintained the appropriate accreditation from a nationally known accreditation organization or independent quality review organization.

11.5.3 Reporting and Disclosure Requirements

11.5.3.1 An MCO shall document and communicate information about its quality assessment program and its quality improvement program, and shall:

11.5.3.1.1 include a summary of its quality assessment and quality improvement programs in marketing materials;

11.5.3.1.2 include a description of its quality assessment and quality improvement programs and a statement of enrollee rights and responsibilities with respect to those programs in the materials or handbook provided to enrollees; and

11.5.3.1.3 make available annually to participating providers and enrollees findings from its quality assessment and quality improvement programs and information about its progress in meeting internal goals and external standards, where available. The reports shall include a description of the methods used to assess each specific area and an explanation of how any assumptions affect the findings.

11.5.3.2 An MCO shall submit to the Department such performance and outcome data as the Department may request.

18 Del. Admin. Code § 1403-11.0