10-144-109 Me. Code R. § 1.04

Current through 2024-51, December 18, 2024

Section 144-109-1.04 - Certificate of Authority Review

1.04-1 Document Submittal

An applicant for a Certificate of Authority shall submit documentation consistent with the requirements of Chapter 850(6) or the following documentation:

A. A written description of its QMP including:

1. a timeline for implementation;

2. an organizational chart or charts;

3. a job description and the credentials of the senior executive and other principal staff responsible for quality management activities;

4. a job description and the credentials of the applicant's medical director;

5. the job description and the credentials of the members of the QMP committee;

6. a description of the QM committee function and plan for ongoing operation;

7. a description of the resources that will be devoted to QM activities;

8. a description of the system for peer review activities;

9. a description of the applicant's plan for developing and disseminating clinical guidelines;

10. a description of the applicant's plan for conducting quality management studies;

11. a description of the applicant's plan for conducting intervention and assessment when the quality management studies identify opportunities for improvement;

12. a description of the applicant's plan for monitoring and evaluating the continuity of care and utilization;

13. a description of the applicant's plan for evaluating the performance of its QMP; and

14. such other information as may be reasonably required by the Department.

B. Documentation describing the applicant's credentialing policies and procedures. If the same or similar information pertaining to credentialing is supplied to the Bureau of Insurance, a copy of that information submitted to the Department will satisfy the requirement of this section.

C. A written description of the applicant's proposed QMP work plan for its initial year of operation and a certification from the governing body that it has reviewed and approved the work plan for that year.

D. Other information as may be reasonably required by the Department.

1.04-2 Examination. The Department shall conduct an examination of the applicant. The examination may include a desk audit and an onsite review.

1.04-3 Certification. The Department shall certify the applicant's compliance with the requirements of Title 24-A M.R.S.A., §4204(2-A)(B), if the following conditions are met:

A. The applicant has in place systems, policies and procedures and required written documentation complying with the requirements of this rule and of Title 24-A M.R.S.A., §4204(2-A)(B)

B. The Department determines that the applicant has a work plan in place for implementing the systems, policies and procedures identified in Section 1.04-3(A) in satisfaction of the requirements of this rule, within a maximum of three years from the date of the examination conducted under this section; and

C. The Department determines that the safeguards are in place to ensure the health care services to be provided by the applicant are rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice.

10-144 C.M.R. ch. 109, § 1.04