10-144-109 Me. Code R. § 1.06

Current through 2024-51, December 18, 2024

Section 144-109-1.06 - Annual Statement

The HMO shall submit an annual statement to the Commissioner on March 1 of each year, except that an HMO that has been licensed less than six months as of March 1 shall not be required to report until the following year.

1.06-1 Specifications for the Annual Statement

The annual statement shall be in a format and meeting specifications acceptable to the Commissioner and shall contain the following information:

A. QMP Description. The HMO's most recently approved written description of its QMP;

B. Work Plan. The HMO's most recently approved work plan;

C. Evaluation. The HMO's most recently approved annual QMP evaluation report;

D. HEDIS Effectiveness of Care Measures. The HMO's HEDIS Effectiveness of Care Measures for the most recent NCQA reporting period. Beginning two years after the effective date of this rule or approval of the HMO's certificate of authority application, whichever is later, the Effectiveness of Care Measures shall have been audited by an NCQA-certified auditor or other auditor approved by the Department; and

E. Credentialing Activity. For the most recent calendar year, the HMO shall submit the following information relating to practitioner credentialing, broken down by type and specialty:

1. number of practitioners reviewed for credentialing;

2. number of practitioners given credentials;

3. number of practitioners denied credentials and why;

4. number of practitioners given provisional credentials;

5. average duration of provisional credentials prior to full credential decision;

6. identity and number of practitioners given provisional credentials but not given full credentials and why;

7. number of practitioners reviewed for recredentialing;

8. identity and number of practitioners denied recredentialing, and why; and

9. identity and number of practitioners with whom affiliation was terminated outside of periodic recredentialing process, and why.

F. Certification

Certification by the governing body or a member of senior HMO management that the reports submitted pursuant to this section are accurate, to the knowledge and best ability of that body or person.

10-144 C.M.R. ch. 109, § 1.06