W. Va. Code R. § 114-53-4

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-53-4 - Requirements of a Quality Assurance Program

4.1. A health maintenance organization shall develop a quality assurance program which adheres to all applicable state and federal laws, federal regulations and state rules.

a. A health maintenance organization that has obtained full accreditation or equal status from a nationally recognized accreditation and review organization approved by the commissioner pursuant to W. Va. Code § 33-25A-17a is deemed to be in compliance with this rule. If, at any time subsequent to the granting of full accreditation or equal status by a nationally recognized accreditation and review organization, the commissioner determines that the quality assurance program of the health maintenance organization has become deficient in any significant area, the commissioner, in addition to other remedies available, may establish a corrective action plan that the HMO must follow as a condition to the issuance or maintenance of a certificate of authority.

4.2. Each application for a certificate of authority or renewal thereof filed with the commissioner pursuant to the Health Maintenance Organization Act, W. Va. Code §§ 33-25A-1 et seq., shall be accompanied by a description of a health maintenance organization's quality assurance program, which shall include, but not be limited to, the requirements of the quality assurance program set forth in this rule. The HMO's quality assurance program may be inspected by providers, enrollees or their agents at the offices of the commissioner pursuant to the provisions of the West Virginia Freedom of Information Act, W.Va. Code §§ 29B-1-1 et seq.

a. Pursuant to the requirements of W. Va. Code § 33-25A-3, a health maintenance organization shall file notice with the commissioner prior to any modification of the quality assurance program.

4.3. A health maintenance organization shall have a program for quality assurance which clearly defines the structure, design and responsibilities of both delegated and non-delegated activities.

a. The basic components of the quality assurance program shall include:

1. Organizational arrangements and responsibilities for quality management and improvement processes;

2. A documented utilization review program;

3. Written policies and procedures for credentialing and recredentialing physicians and other licensed providers;

4. A written policy addressing members' rights and responsibilities; and

5. The adoption of practice guidelines for the use of preventive health services.

b. Utilization management rules contained in 114 CSR 51 shall be incorporated in and made a part of this rule.

4.4. If a health maintenance organization delegates any quality assurance activity to contractors, there shall be evidence of oversight and auditing of the contracted activity.

a. The HMO shall maintain a written description of the delegated activities, the contractor's accountability for the activities, the frequency of reporting to the HMO, the process by which the delegation will be evaluated and the remedies available, including revocation of delegation, if the contractor does not fulfill its obligations.

b. The HMO shall maintain evidence of its regular evaluation and approval of the delegated activities by the contractor.

c. The HMO shall be responsible for monitoring the activities of the contractor to which it delegates quality assurance activities and for ensuring that the requirements of this rule are met.

4.5. No health maintenance organization may place restrictions upon any provider or upon any primary care physician which would serve to limit the communication of medical advice or options available to the member, subscriber or enrollee or would act in any way to limit the communication between the provider or physician and his or her patient. An HMO may not prevent any provider from advising an enrollee whether or not a treatment is covered by the plan.

a. No health maintenance organization may provide to any provider or any primary care physician an incentive or disincentive plan that includes specific payment made directly or indirectly, in any form, to the provider or primary care physician as an inducement to deny, release, limit, or delay specific, medically necessary and appropriate services provided with respect to a specific enrollee or groups of enrollees with similar medical conditions.

4.6. Data or information pertaining to the diagnoses, treatment or health of a member obtained from the member or from a provider by a health maintenance organization is confidential and shall not be disclosed to any person except:

a. To the extent that it may be necessary to carry out the purposes of these rules and as allowed by state law;

b. Upon the express consent of the member;

c. Pursuant to statute or court order for the production of evidence or the discovery thereof;

d. In the event of a claim or litigation between the member and the health maintenance organization where the data or information is pertinent, regardless of whether the information is in the form of paper, preserved on microfilm, or stored in computer retrievable form.

4.7. If any data or information pertaining to the diagnosis, treatment or health of any enrollee or applicant is disclosed pursuant to the provisions of subsection 4.6, the health maintenance organization making this required disclosure shall not be liable for the disclosure or any subsequent use or misuse of the data.

W. Va. Code R. § 114-53-4