Current through Register Vol. 42, No. 11, August 30, 2024
(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
Statutory Authority:
Code of Ala.
1975, §§
22-2-2(6),
et
seq., 22-21-20,
et
seq., 27-21A-1,
et
seq.
