Current through Register Vol. 51, No. 19, September 20, 2024
A. The PACE provider shall collect and submit to the Department service-specific encounter data by service type in the format and at the frequency and level of detail designated by the Department and in conformance with the Department's computer coding requirements.
B. Encounter data submitted by PACE providers under §A of this regulation shall include, at a minimum:
(1) Participant and provider identifying information;
(2) Service, procedure, and diagnosis codes;
(3) Allowed, paid, and third-party liability amounts; and
(4) Service, claims submission, adjudication, and payment dates.
C. The PACE provider shall prepare and submit to the Department reports related to third-party liability as required by Regulation .20 of this chapter.
D. The PACE provider shall immediately notify the Department if it has knowledge of a participant's death.
E. The PACE provider shall have an effective procedure for reporting to the Department the following information:
(1) Patterns of utilization;
(2) Health status of participants; and
(3) Appeals and grievances made by participants.
F. Quarterly Reports. A PACE provider shall submit to the Department quarterly, within 30 days of the close of each calendar quarter, and in a format designated by the Department:
(1) Financial reports specified by the PACE program agreement;
(2) Quality assurance reports including, but not limited to, quality assurance committee meeting minutes reflecting major quality assurance corrective action plans, initiatives, and activities;
(3) Grievance reports, including emergency room based grievances, as specified in Regulation .19 of this chapter, that contain at a minimum:
(a) An analysis of participant appeal and grievance records;
(b) Identification of significant trends or anomalies;
(c) The root causes of the trend or anomaly; and
(d) Actions taken to address the trend or anomaly;
(4) A list of all pre-service denials or reduction of services or benefits issued by the PACE provider or subcontractors during the preceding quarter; and
(5) A report of the PACE provider's participant advisory committee outlining the committee's activities and recommendations.
F. Annual Reports. The PACE provider shall submit to the Department annually, within 90 days after the end of the calendar year:
(1) An annual summary of the information required by §E of this regulation;
(2) Any revisions to the PACE provider's quality assurance or utilization management plans;
(3) A copy of any changes in contractor agreements;
(4) On-site proof that the PACE provider has obtained adequate insurance coverage, issued by an insurer authorized by the Maryland Insurance Administration to engage in the insurance business in the State, to protect its financial viability, and its ability to carry out its PACE program agreement obligations, including at a minimum:
(a) Malpractice coverage for all professional and related employees of the PACE provider, as well as for the PACE provider itself;
(b) Bonding of all employees and officers who have any responsibilities for the accounting and financial management activities of the PACE provider; and
(c) Workers' compensation, fire, theft, casualty, and other coverage as required by State and local laws;
(5) A proposed budget and financial plan for the PACE provider's operation, including:
(a) An annualized cash flow chart;
(b) The cost of operations;
(c) Information demonstrating that the PACE provider has a fiscally sound operation; and
(d) A statement of policy and procedures for accounting, capitation collection, methods of reimbursing providers and contractors, and method of payment for emergency and out-of-area claims; and
(6) Financial monitoring reports, including any supplemental schedules required by the Department, prepared according to the criteria and reporting instructions and in the format and pursuant to the schedule required by the Department.
G. For the purposes of Program administration or monitoring of the PACE provider's performance pursuant to this chapter, given a reasonable period of notice, the PACE provider shall supply other information the Department may request from time to time.
