Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Annual reports. A plan shall submit to the Department on or
before April 30 of each year, a detailed report of its activities during the
preceding calendar year. The plan shall submit the report in a format specified
by the Department in advance of the reporting date, and shall include, at a
minimum, the following information:
(1)
Enrollment data by product line-for example, commercial, Medicare and Medicaid
and by county.
(2) Utilization
statistics containing the following minimum data:
(i) The number of days of inpatient
hospitalization on a quarterly, year-to-date and annualized basis.
(ii) The average number of physician visits
per enrollee on a quarterly, year-to-date and annualized
basis.
(3) The number,
type, and disposition of all complaints and grievances filed with the plan or
subcontractors.
(4) A copy of the
current enrollee literature, including subscription agreements, enrollee
handbooks and any mass communications to enrollees concerning complaint and
grievance rights and procedures.
(5) A copy of the plan's current provider
directory.
(6) A statement of the
number of physicians leaving the plan and of the number of physicians joining
the plan.
(7) A listing of all IDS
arrangements and enrollment by each IDS.
(8) Copies of the currently utilized generic
or standard form health care provider contracts including copies of any
deviations from the standard contracts and reimbursement methodologies.
Reimbursement information submitted to the Department under this paragraph may
not be disclosed or produced for inspection or copying to a person other than
the Secretary or the Secretary's representatives, without the consent of the
plan which provided the information, unless otherwise ordered by a
court.
(9) A copy of the plan's
written description of its quality assurance program, a copy of the quality
assurance work plan, and a copy of the quality assurance report submitted to
the plan's Board of Directors.
(10)
A listing, including contacts, addresses and phone numbers, of all contracted
CREs that perform UR on behalf of the plan or a contracted IDS.
(b)
Quarterly
reports. Four times per year, a plan shall submit to the Department
two copies of a brief quarterly report summarizing data specified in subsection
(a)(2) and (6) and enrollment, and complaint and grievance system data. Each
quarterly report shall be filed with the Department within 45 days following
the close of the preceding calendar quarter. The plan shall submit each
quarterly report in a format specified by the Department for that quarterly
report.
This section cited in 28 Pa. Code §
9.631 (relating to content of an
application for an HMO certificate of
authority).
