33-20A-7 (2019)

global reimbursement payment, or otherwise, paid by the managed care plan to each class of health care provider or hospital under contract with the managed care plan.

(B) Such information shall be disclosed to each enrollee under this article at the time of enrollment and at least annually thereafter.

(C) Any managed care plan licensed under Chapter 21 of this title is deemed to have met the certification requirements of this paragraph.

(D) A managed care entity which negotiates with a primary care physician to become a health care provider under a managed care plan shall furnish that physician, beginning on and after January 1, 2001, with a schedule showing fees payable for common office based services provided by such physicians under the plan;

(2) Access to services. A managed care entity must demonstrate that its plan:

(A) Makes benefits available and accessible to each enrollee electing the managed care plan in the defined service area with reasonable promptness and in a manner that promotes continuity in the provision of health care services, including continuity in the provision of health care services after termination of a physician’s contract as provided in Code Section 33-20A-61;

(B) When medically necessary provides health care services 24 hours a day and seven days a week;

(C) Provides payment or reimbursement for emergency services and out-of-area services; and

(D) Complies with the provisions of Code Section 33-20A-9.1 relating to nomination and reimbursement of out of network health care providers and hospitals; and

(3) Quality assurance program. A managed care plan shall comply with the following requirements:

(A) A managed care plan must have arrangements, established in accordance with regulations of the Commissioner, for an ongoing quality assurance program for health care service it provides to such individuals; and

(B) The quality assurance program shall:

(i) Provide for a utilization review program which, in addition to the requirements of Chapter 46 of this title:

(I) Stresses health outcomes;

(II) Provides for the establishment of written protocols for utilization review, based on standards of the relevant health care profession;

(III) Provides review by physicians and appropriate health care providers of the process followed in the provision of such health care services;

(IV) Monitors and evaluates high volume and high risk services and the care of acute and chronic conditions;

(V) Evaluates the continuity and coordination of care that enrollees receive; and

(VI) Has mechanisms to detect both underutilization and overutilization of services; and

(ii) Establish a grievance procedure which provides the enrollee with a prompt and meaningful hearing on the issue of denial, in whole or in part, of a health care treatment or service or claim therefor. Such hearing shall be conducted by a panel of not less than three persons, at least one member of which shall be a physician other than the medical director of the plan and at least one member of which shall be a health care provider competent by reason of training and licensure in the treatment or procedure which has been denied. The enrollee shall be provided prompt notice in writing of the outcome of the grievance procedure. In the event the outcome of the grievance is favorable to the enrollee, appropriate relief shall be granted without delay. In the event the outcome is adverse to the enrollee, the notice shall include specific findings related to the care, the policies and procedures relied upon in making the determination, the physician’s and provider’s recommendations, including any recommendations for alternative procedures or services, and a description of the procedures, if any, for reconsideration of the adverse decision.