12VAC5-408-320: Delegated services

A. If the MCHIP licensee contracts for any of the following services, it shall retain accountability for the oversight of those services:

1. Quality assurance activities;

2. Credentialing and recredentialing;

3. Covered person education, communication and satisfaction;

4. Utilization management;

5. Health promotion;

6. Records management;

7. Data management;

8. Providers and provider networks;

9. Claims administration; or

10. Pharmacy benefits.

B. The MCHIP licensee shall establish and implement written procedures to evaluate the effectiveness of any delegated service.

C. The MCHIP licensee shall require the delegated service entity to maintain documentation of its compliance with this chapter, its agreement with the MCHIP licensee to provide services, and any applicable state and federal laws.

D. Data and information exchanged between the delegated service entity and the plan shall be accomplished in a manner that is timely, efficient, and effective.

E. The MCHIP licensee shall require the delegated service entity to provide for timely and efficient access by state examiners to data, records, and personnel necessary to determine compliance with this chapter.