§ 9.633. Location of HMO activities, staff and materials.
To demonstrate its ability to assure both availability and accessibility of adequate personnel and facilities to effectively provide or arrange for the provision of basic health services in a manner enhancing access, availability and continuity of care, the HMO shall meet the following minimum standards:
(1) The HMO shall make available for review at a location within this Commonwealth, by the Department or an agent of the Department, the books and records of the corporation and the essential documents as the Department may require, including signed provider contracts, credentialing files, complaint and grievance files, committee meeting (quality assurance and credentialing) minutes and hearing transcriptions. Documents need not be permanently maintained in this Commonwealth but shall be made available within this Commonwealth within 30 days, unless the Department determines for matters of patient safety the documents must be provided within 2-business days.
(2) The HMO shall identify a physician to serve as its medical director who is licensed in this Commonwealth and qualified to perform the duties of a medical director. The medical director shall be responsible for the following:
(i) Oversight of the UR and quality assurance activities regarding coverage and services provided to enrollees.
(ii) General coordination of the medical care of the HMO.
(iii) Appropriate professional staffing of the HMO’s medical management operations.
(iv) Designing protocols for quality assurance.
(v) Implementation of quality assurance programs and continuing education requirments.
(3) The HMO’s quality assurance/improvement committee shall include at least one health care provider licensed in this Commonwealth.
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