§ 9.604. Plan reporting requirements.

 (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.

Cross References

   This section cited in 28 Pa. Code §  9.631 (relating to content of an application for an HMO certificate of authority).



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