211 CMR 52.06 - Review of Application for Accreditation

Current through Register 1466, April 1, 2022

(1) Carriers shall comply with the standards set forth in M.G.L. c. 176O, 211 CMR 52.00; 958 CMR 3.000: Health Insurance Consumer Protection; 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks, if applicable; and all other applicable state and federal law.
(a) For all products, a Carrier shall not be accredited unless the Carrier scores 65% or higher of an aggregate of the applicable elements in the NCQA Standards, effective July 1, 2017, or any edition of such standards determined by the Commissioner to be functionally equivalent or appropriate, for the Accreditation of Health Benefit Plans, including health maintenance organizations, gatekeeper preferred provider plans, and Nongatekeeper Preferred Provider Plans, in the categories of utilization management, quality management and improvement, and credentialing and recredentialing.
(b) The NCQA Standards, effective July 1, 2017, or any edition of such standards determined by the Commissioner to be functionally equivalent or appropriate, are incorporated by reference into 211 CMR 52.00 to the extent that the NCQA Standards do not conflict with other laws of this Commonwealth. The NCQA Standards can be obtained from the NCQA.
(c) In reviewing the Carrier's application for Accreditation under 211 CMR 52.06, the Carrier may be given credit toward the relevant score for any Accreditation that it received, or which the Carrier's subcontracting organization, with which the Carrier has a written agreement delegating certain services, received, from a National Accreditation Organization for the standards described in 211 CMR 52.07, 52.08 or 52.09.
(2) A Carrier's application will not be considered to be complete until all materials required by M.G.L. c. 176O and 211 CMR 52.00 have been received by the Bureau. A Carrier shall respond to any request for additional information by the Bureau within 15 Days of the date of the Bureau's request. A Carrier that fails to respond in writing to requests within the 15 Days shall be subject to the penalties described in 211 CMR 52.17.
(3) The Bureau may schedule, at the Carrier's expense, on-site surveys of the Carrier's Utilization Review, quality management and improvement, credentialing and Preventive Health Services activities in order to examine records. Any on-site visit shall be scheduled within 15 Days of receipt of a Carrier's complete application.
(4) The Bureau shall notify a Carrier in writing that it is accredited or that its application for Accreditation has been denied. If an Accreditation is denied, the Bureau shall identify those items that require improvement in order to comply with Accreditation standards.
(5) A Carrier may seek reconsideration of a denial of its application for Accreditation.
(a) A Carrier whose application for Accreditation has been denied may make a written request to the Bureau for reconsideration within ten Days of receipt of the Bureau's notice.
(b) The Bureau shall schedule a meeting with the Carrier within ten Days of the receipt of the request for reconsideration to review any additional materials presented by the Carrier.
(c) Following the meeting pursuant to 211 CMR 52.06(5)(b) the Bureau may conduct a second on-site survey at the expense of the Carrier.
(d) The Bureau shall notify a Carrier in writing of the final disposition of its reconsideration.


211 CMR 52.06
Amended by Mass Register Issue 1345, eff. 8/11/2017.

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