Medical Director’s Office is amended by REPLACING the federal citations in bullet five of paragraph two as follows “42 CFR 447.26, 42 CFR 447,434,438, and 1902(a)(4)i, 1902(a)(6)i, and 1903ii” to “42 C.F.R. §447.26, 434.6(a)(12), 438.3(g), and Section 2703 of the Patient Protection and Affordable Care Act.”
Medical Director’s Office. Contractor shall designate a Medical Director responsible for the development, implementation, and review of the internal quality assurance program (QAP). The Medical Director shall have adequate and appropriate experience in successful QA programs and be given sufficient time and support staff to carry out the Health Plan's QA functions. The Medical Director shall be full-time employed by the Contractor. Contractor may use assistant or associate Medical Directors to help carry out the responsibilities of this office. The qualifications and responsibilities shall include, but need not be limited to, what follows below. Specifically, the Medical Director shall: • Be licensed to practice medicine in the State of Rhode Island and be board-certified, - eligible, or trained in his or her field of specialty • Be responsible for Contractor's UR and QA Committees, direct the development and implementation of Contractor's internal Quality Assurance Plan, utilization review activities, and monitor the quality of care that members receive • Be responsible for the development of medical practice standards and protocols for Contractor • Oversee the investigation of all potential quality of care problems, including but not limited to member-specific occurrences of possible Health Care-Acquired Conditions and Other Provider-Preventable Conditions in accordance with 42 CFR 447,434,438, and 1902(a)(4), 1902(a)(6), and 1903, and possible hospital acquired conditions and recommend development and implementation of corrective action plans. • Be responsible for the development of Contractor’s medical policies • Be responsible for the Contractor’s referral process for specialty and out-of-plan services • Be involved in the Contractor’s recruiting and credentialing activities • Be involved in the Contractor’s process for prior authorizing and denying services • Be involved in the development and oversight of the Contractor’s disease management programs • Be involved in the Contractor’s process for ensuring the confidentiality of medical records/client information • Be involved in the Contractor’s process for ensuring the confidentiality of sexually transmitted infection (STI) appointments and mental health and substance abuse appointments • Serve as a liaison between the Contractor and its providers and communicate regularly with the Contractor's providers, addressing areas of clinical relevance including but not limited to: o Contractor’s utilization management functions o Cont...
