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Maine Inter-Agency Council on HMO Quality
Review of
Harvard Pilgrim Health Care, Inc./
Harvard Pilgrim Health Care of New England, Inc.

Findings and Recommendations

The Bureau of Insurance (DPFR) and the Bureau of Medical Services (DHHS) completed a joint triennial examination of Harvard Pilgrim Health Care, Inc./Harvard Pilgrim Health Care of New England, Inc., hereafter "HPHC", for compliance with 24-A M.R.S.A., Chapters 56 and 56A, Bureau of Insurance Rule Chapter 850, and Department of Human Services Rule Chapter 109. This report represents the finding of State surveyors as of November 6, 2006. HPHC scored a "Pass" for this triennial examination.

Acknowledgement of cooperation and assistance extended to the examiners by all HPHC representatives is hereby expressed.

This section highlights the findings associated with the examination of HPHC:

  1. Quality Management Program was determined to be in full compliance with Rule 109.
  2. Credentialing Program was determined to be in full compliance with Rule 850.
  3. Utilization Review Program was determined to be in full compliance with Rule 850.
  4. Grievance and Appeals procedures were determined to be in full compliance with Rule 850.

    Recommendation, GA 1, “UR Appeals Procedure:” HPHC’s adverse determination notification policy included the titles and qualifying credentials of persons evaluating the appeal, but not the names. However, the names were provided in practice, so credit was given for meeting this element. HPHC is encouraged to modify their policies to include the names of these reviewers.

    Recommendation, GA 3, “First Level Non-UR Procedures,” and GA 4, “Second Level Procedures:” HPHC was given credit for the element of providing printed materials in an accessible format when requested by an enrollee with a visual impairment because this is done in practice, even though it is not in HPHC’s policies. HPHC is encouraged to modify relevant policies to include this.

  5. Access, Availability, and Continuity of Care policies were determined to be in full compliance with Rule 850.

    Recommendation, AC 6, “Barriers to Access:” HPHC had a written strategy for dealing with language barriers. It was given credit for its literacy strategy, although there was no documentation, because it was carried out in practice. HPHC is encouraged to create a written strategy for dealing with literacy barriers.

 

 

Last Updated: August 22, 2012