Maine Inter-Agency Council on HMO Quality
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
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
- Quality Management Program was determined to be in full compliance
with Rule 109.
- Credentialing Program was determined to be in full compliance with
- Utilization Review Program was determined to be in full compliance
with Rule 850.
- 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
- 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