Section 83-41-409 - Conditions for certification or recertificationIn order to be certified and recertified under this article, a managed care plan shall:
(a) Provide enrollees or other applicants with written information on the terms and conditions of coverage in easily understandable language including, but not limited to, information on the following:(i) Coverage provisions, benefits, limitations, exclusions and restrictions on the use of any providers of care;(ii) Summary of utilization review and quality assurance policies; and(iii) Enrollee financial responsibility for copayments, deductibles and payments for out-of-plan services or supplies;(b) Demonstrate that its provider network has providers of sufficient number throughout the service area to assure reasonable access to care with minimum inconvenience by plan enrollees;(c) File a summary of the plan credentialing criteria and process and policies with the State Department of Insurance to be available upon request;(d) Provide a participating provider with a copy of his/her individual profile if economic or practice profiles, or both, are used in the credentialing process upon request;(e) When any provider application for participation is denied or contract is terminated, the reasons for denial or termination shall be reviewed by the managed care plan upon the request of the provider; and(f) Establish procedures to ensure that all applicable state and federal laws designed to protect the confidentiality of medical records are followed.Laws, 1995, ch. 613, § 40, eff. 7/1/1995.