PARRIS N. GLENDENING, Governor

Ch. 363

2. Utilization and outcome reports, such as the Health Plan
Employer Data and Information Set (HEDIS), as directed by the Department;

(iii) Promote timely access to and continuity of health care services for
enrollees, INCLUDING;

1. PROVIDING A 24-HOUR TOLL FREE TELEPHONE ACCESS

SYSTEM;

A. FOR ENROLLEES AND PROVIDERS TO DETERMINE, WITH
ONE TELEPHONE CALL TO A CURRENT ROSTER, THE PRIMARY CARE PROVIDER
ASSIGNED TO AN ENROLLEE; AND

B. FOR PROVIDERS TO DETERMINE, WITH ONE TELEPHONE
CALL TO A CURRENT ROSTER, EACH SPECIALTY PROVIDER CONTRACTED TO BE ON
CALL FOR EACH MANAGED CARE ORGANIZATION AT EACH HOSPITAL IN THE STATE
FOR EACH DAY OF THE MONTH;

2. PROVIDING AUTHORIZATION AT THE INITIAL

TELEPHONE ACCESS FOR ENROLLEES WHO DO NOT HAVE AN ASSIGNED PRIMARY
CARE PROVIDER; AND

3. PROVIDING FOR THE REIMBURSEMENT OF THE MEDICAL
OR SURGICAL PROVIDER ON CALL FOR UNASSIGNED PATIENTS GENERALLY OR THE
APPROPRIATE SPECIALIST ON CALL FOR THE HOSPITAL ON THAT DATE IN THE
EVENT A TELEPHONE ACCESS SYSTEM IS NOT ESTABLISHED, OR IF AN ENROLLEE'S
PRIMARY CARE PROVIDER OR THE SPECIALIST NEEDED BY AN ENROLLEE CANNOT
BE DETERMINED WITHIN A REASONABLE TIME, AS DETERMINED BY THE
CIRCUMSTANCES OF THE CASE IN THE JUDGMENT OF THE TREATING EMERGENCY
PHYSICIAN, BUT NOT EXCEEDING 30 MINUTES AFTER THE INITIAL DOCUMENTED
CALL TO THE TELEPHONE ACCESS SYSTEM, WITH REIMBURSEMENT FOR
NONCONTRACTING PROVIDERS AS PROVIDED IN § 19-710.1 OF THIS ARTICLE;

(iv) Demonstrate organizational capacity to provide special programs,
including outreach, case management, and home visiting, tailored to meet the individual
needs of all enrollees;

(v) Provide assistance to enrollees in securing necessary health care

services

(vi) Provide or assure alcohol and drug abuse treatment for substance
abusing pregnant women and all other enrollees of managed care organizations who
require these services;

(vii) Educate enrollees on health care prevention and good health

habits;

(viii) Assure necessary provider capacity in all geographic areas under

contract;

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