Review Of Geographic Service Area Expansion Requests

(1) When a health maintenance organization applies for a service area expansion, the following information shall be submitted to the Tennessee Department of Health, Division of Health Care Facilities for review: (a) List of counties to be added to the current service area and projected member enrollment by county; (b) List of contracting physicians, hospitals, pharmacies, and other providers in the expanded geographic service area, categorized by county, including the provider’s name, location (city), and specialty (if applicable). This list is to be submitted to the Division of Health Care Facilities for review when the health maintenance organization has signed contracts with such providers; (c) Description of the medical management, quality improvement, and utilization management programs for the expanded service area; and (d) Any other information which the Department determines is needed to demonstrate the applicant’s proof of capability to provide basic health care services (or additional health care services, as applicable) efficiently, effectively and economically. (2) The review process by the Division of Health Care Facilities shall consist of a review of the medical management, quality improvement, utilization management, and other programs and a review of the network of hospitals, physicians, pharmacies, and other providers in the expanded service area. When the health maintenance organization has developed a provider network and has signed contracts, it shall submit a list of contracting physicians, hospitals, pharmacies, and other providers, categorized by county, including the provider’s name, location (city), and specialty (if applicable). The network will be reviewed and an on-site visit will be scheduled to verify the signed contracts. STANDARDS FOR QUALITY OF CARE FOR HEALTH CHAPTER 1200-08-33 MAINTENANCE ORGANIZATIONS (3) When the review has been completed a letter shall be sent to the Department of Commerce and Insurance indicating whether or not the health maintenance organization’s proposal meets the requirements of the Department of Health. A copy of this letter will be placed in the health maintenance organization’s file.