<html> <head> <title>Rule 20:06:56:12 Accreditation.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:56:12"> <META NAME="Description" Content="Administrative Rules 20:06:56:12 Accreditation."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>20:06:56:12.&nbsp;&nbsp;Accreditation.</span></b> A qualified health plan must be accredited in the following categories by an accrediting entity recognized by HHS prior to certification:</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;Clinical quality measures, such as the healthcare effectiveness Data and Information Set;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;Patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems survey;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;Consumer access;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;Utilization management;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;Quality assurance;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;Provider credentialing;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;Complaints and appeals;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (8)&nbsp;&nbsp;Network adequacy and access; and</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (9)&nbsp;&nbsp;Patient information programs.</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Source:</span></b> 39 SDR 203, effective June 10, 2013.</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>General Authority:</span></b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Law Implemented:</span></b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-80">58-18-80.</A></span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size: 12.0pt'>&nbsp;</span></font></p> </div> </body> </html>