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<regulation prefix="Regulation" num=".15" citation="COMAR 10.09.44.15" title_num="10" subtitle_num="09" chapter_num="44" heading="Reports and Data Collection.">
  <paragraph num="A.">
    <text>The PACE provider shall collect and submit to the Department service-specific encounter data by service type in the format and at the frequency designated by the Department and in conformance with the Department's computer coding requirements.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Encounter data submitted by PACE providers under §A of this regulation shall include, at a minimum:</text>
    <paragraph num="(1)">
      <text>PACE participant and provider identifying information;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Service, procedure, and diagnosis codes;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Allowed, paid, and third-party liability amounts; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Service, claims submission, adjudication, and payment dates.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>The PACE provider shall prepare and submit to the Department reports related to third-party liability as required by Regulation .20 of this chapter.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The PACE provider shall immediately notify the Department if it has knowledge of a PACE participant's death.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The PACE provider shall have an effective procedure for reporting to the Department the following information:</text>
    <paragraph num="(1)">
      <text>Patterns of utilization;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Health status of PACE participants; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Appeals and grievances made by PACE participants.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>Quarterly Reports. A PACE provider shall submit to the Department quarterly, within 30 days of the close of each calendar quarter, and in a format designated by the Department:</text>
    <paragraph num="(1)">
      <text>Financial reports specified by the PACE program agreement;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Quality assurance reports including, but not limited, to quality assurance committee meeting minutes reflecting major quality assurance corrective action plans, initiatives, and activities;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Grievance reports, including emergency room based grievances, as specified in Regulation .19 of this chapter that contain</text>
      <paragraph num="(a)">
        <text>An analysis of PACE participant appeal and grievance records;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Identification of significant trends or anomalies;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The root causes of the trend or anomaly; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Actions taken to address the trend or anomaly;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>A list of all pre-service denials or reduction of services or benefits issued by the PACE provider or subcontractors during the preceding quarter; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>A report of the PACE provider’s participant advisory committee outlining the committee’s activities and recommendations.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Annual Reports. The PACE provider shall submit to the Department annually, within 90 days after the end of the calendar year:</text>
    <paragraph num="(1)">
      <text>An annual summary of the information required by §E of this regulation;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Any revisions to the PACE provider's quality assurance or utilization management plans;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>A copy of any changes in contractor agreements;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>On-site proof that the PACE provider has obtained adequate insurance coverage, issued by an insurer authorized by the Maryland Insurance Administration to engage in the insurance business in the State, to protect its financial viability, and its ability to carry out its PACE program agreement obligations, including at a minimum:</text>
      <paragraph num="(a)">
        <text>Malpractice coverage for all professional and related employees of the PACE provider, as well as for the PACE provider itself;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Bonding of all employees and officers who have any responsibilities for the accounting and financial management activities of the PACE provider; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Workers' compensation, fire, theft, casualty, and other coverage as required by State and local laws;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(5)">
      <text>A proposed budget and financial plan for the PACE provider's operation, including:</text>
      <paragraph num="(a)">
        <text>An annualized cash flow chart;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The cost of operations;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Information demonstrating that the PACE provider has a fiscally sound operation; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>A statement of policy and procedures for accounting, capitation collection, methods of reimbursing providers and contractors, and method of payment for emergency and out-of-area claims; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(6)">
      <text>Financial monitoring reports, including any supplemental schedules required by the Department, prepared according to the criteria and reporting instructions and in the format and pursuant to the schedule required by the Department.</text>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>For the purposes of Program administration or monitoring of the PACE provider's performance pursuant to this chapter, given a reasonable period of notice, the PACE provider shall supply other information the Department may request from time to time.</text>
  </paragraph>
</regulation>