(1)The Authority shall conduct at least one on-site verification review of each recognized PCPCH to determine compliance with PCPCH criteria every five years and at such other times as the Authority deems necessary or at the request of the Health Systems Division (Division), or any other applicable program within the Authority. The purpose of the review is to verify reported attestation and quantitative data elements for the purposes of confirming recognition and Tier level.
(2)PCPCHs selected for verification shall be notified no less than 30 days prior to the scheduled review.
(3)PCPCHs shall permit Authority staff access to the practice’s place of business during the review.
(4)A verification review may include but is not limited to:
(a)Review of documents and records.
(b)Review of patient medical records.
(c)Review of electronic medical record systems, electronic health record systems, and practice management systems.
(d)Review of data reports from electronic systems or other patient registry and tracking systems.
(e)Interviews with practice management, clinical and administrative staff.
(f)On-site observation of practice staff.
(g)On-site observation of patient environment and physical environment.
(5)Following a review, Authority staff may conduct an exit conference with the PCPCH representatives. During the exit conference Authority staff shall:
(a)Inform the PCPCH representative of the preliminary findings of the review; and
(b)Give the PCPCH a reasonable opportunity to submit additional facts or other information to the Authority staff in response to those findings.
(6)Following the review, Authority staff shall prepare and provide the PCPCH specific and timely written notice of the findings.
(7)If the findings result in a referral to the Division pursuant to OAR 409-055-0070 (Compliance), Authority staff shall submit the applicable information to the Division for its review and determination of appropriate action.
(8)If no deficiencies are found during a review, the Authority shall issue written findings to the PCPCH indicating that fact.
(9)If deficiencies are found, the Authority shall take informal or formal enforcement action pursuant to OAR 409-055-0070 (Compliance).
(10)The Authority may share application information and content submitted by practices and verification findings with managed or coordinated care plans, and insurance carriers.
Rule 409-055-0060 — Verification,