Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 3 - LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES › Subchapter X - PREFERRED AND EXCLUSIVE PROVIDER PLANS › Division 2 - APPLICATION, EXAMINATION, AND PLAN REQUIREMENTS › Section 3.3724 - Quality Improvement Program

Current through Reg. 49, No. 28; July 12, 2024
(a) An
					 insurer must develop and maintain an ongoing quality improvement (QI) program
					 designed to objectively and systematically monitor and evaluate the quality and
					 appropriateness of care and services provided within an exclusive provider
					 benefit plan and to pursue opportunities for improvement. The QI program must
					 be continuous and comprehensive, addressing both the quality of clinical care
					 and the quality of services. The insurer must dedicate adequate resources, like
					 personnel and information systems, to the QI program.
(1) Written description. The QI program must
					 include a written description of the QI program that outlines program
					 organizational structure, functional responsibilities, and meeting
					 frequency.
(2) Work plan. The QI
					 program must include an annual QI work plan designed to reflect the type of
					 services and the population served by the exclusive provider benefit plan in
					 terms of age groups, disease categories, and special risk status. The work plan
					 must:
(A) include objective and measurable
					 goals, planned activities to accomplish the goals, time frames for
					 implementation, responsible individuals, and evaluation methodology;
					 and
(B) address each program area,
					 including:
(i) network adequacy, which
					 includes availability and accessibility of care, including assessment of open
					 and closed physician and individual provider panels;
(ii) continuity of medical and health care
					 and related services;
(iii)
					 clinical studies;
(iv) the adoption
					 and periodic updating of clinical practice guidelines or clinical care
					 standards that:
(I) are approved by
					 participating physicians and individual providers;
(II) are communicated to physicians and
					 individual providers; and
(III)
					 include preventive health services;
(v) insured, physician, and individual
					 provider satisfaction;
(vi) the
					 complaint process, complaint data, and identification and removal of barriers
					 that may impede insureds, physicians, and providers from effectively making
					 complaints against the insurer;
(vii) preventive health care through health
					 promotion and outreach activities;
(viii) claims payment processes;
(ix) contract monitoring, including oversight
					 and compliance with filing requirements;
(x) utilization review processes;
(xi) credentialing;
(xii) insured services; and
(xiii) pharmacy services, including drug
					 utilization.
(3) Evaluation. The QI program must include
					 an annual written report on the QI program, which includes completed
					 activities, trending of clinical and service goals, analysis of program
					 performance, and conclusions.
(4)
					 Credentialing. An insurer must implement a documented process for selection and
					 retention of contracted preferred providers that complies with §
												3.3706(c)
					 of this title (relating to Designation as a Preferred Provider, Decision to
					 Withhold Designation, Termination of a Preferred Provider, Review of
					 Process).
(5) Peer review. The QI
					 program must provide for a peer review procedure for physicians and individual
					 providers, as required in the Medical Practice Act, Occupations Code Chapters
					 151 - 164. The insurer must designate a credentialing committee that uses a
					 peer review process to make recommendations regarding credentialing
					 decisions.