Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS › Subchapter D - REGULATORY REQUIREMENTS FOR AN HMO AFTER ISSUANCE OF CERTIFICATE OF AUTHORITY › Section 11.303 - Examination

Current through Reg. 49, No. 28; July 12, 2024
(a) The department has authority to conduct
				  examinations of HMOs under Insurance Code Chapters 401 (concerning Audits and
				  Examinations) and 751 (concerning Market Conduct Surveillance), and Insurance
				  Code §
										843.156 (concerning
				  Examinations) and §843.251 (concerning Complaint System Required;
				  Commissioner Rules and Examination), and such examinations are subject to
				  §
										7.83
				  of this title (relating to Appeal of Examination Reports). The department will
				  conduct examinations to determine the financial condition (financial exams),
				  quality of health care services (quality of care exams), or compliance with
				  laws affecting the conduct of business (market conduct exams).
(b) The following documents must be available
				  for review at the HMO's office located within Texas or at a location approved
				  by the department under Insurance Code §
										803.003
				  (concerning Authority to Locate Out of State):
(1) administrative: policy and procedure
				  manuals; physician and provider manuals; enrollee materials; organizational
				  charts; key personnel information, for example, resumes and job descriptions;
				  and other items as requested;
(2)
				  quality improvement: program description, work plans, program evaluations, and
				  committee and subcommittee meeting minutes;
(3) utilization management: program
				  description, policies and procedures, criteria used to determine medical
				  necessity, and templates of adverse determination letters; adverse
				  determination logs, including all levels of appeal; and utilization management
				  files;
(4) complaints and appeals:
				  policies and procedures and templates of letters; complaint and appeal logs,
				  including documentation and details of actions taken; and complaint and appeal
				  files;
(5) satisfaction surveys:
				  enrollee, physician, and provider satisfaction surveys, and enrollee
				  disenrollment and termination logs;
(6) health information systems: policies and
				  procedures for accessing enrollee health records and a plan to provide for
				  confidentiality of those records;
(7) network configuration information: as
				  required by §
											11.204(19)
				  of this title (relating to Contents) demonstrating adequacy of the physician,
				  dentist, and provider network;
(8)
				  executed agreements, including:
(A)
				  management services agreements;
(B)
				  administrative services agreements; and
(C) delegation
				  agreements;
(9) executed
				  physician and provider contracts: copy of the first page, including form
				  number, and signature page;
(10)
				  executed subcontracts: copy of the first page, including the form number, and
				  signature page of all contracts with subcontracting physicians and
				  providers;
(11) credentialing:
				  credentialing policies and procedures and credentialing files;
(12) reports: any reports submitted by the
				  HMO to a governmental entity;
(13)
				  claims systems: policies and procedures and systems or processes that
				  demonstrate timely claims payments, and reports that substantiate compliance
				  with all applicable statutes and rules regarding claims payment to physicians,
				  providers, and enrollees;
(14)
				  financial records: financial information, including statements, ledgers,
				  checkbooks, inventory records, evidence of expenditures, investments and debts;
				  and
(15) other: any other records
				  requested by the department to demonstrate compliance with applicable statutes
				  and rules.