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 3.3723 - Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) The commissioner may conduct an
					 examination relating to a preferred or exclusive provider benefit plan as often
					 as the commissioner considers necessary, but no less than once every three
					 years.
(b) On-site financial,
					 market conduct, complaint, or quality of care exams will be conducted under
					 Insurance Code Chapter 401, Subchapter B, concerning Examination of Carriers;
					 Insurance Code Chapter 751, concerning Market Conduct Surveillance; Insurance
					 Code Chapter 1301, concerning Preferred Provider Benefit Plans; and §
											7.83 of this title (relating to
					 Appeal of Examination Reports).
(c)
					 An insurer must make its books and records relating to its operations available
					 to the department to facilitate an examination.
(d) On request of the commissioner, an
					 insurer must provide to the commissioner a copy of any contract, agreement, or
					 other arrangement between the insurer and a physician or provider.
					 Documentation provided to the commissioner under this subsection will be
					 maintained as confidential as specified in Insurance Code §
											1301.0056, concerning
					 Examinations and Fees.
(e) The
					 commissioner may examine and use the records of an insurer, including records
					 of a quality of care program and records of a medical peer review committee, as
					 necessary to implement the purposes of this subchapter, including commencement
					 and prosecution of an enforcement action under Insurance Code Title 2, Subtitle
					 B, concerning Discipline and Enforcement, and §
											3.3710 of this title (relating to
					 Failure to Provide an Adequate Network). Information obtained under this
					 subsection will be maintained as confidential as specified in Insurance Code
					 §
											1301.0056. In this
					 subsection, "medical peer review committee" has the meaning assigned by
					 Occupations Code §
											151.002, concerning
					 Definitions.
(f) The following
					 documents must be available for review at the physical address designated by
					 the insurer in accordance with §
											3.3722(c)(12) of
					 this title (relating to Application for Preferred and Exclusive Provider
					 Benefit Plan Approval; Qualifying Examination; Network Modifications):
(1) quality improvement--program description,
					 work plans, program evaluations, and committee and subcommittee meeting minutes
					 as required by §
												3.3724 of this title (relating to
					 Quality Improvement Program) must be available for examinations of an exclusive
					 provider benefit plan offered under Insurance Code Chapter 1301 in the
					 commercial market;
(2) 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;
(3)
					 complaints--complaint files and complaint logs, including documentation and
					 details of actions taken. All complaints must be categorized and completed in
					 accordance with §
												21.2504 of this title (relating to
					 Complaint Record; Required Elements; Explanation and Instructions);
(4) satisfaction surveys--any insured,
					 physician, and provider satisfaction surveys, and any insured disenrollment and
					 termination logs;
(5) network
					 configuration information as required by §3.3712 of this title (relating
					 to Network Configuration Filings) demonstrating adequacy of the provider
					 network;
(6)
					 credentialing--credentialing files; and
(7) reports--any reports the insurer submits
					 to a governmental entity, including the most recent demographic data provided
					 by the insurer in accordance with §
												3.3709 of this title (relating to
					 Annual Network Adequacy Report).