Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 13 - MISCELLANEOUS INSURERS AND OTHER REGULATED ENTITIES › Subchapter E - HEALTH CARE COLLABORATIVES › Division 2 - APPLICATION FOR CERTIFICATE OF AUTHORITY › Section 13.415 - Documents to be Available for Quality of Care and Financial Examinations

Current through Reg. 49, No. 28; July 12, 2024
(a) The following documents must be provided
					 to the department on request and available for review at the HCC's office
					 located within Texas:
(1) administrative:
					 policy and procedure manuals, including procedures relating to confidentiality;
					 patient materials; organizational charts; and key personnel information, such
					 as resumes and job descriptions;
(2) quality improvement: program description
					 and work plan as required by §
												13.481
					 of this title (relating to Quality Improvement Structure for HCCs); and, to
					 support requirements under §
												13.482
					 of this title (relating to Quality Assurance and Quality Improvement) for
					 certified HCCs, program evaluations and meeting minutes for committees and
					 subcommittees;
(3) utilization
					 management: program description; policies and procedures; criteria used to
					 determine medical necessity; templates of adverse determination letters and
					 adverse determination logs for all levels of appeal, or, for certified HCCs,
					 examples of those letters and logs; and, for certified HCCs, utilization
					 management files;
(4) complaints
					 and appeals: policies and procedures; and templates of letters, complaint logs,
					 and appeal logs, or, for certified HCCs, examples of those letters and logs,
					 including documentation and details of actions taken;
(5) health information systems: policies and
					 procedures for accessing patient health records and a plan to provide for
					 confidentiality of those records in accord with applicable law;
(6) network configuration information: as
					 outlined in and required by §
												13.413(e)(2)
					 of this title (relating to Contents of the Application), demonstrating adequacy
					 of the physician and health care provider network;
(7) executed agreements, including:
(A) contracts with payors;
(B) management services agreements;
(C) administrative services agreements;
					 and
(D) delegation
					 agreements;
(8) executed
					 participant contracts: copy of the first page, including the form number, and
					 signature page of individual and group contracts;
(9) executed subcontracts: copy of the first
					 page, including the form number, and signature page of all contracts with
					 subcontracting physicians and providers;
(10) physician and health care provider
					 manuals: current physician manual and current health care provider manual,
					 which must be provided to each contracting physician and health care provider,
					 respectively, and which must contain details of the requirements by which the
					 physicians and health care providers will be governed;
(11) credentialing documentation:
					 credentialing policies, procedures, and files that demonstrate compliance with
					 §
												13.483
					 of this title (relating to Credentialing);
(12) reporting system: the statistical
					 reporting system developed and maintained by the HCC that allows for compiling,
					 developing, evaluating, and reporting statistics relating to the cost of
					 operation, the pattern of utilization of services, and the accessibility and
					 availability of services; and, for certified HCCs, reports generated by the
					 system concerning those components;
(13) claims systems: policies and procedures
					 that demonstrate the capacity to pay claims timely, if applicable, and to
					 comply with all applicable statutes and rules; and, for certified HCCs, as
					 applicable, evidence of timely claims payments and reports that substantiate
					 compliance with all applicable statutes and rules regarding claims payment to
					 physicians, health care providers, and patients;
(14) financial records: including statements;
					 ledgers; checkbooks; inventory records; evidence of expenditures, investments,
					 and debts; and related bank confirmations necessary to ascertain
					 funding;
(15) compliance or
					 accreditation: records regarding compliance with applicable statutes and rules
					 or accreditation standards, including audits or examination reports by other
					 entities, such as governmental authorities or accrediting agencies;
(16) satisfaction surveys: for certified HCCs
					 only, patient, physician, and provider satisfaction surveys; and patient
					 disenrollment and termination logs;
(17) reports: for certified HCCs only, any
					 reports submitted by the HCC to a governmental entity; and
(18) other documents and information: any
					 records requested pursuant to Insurance Code §
												848.153.