Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter C - APPLICATION FOR CERTIFICATE OF AUTHORITY
Section 11.205 - Additional Documents to be Available for Review
Universal Citation: 28 TX Admin Code § 11.205
Current through Reg. 50, No. 13; March 28, 2025
(a) The following documents must be made available for review at the applicant's office in Texas or another location within Texas agreed to by the department and on request during the application process:
(1) administrative: policy and
procedure manuals;
(2) health
information systems: policies and procedures for accessing enrollee health
records and a plan to provide for confidentiality of those records complying
with applicable law;
(3) executed
agreements, including:
(A) management
services agreements;
(B)
administrative services agreements; and
(C) delegation agreements;
(4) executed physician and
provider contracts: a copy of the first page, including the form number, and
signature page;
(5) executed
subcontracts: a copy of the first page, including the form number, and
signature page of all contracts with subcontracting physicians and
providers;
(6) manuals: current
physician manual and current provider manual provided to each contracting
physician or provider, which must contain details of the provisions that govern
the physicians and providers;
(7)
credentialing files: as specified in §
11.1902(4) of
this title (relating to Quality Improvement Program for Basic, Single Service,
and Limited Service HMOs);
(8)
reporting system: the statistical reporting system developed and maintained by
the applicant 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;
(9) claims systems: policies and procedures
that demonstrate the capacity to pay claims timely and to comply with all
applicable statutes and rules;
(10)
financial records: financial information, including statements, ledgers,
checkbooks, inventory records, evidence of expenditures, investments, and
debts; and
(11) any other records:
demonstrating compliance with applicable statutes and rules, including audits
or examination reports by other entities, including governmental authorities or
accrediting agencies.
(b) After approval of the application, the following documents may be maintained outside Texas if the HMO has received prior approval by the commissioner in compliance with Insurance Code § 803.003 (concerning Authority to Locate Out of State):
(1) the
financial records listed in subsection (a)(10) of this section;
(2) minutes of HMO organizational meetings,
which indicate the type and date of each meeting and the officer or officers
who are responsible for the handling of the funds of the applicant;
(3) minutes of meetings of the HMO board of
directors; and
(4) management
committee meeting minutes.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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