Current through Reg. 50, No. 13; March 28, 2025
(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.
(c) The
department will conduct quality of care exams as follows:
(1) Entrance conference. The examination team
or assigned examiner may hold an entrance conference with the HMO's key
management staff or their designee before beginning the examination.
(2) Interviews. Examination team members or
the examiner may conduct interviews with key management staff or their
designated personnel.
(3) Exit
conference. On completion of the examination, the examination team or examiner
may hold an exit conference with the HMO's key management staff or their
designee.
(4) Written report of
examination. The examination team or examiner will prepare a written report of
the examination. The department will provide the HMO with the written report,
and if any significant deficiencies are cited, the department will issue a
letter outlining the time frames for a corrective action plan and corrective
actions.
(5) Corrective action
plan. If the examination team or examiner cites significant deficiencies, the
HMO must provide a signed corrective action plan to the department no later
than 30 days from receipt of the written examination report. The HMO's plan
must provide for correction of these deficiencies no later than 90 days from
the receipt of the written examination report.
(6) Verification of correction. The
department will verify the correction of deficiencies by submitted
documentation or by on-site examination.