Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 11 - HEALTH MAINTENANCE ORGANIZATIONS
Subchapter T - QUALITY OF CARE
Section 11.1902 - Quality Improvement Program for Basic, Single Service, and Limited Service HMOs
Current through Reg. 50, No. 13; March 28, 2025
The QI program for basic, single service, and limited service HMOs must be continuous and comprehensive, addressing both the quality of clinical care and the quality of services. The HMO must dedicate adequate resources, such as personnel and information systems, to the QI program.
(1) Written description. The QI program must include a written description of the QI program that outlines program organizational structure, functional responsibilities, and meeting frequency.
(2) Work plan. The QI program must include an annual QI work plan designed to reflect the type of services and the population served by the HMO in terms of age groups, disease categories, and special risk status. The work plan must:
(3) Evaluation. The QI program must include an annual written report on the QI program, which includes completed activities, trending of clinical and service goals, analysis of program performance, and conclusions.
(4) Credentialing. An HMO must implement a documented process for selection and retention of contracted physicians and providers. The credentialing process must comply with NCQA or American Accreditation HealthCare Commission, Inc., standards, to the extent that those standards do not conflict with the laws of this state. An HMO must have a documented process for expedited credentialing of physicians, podiatrists, and therapeutic optometrists, including a documented process for payment of claims during the expedited credentialing process, in compliance with Insurance Code Chapter 1452 (concerning Physician and Provider Credentials).
(5) Site visits for cause.
(6) Peer Review. The QI program must provide for a peer review procedure for physicians and individual providers, as required by the Medical Practice Act, Occupations Code, Chapter 151, Subchapter A, (concerning General Provisions). The HMO must designate a credentialing committee that uses a peer review process to make recommendations regarding credentialing decisions.
(7) Delegation of Credentialing. If the HMO delegates credentialing functions to other entities, its credentialing process must comply with the standards promulgated by the NCQA, to the extent that those standards do not conflict with other laws of this state.